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Fifty-fifth World Health Assembly, Geneva, 13-18 May 2002: summary records of committees and ministerial round tables; reports of committees

31 décembre 2002 Organisation mondiale de la santé

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WHA5 5/2002/REC/3

WORLD HEALTH ORGANIZATION

FIFTY-FIFTH WORLD HEALTH ASSEMBLY GENEVA, 13-18 MAY 2002

SUMMARY RECORDS OF COMMITTEES AND MINISTERIAL ROUND TABLES REPORTS OF COMMITTEES

GENEVA 2002

WHASS/2002/REC/3

WORLD HEALTH ORGANIZATION

FIFTY-FIFTH WORLD HEALTH ASSEMBLY GENEVA, 13-18 MAY 2002

SUMMARY RECORDS OF COMMITTEES AND MINISTERIAL ROUND TABLES REPORTS OF COMMITTEES

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 ofthe 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 Organisation for Economic Co-operation and Development Pan American Health Organization Joint United Nations Programme UN AIDS on HIV/AIDS UNCTAD- United Nations Conference on Trade and Development United Nations International Drug UNDCP Control Programme United Nations Development UNDP Programme United Nations Environment UNEP Programme UNESCO- United Nations Educational, Scientific and Cultural Organization United Nations Population Fund UNFPA Office of the United Nations High UNHCR Commissioner for Refugees United Nations Children's Fund UNICEF United Nations Industrial UNIDO Development Organization United Nations Relief and Works UNRWA Agency for Palestine Refugees in the Near East - World Food Programme WFP World Intellectual Property WIPO Organization World Meteorological WMO Organization World Trade Organization WTO PAHO

CIOMS

FAO

IAEA IARC ICAO IFAD ILO IMF IMO ITU 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 Fifty-fifth World Health Assembly was held at the Palais des Nations, Geneva, from 13 to 18 May 2002, in accordance with the decision of the Executive Board at its 108th session. Its proceedings are issued in three volumes, containing, in addition to other relevant material: Resolutions and decisions, Annexes- document WHA55/2002/REC/1 Verbatim records of plenary meetings, list of participants- document WHA55/2002/REC/2 Summary records of committees and ministerial round tables, reports of committees - document WHA55/2002/REC/3

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CONTENTS

Page

Abbreviations .. .. .. .. . .. .. ...... .. . .. . .. ... .. .. ... .. ... .. ..... .. .. ... ... ... .. .. . .. .... .. .. ....... .. ... .. .. .. .... .. ..... ....... .. .... .. .. . .. .. .. Preface ......................................................... .................................................................................... Officers of the Health Assembly and membership of its committees . .. .. .. ... ... .. .. ... .. ..... .. .. .. .... .. .. .. .. Agenda............................................................................................................................................. List of documents ........................................ ....................................................................................

n nt IX

PART I SUMMARY RECORDS OF MEETINGS OF COMMITTEES GENERAL COMMITTEE

First meeting.................................................................................................................................... Second meeting ...............................................................................................................................

3 12

COMMITTEE A First meeting

1. 2. 3.

Opening of the Committee ................................................................................................... . Election ofVice-Chairmen and Rapporteur ............................................................. .. Organization of work ........................................................................................................... . Technical and health matters Report of the WHO Commission on Macroeconomics and Health............................

15 15 15 16

Second meeting

Technical and health matters (continued) WHO's contribution to achievement of the development goals ofthe United Nations Millennium Declaration................................................................................. World Summit on Sustainable Development.............................................................. Global Fund to Fight AIDS, Tuberculosis and Malaria.............................................. Third meeting

26 34 36

Technical and health matters (continued) Global Fund to Fight AIDS, Tuberculosis and Malaria (continued)...........................

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Page Fourth meeting Technical and health matters (continued) Mental health............................................................................................................... Global Fund to Fight AIDS, Tuberculosis and Malaria (continued)...........................

44 53

Fifth meeting Technical and health matters (continued) Global Fund to Fight AIDS, Tuberculosis and Malaria (continued)........................... HIVIAIDS ................................................................................................................... Quality of care: patient safety ... .. .. ... .. .. ..... .. .... .. .. .. ... ... ... .. .... .. ... .. .. ... ..... .... ........ .... .. ....

59 61 77

Sixth meeting 1. 2. First report of Committee A ................................................................................................. . Technical and health matters (continued) World Summit on Sustainable Development (continued) .......................................... . HIVI AIDS (continued) ............................................................................................... . Quality of care: patient safety (continued) ................................................................. . HIVI AIDS (resumed) ................................................................................................. . Global Alliance for Vaccines and Immunization ....................................................... . 81

82 82 85 92 93

Seventh meeting Technical and health matters (continued) Global Alliance for Vaccines and Immunization (continued)..................................... Eradication of poliomyelitis........................................................................................ WHO's contribution to achievement of the development goals ofthe United Nations Millennium Declaration (continued).............................................................. WHO medicines strategy............................................................................................. Smallpox eradication: destruction of variola virus stocks........................................... Natural and accidental release of biological, chemical or radionuclear agents affecting health or their deliberate use to cause harm .. ... .. .. .. ... .. .. ... .. ... .. .. ...... .. ..... ... ...

97 99 105 107 117 121

Eighth meeting 1. 2. Second report of Committee A.............................................................................................. Technical and health matters (continued) Quality of care: patient safety (continued).................................................................. Dengue prevention and control ................................................................................... WHO's contribution to achievement of the development goals of the United Nations Millennium Declaration (continued).............................................................. Natural and accidental release of biological, chemical or radionuclear agents affecting health or their deliberate use to cause harm (continued).............................. Third report of Committee A................................................................................................. Closure................................................................................................................................... 126 126 127 130 133 135 136

3. 4.

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Page COMMITTEEB First meeting 1. 2. Opening of the Committee including election ofVice-Chairmen and Rapporteur............... Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine............................................................................................... 137 13 7

Second meeting 1. 2. First report of Committee B .................................................................................................. Financial matters Financial report on the accounts of WHO for 2000-2001, report of the External Auditor, and comments thereon made on behalf ofthe Executive Board; report of the Internal Auditor..................................................................................................... 151

151

Third meeting 1. Financial matters (continued) Status of collection of assessed contributions, including Members in arrears in the payment of their contributions to an extent that would justify invoking Article 7 of the Constitution....................................................................................................... Miscellaneous income................................................................................................. Revolving and other long-term funds ......................................................................... Assessments for 2003 ................................................................................................. Second report of Committee B.............................................................................................. Staffing matters Human resources: annual report ................................................................................. Amendments to the Staff Regulations and Staff Rules...............................................

2. 3.

154 156 157 158 158 158 162

Fourth meeting 1. Staffing matters (continued) Amendments to the Staff Regulations and StaffRules (continued)............................ Appointment of representatives to the WHO StaffPension Committee..................... Collaboration within the United Nations system and with other intergovernmental organizations ......................................................................................................................... International Decade of the World's Indigenous People............................................ Review of working methods of the Executive Board............................................................ Technical and health matters (continued) Infant and young child nutrition..................................................................................

165 166 166 166 168 169

3. 4.

Fifth meeting 1. 2. Third report of Committee B................................................................................................. Technical and health matters (continued) Infant and young child nutrition (continued) • Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes (continued).................................................. • Global strategy for infant and young child feeding (continued)............................. Diet, physical activity and health................................................................................ Ageing and health ....................................................................................................... Staffing matters (continued) Human resources: annual report (continued) ... ... ... ... .. .. .. .. .. .. .. .. .... .... .. ... ... .. .. .. ... ... .. .. .. - Vll -

177

177 177 182 193 200

Page Sixth meeting 1. 2. 3. 4. 5. Staffing matters (continued) Human resources: annual report (continued) .... .. ... .. ... .. .. ... .. .. ..... .. .. .. .. .. ... ... .. .. .. .... ... .. . Organization of work............................................................................................................ Technical and health matters (continued) Infant and young child nutrition (continued) .... ... .... ... ..... .. .. ..... .. .. ... ..... ... ..... .. .. ...... .. .. Fourth and fifth reports of Committee B............................................................................... Closure...................................................................................................................................

211 221 221 223 224

PARTII SUMMARY RECORDS OF THE MINISTERIAL ROUND TABLES Round tables: risks to health Salle VII................................................................................................................................. Salle XII................................................................................................................................. Salle XVII.............................................................................................................................. Salle XVIII ............................................................................................................................

227 23 7 245 254

PART Ill REPORTS OF COMMITTEES Committee on Credentials ............................................................................................................... Committee on Nominations............................................................................................................. General Committee.......................................................................................................................... Committee A.................................................................................................................................... Committee B.................................................................................................................................... 269 270 272 272 274

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OFFICERS OF THE HEALTH ASSEMBLY AND MEMBERSHIP OF ITS COMMITTEES

President Dr J.F. LOPEZ BELTRAN (El Salvador) Vice-Presidents Mrs J. PHUMAPHI (Botswana) Professor V.F. MOSKALENKO (Ukraine) Mr S.S. BHANDARI (Nepal) Mr B.R. MOOA (Kiribati) Dr A.J.M. SULEIMAN (Oman) Secretary Dr Gro Harlem BRUNDTLAND, DirectorGeneral Committee on Credentials The Committee on Credentials was composed of delegates of the following Member States: Cyprus, Equatorial Guinea, Estonia, Ethiopia, Fiji, Iceland, Panama, Qatar, Thailand, Togo, Turkey, and Uruguay. Chairman: Dr F. GRACIA (Panama) Vice-Chairman: Dr K. AL-JABER (Qatar) Rapporteur: Mr I. EINARSSON (Iceland) Secretary: Mr T.S.R. TOPPING, Legal Counsel Committee on Nominations The Committee on Nominations was composed of delegates of the following Member States: Angola, Canada, Central African Republic, Chile, China, Ecuador, France, Greece, Guatemala, Indonesia, Iran (Islamic Republic of), Jamaica, Kuwait, Lebanon, Malawi, Maldives, Mauritania, Russian Federation, Samoa, Seychelles, Slovakia, United Kingdom of Great Britain and Northern Ireland, Uzbekistan, Zimbabwe; and Dr Hong Sun Huot, Cambodia (President, Fiftyfourth World Health Assembly, ex officio).

Chairman: Dr HONG Sun Huot (Cambodia) Secretary: Dr Gro Harlem BRUNDTLAND, Director-General General Committee The General Committee was composed of the President and Vice-Presidents of the Health Assembly and the Chairmen of the main committees, together with delegates of the following Member States: Barbados, China, Cote d'Ivoire, Cuba, Democratic People's Republic of Korea, France, Japan, Mexico, Morocco, Russian Federation, Rwanda, Sao Tome and Principe, Sierra Leone, Spain, United Arab Emirates, United Kingdom of Great Britain and Northern Ireland, and United States of America. Chairman: Dr J.F. LOPEZ BELTRAN (El Salvador) Secretary: Dr Gro Harlem BRUNDTLAND, Director-General

MAIN COMMITTEES Under Rule 3 5 of the Rules of Procedure of the World Health Assembly, each delegation was entitled to be represented on each main committee by one of its members. Committee A Chairman: Dr J. KIELY (Ireland) Vice-Chairmen: Ms D. COSTA COITINHO (Brazil) and Dr S.P. AGARWAL (India) Rapporteur: Dr A. MSA MLIVA (Comoros) Secretary: Dr S. HOLCK, Director, Health Information Management and Dissemination

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FIFTY-FIFTH WORLD HEALTH ASSEMBLY

Committee B Chairman: Professor A.M. COLL SECK (Senegal) Vice-Chairmen: Mr H. M'BAREK (Tunisia) and Professor PHAM MANH HUNG (Viet Nam) Rapporteur: Dr S. SOEPARAN (Indonesia) Secretary: Dr M.K. BEHBEHANI, Director, Eastern Mediterranean Liaison

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AGENDA 1

PLENARY MEETINGS

Opening ofthe Assembly 1.1 1.2 1.3 Appointment of the Committee on Credentials Election of the Committee on Nominations Reports of the Committee on Nominations • Election of the President Election of the five Vice-Presidents, the Chairmen of the mam committees, and establishment of the General Committee 1.4 Adoption of the agenda and allocation of items to the main committees

2. 3. 4. 5. 6. 7. 8. 9. 10.

Reports ofthe Executive Board on its 108th and 109th sessions Address by Dr Gro Harlem Brundtland, Director-General Invited speaker [Deleted] Executive Board: election Awards Centenary of the Pan American Health Organization Reports of the main committees Closure of the Assembly

ROUND TABLES 11. Round tables: Risks to health 1

Adopted at the second plenary meeting.

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FIFTY-FIFTH WORLD HEALTH ASSEMBLY

COMMITTEE A

12. 13.

Opening of the Committee, including election ofVice-Chainnen and Rapporteur Technical and health matters 13.1 Report of the WHO Commission on Macroeconomics and Health 13.2 WHO's contribution to achievement of the development goals of the United Nations Millennium Declaration 13.3 World Summit on Sustainable Development 13.4 Global Fund to Fight AIDS, Tuberculosis and Malaria 13.5 HIV/AIDS 13.6 Global Alliance for Vaccines and Immunization 13.7 Eradication of poliomyelitis 13.8 WHO medicines strategy 13.9 Quality of care: patient safety 13 .1 0 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 13.11 Diet, physical activity and health 13.12 Ageing and health 13 .13 Mental health 13.14 Dengue prevention and control 13.15 Natural and accidental release of biological, chemical or radionuclear agents affecting health or their deliberate use to cause harm 13.16 Smallpox eradication: destruction of Variola virus stocks 13.17 Pan African Tsetse and Trypanosomiasis Eradication Campaign

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AGENDA

13 .18 Control of neurocysticercosis 13.19 The role of contractual arrangements in improving health systems' performance

COMMITTEEB 14. 15. Opening of the Committee, including election ofVice-Chairmen and Rapporteur Financial matters 15.1 Financial report on the accounts of WHO for 2000-2001, report of the External Auditor, and comments thereon made on behalf of the Executive Board; report of the Internal Auditor 15.2 Status of collection of assessed contributions, including Members in arrears in the payment of their contributions to an extent that would justify invoking Article 7 of the Constitution 15.3 Miscellaneous income 15.4 Revolving and other long-term funds 15.5 [Deleted] 15.6 Assessments for 2003 15.7 [Deleted] 16. Staffing matters 16.1 Human resources: annual report 16.2 Amendments to the Staff Regulations and StaffRules 16.3 Appointment of representatives to the WHO Staff Pension Committee I 7. 18. Review of working methods of the Executive Board Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine Collaboration within the United Nations system and with other intergovernmental organizations • International Decade of the World's Indigenous People

19.

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LIST OF DOCUMENTS

A55/1 Rev.1 A55/2 A55/3 A55/4 AS 5/5 and Corr.1 A55/6

Agenda 1 Reports of the Executive Board on its 108th and 109th sessions Address by the Director-General to the Fifty-fifth World Health Assembly Centenary ofthe Pan American Health Organization Report of the WHO Commission on Macroeconomics and Health WHO's contribution to achievement ofthe development goals ofthe United Nations Millennium Declaration The World Summit on Sustainable Development Global Fund to Fight AIDS, Tuberculosis and Malaria HIV I AIDS: global health-sector strategy Global Alliance for Vaccines and Immunization Eradication of poliomyelitis WHO medicines strategy: expanding access to essential drugs Quality of care: patient safety Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes Infant and young child nutrition: global strategy on infant and young child feeding 2 Diet, physical activity and health Ageing and health

A55/7 A55/8 and Add.1 A55/9 and Corr.1 A55/10 A55111 A55/12 A55/13 A55114

A55/15

A55/16 and Corr.1 A55117 and A55117 Add.1 A55/18 and Corr.1

Mental health: responding to the call for action

1 2

See page ix. See document WHASS/2002/REC/1, Annex 2.

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FIFTY-FIFTH WORLD HEALTH ASSEMBLY

A55/19 A55/20

Dengue prevention and control Deliberate use of biological and chemical agents to cause harm: public health response Smallpox eradication: destruction of variola virus stocks Pan African tsetse and trypanosomiasis eradication campaign Control of neurocysticercosis The role of contractual arrangements in improving health systems' performance Financial Report and Audited Financial Statements for the period 1 January 2000-31 December 2001 and Report of the External Auditor to the World Health Assembly Financial Report and Audited Financial Statements for the period 1 January 2000-31 December 2001: Annex: Extrabudgetary resources for programme activities Status of collection of assessed contributions, including Members in arrears to an extent which would justify invoking Article 7 of the Constitution: second report of the Administration, Budget and Finance Committee of the Executive Board to the Fifty-fifth World Health Assembly Miscellaneous Income Revolving and other long-term funds Assessments for 2003 Human resources: annual report, 2001 Appointment of representatives to the WHO Staff Pension Committee Review of the working methods of the Executive Board Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine Collaboration within the United Nations system and with other intergovernmental organizations International Decade of the World's Indigenous People Collaboration within the United Nations system and with other intergovernmental organizations: International Decade of the World's Indigenous People

A55/21 A55/22 A55/23 A55/24 A55/25 and Corr.l

A55/25 Add.1

A55/26

A55/27 A55/28 A55/29 A55/30 A55/31 A55/32 A55/33 and A55/33 Add.1 A55/34

A55/35 A55/35 Add.1

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LIST OF DOCUMENTS

A55/36 A55/37 A55/38

Amendments to the Staff Regulations 1 Management and financial matters: report ofthe Internal Auditor Financial report on the accounts of WHO for 2000-2001: report of the External Auditor, and comments thereon made on behalf of the Executive Board; report of the Internal Auditor: first report of the Administration, Budget and Finance Committee ofthe Executive Board to the Fifty-fifth World Health Assembly Committee on Nominations: first report Committee on Nominations: second report Committee on Nominations: third report Committee on Credentials: first report First report of Committee B Election of Members entitled to designate a person to serve on the Executive Board Second report of Committee B Committee on Credentials: second report First report of Committee A Third report of Committee B Second report of Committee A Fourth report of Committee B Fifth report of Committee B Third report of Committee A

A55/39 A55/40 A55/41 A55/42 A55/43 A55/44

A55/45 A55/46 A55/47 A55/48 A55/49 ASS/50 ASS/51 ASS/52

Information documents A55/INF.DOC./1 Awards: amendments to the Statutes governing the Ihsan Dogramaci Family Health Foundation Miscellaneous Income

A55/INF.DOC./2

See document WHASS/2002/REC/1, Annex 1.

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FIFTY-FIFTH WORLD HEALTH ASSEMBLY

A55/INF.DOC./3

Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine Global Fund to Fight AIDS, Tuberculosis and Malaria: the global malaria situation: current tools for prevention and control

A55/INF .DOC./4

A55/INF.DOC./5

A55/INF .DOC./6

Diverse A55/DIV/5 A55/DIV/6 Ministerial round tables -risks to health Ministerial round tables - risks to health

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PART I SUMMARY RECORDS OF MEETINGS OF COMMITTEES

GENERAL COMMITTEE FIRST MEETING Monday, 13 May 2002, at 12:10 Chairman: Dr J.F. LOPEZ BELTMN (El Salvador) President of the Health Assembly

ADOPTION OF THE AGENDA (Document A55/1)

The CHAIRMAN reminded the Committee that, under its terms of reference as defined in Rule 33 of the Rules of Procedure of the World Health Assembly, its first task was to consider item 1.4 (Adoption of the agenda and allocation of items to the main committees) of the provisional agenda, which had been prepared by the Executive Board and issued as document A55/l. The Committee would also consider proposals for the addition of a supplementary agenda item and the programme of work of the Health Assembly. Deletion of agenda items The CHAIRMAN indicated that, if there was no objection, three items on the provisional agenda would be deleted, namely, item 5 (Admission of new Members and Associate Members), item 15.5 (Assessment of new Members and Associate Members), and item 15.7 (Amendments to the Financial Regulations). It was so agreed.

The delegate of CUBA proposed rewording the title of item 13.15 on the deliberate use of biological and chemical agents to cause harm. His delegation had considered that the scope of the phrase "deliberate use" was too narrow, particularly when compared with natural phenomenon or accidents. Therefore, he proposed, after consultation and to reflect the text in paragraph 4 of document A55/20, that the title be amended to read as follows: Natural and accidental release of biological, chemical or radiological agents or the deliberate use thereof to cause harm. The proposal was not intended to be restrictive, rather to expand the scope of the agenda item. The observer of PAKISTAN' supported that proposal, arguing that the new title would better reflect the mandate of the Organization. The delegate of CHINA endorsed the proposal of the Cuban delegate. The amendment would broaden the scope of the item and allow more comprehensive discussion. The delegate of the UNITED KINGDOM OF GREAT BRITAIN AND NORTHERN IRELAND also supported the proposal, but he asked for the term "radionuclear" to be used, as in resolution EB 109 .R5, in preference to "radiological".

Participating by virtue of Rule 32 of the Rules of Procedure of the World Health Assembly.

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FIFTY -FIFTH WORLD HEALTH ASSEMBLY

The observer of BRAZIL 1 added his country's support to the Cuban proposal. Acknowledging the usefulness of the proposal, the delegate of the UNITED STATES OF AMERICA cautioned, however, that the change should not prejudice the discussion in Committee A ofthe draft resolution contained in resolution EB109.R5. The CHAIRMAN concluded that the Committee agreed that the proposed change to the title, with the observations made, should be recommended to the Health Assembly at its plenary meeting later that afternoon. It was so agreed.

PROPOSED SUPPLEMENTARY AGENDA ITEM (Document ASS/GC/2)

The CHAIRMAN drew the Committee's attention to a proposal for inclusion of a supplementary agenda item, in accordance with Rule 12 of the Rules of Procedure of the World Health Assembly, from the governments of Paraguay, Solomon Islands, Sao Tome and Principe, Tuvalu, Chad, Nicaragua, Grenada, Senegal and Honduras, "Inviting Taiwan to participate in the World Health Assembly as an observer"? The delegate of CHINA firmly opposed the proposal regarding Taiwan's participation as an observer in the Health Assembly, the highest policy-making authority of WHO, which was a United Nations special agency. Resolution 2758 (XXVI), adopted by the United Nations General Assembly at its twenty-sixth session in 1971, and resolution WHA25 .1, adopted by the Health Assembly in 1972, had resolved once and for all the issue of the representation of China in both the United Nations and WHO: the representatives of the Government of the People's Republic of China were the only legitimate representatives of China in those organizations. Taiwan, as a province of China, was not entitled to participate in the activities of either, in any manner. The proposal for its participation in the Health Assembly violated both the above resolutions. In each of the past five years the General Committee had rejected similar proposals from a few countries, a decision endorsed each time by the Health Assembly. Furthermore, at its 109th session in January 2002 the Executive Board had unequivocally rejected another similar proposal. Common sense should have persuaded the sponsors of the proposal to show respect for WHO, the decisions of its governing bodies and the will of the overwhelming majority of its Members, and to desist, but regrettably the proposal had been raised again. The Taiwanese authorities had blatantly argued before the Health Assembly that Taiwan could join WHO as a ''health entity" or participate as a nongovernmental organization. WHO's Constitution recognized no such concept as a "health entity"; an invitation to participate in the Health Assembly in such a capacity had no legal ground or precedence in WHO. Article 18 of the Constitution ruled that participation of a national organization of a Member State in WHO's activities was subject to the consent of the government concerned, and Article 1.2 of the Principles governing Relations between the World Health Organization and Nongovernmental Organizations3 clearly provided that any such relation had to conform with the relevant resolutions of the General Assembly or Economic and Social 1 2

Participating by virtue of Rule 32 of the Rules of Procedure of the World Health Assembly.

Contained in document A55/GC/2. The Director-General also received on 13 May, after the Committee's meeting, a letter dated 10 May 2002 from the Ambassador of the Permanent Mission in Geneva of the Dominican Republic, expressing support for the proposal. 3

See Baste Documents, 43rd ed., Geneva. World Health Organization, 200 l.

GENERAL COMMITTEE: FIRST MEETING

Council of the United Nations. Inviting Taiwan to participate in the Health Assembly as an observer violated General Assembly resolution 2758 and the Constitution of WHO. The Chinese Government was committed to protecting the health and well-being of its compatriots in Taiwan, being ready to consult and find solutions on health-related matters through proper channels and to make appropriate arrangements for exchanges across the Taiwan Straits. If the Taiwanese authorities were sincere, all issues including health could be settled through cross-Straits consultations. The Chinese Government continued to promote actively such cooperation, and would have done more had it not been for Taiwanese obstruction. Taiwan's purpose in instigating proposals for participation in the Health Assembly was to create "two Chinas" or "one China, one Taiwan". On both sides of the Straits the common aspiration was peaceful reunification. If the sponsors of the proposal before the Committee cared for the people of Taiwan, they should refrain from raising proposals that obstructed that goal. The question of Taiwan was entirely an internal affair and had to be resolved by the Chinese people themselves. No foreign country had the right to meddle or interfere. The proposal under consideration infringed China's sovereignty and territorial integrity and attempted to split China. The Chinese delegation urged members of the Committee to support its position and reject the proposal. The delegate of the DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, recalling the rejection of previous attempts to gain observer status for Taiwan in the Health Assembly, said that to discuss the matter further was pointless. The Chairman of Committee B, speaking in her capacity as the observer of SENEGAL and as one of the sponsors of the proposal, stressed that the move was not designed to create difficulties but to act in conformity with WHO's Constitution. That document embodied several fundamental principles, including the right to health of every human being without distinction of race, religion, political belief, economic or social condition, and Article 1 stated the objective of WHO as "the attainment by all people of the highest possible level of health". The sponsors of the proposal sought to exclude no people in the world from the activities of WHO, in particular not to leave Taiwan's 23 million people outside the international health system. Granting Taiwan observer status would allow it to follow health developments at the international level. If the concept of a health entity was not taken into account at the current juncture, she recommended that it should be so considered. Entities were accepted in other sectors, such as customs, where international organizations and bodies included both the People's Republic of China and Taiwan. A country with such a large population as Taiwan's should be involved in WHO's activities, hence the promotion of the idea of a health entity with observer status, rather than full membership for Taiwan. The objective of the sponsors was humanitarian and social: access for the people of Taiwan to high-quality health care. The delegate of the RUSSIAN FEDERATION confirmed its unchanging position of principle on Taiwan, namely that the Government of the People's Republic of China was the only legal government of China, of whose territory Taiwan was an inalienable part. He opposed any form of participation by Taiwan in United Nations or other international organizations or bodies on the grounds that their membership was limited to sovereign States. Noting the repeated discussions over the past few years, the delegate of SPAIN opposed inclusion of the supplementary agenda item. However, she supported maintaining the practice of two delegates speaking for and two against the proposal. The delegate of MEXICO, expressing his support for the sovereignty and territorial integrity of China, considered that inclusion ofthe item on the agenda would be incompatible with the interests of WHO. He saw no justification for questioning the validity of United Nations General Assembly resolution 2758 and resolution WHA25.1, and opposed the proposal.

FIFTY-FIFTH WORLD HEALTH ASSEMBLY

The delegate of CUBA, citing the relevant resolutions, recalled that the international community had long recognized the People's Republic of China as the legitimate representative of all the Chinese people. Despite the claims by certain Member States that the situation had changed, Taiwan continued to be a matter that should not be addressed by the Health Assembly, as it undoubtedly constituted an internal policy issue concerning an inalienable part of the country that only the people and Government of China could resolve. Any initiative to invite Taiwan to be an observer therefore constituted interference in the internal affairs of China. WHO was a specialized agency of the United Nations system in which only sovereign States could be represented. The Cuban delegation therefore opposed the proposal. The delegate of FRANCE questioned the reasons for the proposal and the basis on which it had been made. Referring to the intervention by the observer of Senegal, he considered that the issue was not a matter of health as such, and he was therefore opposed to its inclusion on the agenda. The delegate of BARBADOS expressed his opposition to inclusion of the proposal on the agenda. The issue of the representation of the People's Republic of China had been settled by the United Nations General Assembly. Barbados had long supported the one-China policy. He pointed out that, with the consent of the Chinese Government, Taiwan, like the Hong Kong Special Administrative Region of China, had been admitted to WTO with the status of a separate customs territory, which was a special arrangement limited to WTO for non-sovereign and non-independent States. The observer of MYANMAR 1 supported the opposition of the People's Republic of China to the proposal, which could only serve to detract from the main work of the Health Assembly. The delegate of COTE D'IVOIRE recalled that the issue of Taiwan had already been discussed on several occasions, including by the Executive Board at its 109th session. Based on his belief in the one-China policy, he opposed the proposal. The delegate of MOROCCO also expressed his opposition to the proposal, based on the recognition of States rather than entities and the United Nations General Assembly and Health Assembly resolutions referred to by previous speakers. The observer of NEPAL 1 recalled the previous unsuccessful attempts to include on the agenda the proposal to invite Taiwan to participate in the Health Assembly as an observer. The Constitution of WHO stipulated that membership of the Organization was open to all sovereign States; observer status was restricted to non-Member States and territories, the latter with the consent of the Member having responsibility for their international relations. Citing arguments raised by other speakers, he rejected the proposal. The observer of ZIMBABWE 1 also opposed the proposal, on the grounds stated by previous speakers. The delegate of the UNITED ARAB EMIRATES supported the position of the People's Republic of China in opposing the proposal. The delegate of SPAIN, speaking on behalf of the European Union and its Member States, recalled that this proposal had already been discussed extensively and rejected by the Executive Board at its 109th session. He reiterated the position of the European Union on the issue of substance, which remained unchanged.

Participating by virtue of Rule 32 of the Rules of Procedure of the World Health Assembly.

GENERAL COMMITTEE: FIRST MEETING

The observer of BURKINA FAS0 1 commented that WHO had made great efforts to provide support to development programmes promoting health, which required both substantial financial resources and experience in combating disease and illness. He expressed his support for the proposal, based on the potential contribution of Taiwan to such efforts. The delegate of SAO TOME AND PRINCIPE expressed his convictiOn that Taiwan's participation in the Health Assembly would help WHO to operate better and to promote international cooperation. As stated in the Constitution of WHO, the health of all peoples was fundamental to the attainment of peace and security, and was dependent upon the fullest cooperation of all States. Promoting the exchange of information and experience between nations was important in promoting access of all nations to the benefits of civilization. He supported the proposal, on the grounds that international organizations and especially WHO should be open to all health entities and to all participants. The observer of SRI LANKA 1 expressed her support for the position taken by China, that Taiwan had no legal basis on which to participate in any capacity as an observer at the Health Assembly and that the matter was an internal affair of China. She therefore opposed the proposal. The observer of HONDURAS 1 expressed her support for the views stated by the delegate of Sao Tome and Principe and the observers ofBurkina Faso and Senegal and regretted the distortion oftheir good intentions. Taiwan met all the requirements to be granted observer status and should not continue to be excluded from the Health Assembly. She urged delegates to agree to Taiwan's participating in and contributing to the current Health Assembly. The observer of BANGLADESH 1 stated that the issue of Taiwan should be carefully examined in the light of the relevant resolutions of the United Nations General Assembly and the Health Assembly, which clearly established the People's Republic of China as the sole legal representative of China in the United Nations and WHO. Nothing had occurred that would make it imperative for the General Committee to review its previous position or to make any other recommendations on the subject. Expressing his support for the one-China policy, he rejected the proposal. The observer of PANAMA, 1 noting that WHO was the only global forum coordinating activities related to health, affirmed that WHO should ensure that all health entities could benefit from and contribute to the Organization. No group should be excluded. According to the Constitution of WHO, the health of all peoples was fundamental to the attainment of peace and security and was dependent on the fullest cooperation of individuals and States. In order to promote exchange of experience and knowledge between nations and to ensure that everyone benefited from achievements, WHO should be open to all. There were specific examples of different entities that already participated in WHO with observer status, including governmental entities and nongovernmental organizations. The participation of Taiwan as an observer should be considered as a functional issue rather than one of sovereignty. The observer of PAKISTAN 1 rejected the proposal on legal grounds. Only sovereign States were eligible for WHO membership; Taiwan was an inalienable part of China. Article 8 of the WHO Constitution allowed territories or groups of territories that were not responsible for the conduct of their international relations to be admitted as Associate Members only with the consent of the Member or other authority having responsibility for their international relations. The proposal under consideration did not fall under the framework of Article 8. Taiwan was an integral part of China and recognized as such by the United Nations; a request to make it an Associate Member or to invite its representatives to attend the Health Assembly could therefore only be made with the consent of China.

Participating by virtue of Rule 32 of the Rules of Procedure of the World Health Assembly.

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The argument about Taiwan's membership of WTO was invalid, because "Chinese Taipei" had been admitted as a separate customs territory and not as a sovereign State. The observer of BELIZE 1 commented that, with WHO working towards more effective health systems, the issue of resources arose: unless more affluent countries were willing to increase the scale of cooperation, developing countries might legitimately be concerned about the inequity of wealth in the international system. In that context, WHO could benefit from Taiwan's rich experience and resources in the eradication of infectious and other diseases. Taiwan had shown its ability to fulfil the purposes of WHO, promoting health and medicine through bilateral cooperation with many countries and such initiatives as eradication of poliomyelitis and the programme to prevent and control iodinedeficiency disorders. Consideration should be given to the admission of Taiwan to the Health Assembly as a health entity. The CHAIRMAN said that, having heard the arguments, he took it that the Committee agreed not to support the proposal for inclusion of the proposed supplementary agenda item, and that a recommendation to that effect should be conveyed to the Health Assembly. The agenda, as amended, would therefore be submitted in plenary later that afternoon. It was so agreed.

ALLOCATION OF ITEMS TO THE MAIN COMMITTEES AND PROGRAMME OF WORK OF THE HEALTH ASSEMBLY (Documents ASS/1 and ASS/GC/1)

The CHAIRMAN noted that the Committee's recommendation on item 1 would be transmitted to the next plenary meeting. Items 2 to 4 and 6 to 10 would also be taken up in plenary. With regard to item 11 (Round tables: risks to health) four concurrent round tables had been proposed. Each would be considered as a separate committee of the Health Assembly with membership limited to those ministers of health or delegates designated to represent ministers of health who had registered for participation. All other delegations, representatives of Associate Members and observers, including members of the delegation of the ministers of health participating in the round table, could attend as observers. The purpose of the round tables was an exchange of views; there was no mandate to reach consensus or to adopt resolutions. He proposed the following ministers or secretaries of health as chairmen of the four round tables: Dr M. Dayrit (Philippines), Mr T. El Kyari (Morocco), Dr J. Frenk (Mexico) and Dr C.P. Thakur (India). It was so agreed.

The CHAIRMAN said that he would transmit the information to plenary that afternoon. He took it that the Committee wished to recommend to the Health Assembly the acceptance of the allocation of the items to the main committees as set out in the provisional agenda. It was so agreed.

The CHAIRMAN drew attention to the preliminary daily timetable drawn up by the Executive Board? As one of the invited speakers, Professor Jeffrey Sachs, would arrive on Wednesday, 15 May, 1 2

Participating by virtue of Rule 32 of the Rules of Procedure of the World Health Assembly. Document ASS/GC/1.

GENERAL COMMITTEE: FIRST MEETING

his address should be rescheduled for the fifth plenary meeting beginning at 14:30 that afternoon, putting back the scheduled start of the meeting of Committee A. He understood, however, that many delegations wished to bring forward discussion of agenda item 18 (Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine). Although the order in which agenda items were dealt with was normally determined by the committees themselves, Committee B was not scheduled to begin until the Wednesday afternoon, leaving any decision about the timing of the discussion until relatively late in the session. Further, he was also aware of a wish that neither Committee A nor the plenary meeting of the Health Assembly should run concurrently with the debate of agenda item 18, so that all delegations could follow the debate. Such decisions lay within the powers of the General Committee. He proposed that the General Committee should suggest to the Health Assembly that it decide at its plenary meeting that afternoon any rescheduling so as to ensure advance notice of any new timing. Specifically, he proposed that on Wednesday, 15 May, Committee B consider agenda item 18 immediately after its election of officers. Further, he proposed the following consequent amendments to the preliminary daily timetable for that afternoon. Committee A would adjourn once it had finished the list of speakers on the address by the Director-General (agenda item 3). At that time, around 16:00, Committee B would start its work, continuing its first meeting beyond the normal closing time. The meeting of the General Committee could take place as scheduled or later if necessary. The schedule set out in the preliminary daily timetable would be resumed on Thursday, 16 May, unless Committee B needed to finalize its discussion of agenda item 18. The delegate of the UNITED STATES OF AMERICA accepted the suggestion to advance agenda item 18 to be the first item considered by Committee B, but he strongly opposed the proposal to suspend the meeting of Committee A in order to allow the meeting of Committee B alone. Many delegations had come to discuss health issues, the substantive matters of the Health Assembly being discussed in Committee A. He would be very reluctant to see debate of such important subjects held in abeyance. Further, he considered that delegations had adequate numbers to cover meetings of both committees. He also requested information on the financial and other implications of a late meeting. The delegate of SPAIN, speaking on behalf of the European Union and its Member States and recognizing the importance of the matter of the occupied Arab territories, accepted the Chairman's proposals. He expressed concern, however, about possible delays in the work of committees on other important topics. Although he did not support the position of the United States of America on the suspension of Committee A, he argued that either the meeting of that Committee should not be suspended or, if it were, the suspension should be as short as possible. The SPECIAL POLICY ADVISER to the Director-General, responding to the delegate of the United States of America, stated that provision had already been made for an evening meeting and that the extra cost had been budgeted for. Responding to the CHAIRMAN's intimation that there was agreement on the proposed amendments to the timetable, and citing Rule 33 of the Rules of Procedure of the World Health Assembly, the delegate of the UNITED STATES OF AMERICA commented that suspension of the most important committee was not a step that would facilitate the orderly dispatch of the business of the session. He reiterated the opposition of his delegation to the Chairman's proposal. The delegate of CUBA, supporting the proposal, noted that the subject matter of the meeting under consideration was complicated and important, and that many delegations were small in number. The proposal for a single meeting of Committee B was appropriate and pragmatic. He expressed confidence that there would be no detrimental effect on the work of the other committees and appealed to other delegations to take those aspects into consideration.

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The delegate of SPAIN, speaking on behalf of the European Union and its Member States, said that, although supporting the proposal, he sought a guarantee that the discussions would not unduly encroach on subsequent scheduled work of Committee B. The observer of PAKISTAN, 1 supported by the delegate of the UNITED ARAB EMIRATES, agreed with the contention of the Cuban delegate and with the Chairman's proposal, recognizing especially the constraints on small delegations. The CHAIRMAN restated the proposed schedule, in response to a request for clarification from the delegate of the UNITED STATES OF AMERICA, and emphasized that both committees would meet on Thursday, 16 May, with Committee B only continuing with discussion of item 18 if necessary. Replying to a further question from the delegate of the UNITED STATES OF AMERICA, the DIRECTOR-GENERAL commented that the proposal was a reasonable compromise, which tried to accommodate several points of view. On the one hand, small delegations might find it difficult to cover parallel committee meetings when the item was being debated and, on the other, the burden of work meant that Committee A needed to expedite its business. The suggestion of a sole meeting of Committee B on Wednesday, 15 May, and parallel meetings of Committees A and B on Thursday, 16 May, when Committee B could conclude discussion of item 18 if necessary, appeared to reconcile those views. The delegate of CUBA, thanking the Director-General for her intervention, supported the Chairman's approach. The delegate of the UNITED STATES OF AMERICA said that his delegation was not in a position to accept the open-ended proposal for continued discussion on the morning of Thursday, 16 May, and asked for the matter to be referred to the plenary meeting of the Health Assembly as not decided. The delegate of SPAIN suggested that a time limit could be proposed for discussion of agenda item 18 in Committee B on the morning of Thursday, 16 May. The observer of CANADA, 1 expressing doubts about the suspension of Committee A, urged that a compromise should be reached that would allow Committee A to conclude its work without disruption. The CHAIRMAN, observing that the majority of members of the General Committee appeared to accept the proposed rescheduling, proposed that a recommendation to that effect should be made to the Health Assembly at the plenary meeting that afternoon. It was so agreed.

The delegate of MEXICO, supported by the delegate of BARBADOS, requested that item 8 of the provisional agenda (Centenary of the Pan American Health Organization) should be rescheduled for the third plenary meeting on the afternoon of Tuesday, 14 May from Thursday, 16 May, so as to give due recognition to PAHO for its major contribution to the improvement and promotion of health in the Region of the Americas over the past 100 years.

Participating by virtue of Rule 32 of the Rules of Procedure of the World Health Assembly.

GENERAL COMMITTEE: FIRST MEETING

The CHAIRMAN took it that the Committee had no objection and would propose to the plenary meeting that afternoon that agenda item 8 should be scheduled for 17:00 on Tuesday, 14 May, and that the first meeting of Committee A should be adjourned in time to enable all Member States to participate. It was so agreed.

The General Committee then drew up the programme of work of the Health Assembly until Wednesday, 15 May. The CHAIRMAN drew attention to decision EB109(10) to the effect that the Fifty-fifth World Health Assembly should close no later than Saturday, 18 May. Referring to the list of speakers for the general debate, he suggested that, in accordance with established procedure, the order of speakers on the list, which already contained 61 names, should be strictly adhered to, with subsequent speakers following in the order in which their inscriptions were received by the Assistant to the Secretary of the Health Assembly. The list would be closed on Tuesday, 14 May, at noon. In the absence of any objection, he would inform the Health Assembly of those arrangements at the following plenary meeting. It was so agreed.

The CHAIRMAN reminded the Committee that its next meeting would be held on Wednesday, 15 May, after discussion of agenda item 18.

The meeting rose at 14:00.

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SECOND MEETING Wednesday, 15 May 2002, at 19:20 Chairman: Dr J.F. LOPEZ BELTRAN (El Salvador) President of the Health Assembly

PROPOSALS FOR THE ELECTION OF MEMBERS ENTITLED TO DESIGNATE A PERSON TO SERVE ON THE EXECUTIVE BOARD

The CHAIRMAN reminded members that the procedure for drawing up the list of proposed names to be transmitted by the General Committee to the Health Assembly for the annual election of Members entitled to designate a person to serve on the Executive Board was governed by Article 24 of the Constitution and by Rule 102 of the Rules of Procedure of the World Health Assembly. To help the General Committee in its task, three documents were before it. The first indicated the present composition of the Executive Board by region, on which list were underlined the names of the 10 Members whose term of office would expire at the end of the Fifty-fifth World Health Assembly and which had to be replaced. The second tabulated, by region, Members of the Organization which were or had been entitled to designate persons to serve on the Executive Board. Vacancies, by region, were: Africa, 4; the Americas, 1; South-East Asia, 1; Europe, 2; the Eastern Mediterranean, 1; and the Western Pacific, 1. The third document contained a list, by region, of the 10 Members that it was suggested should be entitled to designate a person to serve on the Executive Board. As no additional suggestion was made by the General Committee, he noted that the number of candidates was the same as the number of vacant seats on the Executive Board. He therefore presumed that the General Committee wished, as was allowed under Rule 80 of the Rules of Procedure, to proceed without taking a vote since the list apparently met with its approval. There being no objection he concluded that it was the Committee's decision, in accordance with Rule 102 of the Rules of Procedure, to transmit a list comprising the names of the following 10 Members to the Health Assembly, for the annual election of Members entitled to designate a person to serve on the Executive Board: China, Gabon, Gambia, Ghana, Guinea, Kuwait, Maldives, Russian Federation, Spain and United States of America. The list would be transmitted to the Health Assembly. It was so agreed.

PROGRAMME OF WORK OF THE HEALTH ASSEMBLY

The General Committee heard reports from Dr KIEL Y (Ireland), Chairman of Committee A, and Professor COLL SECK (Senegal), Chairman of Committee B, on the progress of work in their committees. The CHAIRMAN proposed to review progress of work with the Chairmen of the committees and to revise the programme accordingly, if necessary. It was so agreed.

The General Committee then drew up the programme of meetings for Thursday, 16 May, Friday, 17 May and Saturday, 18 May.

GENERAL COMMITTEE: SECOND MEETING

CLOSURE

After the customary acknowledgements, the CHAIRMAN declared the work of the Committee closed.

The meeting rose at 19:35.

COMMITTEE A FIRST MEETING Tuesday, 14 May 2002, at 14:40 Chairman: Dr J. KIELY (Ireland)

OPENING OF THE COMMITTEE: Item 12 of the Agenda (Document A55/1 Rev. I)

The CHAIRMAN welcomed delegates of Member States, representatives of the United Nations and its specialized agencies, and observers. He also welcomed Mrs Abel and Ms Wigzell, the two representatives of the Executive Board assigned to the Committee in accordance with Rules 44 and 45 of the Rules of Procedure of the World Health Assembly. They would convey to the Health Assembly the views expressed by the Board during its most recent meetings, and would explain recommendations made by the Board for the Health Assembly's consideration. He emphasized that representatives of the Board were appointed to represent its views, not those of their governments. Election of Vice-Chairmen and Rapporteur (Document A55/41) The CHAIRMAN drew attention to the third report of the Committee on Nominations (document A55/41)/ in which Ms D. Costa Coitinho (Brazil) and Dr S.P. Agarwal (India) were nominated as Vice-Chairmen of Committee A and Dr A. Msa Mliva (Comoros) as Rapporteur. Decision: Committee A elected Ms D. Costa Coitinho (Brazil) and Dr S.P. Agarwal (India) as Vice-Chairmen and Dr A. Msa Mliva (Comoros) as Rapporteur?

ORGANIZATION OF WORK

The CHAIRMAN reminded delegates that the Committee had a full agenda, and asked them to limit their statements to a maximum of three minutes. He drew the Committee's attention to item 13 of the agenda, entitled "Technical and health matters", which had 19 subitems. He suggested that the subitems should be dealt with in numerical order, except for sub item 13.13 (Mental health) which would be discussed at the morning meeting on 16 May together with a draft resolution submitted by the delegation of Belgium. It was so agreed.

See page 271. Decision WHA55(4).

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TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda

Report of the WHO Commission on Macroeconomics and Health: Item 13.1 of the Agenda (Document A55/5) Mrs ABEL (representative of the Executive Board) said that the Board had welcomed the findings in the report of the WHO Commission on Macroeconomics and Health, and especially the central role given to health in the fight against poverty. The report clearly illustrated that poor health slowed economic growth, and that poverty could be considerably reduced by addressing a few health conditions responsible for a high proportion of avoidable deaths and disabilities. In combination with the Global Fund to Fight AIDS, Tuberculosis and Malaria, the report provided an important opportunity to make the Millennium Development Goals an economic reality. It highlighted the key role of health in achieving sustainable development on a global scale. The Board therefore felt that it should be viewed in the context of the World Summit on Sustainable Development (Johannesburg, South Africa, 26 August- 4 September 2002). Finally, the Board considered that, in addition to major investments in health, national leadership was essential in coordinating local needs and national priorities. The follow-up to the report would therefore be of paramount importance. Dr LARIVIERE (Canada) welcomed the Commission's report, especially the recommendation on the need to strengthen aid effectiveness, and the suggested means of ensuring that resources were used in the best possible way. He agreed with the Commission's suggestion that the emphasis should be placed on the delivery of select interventions known to meet priority needs in a cost-effective manner. The report rightly emphasized the need to invest in carrier health systems so that interventions could be delivered by appropriately trained staff, and evaluated by appropriate mechanisms. He favoured intensified health research to address health problems in the developing countries, and the strengthening of health research capacity in those countries. They should be helped to find local solutions to local problems, drawing upon intellectual as well as economic resources. Mr GUNNARSSON (Iceland) said that the Commission's report provided new evidence of the strong link between health and the economic situation at the international and national levels. In today's globalized world, it was imperative to focus on issues that affected everyone. The report highlighted the need for health policy to address four areas: the underlying infrastructure and technology for health; ecological conditions; social conditions, education and gender equality; and globalization. Social conditions were crucial, and education had been his country's most valuable long-term asset. Its open-door policy had been instrumental in developing its economy, and there was no doubt that globalization would ultimately bring prosperity and ensuing health benefits to all countries. Nevertheless, globalization could have dangers for low-income countries: for example, it could intensify the problems of brain drain, increase international transmission of disease, and undercut local culture patterns related to diet and drug use. With the assistance of modem science and technology, the wealth of the rich countries, and the united efforts of international institutions such as WHO, the World Bank, WTO and OECD, the opportunities discussed in the report should be seized in order to transform the lives and livelihoods of the world's poor. Mr CICOGNA (Italy) said that the Commission's report was much more than an academic dissertation; it was a road map to boost investment and to improve the efficacy of investment in health by both developed and developing countries. As the Brundtland Commission had done for the environment, it paved the way for innovative actions, in the current case to expand access to health services for the poor and to achieve the health-related Millennium Development Goals. The responses set out in document A55/5 clearly outlined the path ahead for WHO, in partnership with other organizations, including bilateral partners. Italy was strongly committed to the Global Fund to Fight AIDS, Tuberculosis and Malaria, and was fully involved, along with other development partners, especially the European Union and the private sector, in seeking new mechanisms to improve the

COMMITTEE A: FIRST MEETING

delivery of cost-effective interventions to the poor. Consultation among the development partners to follow up the report would be useful. Italy would continue to support action by WHO at country level to scale up health interventions and improve the efficiency of health systems. Dr OKAMOTO (Japan) welcomed the report and expressed the complete agreement of his country's Ministry of Health, Labour and Welfare with the principle of increased investment in health. Japan was aware that it was the responsibility of Member States to advocate that principle and to bring it to the general public and the financing authorities. The report would help it in supporting the efforts of Member States. The Commission's proposal for a new global health research fund was attractive, but its purpose and operation should be explained in greater detail. Dr MOLIN (Sweden) said that the Commission's report was a logical step in the process of restoring health to the top of the international development agenda, clearly demonstrating the links between health and development or, more especially, economic growth. It was vital for governments to understand that investing in health was economically and socially sound. The report pinpointed a few health conditions that accounted for a high proportion of avoidable deaths and showed what needed to be done. One significant element was its quantification of the resource gap, which called for concerted efforts by both developing and developed countries. It also placed great importance on global goods: many health advances, such as research and development in the fields of new drugs, vaccines and diagnostics, could not be tackled at the national level. Investment in that area was also a priority for Sweden. In order to move forward, a number of guiding principles should be established, in particular strong national ownership of any country-level activity, the need to coordinate global activities at the country level, and the basing of initiatives and resources on national priorities and plans. Concentrating on a limited number of defined health problems ran the risk of introducing new vertical structures that would bypass those already in existence. A successful and sustainable fight against the major health conditions defined by the Commission required functioning health systems to be in place. The AIDS pandemic and the creation of the Global Fund to Fight AIDS, Tuberculosis and Malaria had rightly focused attention on those three infectious diseases, but should not result in the neglect of other important causes of mortality such as maternal and perinatal conditions, childhood infections, tobacco-related illness and nutritional deficiencies. Furthermore the solutions proposed in the report focused on health systems development at the expense of prevention. Tackling health determinants was an equally important strategy and long-term disease prevention and health promotion were likely to be cost-effective. Additional resources for health were clearly necessary, but should be truly additional and not shifted from other important areas of development. Funds should be mobilized from new partners in the private sector. It should not be impossible for high-income countries to allocate 0.7% of their gross domestic product to development assistance. WHO had an important role to play in supporting countries to assume leadership and coordinate global initiatives, and for that purpose should strengthen its role at country level. Mr ESKOLA (Finland) welcomed the Commission's emphasis on the need for increased funding for the health sector and for greater donor financing for the health sectors of low- and middleincome countries. Care should be taken, however, to ensure that countries were capable of making full use of extra funds and that most of the money was devoted to development of sustainable health systems rather than to pharmaceuticals or vaccines. The Commission's report acknowledged the need to develop the health sector as a whole but ended up recommending increased funding for certain vertical outcome-oriented approaches focused on communicable diseases and maternal and child health. Finland was concerned about some of its recommendations from a public health point of view. First, the Commission appeared to have overlooked many recent lessons regarding the development of health systems in poor countries, which had shown that vertical interventions to tackle specific diseases did not work as expected but simply diverted human and financial resources from the building of comprehensive and universal health

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services. Secondly, although acknowledged to be of great significance for developing countries, noncommunicable diseases had almost been excluded from the list of funding priorities. The diseases that were included in the list accounted for only a third of the disease burden in low- and middle-income countries. The recommendation that noncommunicable diseases should be tackled by other means such as self-financing would seriously compromise equity of access to health services. Thirdly, the report embraced public-private partnerships despite the lack of evidence of their contribution to sustainable improvements in health. Concern had also been expressed about priority setting in such ventures and their accountability. Moreover, there was little evidence that they would attract substantial funds apart from public development aid, at the risk of draining public funds from other development needs. Such concerns needed to be addressed. Finally, the Commission's recommendations for funding priorities should not be regarded as recommendations for health policy priorities. The report paid little attention to the normative framework or to functions, policies, and activities outside the health sector, all of which should remain on the international health policy agenda. Although it was important for macroeconomic decision-makers to understand health issues, WHO must ensure that the health and health policy implications of macroeconomic and trade policies continued to be assessed and that health priorities were not compromised by other interests. Normative work at global level and technical assistance to countries on the basis of health determinants and healthy public policies urgently needed strengthening. In accordance with the health-for-all strategy, WHO must emphasize the need to develop comprehensive health systems, uncompromised by selected vertical interventions. The Organization's health policy directions should come from its governing bodies. Discussions on essential policy issues must take place in the governing bodies before positions were promoted outside the Organization. Mr NAIK (India) said that the report showed that better health was not only a goal in itself but could act as a catalyst for economic development and reduce poverty. Current spending on health in developing countries was insufficient to meet such goals. The report contained useful ideas for utilizing domestic resources and international donations and quantified the resources needed. The challenge was to secure the requisite donor funding. The report asked WHO to cooperate with the World Bank, WTO, IMF, OECD and the private sector, although WTO's intellectual property-related agenda had complicated WHO's task. Furthermore, the study should have focused on all developing countries instead of proposing solutions according to various subcategories, and it would have been more appropriate to have kept to the United Nations classification of least developed countries and other developing countries rather than using the OECD categories. The report envisaged an increase in domestic budgetary resources of 1% of gross national product by 2007 and 2% by 2015 in low-income developing countries, but did not adequately address the availability of such resources. In the case of low-income countries, such as India, it called for additional domestic resources, a commitment to transparent governance, leadership and accountability, and improved internal management of resources. India was committed to transparency in government and domestic resource allocation, and would like its efforts to be acknowledged. At the same time, it reiterated the need for predictable donor financing to meet the health needs of the world's poor. There was an obvious need for increased investment in public goods, which should focus on research and development directed to new drugs, vaccines and diagnostics for diseases affecting the poor in developing countries. With regard to access to affordable medicines, the Commission had recommended full utilization of the safeguards contained in the WTO Agreement on Trade-related Aspects of Intellectual Property Rights (TRIPS). The best solution would undoubtedly be a cooperative and voluntary arrangement that would protect intellectual property while ensuring access to medicines at affordable prices through differential pricing mechanisms, but donor support had been modest in relation to donor capacity and the extent of need. It was to be hoped that WHO would pay close attention to India's comments when envisaging further action on the report.

COMMITTEE A: FIRST MEETING

Ms WARANYA TEOKUL (Thailand), welcoming the Commission's report, emphasized the need to base any further action on a number of guiding principles. First, mechanisms for the pooling of resources at national level should be encouraged, since out-of-pocket payments penalized the poor's access to essential health and social services. Secondly, a health financing policy that favoured the poor and mechanisms to provide them with proper access to basic services should be developed. Studies in many countries had shown that the rich always had significantly greater access to treatment than the poor. Without policies and strategies that favoured them, the poor would be unable to benefit from public services. Such policies must actively target the poor and remove all barriers to essential health services. Thirdly, while the report emphasized the role of the public sector and private foundations in generating additional resources, the private for-profit sector, such as multinational corporations, might also contribute. More rigorous efforts should therefore be made to generate more resources from that sector at both the global and national levels. Fourthly, countries should be helped to build their capacity to allocate resources efficiently for proven cost-effective interventions, and be guided by disease burden profiles at the country level, to ensure that funds were not directed towards less cost-effective tertiary care. Fifthly, mechanisms should be established to ensure that donor resources were consistent with national priorities. The Global Alliance for Vaccines and Immunization (GA VI) and the Global Fund to Fight AIDS, Tuberculosis and Malaria were good examples of country-driven processes, and positive lessons could be drawn from sector-wide approaches in several developing countries. Sixthly, the global public goods deriving from research and development should be guided by the disease burden in developing countries and ensure equitable access to new vaccines and drugs for the poor. Lastly, a strong political commitment from both donor and developing countries was needed to ensure long-term financial sustainability. WHO's catalytic role in generating more resources at the country and international levels was commendable. Ms KONGSVIK (Norway) commended WHO for its initiative in establishing the Commission on Macroeconomics and Health. The Commission's report broke new ground and reaffirmed WHO's leadership in global health as well as serving as a precedent for the United Nations system. It successfully refuted the notion that health goals were an automatic by-product of economic growth and showed investment in health to be a prerequisite for poverty eradication and economic development, thus making it easier to convince politicians, ministers of finance and the general public to increase spending on health and ensure the right of all human beings to the highest attainable standard of health. Norway could support a "close-to-client" system of essential actions to tackle major causes of mortality and morbidity in poor countries, but at the same time emphasized the need for health systems to be strengthened to respond to diseases particularly associated with poverty and to deal with both communicable and noncommunicable diseases. Sector-wide approaches were to be encouraged. The increased spending envisaged, however, would put great pressure on already overstretched health care systems. Health care personnel were in short supply owing to poor working conditions, shortage of drugs and equipment, and the lack of supportive supervision. As it took time to train health care staff, contingency plans must be developed. She endorsed the recommendations on partnership and cost-sharing between developed and low-income developing countries. Norway had found that the allocation of 0.1% of gross national product for health assistance was perfectly feasible, and encouraged other countries to do the same. In that connection the views of developing countries on the possibility of increasing their health expenditure on the scale proposed by the Commission would be useful. The saving of many lives and the high return on investment provided ample justification for implementing the proposals, within the framework of national poverty reduction strategies. Recipient countries should be in control and donor assistance should be channelled in keeping with the country's own plans. Moreover, all donors should harmonize their procedures so as not to overburden hardpressed administrations in recipient countries.

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The report's proposals for establishing new institutions at country level should be considered by each country in accordance with the national context, and closer cooperation between ministers of health and ministers of finance should be encouraged. She endorsed the need for a broad intersectoral approach. To reach health goals, and more generally to reduce poverty, complementary investment was needed in other areas such as education, water and sanitation, and agricultural improvement. Investment in such areas worked best when carried out within comprehensive frameworks such as national poverty-reduction strategies. Dr PAVLOV (Russian Federation) thanked the Director-General for providing the international community with factual data bearing out the mutual interdependence of development processes and health. The Commission's report convincingly showed that poor health was a serious obstacle to sustainable socioeconomic development and was a cause of poverty, whereas investment in health contributed to development and to combating poverty. The report was useful, important and timely; its findings should be carefully studied by governments and by development and funding authorities in all Member States. Many of the Commission's recommendations could be implemented by the Member States themselves, but it was obvious that low- and middle-income countries would need additional funds from outside sources in order to make the necessary investment. In addition to providing technical support, therefore, WHO should take the lead in mobilizing resources for that purpose, together with other international organizations, financial institutions, the private sector and all the development partners. Russian experts were carefully studying the report's findings and recommendations, which they would disseminate widely to appropriate audiences within the country. Mr BASIT (Pakistan) welcomed the recommendations contained in the Commission's report but emphasized that developing countries could not be expected to increase their investments in the health sector in the absence of alternative sources of funding, even though health was a priority goal in its own right. Many were already struggling to provide health services to their peoples with extremely limited resources, coupled with other constraints such as heavy debt burdens, an unequal international trading system, and difficult security environments. It was therefore essential to emphasize the partnership approach between developed and developing countries, as recommended in the report, bearing in mind that, in an interdependent world, the advantages of development enjoyed by the former could prove finite unless the latter were lifted out of poverty. It was also essential to remove the artificial hurdles to the provision of donor funding with a view to focusing on the recommendations contained in the report. The Health Assembly should make it a priority to raise US$ 27 000 million per year by 2007 in donor grants in the health sector alone. Moreover, it was both unfair and unfortunate that some developing countries received a large proportion of international donor assistance while others received none. Donor assistance in the health and social sectors should be generous and fair, with priority given to countries in the greatest need. He expressed the hope that WHO would finally take an active lead in securing arrangements for cheap and affordable drugs. Ms BLACKWOOD (United States of America) concurred with the findings of the Commission's report that HIVI AIDS represented an unparalleled economic and human catastrophe and that increased funding and strategic public-private partnerships to counter HIV I AIDS and other diseases of major concern should be a shared priority. She also agreed that donor countries should make a commitment to increase investment in health and that recipient countries should enhance national leadership, transparency, resources and accountability with a view to more effectively controlling the main health problems that caused human suffering and hindered economic development. The United States Administration had demonstrated its commitment to improving global health through its US$ 500 million pledge to the Global Fund to Fight AIDS, Tuberculosis and Malaria. In addition, the eventual US$ 500 million annual increase in funding for core development assistance in its recently launched Millennium Challenge Account would enable strategic investments to be made in

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the fields of health and education. Joint efforts were essential, however, to ensunng that key interventions in those fields were implemented at the community level. The United States Secretary of Health and Human Services had recently led a presidential mission to African countries focusing on HIVIAIDS and other infectious diseases, and had hosted a Caribbean Conference on HIV/AIDS in Guyana. Both trips had provided an opportunity to see essential interventions in practice at the community level. Countries needed to work together to implement such interventions. Dr VIOLAKI-PARASKEVA (Greece) said that the multidisciplinary composition of the WHO Commission on Macroeconomics and Health had made it possible to crystallize the link between health, poverty reduction and economic growth. She commended the Director-General's report (document A55/5), and drew particular attention to paragraphs 4 and 16. WHO should work closely with all United Nations partners, governments and recipient countries with a view to incorporating health and poverty-reduction programmes in a viable macroeconomic framework at the country level. Dr FERREIRA SONGANE (Mozambique) welcomed the long-overdue initiative to emphasize health as a key element in development. He also commended the Commission's multidisciplinary approach, although input from public health specialists from developing countries would have avoided proposals for a vertical approach and furthered integrated development by dealing with other crucial determinants of health, such as safe water, roads and education, particularly for women. Without strong support from leaders in government and finance, however, a country's efforts to improve its health situation were liable to falter. The commitment of heads of state and government to join those efforts could perhaps be engaged by raising the issue in the United Nations General Assembly. Urgent changes in the framework of trade relations would also be necessary to generate the resources needed to fund the efforts. The forthcoming World Summit on Sustainable Development would provide further opportunity to discuss health and development in the context of the 10-year Review of Implementation of the 1992 Rio Declaration on Environment and Development (Agenda 21 ), failing which the damage to the environment caused by the poor - who had no choice - would persist. Mr ROKOV ADA (Fiji) noted the strong linkages between health and economic development underlined in the Commission's report, which clearly placed the responsibility for the mobilization of health resources on all sectors, both inside and outside government, and on regional and global development partners. As presaged by its positive impact at the recent International Conference on Financing for Development (Monterrey, Mexico, March 2002), the report would act as a catalyst in prompting governments, particularly in developing and low-income countries, to allocate appropriate resources to health and increase health investment. To their economic advantage, the developed countries frequently recruited highly trained health professionals from developing countries, which were consequently deprived of human resources and also suffered financially. He therefore proposed the establishment of an international or bilateral mechanism that would offer reciprocal arrangements to compensate for such losses. Dr QI Xiaoqiu (China) said that the Commission's report fully reflected the situation of lowand middle-income countries and stressed the relationship of health to long-term economic growth. Its contents were factual and its analysis accurate. The key question was how to implement the new strategy; in that regard, he suggested a thorough study by WHO of ways to ensure the utmost benefit for Member States. The financing strategy recommended by the Commission envisaged an increase in domestic budgetary resources of 1% of gross national product by 2007 and 2% by 2015. In that connection, health budgets should not be viewed solely in terms of government budgets but should include all expenditure on health by governments, the private sector and individuals. A further difficulty would arise if the same goal was set for all countries. In a country as large as China, for example, the absolute gross national product was huge, out of proportion to per capita figures. The setting of flexible targets would therefore be more realistic.

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The report rightly proposed that most assistance should be channelled to the least developed countries, but it was important to ensure also that middle-income and other low-income countries received suitable attention. Dr THAPA (Nepal) welcomed the Commission's ground-breaking report, which showed, for the first time, that investment in health could stimulate economic growth. However, the evidence needed to be translated into action in developing countries such as her own. Nepal's annual per capita income was US$ 220, while over half of its disease burden related to communicable diseases, perinatal and maternal mortality, and nutritional disorders. Since skilled carers attended only 13% of births, Nepal's maternal mortality was one of the world's highest. As in other developing countries, households bore most health expenditure through direct payments, thus ever widening the poverty gap. Current annual per capita expenditure on health was roughly US$ 4, far below the report's recommendation. The challenge was how to overcome that gap. Nepal's next five-year plan would focus on poverty eradication. Against that background, WHO should accelerate its efforts to implement the report, especially in four specific areas. First, both public and private resources needed to be mobilized for health from among the international community. Secondly, revenue pooling and risk sharing should be promoted. Thirdly, equitable, gender-sensitive and efficient resource allocation should be promoted for health development, through countries' existing integrated systems. In that regard, Nepal's health infrastructure, including over 48 000 female voluntary health workers, reached all villages. Fourthly, dynamic partnerships should be forged between the Commission and corresponding national committees in order to ensure that implementation of the report's recommendations would be appropriate to the realities of low-income countries such as Nepal. Professor ABENHAIM (France) congratulated WHO and the Commission on their thorough and important work, and their attempt to change the basic paradigm according to which health was a secondary effect of development. Although it would be wrong to question the original paradigm, long established through the study of epidemiology, that progress in health was predicated first and foremost on economic development, the reverse was also true, that investment in well-being led to economic progress. The report also indicated that access by the poor to health and care systems was one ofthe best predictors of performance in general, both in countries with serious economic problems and those at the middle-income level. The two situations were not the same; in the first group, the basic problem was the difficulty of being "close to clients", whereas the problem in the second group was rather that of income distribution, and particularly taxes. The point was important since it raised the question of how best to organize the relationship between donor and recipient countries, particularly in regard to the extent to which support should be brought closer to the end user. In that respect, therefore, the report was a step forward. While it seemed premature to envisage a complete overhaul of existing mechanisms, the question should be further studied with a view to possible changes. Two points had not been touched on in the report: the impact that the changes envisaged would have, not just on health but on the economic system as a whole; and whether the model proposed applied equally to countries in transition, and not only to the low-income countries and the poor in middle-income countries on which the report had focused. He supported the initiative in general, provided that substantial changes were made in terms of research funding and investment. Mr ZEPEDA BERMUDEZ (Brazil) said that the Commission's report, representing two years of intensive work, had been thoroughly discussed in Brazil, particularly in the light of its conclusions and recommendations, which provided a framework for an international health agenda. He commended the work carried out, but stressed that the proposed framework should be carefully adapted to the realities of each country, and some areas dealt with in greater detail in order that the recommendations would be appropriate to each country's infrastructure. Increased health investment would undoubtedly enable countries to provide better cover for low-income groups, and as a result

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millions of lives would be saved. In that regard, as the delegate of India had pointed out, donor funding had been modest compared to donor capacity. The report's focus had been mainly from an economic standpoint, but Brazil attached equal importance to the public health perspective. The interministerial commissions for health promotion active in some countries were as important as the proposed national commissions on macroeconomics and health. Dr MUNOZ (Chile) welcomed the decision to discuss the relationship between macroeconomics and health and the solid theoretical foundation provided by the Commission's report. In reply to the comment by the delegate of France about economies in transition, he considered that the report responded to the concerns of countries such as Chile. The contribution of health, and social policies in general, to the reduction of inequalities between and within countries was fundamental, especially since it was difficult for governments to use macroeconomic instruments for that purpose in an increasingly globalized world. Investment of both domestic and international resources should aim at measurable and prioritized results to meet medium-term national health targets. The report should be disseminated and discussed as widely as possible among banks and other international bodies concerned with trade and the promotion of sustainable development with a view to promoting the sort of local agreements advocated in the report. It should also be linked to the work of WHO and PAHO in assessing the performance of health systems more precisely, which was essential if the use of resources was to achieve the expected results. Dr MOHAMED (Kenya) said that his country supported the Commission's report in principle and was committed to bringing its aims to fruition. However, developing countries faced many competing priorities. In Kenya, during the development of poverty-reduction strategies, the emphasis - especially among bilateral agencies and development partners - on commercial interests and infrastructure had resulted in health issues being ranked fifth in the order of priorities. Domestic and international advocacy must focus on bringing health to the forefront as an agent for poverty reduction; WHO's leadership was important for that purpose. Attention to a sector-wide approach was overdue, since it had proved difficult to implement at country level. A re-evaluation was important for the benefit of the many stakeholders in the decentralized health systems of many developing countries. A large number of communities already funded as much as 40% of the services out of their own pockets. It was essential, therefore, to harness resources so as to maximize benefits - for example, through innovative health insurance schemes and the promotion of service quality. Lastly, health must be defined in a way that embraced traditional community systems. A nagging problem was the inability of poor people to have access to health services through costsharing mechanisms. Although the latter had been suggested by bilateral and multilateral agencies as a means of mobilizing resources, the schemes had shown diminishing returns as most of those affected resorted to alternative medicine. Investment in social health insurance schemes was urgently needed, therefore, in a way that could harness the potential of traditional medicine through informed research. Mr ARRIAGA (Mexico) expressed his appreciation of the Commission's report and the evidence it contained of the vital role of health in combating poverty and promoting economic growth. Health and that report had been at the heart of the United Nations Conference on Financing for Development (Monterrey, Mexico, March 2002). Finding the money to reduce premature death and disability was productive as well as ethical. At the national level, in accordance with the report, the Government of Mexico had already set up a national commission on macroeconomics and health in order to meet the three major objectives of the health system set out in the national health plan for 2001-2006, namely fairness, quality and financial protection. The plan identified the action necessary to achieve those goals and to evaluate health policy using comparative methods.

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Professor OMASWA (Uganda) congratulated the Commission on the report. The question had often been posed whether the recipient countries had the capacity to absorb the level of additional funding envisaged by the report. In Uganda's experience, absorptive capacity depended on a number of prerequisites. Countries must have the commitment and capacity to implement reforms. They must formulate a comprehensive national development programme, across all sectors, which must also involve civil society. There must also be constructive partnerships between recipients and donors, and each side must employ highly capable people. By such means, Uganda had succeeded in attracting sufficient donor assistance and the health sector looked set to deliver the required results. Nevertheless, Uganda had been informed that its health sector would not receive any additional funding because that would destabilize the national economy - despite its limited per capita expenditure on health of US$ 9 instead of the US$ 34 recommended in the report. If that were true, most recipient countries would soon reach Uganda's level of saturation. The question as to how much donor money could be absorbed by efficient health policies, and plans must be considered critically, and well in advance, bearing in mind the need to maintain macroeconomic stability in the recipient countries. Uganda therefore endorsed the proposal to use the report to initiate a process of mobilization to place public health at the centre of equitable, sustainable development. Dr ARMADA (Venezuela) said that the Commission's report provided the basis for a serious discussion of the link between macroeconomics and health. Nevertheless, he would have preferred to see references to foreign- debt, income distribution, and the balance of payments. Equity was a major factor, not only for health but for economic development. He therefore endorsed Brazil's suggestion of matching recommendations to national capacity. Venezuela had set up a ministerial commission to explore the links between social policy and health, in line with its global vision of health and its constitutional vision of health as a right. The participation of the private sector should be boosted to match each region's particular needs. Venezuela was working to design a publicly-financed national health system. Ms KEITH (The Save the Children Fund), speaking at the invitation of the CHAIRMAN, said that her organization had been encouraged by the report and recommendations. Applauding WHO for increasing global attention to health, and for providing further evidence of the link between poverty and ill-health, she welcomed the emphasis on improving data by encouraging the least developed countries to develop strong epidemiological baselines. Save the Children UK was concerned, however, that the report focused on disease-specific, outcome-oriented programmes, which favoured donordriven vertical programmes. Save the Children UK, and others, had produced research on the fragmentation of health systems caused by such vertical programmes, especially with regard to inadequate access to good-quality, appropriate services that were both sustainable and equitable. Further, its recent research had shown that joint private-public initiatives, being short-term and donordriven, were unsustainable and inadequately linked to established national systems, and she wondered what sort of links there would be between such new public-private initiatives and existing national, multisectoral strategies. WHO should continue to call for international policies favouring the poor, to provide support to countries, especially in relation to best practice and developing baseline data, and to promote a coherent approach, ensuring that the large number of new initiatives would be coordinated through national systems and that countries would be given adequate support in that stewardship role. Health was a fundamental right and Save the Children UK would continue to adopt a multisectoral approach, working with WHO to achieve that end. Dr NABARRO (Executive Director) welcomed the rich and interesting debate. Most delegates had recognized the value of the Commission's report in placing health in the context of total economic development, and had commented on the potential for reducing poverty by investing in health. Health had been identified as a central aspect of development. Delegates had further commented on those aspects of the report that had argued for investment in equitable health outcomes and on the importance of its focus on results. Some had said that the report had highlighted the ill-health of the

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poor as a global issue, affecting not only poor countries but middle-income ones as well. The talk to be given by Professor Sachs during the Health Assembly would no doubt explore the issue further. Several Member States had noted with appreciation that the report focused on a small number of diseases and conditions that led to poverty, and on the interventions and research required to tackle them. At the same time, they had urged WHO to pay more attention to health systems issues, to the human resources necessary for health systems to work, and to the funding of health systems, whether private or public. Delegates had warned that a focus on health outcomes could lead to vertical programmes, which might be damaging. They had called for attention to be paid to ways of financing health care for the poor and pooling risks, and had urged that good development aid practice be encouraged, thus enabling countries to take primary control of their health systems agendas. The need for new thinking on intellectual property had been mentioned. Further, delegates had proposed that the report's findings be applied not only to the poorest countries but to countries with a variety of different circumstances and different institutions. How then should WHO respond? Much had already been said by the Director-General in her address to the Health Assembly. As Finland had pointed out, a response must come from the Health Assembly and the other governing bodies. Delegates had urged WHO to pay heed to the burden of disease and to the cost-effectiveness of interventions. Some had urged the inclusion of noncommunicable diseases and maternal and childhood conditions alongside AIDS, tuberculosis and malaria. There had been calls for the broader determinants of health to be taken into account, for WHO's normative work and technical assistance to be strengthened, for new partners to be sought, for the potential of public-private partnerships to be examined, and for cost-sharing and its impact on the poor not to be neglected. WHO would endeavour to follow that advice, at the front line, working with countries and with communities. In her address, the Director-General had outlined the Country Focus Initiative, and WHO's response to the report would probably be implemented in the framework of that Initiative. There was no single prescription: instead, the response would reflect countries' customs and institutions. The report had made it clear that funding must rise and some delegates had sought clarification concerning the implications for funding. Several had said that if more funds were required, those funds should be additional. Other issues to be addressed, according to delegates, were access to medicines, making money go further, and the broader context of terms of trade. He observed that all those present were well aware of the ultimate goal, and that the report constituted a road map for reaching that goal. WHO would work with Member States to implement the report, within countries and as part of international initiatives. The CHAIRMAN took it that the Committee wished to take note of the report contained in document A55/5. It was so agreed.

The meeting rose at 16:45.

SECOND MEETING Wednesday, 15 May 2002, at 9:30 Chairman: Dr J. KIELY (Ireland) later: Ms D. COSTA COITINHO (Brazil)

TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued) WHO's contribution to achievement of the development goals of the United Nations Millennium Declaration: Item 13.2 ofthe Agenda (Resolution EB109.R3; Document ASS/6) Ms WIGZELL (representative of the Executive Board), introducing the item, reported that the Executive Board had discussed the United Nations Millennium Declaration in the context of the Director-General's report to the Board. The Board had noted that governments were deeply committed to alleviating poverty. With the Global Fund to Fight AIDS, Tuberculosis and Malaria and the findings of the Commission on Macroeconomics and Health, the Millennium Declaration provided a unique opportunity to respond to the commitment of States with regard to health. During the debate, members of the Board had recognized that maternal, child and reproductive health were greatly influenced by poverty. After extensive discussions, resolution EB 109 .R3 had been adopted for consideration by the Health Assembly. The draft resolution called on Member States to strengthen efforts to meet the goals and targets of the Millennium Declaration and requested the Director-General of WHO to develop a strategy for accelerating progress towards attainment of international development goals and targets related to reproductive health. Professor SMALLWOOD (Australia) stated that his country accepted the Millennium Development Goals as aspirational targets, which were compatible with the emphasis on poverty reduction in the Australian aid programme. The goals would help to focus national and international development efforts, and his Government therefore supported the draft resolution recommended in resolution EB109.R3. Australia's health programme gave high priority to women and children's health, including family planning and reproductive health. His country consequently welcomed the formulation of strategies for reproductive health and for child and adolescent health. It also welcomed the emphasis given to national governments' responsibility for self-development and the attainment of the Millennium Development Goals. While donors could assist with resource transfers and capacity building, national governments retained responsibility for their own development policy setting, including progress towards the goals. Australia was in favour of the proposed reporting on attaining the goals, and recognized the challenges associated with measuring such advances and with attributing improvements to any single factor. It had established specific national performance indicators for the health of indigenous peoples, and reports on those indicators, covering life expectancy, mortality, access to health services and risk factors were submitted annually, although his country recognized that it would take a generation before substantial changes in health status would emerge. If any headway were to be made towards the goals, the emphasis should be on poor people and not just on poor countries. Effective and sustained support for the Asia-Pacific Region would therefore be required, along with a focus within developed countries on policies and programmes to reduce health inequalities. Dr RlVEROS DUENAS (Colombia) drew attention to a public health problem encountered in Colombia and possibly elsewhere: the irreplaceable work of medical missions, vital for the protection -26-

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and restoration ofthe population's health, especially that of the most needy, such as mothers, children and the poor, was being hampered in Colombia by armed conflict. Hospitals, health centres, ambulances, communication systems and river transport had been blown up, blockaded and seized by violent groups bent on destruction and the intimidation of the civilian population. Vaccines and drugs had been lost in the havoc. Doctors, nurses, administrators and technical staff had been killed, wounded, kidnapped and forced to move to other areas. The coverage of priority public health programmes had clearly deteriorated as a result, and violence and war had cast a shadow on the health of the general public. The Colombian population and the peoples of other countries suffering from those scourges needed the help of governments the world over. The latter should condemn any action that infringed the most elementary human right, the right to health guaranteed by the presence of doctors and health personnel. It should not be forgotten that the work of medical missions transcended armed conflict and drew no distinctions. He therefore requested the Health Assembly to send a message of peace and solidarity to his country, by adopting a draft resolution on the protection of medical missions from terrorism and armed conflict, which read as follows: The Fifty-fifth World Health Assembly, Recalling and reiterating resolution WHA46.39 entitled "Health and medical services in times of armed conflict"; Aware that, over the years, considerations based on fundamental principles of humanity have resulted in improved protection for medical personnel and for their recognized emblems; Deeply disturbed by recent reports of increasing attacks on medical establishments and units, especially in times of armed conflicts; Alarmed by the extent to which civilian populations are being affected by the lack of medical care as a consequence of attacks against health personnel during armed conflicts; Aware of the adverse effects of such conflicts on high-priority public health programmes, such as the Expanded Programme on Immunization and control of malaria and tuberculosis; Convinced that it is indispensable to protect against attacks on health personnel, hospitals, health facilities and infrastructures, ambulances and other medical vehicles, communication systems or other infrastructure which facilitate the work of health personnel, 1. CALLS on all parties to armed conflicts fully to adhere to and implement the rules of international humanitarian law protecting civilians as well as medical, nursing and other health personnel, and to respect provisions that regulate the use of Red Cross and Red Crescent emblems; 2. URGES Member States to condemn all attacks and other actions detrimental to the ability of health personnel to carry out their humanitarian function; 3. ALSO URGES Member States, organizations of the United Nations system, other intergovernmental and nongovernmental bodies active in the humanitarian or health fields to promote actions that ensure the safety of health personnel; 4. REQUESTS the Director-General: (I) to advocate the protection and respect of health personnel and establishments; (2) to liaise closely with the United Nations, UNICEF, the Office of the High Commissioner for Refugees, the Office of the High Commissioner for Human Rights, the International Committee of the Red Cross, the International Federation of Red Cross and Red Crescent Societies and with competent organizations of the United Nations system and other relevant intergovernmental and nongovernmental bodies in order to promote implementation of this resolution; (3) to disseminate this resolution widely.

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Ms BALOCH (Pakistan) said that although the Millennium Development Goals were almost two years old there was every indication that they would not be achieved unless revolutionary steps were taken to reverse current trends. Renewed commitment to the goals by all present was therefore necessary, with leadership from the Health Assembly. The previous day's debate had acknowledged that the report of the Commission on Macroeconomics and Health provided a useful and interesting guide to the means of achieving the Millennium Development Goals, but unfortunately the draft resolution recommended in resolution EB109.R3 made only passing reference to that report. For example, it failed to mention alternative sources of funding, the need for increased donor assistance and the establishment of global funds for health research. Her delegation therefore proposed that in the fourth preambular paragraph, the phrase "commitments made at the Copenhagen Summit" should be added after the word "Development". Two new preambular paragraphs should be added after the eleventh such paragraph that would read: "Welcoming the report of the Commission on Macroeconomics and Health which provides a useful approach to the achievement of the Millennium Development Goals;" and "Recognizing that the Millennium Development Goals cannot be achieved without a renewed commitment from the international community and aware of its own leadership in this context,". She further proposed the inclusion of two new paragraphs, 1( 1bis) worded "Calls upon the international donor community to increase its financial assistance in the health sector so as to achieve the target of US$ 27 thousand million per year by 2007, as recommended by the Commission on Macroeconomics and Health," and 1(1ter) that would read: "Endorses the recommendation of the Commission on Macroeconomics and Health for the establishment of a global health research fund and requests the Director-General to lead an international drive in the creation of this fund and for generating resources for research on developing countries' diseases." Lastly, in paragraph 2(1 ), the phrase "and in implementation of this resolution" should be inserted after the words "Millennium Declaration". Dr QI Xiaoqiu (China) recalled that the United Nations General Assembly had adopted the Millennium Declaration with a view to reducing the maternal mortality rate and the under-five mortality rate by three-quarters and two-thirds respectively by 2015. That goal was of great significance for fostering social development and the health of the world's people and would help to protect maternal and child health. For that reason, his delegation particularly supported paragraph 1(2) ofthe draft resolution recommended in resolution EB109.R3. The Chinese Government continued to take vigorous action to strengthen maternal and child health facilities in rural areas and in the western regions of the country, to improve primary health care and expand the capacity of health institutions in rural areas and to make it easier for people living in those areas to avail themselves of such services, thus ensuring that women and children had access to basic medical care. Developing countries were facing great challenges in achieving the Millennium Development Goals. It was therefore to be hoped that the international community, including WHO, would continue to provide the necessary technical support to help them to build capacity to attain those goals. Professor CHURNRURTAI KARNCHANACHITRA (Thailand) welcomed WHO's emphasis on the health of women and children. Achievement of the Millennium Development Goals would necessitate the cooperation of all partners at both national and global levels. She therefore urged WHO to work closely with other United Nations specialized agencies, international banks, donor countries, the private sector and civil society. Strong global cooperation would set a precedent for intersectoral collaboration within countries. She agreed on the importance of focusing on reproductive health as a means of reducing maternal and child mortality, and urged WHO to give greater priority to curbing violence against women, in view of its adverse effect on their health and that of their children, physically, mentally, socially and spiritually. Violence against women during pregnancy, which in Thailand affected 4% of pregnancies, caused abortion and low birth weight. She therefore proposed that the words "in particular the Declaration on the Elimination of Violence against Women" should

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be added to the end of the fourth preambular paragraph of the draft resolution recommended in resolution EB109.R3, and that the phrase "and elimination of violence against women" should be placed at the end of paragraph 1(3 ). Dr AL-KATTAMI (United Arab Emirates) said that her country endeavoured to provide highquality health care for women and children through a health system in which maternal and child health were priorities. Mothers were offered comprehensive protection, and the fact that 99% of women gave birth in hospitals or clinics had significantly cut maternal mortality rates. Strategies to cover children, especially the under-fives, had resulted in a substantial decline in mortality in that age group to fewer than eight per 1000 live births. A number of studies had been conducted to investigate the incidence of diseases that affected infants. Hereditary diseases were the chief cause of death among infants, and efforts had been made to determine the causes and to provide information to ensure better coverage. Diagnosis and counselling were likewise provided. Birth deformities were registered with a view to formulating a prevention programme. Her delegation endorsed the draft resolution recommended in resolution EB109.R3. Dr OKAMOTO (Japan) commended WHO's contribution to the achievement of the Millennium Development Goals, particularly with regard to health status. Countries should work together to achieve the precise numerical goals set forth in the Declaration in respect of reproductive health. He therefore endorsed the draft resolution recommended in resolution EB109.R3. Dr MALEFOASI (Solomon Islands) said that his country supported WHO's contribution to the achievement of the United Nation's development goals. Reducing poverty, fighting malaria, tuberculosis and HIV infection and improving reproductive health should take precedence in national health policies. His country's capacity at policy and operational levels was to be improved through a five-year programme to strengthen health institutions, concentrating on improving the management of health resources, including manpower and finances, and on delivering more effective services in the fields of malaria, tuberculosis, and reproductive health. His country was therefore strongly committed to achieving the Millennium Development Goals. Dr PAVLOV (Russian Federation) said that his delegation supported the draft resolution recommended by the Executive Board, especially its request to the Director-General to formulate a strategy to strengthen efforts to achieve international development goals and targets related to reproductive health. The strategy should take the form of a practical document spelling out specific aims and objectives. Improving the health of families, mothers and children had long been one of the top priorities of the Organization. Nevertheless if the goals set forth in the Millennium Declaration were to be attained, WHO and its partners would have to scale up their efforts to reduce maternal and child mortality and improve the access of the poor to primary health care. The Organization, its Member States and the Commission on Macroeconomics and Health were working in that direction. The Commission's report regarded an improvement in maternal and child health as the best way of alleviating poverty and recommended greater financial support for reproductive health services, including measures to reduce the number of abortions. Those measures should be carried out by primary health care facilities as they were closest to the population. Dr TROOP (United Kingdom of Great Britain and Northern Ireland) said that her delegation firmly supported the draft resolution recommended in resolution EB 109 .R3. The Millennium Declaration captured the resolve of the international community to eliminate world poverty and place health at the centre of that collective effort. The draft resolution highlighted the particular importance of reproductive health to the attainment of the key goals, especially in reducing maternal and child mortality. Access to reproductive health care and information was essential to the efforts to halt and reverse the HIVI AIDS epidemic. Her country was committed to achieving the goals of the Millennium Declaration, a commitment strengthened by the International Conference on Financing for

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Development held in Monterrey, Mexico, in March 2002. The United Kingdom was working with others to increase the capacity of health systems to deliver effective, equitable health care. It endorsed the Declaration's call to Member States to meet key international development goals and to improve access to primary health care services, including reproductive health, and also endorsed the draft resolution's call to WHO to help speed attainment of international development goals related to reproductive health and to promote reporting on that subject as part of the United Nations' SecretaryGeneral's regular report on the Millennium Declaration. Dr STEIGER (United States of America) said that the United States supported improving, expanding and strengthening effective maternal and child health care programmes, and intended to increase funding for core development assistance by US$ 5000 million annually, some of which would be devoted to basic health care. His delegation supported the intent of the draft resolution, but suggested that it should be amended to reflect the outcome document adopted at the United Nations General Assembly special session on Children in May 2002, "A World Fit for Children". Specifically, preambular paragraph 3 should read: "recognizing that increased access to basic social services, including reproductive health care, is critical for attainment of several development goals of the Millennium Declaration". Preambular paragraph 6 should reflect resolution WHA54.10 on scaling up the response to HIV I AIDS and should read: "recalling that the Constitution of WHO states that enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition and considering that the progressive realization of that right should involve access to good quality reproductive health care, including family planning services that are effective, affordable and acceptable". Paragraph 1(2) should also reflect the outcome document and be amended to read: "to strengthen and expand efforts to meet, in particular, international development goals and targets related to the reduction of maternal and child mortality and malnutrition and to address effectively, for all individuals of appropriate age, the promotion of their healthy lives, including their reproductive and sexual health, with special attention to the needs of the poor and other underserved populations". Mrs HUTT (Canada) said that her delegation endorsed the draft resolution recommended by the Executive Board and strongly supported international development goals, including those stated in the Millennium Declaration. Canada worked actively towards such goals, identifying as two key priorities the improvement of health and nutrition and addressing HIV/AIDS. Sexual and reproductive health were critical aspects of the health, survival and well-being of children and adolescents around the world. In that connection she reiterated Canada's strong support for ensuring the right to the highest attainable standard of health, including the right to make informed choices about one's own sexual and reproductive health. Access to programmes and services that included safe, reliable, high-quality family planning methods, information, education and counselling was an essential part of a comprehensive health-care programme and should be equitable and responsive to diversity. The outcomes of the International Conference on Population and Development (Cairo, 1994) and the Fourth World Conference on Women (Beijing, 1995) and their five-year reviews were significant for understanding the issues and the requirements for implementation and action and would serve her country as benchmarks for future work. Dr MOLIN (Sweden), speaking on behalf of the Nordic countries (Denmark, Finland, Iceland, Norway and Sweden), said they strongly supported the draft resolution recommended in resolution EB109.R3. The United Nations Millennium Summit and adoption of the Millennium Declaration had been landmark events, and full implementation of the Declaration would be a necessary part of the global effort to create a more peaceful, prosperous, just world for all mankind. The overriding challenge was to translate the commitments in the Declaration into concrete action, which would require national and international political will and leadership, as well as increased cooperation, financial input and innovative thinking. WHO had led the way not only in respect of health goals but

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also in establishing the Commission on Macroeconomics and Health. The main goal of the Millennium Declaration was to eradicate poverty in its broadest sense. Three goals were health outcomes and the remaining five were important prerequisites for health, including improvements in education and the environment and equality between the sexes. Recent reductions in child mortality had unfortunately not been matched by any decrease in the mortality rate of newborn infants. At least four million newborn infants died annually, almost all in developing countries. That situation could only be remedied by improving perinatal care. Although the Millennium goals focused on crucial components of reproductive health, it was important that the whole area be addressed, in particular, ensuring the right of young women and men to reproductive health care; monitoring access to reproductive health care was an important indicator of fulfilment of that right. The Nordic countries supported WHO's intention to report on progress towards internationally agreed goals in the area of reproductive health, and, as some of the main contributors to international development assistance, were prepared to engage fully in international efforts to achieve the Millennium goals. He urged WHO, especially at the country level, to strengthen health ministries' capacity and to include health as a priority in World Bank poverty reduction strategy papers, by training and employing professionals in the interrelation between macroeconomics and health and helping to create links between health ministries and ministries of finance and planning. Mr ROKOVADA (Fiji) endorsed the draft resolution recommended in resolution EB109.R3, the United Nations Millennium Declaration development goals and WHO's contribution to achieving those goals. He supported, in particular, the goals to reduce infant and child mortality and promote a better quality of life for children, as well as to improve maternal health and reduce the maternal mortality rate through safer motherhood practices and improved maternity services. Fiji had strengthened and intensified efforts in those areas of reproductive health. Dr TEE (Malaysia) said that her delegation fully endorsed the draft resolution recommended by the Executive Board. Malaysia's health system was based on primary health care, and, to ensure equity, more focus was given to disadvantaged groups, including rural and poor communities, women of reproductive age and children. Regrettably, the coverage and quality of reproductive health services for adolescents called for in resolution 1 of the International Conference on Population and Development held in 1994 had not been fully implemented, although, in cooperation with other governments and government agencies, some progress had been made in creating awareness and in training. In collaboration with the Federation of Family Planning Associations of Malaysia and WHO, Malaysia would shortly be hosting an international training workshop in adolescent health, including reproductive health. Dr OTTO (Palau) welcomed the draft resolution recommended in resolution EB109.R3 and associated himself with the comments of Thailand concerning violence against women. He supported the amendments proposed by the United States and acknowledged their assistance in helping Palau achieve zero maternal mortality and an infant mortality rate of fewer than 15 deaths per 1000 live births. There had been frequent references during the ministerial round tables to the public health problems associated with tobacco use. That problem seriously affected the health of children, adolescents and adults of reproductive age in Palau and contributed to poverty by diverting already constrained family funds to support nicotine addiction. He therefore proposed the addition of a new subparagraph 1(6), that would read: "to support a strong framework convention on tobacco control". Dr AKBARI (Islamic Republic of Iran) welcomed the United Nations Millennium Declaration. Maternal and child mortality rates could be reduced and HIV infection controlled successfully only by incorporating those topics under the umbrella of family health, rather than addressing them individually. Improvements in family health depended on four principal criteria: they should apply to both sexes and all age groups and the activity should be integrated and comprehensive, covering biological, spiritual and psychosocial activity, as mentioned by Canada and Thailand.

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Ms BUIJS (Netherlands) said that, guided by the Millennium Declaration goals, her country had put poverty reduction at the centre of its development cooperation. She fully endorsed the draft resolution recommended in resolution EB109.R3, with its emphasis on maternal, child and adolescent health as essential factors of socioeconomic development. Access to good quality reproductive health care, including family planning services, was crucial for attaining the highest standard of health, particularly for women. Mrs LE THI THU HA (VietNam) supported the draft resolution recommended in resolution EB109.R3, given the importance of reproductive health in improving maternal and child health. Her Government was strongly committed to achieving the Millennium Declaration development goals and considered that reproductive health should be included in the follow-up of those goals. She thanked WHO, UNICEF, UNFPA and other development partners for their cooperation and assistance over the past decade and looked forward to working with them in the future on achieving the development goals. Dr ZAHER (Egypt) welcomed the draft resolution recommended by the Executive Board and supported WHO's efforts to meet the development goals of the Millennium Declaration, which reflected worldwide interest in health care. Her country was taking measures to implement the recommendations, including increased investment in the field of health. Mr CHAKALISA (Botswana) said that his country was committed to the provision of good quality health services to all its citizens, evidenced by improved health indicators over the years. Reproductive health services were available throughout a network of health facilities, so that persons of reproductive age could make and act on informed decisions based on information, education and counselling. Reductions in the total fertility rate, the infant mortality rate and teenage pregnancies proved the efficacy of those services. HIVIAIDS remained the largest threat to health in Botswana, resulting in a decline in the health indicators of children. A national programme for the prevention of mother-to-child transmission of HIV had been launched, and a programme focusing on adolescent sexual and reproductive health had been initiated. Botswana was committed to the action required at country level to improve global reproductive health and looked forward to progress towards the attainment of the Millennium Declaration development goals through implementation of the draft resolution recommended in resolution EB 109 .R3. Dr VIOLAKI-PARASKEVA (Greece) commended WHO's contribution to the development goals of the United Nations Millennium Declaration. Referring to the annex to document ASS/6, she expressed particular satisfaction with respect to item 7, given the large number of people affected by waterborne diseases. She welcomed the statement in paragraph 6 of the document that the development goals were being taken into account both in current work and in preparing the strategic programme budget for 2004-2005. Her delegation supported the draft resolution recommended in resolution EB 109 .R3. Mr NAIK (India) said that his country fully supported the draft resolution recommended by the Executive Board. Essential medicines, however, must be made available at affordable prices if mortality and morbidity rates were to be improved. The Director-General in her address to the Health Assembly had reiterated that further efforts were needed to reduce the price of medicines and to expand quality services to those in need. In that context, he proposed that the draft resolution be amended by adding a new paragraph l (2), consisting of the third bullet under paragraph 20 of the United Nations Millennium Declaration, 1 which read: "to encourage the pharmaceutical industry to

United Nations General Assembly resolution 55/2.

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make essential drugs more widely available and affordable by all who need them m developing countries". Mrs LAMBERT (South Africa) said that, in taking action to meet the goals of the Millennium Declaration, developing countries would need help in quantifying and qualifying the deaths of women and children. Technical assistance would also be required to translate observations into practice, as for example in reducing mortality from postpartum infections associated with HIV, which was currently the commonest cause of death among women in her country. Urgent action was also required to prevent violence against women. Her delegation associated itself with the amendments proposed by Pakistan and Thailand to the draft resolution recommended by the Executive Board, and also with the statement by Palau that a strong framework convention on tobacco control was central to the attainment of those development goals. Her country was prepared to take all necessary actions to achieve the development goals and consequently supported the draft resolution. Mrs SOSA MARQUEZ (Mexico) said that her delegation supported the draft resolution recommended in resolution EB109.R3 and reiterated its conviction as to the importance of improving access to primary health care services, including reproductive health, in order to reduce mother and infant mortality rates. Accelerated achievement of those goals would be a valuable contribution to the fight against poverty and to social and economic development. She agreed with delegates from other developing countries that increased contributions would be needed to attain those goals. Dr DODD (UNFPA) welcomed the attention given to reproductive health. The action programme of the International Conference on Population and Development emphasized the role of UNFP A in assisting countries to take the strategic action necessary to ensure the availability of reproductive health services and choice of reproductive health products, with the goal of universal access by 2015. That assistance would be given in cooperation with the governments of developing countries and also donor countries, United Nations funds, programmes and agencies, international financial institutions, nongovernmental organizations and civil society, according to the advantages and mandates of each body. UNFP A assistance should contribute to strengthening basic health services, reflecting the concerns expressed by delegates. Within each of the four basic components of reproductive health - access to family planning, ensuring maternal health, prevention and treatment of sexually transmitted infections and prevention of HIV infection - effective strategies should be identified and promoted to improve the reproductive health and quality of life of poor women, men and adolescents in developing countries, thus contributing significantly to achieving the development goals. Dr NABARRO (Executive Director), responding to comments, observed that the importance of the Millennium Development Goals had been recognized by all. Delegates had expressed the need for reproductive health issues to be represented more strongly in the development goals, and the draft resolution recommended by the Executive Board sought to do that. The various amendments proposed by delegates implied that WHO would have to report regularly on how countries were achieving the goals and to contribute more to country capacity both to address the issues and to monitor progress. WHO would continue to support global and regional processes, particularly in relation to child and adolescent reproductive and sexual health care, HIV/AIDS, malaria, tuberculosis and essential medicines and would continue to work with the United Nations statistics division, UNDP and other agencies to help quantify progress towards the goals and press for the resources to achieve them. The CHAIRMAN proposed that the draft resolution proposed by Colombia, which had been circulated only the previous day, and a revised version of the draft resolution recommended in resolution EB109.R3 incorporating all the proposed amendments, be considered at a later meeting of the Committee.

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It was so agreed.

(For continuation, see summary record ofthe seventh meeting.) Ms Costa Coitinho took the Chair. World Summit on Sustainable Development: Item 13.3 of the Agenda (Document ASS/7) Dr GONZALEZ FERNANDEZ (Cuba) regretted the late availability of documents ASS/5 and ASS/6, which were closely related to the item under discussion. The report contained in document ASS/7 was good, but he questioned the statement in paragraph 17 that HIV/AIDS, malaria, tuberculosis and other infectious diseases caused poverty. Rather, the poor were more often affected by those diseases. He called on the more developed countries to respond to the findings of the WHO Commission on Macroeconomics and Health, by making a greater effort to reduce poverty in those countries in greatest need. To optimize preparedness for the forthcoming World Summit on Sustainable Development, all the recommendations emerging from the various forums held in 2001 and 2002 should be collated and made available to participating countries. Dr QI Xiaoqiu (China) welcomed WHO's contribution to preparations for the World Summit and in particular its clarification of the relationship between investment in health and sustainable development and making health development an important issue for discussion. Poverty and disease were interrelated, the greatest disease burden being borne by the poor. Poverty also constrained sustainable development and its eradication was therefore the first task of developing countries. In addition, globalization tended to exacerbate existing inequalities. Developed countries should be more active in helping developing countries to resolve those problems. His Government was committed to sustainable development and was conscious of its responsibilities for protecting the environment. It had signed multilateral treaties to that effect, and would continue to participate in such initiatives. Professor CHURNRURTAI KARNCHANACHITRA (Thailand) said that her delegation welcomed the report, with its emphasis on health as an integral part of social, economic and environmental development. The role of WHO in improving health was crucial for achieving the goal of sustainable development. However that goal could not be reached in a world of inequalities and investments in health should be made simultaneously at the individual and the structural level. There were four structural dimensions to achieving sustainable development. At the economic level, there should be political leadership to reduce economic inequity, promote income distribution and redistribution, institute progressive taxation, reduce poverty and monitor progress in each of those areas. At the social level, emphasis should be placed on reducing inequities between the sexes and between social classes, strengthening social capital and minimizing cultural barriers to healthy behaviour. Policies were needed to promote and monitor equal access to education and other social services. The third dimension of sustainable development was environmental protection and wise use of natural resources. The fourth was the existence of health systems that were responsive to the legitimate needs of the populations, and particularly the poorer segments. Achieving those aims would require strong political will, good governance at all levels, active community participation, democratization and genuine public-private partnership. A healthy public policy and the means of assessing the impact of that policy on health were essential. She reaffirmed her country's commitment to progress towards sustainable development and health. Mr NAIK (India) joined previous speakers in underlining the close relationships between economic development, poverty reduction and health, reflected in the two previous agenda items. The challenge facing the forthcoming World Summit would be to create the necessary conditions, especially the financial resources to ensure progress in those areas. In that context, he noted WHO's proposed emphasis on an assessment of the impact of national and international development policies.

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The formulation of health policies and optimal allocation of resources to health needs were the responsibility of national governments, which were best able to judge local conditions. To ensure the soundness of such policies required a climate of transparency and accountability. Prescriptive norms imposed from outside could be counterproductive. WHO should carry out a detailed study of the impact on health of international economic and development policies, as illustrated by the effects on health of insufficient financial resources for health and of intellectual property rights on the availability of medicines and equipment for health care facilities. He acknowledged the importance of partnerships and alliances as a means of addressing threats to health and promoting sustainable development. Such partnerships should be based on respect for national policies and priorities and national control over programmes. The requisite funding for health programmes from donors was required, and he welcomed the focus on those considerations in paragraph 21 of the report. With regard to the environmental issues raised in paragraph 22, he called attention to the principle of "common and differentiated responsibility". Mr PETTERSSON (Sweden), speaking on behalf of Denmark, Finland, Iceland, Norway and Sweden, said that the forthcoming World Summit provided a strategic opportunity to strengthen the health dimension of sustainable development. Although it had been agreed at the United Nations Conference on Environment and Development in Rio de Janeiro, Brazil, in 1992 that sustainable development contained economic, social and environmental dimensions, the main focus appeared to have been on environmental improvements. It was clear that there were links between health and social and economic development. The Nordic countries had noted with interest the forthcoming WHO initiative to emphasize the impact of the environment on children's health. The health problems of children due to environmental degradation, exposure to chemicals and air pollution and injuries had been a focus of the Third Ministerial Conference on Health and Environment held in London in 1999, and was to be addressed at the fourth such conference, to be held in Budapest in 2004. Investing in future generations encapsulated the idea of sustainable development, and was equally valid for all countries, thus deserving greater attention at the World Summit. The health sector should not operate on its own but should collaborate with other sectors of society. WHO had an important role in supporting countries in that endeavour. Dr SLATER (United States of America) said that the forthcoming World Summit would provide an important opportunity for the entire global community to acknowledge the importance of health and investing in health within the context of sustainable development. WHO's leadership in both the preparatory and follow-up processes would be especially important. The United States supported the major health priorities identified for global action, and the evolving consensus regarding voluntary and innovative partnerships and the importance of working with partners across all sectors. Finally, she endorsed the comments made by Cuba regarding the timeliness of documentation. Mr BARBOSA DA SILVA Jr (Brazil) said that the report under discussion highlighted the role of Agenda 21 as a global programme for sustainable development in preparation for the Summit. The Ministry of Health in his country was reviewing the Brazilian contribution to Agenda 21 and planned to issue two documents: a comprehensive report covering significant achievements and challenges relating to health over the past 10 years, and a contribution from the health sector to Agenda 21. It intended to call for more effective measures to reduce social inequity and poverty and for strengthening the evidence base for links between health and sustainable development. His delegation agreed that reinforcement of the links between health, development and environment was a major issue in implementation of Chapter 6 of Agenda 21. A comprehensive health system was also needed to promote and maintain health. Dr FURGAL (Russian Federation) considered that inclusion of the World Summit on Sustainable Development on the Health Assembly's agenda demonstrated the Organization's conviction that poverty and health were essential elements of sustainable development. He expressed

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the hope that participants at the Summit would be informed of the concern expressed at the Health Assembly about urgent global-scale health problems that impeded sustainable development and could only be resolved with the participation of the entire international community. The active support of WHO, using evidence derived from the reports submitted, would raise awareness about the significance of health in improving economic development and help countries to formulate a strategy for action. WHO should lead and coordinate action across the board, so that account could be taken of the needs of health care systems in low- and middle-income countries and issues of privatization of health systems, models for national health care regulation, ensuring equal access to primary health care and enhancing the effectiveness of health care systems, developing partnerships and intersectoral cooperation, all of which were priorities if the potential for achieving the highest possible indicators of health and development of health care services were to be maximized. The considerable experience accumulated by WHO should be drawn upon to the utmost to help the countries most in need. Dr OKAMOTO (Japan) said that the forthcoming Summit would provide an opportunity to enhance the effectiveness of Agenda 21, based on an assessment of progress made in its implementation. WHO should be able to make a major contribution towards strengthening such implementation, but would need to provide convincing scientific evidence if the non-health sector were to be persuaded of the necessity for action. Mrs LAMBERT (South Africa), speaking on behalf of the member States of the Southern African Development Community, said that a draft resolution on health and sustainable development was being prepared. Dr NABARRO (Executive Director), responding to the delegates' interventions, said that the comments would influence WHO's preparations for the World Summit. He had noted the general support for the strategies outlined in the report, emphasis on the linkages between the report of the Commission on Macroeconomics and Health and the drafting of documentation for the World Summit, and the suggestion that the evidence for linkages between ill health and poverty should be increased. Work on understanding those linkages would be pursued with developing countries and others as they prepared for the Summit. He had also noted the comment about late arrival of documents. In respect of WHO's preparations for the Summit, he understood that delegates wished for greater emphasis on health at the Summit and in the outcome materials. WHO would bring together country offices, regional offices and headquarters to ensure the availability of authoritative briefing materials for the Summit. In positioning health within the various aspects of the Summit, every effort would be made to highlight the principles raised in the preceding discussion, particularly strengthening health systems and those conditions that caused the greatest suffering. WHO would continue to cooperate with other health-related development agencies to establish a common position. Documentation on healthy environments for children would be made available as far as possible, both within WHO and beyond, before the Summit. The CHAIRMAN invited the Committee to note the report contained in document ASS/7. She proposed that the agenda item under discussion remain open, pending the availability of the draft resolution proposed by the Southern African Development Community. It was so agreed.

(For continuation, see summary record of the sixth meeting, section 2.) Global Fund to Fight AIDS, Tuberculosis and Malaria: Item 13.4 of the Agenda (Documents ASS/8, ASS/8 Add.l and ASS/INF.DOC./6)

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Dr MAM Bun Heng (Cambodia) emphasized the importance of the Global Fund for developing countries in scaling up the HIVI AIDS response, helping to eradicate tuberculosis and strengthening the Roll Back Malaria programme. It should also serve to imp~ove the partnership between governments, specialized agencies and civil society in fighting the three diseases. HIV, tuberculosis and malaria all constituted serious public health issues for Cambodia. A multisectoral effort had been made with the international <:ommunity, civil society and nongovernmental organizations to stabilize the HIV epidemic, including 100% condom use, continuum care, home-based care and antiretroviral treatment. Action was also being taken in relation to tuberculosis and malaria. He sought formal guidance on how the Fund would be disbursed and requested technical support from the relevant United Nations agencies in effective use of the Global Fund. Mr GREAVES (Saint Lucia) reported that, as a region, the Caribbean had the second highest rate of HIVI AIDS in the world. By way of response, a pan-Caribbean partnership against HIVI AIDS had been created, covering many territories; however, the regional nature of the partnership had created a number of problems, including a delay in the region's submission to the Global Fund. The Caribbean was a community of small countries which, individually, did not have the capacity to implement full programmes; as a consequence, a regional approach, with the attendant economies of scale, had been sought. Among underlying problems, the region's debt burden constituted a major impediment to a concerted approach. The region as a whole had to have access to the Fund, in order to mobilize the necessary resources. Mr ZEPEDA BERMUDEZ (Brazil) said that the importance of the Fund as a major tool in the fight against HIVI AIDS was undeniable. Brazil had been closely involved since its inception and intended to contribute its accumulated experience and expertise in prevention, support, care and treatment and the transfer of technology for the production of generic antiretroviral drugs. Countries should be able to use the Fund's resources for vaccine development according to established principles and criteria. One particular success in Brazil had been condom use in the prevention of HIV transmission. Condom use at first intercourse had increased consistently, from 4% in 1986 to 48% in 1999 and was an important part of Brazil's prevention policy. Mr CHAKALISA (Botswana), while commending the establishment of the Global Fund, expressed concern at WHO's non-voting status. As the lead agency in international health, WHO should be more influential in the management of the Fund. He said that he was pleased to note the swift progress that had been made, with the first round of proposals already assessed and approved; however, there had been poor communication about the outcome of applications, and he was especially concerned that Botswana's application had been unsuccessful, given its high prevalence of HIVI AIDS. Botswana nevertheless appreciated the assistance it had received in preparing its proposal. In that connection he suggested that in future the deadline for proposals should be extended. WHO's commitment to support the preparation of proposals by countries most in need was welcome, as they were often the least capable of preparing high-quality proposals. It was critical that the guidelines for applications to the Fund were made more "user friendly". Efficient management of the Fund should not be at the expense of rapid disbursement of funds to deserving nations. The operational framework of the Fund should be kept under constant review in order to maximize its efficiency and its impact on disease in the countries most severely affected. Africa's representation on the Board, the secretariat, the technical committees and the working groups of the Fund should also be reviewed to ensure that it was proportional to its burden of disease. Mr GUNNARSSON (Iceland) noted that the speedy establishment of the Fund was evidence of the urgency of the situation it had been created to address and was proof of the global community's commitment to deal with it. He welcomed the decision to locate the secretariat of the Fund in Geneva but was concerned about possible duplication of work and administrative costs as the Fund was a

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parallel organization to WHO and UNAIDS. In order to achieve a successful outcome, the strategy to fight AIDS, tuberculosis and malaria must gain wide acceptance. It was also important that the Fund respect the principles of country ownership and leadership, that existing structures and resources be used and that the Fund give its support to national plans. WHO and UNAIDS should continue to serve the Fund with their knowledge and competence. Or SADRIZADEH (Islamic Republic of Iran) noted with regret that HIV/AIDS, tuberculosis and malaria, the major diseases of poverty, imposed a heavy burden on the affected countries, particularly the developing countries. It was expected that the establishment of the Global Fund would support the countries concerned in tackling their public health problems. In order to enhance its effectiveness, WHO should be more strongly represented in the management structure of the Fund, and there needed to be a more equitable basis for participation in the Technical Review Panel, on which some regions, such as the Eastern Mediterranean Region, had no voice. In relation to malaria, the African countries of the Eastern Mediterranean Region had been neglected, as had some nonAfrican countries, even though they accounted for some 95% of all cases of malaria in the Region. It was particularly important that WHO did not accept a complacent approach to countries in which malaria had been eradicated: they needed continued support to prevent reintroduction of the disease. Professor MOSKALENKO (Ukraine) welcomed the setting up of the Global Fund and thanked those who had made it possible to process the first applications for assistance. The Fund was evidence of the international community's resolve to mobilize global forces in the interests of health and development. Ukraine had been chosen to speak for the recipient countries of central and eastern Europe on the Board of the Global Fund, and he was grateful for the trust shown, taking it as recognition of the modest part Ukraine had played in making the Fund operational. Ukraine would do its utmost to ensure that assistance was channelled to the countries which needed it most. He was confident that the Global Fund would prove a new model partnership for international development by reducing the burden caused by three of the most dangerous and destabilizing diseases currently known. Mr MORENO PALANQUES (Spain), speaking on behalf of the European Union, congratulated WHO and UNAIDS on their valuable contributions to establishing the Global Fund. The Member States of the European Union and the Commission saw the Fund as evidence of the international community's political will to join forces to fight three major diseases. The European Union had already demonstrated its firm commitment to the Fund by providing more than 50% of the contributions so far. He encouraged WHO to continue its efforts to secure greater private-sector involvement as a way of attracting more resources, and endorsed its continuing involvement in the management of the Fund. Mrs HUTT (Canada) said that her country had been pleased to be able to play a role in building international support for establishment of the Global Fund and to make a significant financial contribution. Canada supported the Fund's guiding principles, in particular the emphasis on countryled processes, the results-based approach and the fact that it was complementary to existing structures and processes. It was committed to making the Fund work, and commended WHO's valuable contribution to the Fund's impressive progress since its inception. She asked for more information about the "administrative services agreement" mentioned in document A55/8, paragraph 9, between the Fund and WHO, in particular whether it involved full cost recovery. WHO would be counted on to continue providing technical support to the Fund, and she wondered whether that, too, would be covered by the agreement. If not, what were the cost implications to WHO and how did WHO envisage its relationship with the Fund in the medium term? The "lean and mean" character of the Fund and its secretariat should not be allowed to exert greater pressures on, and generate increased costs for, United Nations partners and others.

COMMITTEE A: SECOND MEETING

Mr MOON (Republic of Korea) said that his country would make every effort to support the Fund in achieving its goal of providing timely, appropriate assistance to fight AIDS, tuberculosis and malaria. That goal could not be achieved, however, without global participation by governments, the private sector and nongovernmental organizations. He asked WHO to keep Member States informed of the progress made towards setting up the monitoring and evaluation system mentioned in paragraph 10 of the report and to collect feedback on that system from Member States in order to ensure its satisfactory operation. Ms KONGSVIK (Norway), noting that the contributions made so far to the Fund covered only 10% of the estimated needs, expressed the hope that high-income countries that had not yet contributed or whose pledges were not commensurate with their gross national product, would ·consider increasing their contributions and that the private sector would provide more substantial funding, given the need for long-term commitments. Norway had recently committed about US$ 15 million to the Fund for 2002, and a further US$ 7 million would be allocated through other channels to activities that were in keeping with the Fund's purpose, in addition to its existing bilateral and multilateral contributions. All the partners must make the highest possible contribution to ensure the Fund's operational success. To that end it was crucial that the Fund should fully respect the principles of country ownership and leadership, that existing global and national structures and resources were used, and that national plans formed the point of departure for. Fund support. The role of the country-coordinating mechanisms, their responsibility for monitoring and evaluation and their accountability for spending required further clarification. Given the enormous needs and limited resources, priorities should be set for the allocation of available funds, the highest priority going to the poorest countries. The Fund for its part should draw on the knowledge and competence of other organizations within the United Nations system to avoid duplication of effort and to ensure that it remained the funding mechanism it was intended to be and did not become a new agency. As Botswana had pointed out, the increased funding available for helping countries to tackle AIDS, tuberculosis and malaria posed new challenges in relation to WHO's role at the country level. Countries rightly expected WHO's assistance in areas ranging from the preparation of funding applications to the strengthening of health systems. WHO should take up that challenge and develop a strategy for strengthening country-level performance. Norway was ready to provide further support, including financial support, to WHO's work in that area. Dr MOLIN (Sweden), endorsing the views of the previous speaker, expressed strong support for the Fund. His Government considered that three basic principles were important in relation to the Fund: activities at country level should be based on national priorities and plans, the funds should be truly additional, and the Fund should maintain a strong focus on poverty. Dr OSMAN (Sudan), welcoming the Global Fund as a timely initiative, expressed regret that more countries had been unable to contribute to the Fund owing to lack of notice. He fully endorsed the views expressed by the Islamic Republic of Iran, particularly in respect of the participation of the Eastern Mediterranean Region in the management of the Fund. It was difficult to understand why the health situation in Sudan had been ignored, despite the fact that it had made a contribution: it would be impossible to control or eradicate AIDS, tuberculosis and malaria unless full account were taken of Sudan, one of the largest countries in Africa. WHO should play a major role in the Fund and the Eastern Mediterranean Region should be represented in its secretariat. It would be unfortunate if the Fund's humanitarian nature was weakened by political considerations. Dr OKAMOTO (Japan) suggested that the Fund might serve as a model, in line with the recommendation of the Commission on Macroeconomics and Health. Japan had contributed US$ 200 million to the Fund; it had participated actively in its establishment and would continue its support as Vice-Chairman of its Board. He welcomed the Administrative Services Agreement between WHO and the Fund and the innovative framework of public-private partnership on which the Fund

FIFTY -FIFTH WORLD HEALTH ASSEMBLY

was based. The Fund must operate efficiently and effectively and remain independent. Its success would depend on coordinating new and existing projects, both at the field and national levels. WHO should therefore support the country-coordinating mechanism in cooperation with the Regional Offices. Many developing countries that had submitted project proposals had reported the need for assistance by WHO and UNAIDS with the preparation of their proposals to ensure that they were scientific, evidence-based, practical and realistic, and consistent with existing global strategies. WHO should support the proposal preparation process and the work of the technical review panel. Dr FURGAL (Russian Federation) commended the Fund as an outstanding example of the new approach to resolving global public health problems in the interests of sustainable development. He approved the provision by WHO of technical expertise in establishing the Fund and developing strategies for its future action. Assistance under the Fund should be distributed equitably among regions and groups of countries, focusing on the worst-affected countries, not least those of the European Region, including the Commonwealth of Independent States, where HIV infection had spread alarmingly in recent years. The Russian Federation was prepared to collaborate actively with all other participants in the Fund. Mr CICOGNA (Italy) welcomed the Global Fund and commended all those who had contributed to its establishment. Notwithstanding the remarkable results already achieved, there was still a need to strengthen partnerships and to seek new ways of involving the private sector. Partnerships should include bilateral cooperation between hospitals in developing and developed countries. The competent ministers of France, Italy, Luxembourg and Spain, in cooperation with United Nations organizations and the Global Fund, had already pledged to draw up a programme called the Solidarity Network for Hospital Care against AIDS. Dr SURENA (Haiti), welcoming the establishment ofthe Fund, said that his country's proposal had been accepted, thanks to an effective private-public partnership, the commitment of the principal players and valuable support from WHO, UNAIDS and others. Other countries wishing to submit applications should also request the assistance of WHO and UN AIDS. He thanked the Fund and other donors, whose aid would help Haiti in its efforts to control HIVIAIDS in the near future. Dr KIM Won Ho (Democratic People's Republic of Korea) said that his country was confident that the Global Fund would make a valuable contribution to controlling AIDS, tuberculosis and malaria and to reducing poverty in developing countries. His Government had set up a national coordinating committee to control communicable diseases, and its application to the Fund for assistance in controlling tuberculosis had been approved. His country would continue to take part in the Fund's activities. Dr CHOW (United States of America) welcomed the Global Fund as a new, independent partnership of governments, nongovemmental organizations and the private sector, from the global to the country level, in the fight against the targeted diseases. The Fund had taken two significant steps at its previous meeting with the appointment of a new Executive Director and approval of the first round of applications. Other important decisions still lay ahead before disbursement of funds, regarding monitoring and evaluation functions, fiduciary roles and functions, policies on procurement, application guidelines, and the role and functions of the country-coordinating mechanisms. The structure and functions of the technical review panel needed re-evaluation, and future rounds of applications needed to be prepared. The United States supported the fullest possible degree of openness and transparency in the Fund's processes and deliberations and a more efficient application process.

The meeting rose at 12:30.

THIRD MEETING Wednesday, 15 May 2002, at 15:30 Chairman: Dr J. KIELY (Ireland)

TECHNICAL AND HEALTH MATTERS: Item 13 ofthe Agenda (continued) Global Fund to Fight AIDS, Tuberculosis and Malaria: Item 13.4 of the Agenda (Documents ASS/8, ASS/8 Add.l and ASS/INF.DOC./6) (continued) Mrs HU FIGUEROA (Honduras) said that, in her Government's national strategy, AIDS, tuberculosis and malaria had together been designated a priority, to be tackled in collaboration with other institutions because of their social, economic and political repercussions. Honduras had been classified as a highly indebted country. Its difficulties and lack of financial resources impeded an effective response to the epidemics. Efforts needed to be redoubled, with the support of the international community, to control the targeted diseases on a sustainable basis. Accordingly, Honduras had submitted a project proposal to the Global Fund. Her Government, Honduran civil society and the private sector were confident that the Fund's Board would approve that proposal. Dr FERREIRA SONGANE (Mozambique) stressed the importance of immediate action against the AIDS pandemic, tuberculosis and malaria. He noted, however, that document ASS/8 did not refer to action already taken by African, Caribbean, and South-East Asian countries, giving the impression that only the G8 group of countries and the United Nations system had sought to raise funds. Mention should also have been made of the African Summit on HIV/AIDS, Tuberculosis and Other Infectious Diseases (Abuja, 2001) and a similar meeting in South-East Asia. Another important issue was the weakness of many national health systems, demonstrated by the fact that 60% of the proposals submitted to the Global Fund concerned commodities. Yet antiretroviral drugs could only be introduced if basic health services were in place. Development would become impossible if the AIDS pandemic were not curbed. The Global Fund must recognize the need for immediate action. A good start had been made, but its sustainability was uncertain as decisions had to be based on the funds currently available. Furthermore, it needed to be made absolutely clear to financial institutions and donors that the funds involved were additional to those spent on current programmes. Lastly, care should be taken not to disrupt existing health systems. The independence of the Fund must be respected but must at the same time be carefully balanced so as not to produce the opposite result of that desired in establishing the Fund. Dr QI Xiaoqiu (China) said that China fully supported the aims of the Global Fund and commended WHO's contribution to its establishment and operation. The Fund would play a major role in reducing the disease burden, developing more effective interventions, mobilizing civil society and controlling the spread of the targeted diseases. China was envisaging a contribution to the Fund. As the Fund was new and its operation and application process were little known, WHO should help Member States to make good use of it by playing a bigger role in the application process, as well as in implementation and evaluation, and by providing support in technical matters, management and coordination. It was to be hoped that WHO, UNAIDS and the Global Fund would strengthen the capabilities and technical skills of the developing countries in the manufacture of drugs to enable patients to obtain medicines at more affordable prices.

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Dr AL KHARABSEH (Jordan) said that the Global Fund had refused applications for funding from some low-income countries with a high incidence of AIDS, tuberculosis and malaria. WHO should therefore work with the Fund to define the approval criteria and, where necessary, provide appropriate technical support through its regional offices to ensure the fulfilment of those criteria. Furthermore, as the custodian of global health, it should also support well-founded applications through dialogue with the Fund's administration. Lastly, the Fund should use some of its resources to promote prevention programmes in low-income countries where the incidence of the three diseases was still low, rather than wait until the problem got out of hand. Or ZAHER (Egypt) said that, in view of the threat to health posed by AIDS, tuberculosis and malaria, particularly in developing countries, the technical support which some countries had received from WHO in formulating their proposals to the Global Fund had been welcome. Developing countries should play an equal part in formulating the policies of the Fund and activities should be planned with due regard for their sovereignty and their own priorities. It was extremely important to ensure that tuberculosis and malaria did not compete with AIDS for attention. Or CHITUWO (Zambia) expressed his country's appreciation for the establishment of the Global Fund. As reflected in the report of the WHO Commission on Macroeconomics and Health, Zambia, like other developing countries, was finding it difficult to finance the delivery of health services. The Fund would help greatly in that area. The speed with which funds had been mobilized and committed was impressive, but the short period allowed for the preparation and submission of proposals had posed a challenge. Zambia, being at the epicentre of HIVIAIDS, tuberculosis and malaria epidemics, had suffered greatly from those diseases. The Government had accordingly adopted a multisectoral approach by establishing a National AIDS Council and secretariat, a cabinet committee on HIVI AIDS under the Minister of Health, a country-coordination mechanism for the Global Fund and strategic frameworks for all three diseases. Zambia awaited an official communication from the Global Fund concerning the outcome of its proposal, and looked forward to clear and simple guidelines for the disbursement of approved funds. He expressed the hope that his Government, which was committed to accountability and transparency in the use of such funds, would be trusted to channel them for the intended purposes. Or ISMAIL (Iraq) said that tuberculosis was a major contributor to his country's morbidity and mortality rates, whereas HIVI AIDS was rare, a situation which the authorities were striving to maintain. Although the incidence of disease was an important indicator of legitimate need for support from the Global Fund, preventive efforts should also be taken into account in assessing proposals, as should Iraq's previous preventive action against malaria. Consideration should also be given to providing support for countries under embargo, like Iraq, that were denied free disposal of their own national resources. Mr VARELA (Argentina) said that in order to ensure that the Global Fund would be an important mechanism in the fight against disease and underdevelopment throughout the world, it was vital to ensure flexibility, efficiency and transparency in its management and the active participation of all interested parties. In April 2002, the Fund's Board had approved a project submitted by Argentina, and its rapid implementation was expected to produce positive results. WHO and UNAIDS had an important role in the proper management of the Fund, and in project preparation as the recent approval of his country's project had demonstrated. It was important to keep in mind the global nature of the Fund and its aim of eradicating the targeted diseases throughout the world. Without prejudicing the special attention which the poorest countries deserved, the Fund should not focus on a limited group of countries but cover all areas in need.

COMMITTEE A: THIRD MEETING

Professor CHURNRURTAI KARNCHANACHITRA (Thailand) outlined the strong and proactive roles that WHO and UNAIDS had played at the global, regional and country levels in the upstream processes of the Global Fund, and urged them to continue that participation, particularly at the country level. Following the first round of applications, a number of downstream activities needed the attention of WHO and UN AIDS. At the global level, WHO had an essential normative role in two areas: quality assurance of drugs, and monitoring and evaluation. Approved proposals would create significant demand for diagnostics, drugs and other commodities, providing ample opportunity for WHO to play a crucial role in strengthening the quality standards of such products, particularly those manufactured in developing countries, through good manufacturing practices and certification. A fast-track system should therefore be established to provide technical support to developing countries in that field, and to promote the use of generic products and the strengthening of production capacity in those countries with a view to long-term financial sustainability. The Global TB Drug Facility, which was pivotal in ensuring quality products for the control of tuberculosis, should serve as a procurement agent for the Global Fund. WHO should provide the technical expertise for monitoring and evaluating the Fund's performance at the global level. At the regional and country levels, WHO and UNAIDS could contribute significantly to ensuring that country-coordinating mechanisms functioned well. WHO, UNAIDS, UNDP and other agencies might also perform a fiduciary role if country-coordinating mechanisms so required. WHO and UNAIDS would also be indispensable in ensuring that programmes were effectively implemented in accordance with the set targets and time frames, which would in turn ensure subsequent support from the Fund on the basis of performance and outcome. They could also assist country-coordinating mechanisms with programme monitoring and evaluation. WHO would have an additional role in strengthening national capacities for implementing sustainable programmes aimed at controlling the three diseases. Dr CHILD (Chile) said that the Fund was a powerful means of stimulating the development of innovative proposals that would contribute to the control of the three targeted diseases: it applied criteria that ensured the quality of the proposed projects and demanded achievable and relevant results that could be clearly evaluated. The Fund should in future be open to all countries able to justify their applications, which should be comprehensive and amenable to evaluation. Although the three diseases had different prevalence rates in different countries, control programmes always deserved support. However, prevalence and incidence should not be the only criteria for the allocation of resources. The Fund should be monitored on an ongoing basis and stimulate the exchange of experience in management practices. Chile hoped to participate in subregional efforts to tackle problems common to neighbouring countries. Such an approach should be among the most important criteria for the allocation of resources, the quality of the proposals being the most important factor. The first countries to embark on the process of managing the funds, one of which was Chile, should share their experience with subsequent recipients of funding. (For continuation, see summary record of the fourth meeting.)

The meeting rose at 16:05.

FOURTH MEETING Thursday, 16 May 2002, at 9:00 Chairman: Dr J. KIELY (Ireland) later: Dr S.P. AGARWAL (India) later: Dr J. KIELY (Ireland)

TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued) Mental health: Item 13.13 of the Agenda (Documents ASS/18 and ASS/18 Corr.1) Ms AELVOET (Belgium) said that the 450 million people reported to be suffering from mental or brain disorders, including alcohol and substance abuse disorders (paragraph 2 of document ASS/18) must not be excluded from public health programmes. New policies and legislation as well as additional investment were required to improve the mental health situation worldwide. WHO had a crucial role to play in that regard and its interest in that area was welcome. Belgium had emphasized the importance of mental health both in its own health policy and during its presidency of the European Union. In 2001, World Health Day and The world health report 2001 had generated greater awareness of mental health, and health ministers and senior health officials participating in the round tables at the Fifty-fourth World Health Assembly, had acknowledged the major threat to public health posed by mental illness and expressed their determination to take up the issue in their own countries. Following the adoption of resolution EB109.R8 entitled "Strengthening mental health", Belgium, in an attempt to consolidate the efforts of WHO and Member States and to ensure that mental health continued to be treated as a high priority, had prepared a draft resolution entitled "Mental health: responding to the call for action" that was supported by Australia, Austria, Canada, Finland, Luxembourg, Norway, Portugal and United States of America, and read: The Fifty-fifth World Health Assembly, 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 alcohol- and drug-related problems, resolution WHA30.38 on mental retardation, resolution WHA39.25 on prevention of mental, neurological and psychosocial disorders, and resolution EB109.R8 on strengthening mental health; Bearing in mind World Health Day 2001, the ministerial round tables at the Fifty-fourth World Health Assembly, The world health report 2001 on mental health, 1 and the multitude of activities initiated during 2000-2002 related to advocacy, policy and programme development, legislation, and research; Considering the imperative need to pursue and accelerate such activities worldwide in order to improve the mental-health status of populations, especially the most vulnerable groups; Welcoming the definition in The world health report 2001 of the activities related to promotion, prevention and care and to the protection of the human rights of people with mental illness and their families that all Member States can implement according to their level of priorities and resources in mental health; 1

The world health report 2001. Mental health: new understanding, new hope. Geneva, World Health Organization

2001.

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COMMITTEE A: FOURTH MEETING

Recognizing that the toll of mental health problems is very high and rising worldwide, that such problems cause significant disability, heighten the risk of social exclusion, and increase mortality, that stigmatization and discrimination are major problems obstructing the path to care, and that the human and economic costs are staggering; Further recognizing the need to maintain the momentum on mental health to raise public and professional awareness of the real burden of mental disorders, to protect the human rights of people with mental illness as an integral component of mental-health policies, and to implement strategies, programmes and policies as proposed in WHO's global action programme for mental health, URGES Member States: (1) to reaffirm the provisions of resolution EB109.R8; (2) to provide support to WHO's global action programme for mental health; (3) to increase investments in mental health both within countries and in bilateral and multilateral cooperation, as an integral component of the well-being of populations. Mr GUNNARSSON (Iceland), speaking on behalf of Denmark, Finland, Iceland, Norway and Sweden, supported the draft resolution. Mental health should be a key element of national health policies, because of its vital implications for the well-being of nations at all levels of social and economic development. Mental disorders were among the commonest health problems and accounted for more human suffering and loss of productivity than most other diseases. The Nordic countries also welcomed the report's emphasis on raising public awareness ofthe importance of mental health and its promotion. Mental health was included in the national health plans of all their countries and focused mainly on prevention, mental health determinants and early treatment. Mr ESKOLA (Finland) said that World Health Day 2001 and The world health report 2001 had brought the subject of mental health to the attention of decision-makers. WHO had an important role in ensuring prompt global action to give it due prominence in the field of public health and providing support to countries to ensure that mental health policies, services and treatment were kept under constant review, as requested in resolution EB109.R8. Priority should be given, in promoting the subject, to the mental health of children, which should be considered from all aspects rather than a restrictive, medical perspective. Help early in life should at least minimize problems later and guarantee a better future. Mental health, being subject to the vagaries of everyday life, should be regarded as the province of everybody, not one single professional group. People should therefore be given a say in the way it was dealt with, participation and sharing being the keynotes. Finland fully supported both resolution EB109.R8 and the proposed draft resolution. Mrs REEMANN (Germany) said that her delegation wished to sponsor the draft resolution. The world health report 2001 had highlighted a sharp increase in mental disorders, showing that stigmatization, discrimination and the refusal to recognize mental disorders as illnesses had led to a lack of treatment, care and support. Much progress had been made in Germany since the reform of its psychiatric services in 1975, but there were some shortcomings in nationwide coverage. Special attention needed to be paid to mental health education, destigmatization and the incorporation of mental health into countrywide health surveys to contribute to evidence-based strategies. Priority should be given to early detection, prevention and treatment. Dr ZAHER (Egypt), welcoming the report, said that in Egypt mental health disorders were a major concern. A special mental health department had been set up within the Ministry of Health; special treatment centres had been introduced for drug abusers and the number of mental health specialists had been increased. Medical training covered mental health. Treatment centres had been set

FIFTY -FIFTH WORLD HEALTH ASSEMBLY

up in most general hospitals, offering equal treatment for both sexes, and special telephone lines provided information and support for the mentally ill. Or VIOLAKI-PARASKEVA (Greece) said that all countries were facing an upsurge in mental health and psychosocial disorders. They were a leading cause of illness and disability, and the cost in human and material terms was high. The magnitude and severity of that "silent" epidemic was not yet fully appreciated by public health policy-makers. WHO should strengthen its leadership in the areas of legislation, indicators, diagnostic tools, coordination and research, and in protecting the rights of the mentally ill. Mental health programmes must be integrated horizontally with other related programmes. WHO had a crucial role to play in promoting national policies and providing technical support through research, training and information. Mental health should be linked to child health care and the mental health of schoolchildren, which did not receive enough attention. In a recent reform of its mental health system, Greece had launched a media information campaign to raise public awareness of mental health issues and to tackle stigmatization. With new legislation, it was trying to deinstitutionalize chronic psychiatric patients and encourage their reintegration into the community. Her delegation endorsed resolution EB 109 .R8 and, while fully supporting Belgium's draft resolution, proposed that a reference to resolution EURIRC51/R5 of the Regional Committee for Europe, on the Athens Declaration of Mental Health and Man-Made Disasters, Stigma and Community Care, should be added to the preambular paragraphs, and that a new preambular paragraph should also be added that would read: "Noting the existence of programmes which can prevent a significant proportion of these problems and thus reduce their negative social impact and human suffering". Mr JACKLICK (Marshall Islands) said that in view of the increasing concern in his country over the high incidence of recorded suicides and suicide attempts, often involving young adults, the Ministry of Health had changed from a curative to a preventive approach, placing mental health on a par with other public health programmes. Its objectives for the immediate future were to strengthen mental health policies, legislation and planning and to improve mental health services. Recognizing that community acceptance of mental health programmes was essential to their success, the Ministry was seeking to involve family members and the community in their development, and would continue to seek assistance from WHO for that purpose. Mr HOLMAN (New Zealand) supported the draft resolution and welcomed WHO's efforts to raise the profile of mental health, in particular the special effort being made to assist Member States without mental health policies. In that connection the policy and service guidance package being prepared for the 1st International Training Forum on Mental Health Policy-Making and Service Development, to be held in Tunis in November 2002, would make a valuable contribution to the discussions. His delegation agreed with the call in resolution EB 109 .R8 for increased investment in mental health. New Zealand had more than doubled its mental health expenditure in less than a decade, and had progressed a long way towards its "Blueprint" for more and better services. Or YAACOB (Malaysia) said that, in line with the mental health Global Action Programme and the recommendations of The world health report 2001, Malaysia was taking steps in four key areas: treatment and psychosocial rehabilitation in primary care; the provision of psychotropic drugs at primary health care outlets; community care; and the promotion of mental health through healthy lifestyle campaigns. Malaysia looked forward to working with WHO and other agencies on research into the effectiveness of psychosocial rehabilitation, the follow-up treatment of mentally ill patients, and in relation to the knowledge, attitude and practice of multidisciplinary teams in providing psychosocial rehabilitation in health clinics.

COMMITTEE A: FOURTH MEETING

Mrs TSENILOV A (Ukraine) agreed with the emphasis in the report on the psychological and socioeconomic consequences of mental health problems. More than one million people suffered from mental disorders in Ukraine. Legislation adopted in 2000 had reformed the country's psychiatric care services by taking into account the rights of the individual, and providing for additional medical services, including psychiatric services. The abuse of psychiatry for political purposes had disappeared. Attitudes towards mentally ill people were gradually changing, with the assistance of the Church and the mass media. World Health Day 2001 had been particularly important for promoting mental health and encouraging governments such as hers to draw up long-term plans and priorities for intersectoral cooperation in mental health. Her delegation supported the draft resolution. Dr OTTO (Palau), welcoming the concise and comprehensive report, emphasized the impact of mental disorders on the children and family members ofthose affected, as described in 2001 by a 17year-old girl from Palau in a prize-winning essay that she had read out in a plenary meeting at the Fifty-fourth World Health Assembly. The ministerial round tables the same year had discussed armed conflict as an important determinant in mental illness. The Convention on the Rights of the Child required States to protect children from and in armed conflict. Palau endorsed resolution EB109.R8 and supported Belgium's draft resolution to which he proposed the addition of a fourth paragraph that would read: "(4) to strengthen action to protect children from and in armed conflict". Mr ASLAM (Pakistan) said that in 1986 his country had been the first in its region to develop a national mental health programme, which had subsequently been integrated into primary health care. Legislation had been promulgated in 2001. Mental health indicators had been incorporated into the health management information system, and mental health programmes had been introduced into schools. Pakistan had provided training within its region, and had contributed to the mental health monograph Reaching the unreached: strengthening mental health programmes in the countries of the Eastern Mediterranean Region. 1 Successful strategies included modifying and extending the role of mental health professionals beyond the confines of clinical psychiatry to devising behavioural interventions to deter the harbingers of mental illness. Most interventions for mental health involved other disciplines and sectors, so mental health professionals needed to build intersectoral alliances. Professor SMALLWOOD (Australia) said that his country would welcome regular updates from WHO on progress in mental health, and agreed with the identification of the core strategies of information, policy and service development, advocacy and research as fundamental to the promotion of mental health. His Government perceived an unmet need for mental health services by populations susceptible to mental disorders, specifically those living in conditions of chronic poverty and insecurity, and had provided A$ 500 000 to WHO for the development and implementation of the Regional Strategy for Mental Health endorsed by the Regional Committee for the Western Pacific at its Fifty-second session (resolution WPC/RC52.R5). Dr AKSAKAL (Turkey), supporting the draft resolution, said that in health services the goal of mental health needed the improvement of services and the control of mental and neurological disorders. It was important to integrate mental health services into primary care. Another major principle of health care should be to improve social awareness and combat ignorance and prejudice through intersectoral cooperation. Studies were in progress in Turkey on the integration of mental health services into primary health care, and efforts were being made to increase public awareness. Mr NACUVA (Fiji) expressed his appreciation of the report in document ASS/18. Depression accounted for over 50% of mental disorders in Fiji, and was compounded by factors such as drug and

WHO, Regional Office for the Eastern Mediterranean, in press.

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substance abuse, and increased suicidal tendencies, especially among adolescents and females. The situation was further aggravated by poverty and the weakening of family and traditional ties. Fiji had strengthened outreach activities such as domiciliary follow up, community psychiatric nursing and education for the relatives of psychiatric patients through its comprehensive integrated health system. The core strategies identified by WHO needed to be reinforced and properly coordinated. He supported resolution EB 109.R8 and the draft resolution. Dr LEVENTHAL (Israel) said that his country was reforming its mental health services to integrate them into primary health care, not an easy task but an important one. Mental health promotion, including prevention, could be a bridge between nations at local and regional levels, given the leadership of WHO. He endorsed resolution EB109.R8 and supported the draft resolution, with the amendments proposed by Greece and Palau. The CHAIRMAN explained that the only resolution for the Committee to consider was that proposed by Belgium. Resolution EB109.R8 had been adopted by the Executive Board but was not before the Health Assembly. Dr ANTEZANA ARANIBAR (Bolivia) reminded delegates that the concept of mental health had been part of the Constitution of WHO since its inception 55 years previously. Since then, however, mental health had become identified with psychiatric health or ill-health. Psychiatry had made great strides in the more developed countries, where stress, for example, had become an important factor, but in the poorer countries stress was a luxury few people could afford. It would not be appropriate to amend the draft resolution by including a reference only to the European Region as proposed by Greece. Two aspects were of paramount importance but had been mentioned only indirectly. The first was the need to protect the mental health of children, who were exposed to adverse behavioural patterns and strong media influence, especially from television, that could provoke mental illness in later life. Secondly, WHO action in the field of mental health should focus on those influences, and not promote mental health and education solely from a clinical point of view. There should also be better coordination between the various programmes. Dr LEGNAIN (Libyan Arab Jamahiriya) said that her country was endeavouring to develop its medical services to cope better with mental disorders. There was no alcohol or drug abuse, but many cases of depression. WHO should play a leading role in bringing about peace and security in the world, since armed conflict was a cause of mental disorders. Dr HEIBY (United States of America) expressed support for WHO initiatives in the field of mental health, including its Global Action Programme. In the past two years his country had provided substantial support for those initiatives, in the form of personnel and technical assistance. In the United States, a new National Commission on Mental Health Services would be responsible for studying gaps in current mental health provision, and making recommendations for improvement, taking into account the views of nongovernmental and community-based organizations. Discriminating practices and stigmatizing attitudes were often barriers to mental health treatment, and treatment limitations on mental health care by insurers often blocked effective care. However, mental illness, like physical illness, was treatable, especially at an early stage. His country looked forward to sharing knowledge, experience and techniques in implementing the mental health Global Action Programme, and was pleased to sponsor the draft resolution. Mr KEENAN (Ireland) welcomed the work of WHO to promote mental health. The draft resolution proposed by Belgium maintained a sharp and appropriate focus on mental health at Member State and WHO levels. The call to protect the human rights of the mentally ill in resolution EB109.R8 was particularly important. Action should embrace a range of approaches, including communityoriented mental health services as an alternative to institutional care, increased child and adolescent

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and old-age psychiatric services, enhanced support to voluntary agencies, support for advocacy services and the development of a policy framework for the modernization of mental health provision at national level. Professor PEREIRA MIGUEL (Portugal) said that mental health needed strategic and systematic action. His government had distributed a Portuguese translation of The world health report 2001 on mental health and intended to participate in the Global Action Programme. Professor SZCZERBAN (Poland) said that his delegation wished to sponsor the draft resolution. His country's mental health programme had been designed as a means of implementing WHO's mental health Global Action Programme, by reflecting its goals. In Poland, mental health monitoring systems would provide evidence-based information as a contribution to an international observatory on mental health. The human rights of the mentally ill would be protected, and anti-stigmatization programmes introduced in all population groups, in collaboration with the media. Applied research would aim at developing new methods of mental health promotion, treatment and rehabilitation. Dr FURGAL (Russian Federation), expressing his support for the draft resolution, welcomed WHO's increasing role in fostering improved services for people with mental disorders. The world health report 2001 made a significant contribution to international understanding of the importance of mental health in social development. WHO should be attentive to developing new mental health services as part of primary health care and to stimulating intersectoral cooperation. Member States needed support from WHO in training mental health professionals and in developing national policies, programmes and legislation. Mr CIGOGNA (Italy) said that he shared the concern of other delegations about the high toll of mental disorders, and welcomed WHO's efforts to promote mental health. His delegation wished to sponsor the draft resolution. Italy looked forward to the implementation of the WHO five-year programme of support to Member States to strengthen their capacity to reduce the risk, stigmatization, and the burden of mental health disorders. Dr JIRUTH SRIRATANABAN (Thailand) said that Thailand had welcomed The world health report 2001 on mental health. Its recommendations to involve families, communities and consumers, and to create intersectorallinks were especially relevant in Thailand's fight against drug and substance abuse. The education sector, the military sector and society at large all had a role to play in formulating innovative strategies to overcome deteriorating family and community bonds, poverty, corruption and poor life-management skills. WHO should recognize the importance of multisectoral approaches and provide technical support to developing countries to enable them to implement the recommendations in The world health report. Mr NAIK (India) said that in his country about 1% to 2% of the population suffered from serious mental disorders and a further 5% to 10% were affected by other mental health problems, including depression. Given the size of his country's population, those figures represented a massive public health problem. Increasing life expectancy had resulted in an increase in psychogeriatric problems for which pragmatic and cost-effective strategies had been developed, such as communitybased care and the integration of mental health into existing primary health care services. Psychotropic drugs also offered low-cost solutions and the traditional close family ties were helpful. A programme of information, education and communication had been launched, as part of the new five-year plan, to combat the prejudice and superstition surrounding mental disorders. A national mental health programme had been introduced in India in 1982, and spending on mental health in the new five-year plan would be more than seven times the level of the previous one. The district mental health programme would be extended to 100 districts. Psychiatric training departments would be strengthened, existing psychiatric hospitals modernized, and research on mental

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disorders would be initiated. Following the ministerial round tables held at the Fifty-fourth World Health Assembly, discussions had been held at various levels in India to draw up a national plan of action for mental health in the Indian context, and a national symposium had been organized to reflect on the The world health report 2001. India fully supported the WHO global action programme for mental health. Or QI Xiaoqiu (China) said that mental disorders did not merely harm individual health, but also affected economic development and social stability. Action to promote mental health was therefore vital. The global and regional mental health prevention and control strategy formulated by WHO in the Western Pacific Region provided important guidance. In recent years WHO had done much valuable work on mental health and should in future focus on high-priority areas for action in the Member States. Given the need to strengthen m~ntal health measures, and the difficulty of prevention and control, WHO should ensure appropriate budgetary support for the recommended measures. Or TSHABALALA-MSIMANG (South Africa) said that document A55/18 appeared to criticize, perhaps justifiably, Member States for their poor financial support for mental health programmes. However, less than 1% of the WHO budget was devoted to mental health, and the Organization found it difficult to raise sufficient extrabudgetary funds to meet its objectives in supporting Member States. WHO should increase its own mental health budget and capacity as it recommended its Member States to do. South Africa supported the draft resolution. Mr CHAKALISA (Botswana) welcomed WHO's efforts to strengthen mental health services and raise public awareness of mental illness. Botswana was in the process of introducing a mental health policy to provide greater access to mental health ::;ervices and integrate them into general health services. The policy emphasized destigmatization and the protection of the rights of the mentally ill. Mental health legislation would be updated and a substance abuse strategy developed with the support of WHO. The Organization should continue to provide support to Member States for mental health. His delegation supported the draft resolution. Or KHAZ' AL (United Arab Emirates) said that her delegation supported the draft resolution and endorsed the view expressed by Finland, highlighting the importance both of focusing at an early stage on the prevention of mental health disorders and of strengthening lifespan approach programmes to that effect. It also supported the amendment proposed by Palau. Ms NGHATANGA (Namibia) welcomed the comprehensive information given in the report. In addition to introducing the necessary legislation, Namibia had developed a community-based programme for mental health problems. Mental health services were an integral part of primary health care. Namibia supported the draft resolution but would prefer greater emphasis to be placed on human resources development for mental health, and investment in training and capacity-building for mental health workers. Or PARIRENYATWA (Zimbabwe) welcomed the draft resolution and The world health report 2001. Psychiatric services in Zimbabwe encompassed both mental illness and learning disabilities. There were multiple causes of mental illness, including poverty, unemployment and HIV/AIDS which, by orphaning young children, often provoked early-age mental stress which in turn could lead to drug abuse. Zimbabwe had sought to decentralize services to the primary care level and increase the number of psychiatric nurses. It was also endeavouring to boost the provision of psychotropic drugs. Emphasis was being placed on community-based rehabilitation programmes, rather than treatment in institutions. WHO should continue strengthening mental, health programmes in the Member States.

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Dr RAMATLAPENG (Lesotho) supported the draft resolution. To take account of Lesotho's largely rural population, mental health care had been integrated into primary health care. Mental health legislation was being updated to ensure equal access to mental health care and to safeguard the dignity and rights of those suffering from mental illness. Dr GONZALEZ FERNANDEZ (Cuba) said that mental health problems, like other chronic noncommunicable diseases, and disorders reduced the productivity of those affected, their families and their carers. Although awareness and understanding of mental health problems had improved at all levels, there was nevertheless a severe shortage of resources to tackle them, as indicated in paragraph 7 of the report. WHO should therefore encourage the creation of intersectoral alliances, at the national and international levels, between developed and less developed countries, for the pooling of efforts and resources. At the same time, with the redirection of psychiatric services into primary health care services becoming a worldwide trend, WHO and the Member States should incorporate into primary health care comprehensive intersectoral and community-based mental health strategies. Cuba supported the proposed draft resolution, but was under the impression that all resolutions approved by the Board were submitted to the Health Assembly for adoption, including resolution EB109.R8. Dr DUNCAN-GOFFE (Jamaica) said that The world health report 2001 was a landmark publication that attempted to dispel stigmatization and discrimination and highlight the problem of inadequate mental health services. Jamaica had a newly-developed strategic mental health plan extending to 2006, with objectives similar to those in the WHO report. Mental health was an integral part of the health promotion strategy. Health system reforms had reduced the number of hospital inpatients by 50%, and the integration of mental health into primary health care was continuing, with the training of mental health professionals to diagnose and treat depression. Professor ZIDOUNI (Algeria) welcomed The world health report 2001. Algeria had had a mental health programme in place since October 2001, and was keen to develop outpatient centres where mental health services could be integrated into primary health care. Those centres would not merely be drug-dispensing clinics, but would have a psychosocial approach to treatment, with the aim of replacing institutional care by care in the community. International experience and additional funds would be needed to achieve those goals. Mr ARRIAGA (Mexico) said that Mexico was strongly committed to mental health care. A mental health action programme had been developed as an integral part of the national health programme, giving high priority to depression, schizophrenia, dementia, epilepsy, child development abnormalities, attention deficit disorders, Parkinson's disease and psychological treatment for trauma following disasters. Mental disorders affected between 15% and 18% of the population. The action programme was fully consistent with the recommendations in The world health report 2001. It gave special attention to the development of mechanisms for the early detection and timely treatment of mental health problems, the creation of an essential medicines list and guaranteed supplies, and the creation of a countrywide model for mental health care. Also in line with the report's recommendations was the priority given to education of the public, with a view to eliminating discrimination and the stigmatization of the mentally ill. Community involvement was important, as were the regulation of psychiatric care and psychosocial rehabilitation and the forging of links with higher education. Finally, it was important to determine the extent of mental health problems and to promote basic and epidemiological research into mental health issues. Mexico would be holding a high-level meeting on neuroscience and addiction in June 2002, and was liasing with WHO for that purpose.

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Dr UHAGAZE (Rwanda) said that, following the ·1994 genocide, mental health had become one of Rwanda's five top health priorities. Mental health activities had been decentralized, but were not yet integrated into primary health care. Urgent measures, such as training for trauma counsellors, teachers and health workers, were under way, so as to ilelp communities to fight stigmatization and encourage the mentally ill to seek treatment. The lack of resources posed a constant problem. Rwanda was expecting further mental health problems to surface among both perpetrators and victims once the genocide trials began. Training had already started in order to cope with those problems. WHO's focus on mental health was welcome. Dr OULD MOHAMED VALL (Mauritania) said that the rapid transformation of Mauritanian society from a nomadic to an urban one since the 1970s had brought about the near-collapse of the former social systems that had ensured that the sick, including the mentally sick, were cared for. A national mental health programme had been in plact:: for over a year that aimed at promoting decentralization by providing mental health care services at community level and integrating them into primary health care. Essential psychotropic drugs were being included in the list of basic medicines, and doctors and technicians were receiving specialist training in mental health. However, limitations were imposed by the sociocultural background and the importance of traditional healers in society. With assistance from the WHO Collaborating Centre for Research and Training in Mental Health in Paris, a survey was being undertaken to establish guidelines for the country's future mental health programme. His delegation supported the draft resolution. Dr KAMARA (Sierra Leone) compared the situation in Sierra Leone to that in Rwanda. After a decade of war, the prevalence of psychosocial disorders had risen, with more drug use and, increasingly, post-traumatic stress disorder. The capacity to deal with the problem was limited; the country had only one trained psychiatrist, and its o ttly psychiatric hospital had been seriously damaged. He therefore supported the draft resolution, in the hope that Sierra Leone could depend on WHO and friendly countries for support in tackling its problems. Dr KULAKSASOW (Bulgaria) said that in his country, as elsewhere, the economic burden of mental disorders was not fully recognized. Bulgaria had an official policy on mental health, adopted in 2001, and was in the process of changing its mental health legislation in line with that policy. Psychiatry was being restructured from institutional to community care, to provide outpatient centres as well as psychiatric wards in general hospitals. Bulgaria had two main problems in the area of mental health: the social exclusion of the mentally sick and their families, for which a destigmatization programme was needed, and prevention of and early intervention in psychosis, whose etiology and approaches to care were still, unfortunately, marked by totalitarian thinking. Recommendations on destigmatization and prevention might usefully be added to the draft resolution. Dr FLACHE (World Federation for Mental Health), speaking at the invitation of the CHAIRMAN and also on behalf of the World Psychiatric Association, welcomed document AS 5/18, with its accurate portrayal of the present grim situation. He fully shared its views on the crucial role of primary health care, advocacy, policy and programme development, legislation and research, the emphasis on vulnerable groups and the protection of the human rights of sufferers from mental illness. The mental health Global Action Programme, in particu,lar, brought a message of hope to millions and had his organizations' full and enthusiastic support. They intended to play a positive role in that endeavour. DrY ACH (Executive Director), replying to points raised, said that it was clear from the debate that the call for global action had been taken up. At headquarters and regional level, WHO was gearing up to meet the increased needs for technical support, and welcomed the indications of continuing and increased support. Cuba's suggestion to build stronger partnerships between developing and developed countries would be pursued. The importance of family and community

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action involving consumers and nongovernmental organizations and deep intersectoral action to promote mental health had been mentioned by many Member States. Speakers had also mentioned the impact of profound social, political and economic change on mental health. WHO was already heavily engaged and would be increasing its activities in the area of mental health as it could provide a valuable bridge between countries and communities in conflict and post-conflict situations. He had noted the request by Australia for regular updates, which would be followed up in the form of information on best practices. For that purpose, WHO had been strengthening its work on prevention and promotion in the context of mental health. The CHAIRMAN said that he took it that the Committee wished to note the report and approve the resolution as amended. It was so agreed. 1

Dr Agarwal took the Chair. Global Fund to Fight AIDS, Tuberculosis and Malaria: Item 13.4 of the Agenda (Documents ASS/8, ASS/8 Add.1 and ASS/INF.DOC./6) (continued from third meeting) Dr LEGNAIN (Libyan Arab Jamahiriya) urged WHO to assume a greater role in supporting the Global Fund and providing it with competent administrative staff and technical assistance. Dr TSHERING (Bhutan) urged WHO to play a strong role in providing support to Member States in the form of technical assistance, and assistance in coordination and networking. Developing countries also needed assistance to strengthen their capacity to manufacture drugs for AIDS, tuberculosis and malaria and to focus on generic products, which would be cost-effective and more accessible to developing countries. Dr ASAGBA (Nigeria) welcomed the establishment of the Global Fund. Three of the five proposals submitted by Nigeria had been approved, and a positive response to the other two was expected. Nigeria had embarked on an ambitious programme to improve access to antiretroviral drugs, targeting 10 000 adults and 5000 children. The first two batches of medicines were already being distributed. Another programme aimed to prevent the mother-to-child transmission of HIV. Organizations in the United Nations system, especially UNICEF, and the private sector were providing the necessary material and technical support. The HIV reagent revolving funds scheme had been put in place in all major hospitals in Nigeria, to ensure safe blood transfusions and facilitate diagnosis of HIV/AIDS. As its contribution to Roll Back Malaria, Nigeria was promoting the use of bednets treated with insecticide, improving home management of malaria and initiating preventive treatment of pregnant women. A strategic plan for Roll Back Malaria had been drawn up for the period 2001-2005. Tariffs on mosquito nets had been reduced from 25% to 5% and insecticides for bednets were zero-rated. The strategy of directly observed treatment, short course to combat tuberculosis was in full force; 70% detection and 85% treatment rates had been achieved in 21 states. Dr BELLO DE KEMPER (Dominican Republic) said that the Caribbean region had the second highest prevalence of HIVIAIDS in the world, sexual transmission being the main route of HIV infection. In April 2002, the Caribbean Network of Young People on HIV/AIDS had met for the first time in the Dominican Republic, with members signing an agreement aimed at halting the progression of the disease in the region and ensuring consistency in preventive programmes. In 1999 adolescents

1 Draft resolution transmitted to the Health Assembly in the Committee's first report and adopted as resolution WHA55.10.

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had accounted for 22% of reported cases ofHIV/AIDS. Another factor in the spread ofthe disease was sexual exploitation due to poverty. The country's health authorities had drawn up a strategic plan, through a participatory process, to identify and treat seropositive pregnant women. However, national resources were limited, and the establishment of a Global Fund was most opportune. The Dominican Republic needed the support of the Fund and hoped to re~eive advice from WHO and UNAIDS. The Fund should support regional as well as national projects. She expressed the hope that the Dominican Republic and Haiti could be assisted on a bilateral basis, especially for programmes in border areas. The health authorities of the two countries were already working together on malaria control, with assistance from WHO and PAHO. Prevention campaigns and bilateral cooperation between hospitals, as mentioned by Italy, might well prove valuable in controlling AIDS. Or PARIRENY ATWA (Zimbabwe) said that his country was one of those in the Southern African Development Community most severely affected by the AIDS pandemic, with 70% to 80% of hospital admissions being attributable to HIV/AIDS-related illnesses. In an effort to fight the pandemic, Zimbabwe had mobilized domestic funds through an "AIDS levy" of 3% of taxable income, which had so far yielded 2000 million Zimbabwean dollars. The money was used to assist orphans and people living with AIDS and to provide drugs for opportunistic infections. The US$ 1900 million mobilized by the Global Fund so far was still far short of the targeted US$ 10 000 million. Despite its harsh economic situation, in 2001 Zimbabwe had pledged US$ 1 million to the Fund. He expressed the hope that representation in the Fund's structures would reflect the areas that had the highest burden of disease. Given the cost of caring for orphans, lost work days, opportunistic infections and general ill-health the use of antiretroviral drugs was cost-effective. Ms GARVAL (Denmark) welcomed the Global Fund as proof of the political will of the international community to join forces in confronting devastating pandemics. If the apparent initial success of the Fund in granting assistance to 40 programmes in more than 31 countries was to be sustained, and a massive escalation of the diseases prevented, challenges had to be met. Denmark was anxious that the process should be monitored and evaluated to ensure that the funds available were granted to the poorest, most seriously affected countri{:s, that they were used to implement existing national strategies and programmes, and that a balanc{: was achieved among the three diseases and between prevention and treatment. As the Fund had not yet attracted the financial resources it was estimated to need, WHO should continue its efforts to obtain private sector grants. She commended the valuable contribution of WHO and UNAIDS to the establishment of the Fund, and supported continuing WHO involvement in its administration at the central and local levels. Dr Kiely resum•~d

the Chair.

Or RAFILA (Romania) confirmed his country'~. interest in applying to the Global Fund for assistance with specific projects to combat HIVIAIDS and tuberculosis. However, in many cases countries in the same region shared common problems, so resources might be better used for regional or subregional projects than for national ones. Or SHANGULA (Namibia) said that, when the Global Fund had been established, two important principles had been accepted: that those affi!cted by the diseases must be involved in its governance and that the burden of disease must be the determining criterion for resource allocation. Although making the Fund operational could not be expected to be problem-free, there appeared to be many problems, most of them concerning representation, lack of information about the operation of the Fund, unclear guidelines for the submission of proposals, and the criteria for the approval of proposals. The evaluation of the first round of proposals showed that substantial overhaul was needed. According to document ASS/8 Add.l, of 300 proposals submitted only 40 had been approved. The basic problem was that the application procedure had changed from an intervention-based exercise to an academic one. That implied that countries that could not draft good proposals would never benefit

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from the Fund, irrespective of the gravity of their disease burden, compromising the principle of equity, which was so important in public health. For instance, Namibia's proposal for strengthening its programme to prevent mother-to-child transmission ofHIV had been turned down. The Fund's operation should be consistent with the original"principles. Another mechanism, apart from the submission of proposals, must be added to enable affected countries to benefit. There were sufficient tools and methodologies available to enable the governance of the Fund to compute objective composite indicators that would allow a fair and equitable distribution of funds, taking into account the burden of the disease, population size, demographic indicators, the poverty index and socioeconomic indicators. Unless the Fund abandoned its current approach, it would become entangled in a mesh of problems it could never resolve. As the United Nations Secretary-General had said, it was unacceptable that people should continue to die because they had no access to antiretroviral drugs. Mr BRUNET (France) said that his country had provided financial support to the Fund and regarded its establishment as a success, which was not to say that there was no scope for improvement. He drew attention to the opportunities for cooperation between the Fund and the hospital partnership network set up by France, Italy, Luxembourg and Spain. Under the auspices of national programmes and with the participation of nongovernmental organizations, the network scheme promoted the exchange of experience and expertise, and training and capacity building. It was designed to strengthen the care structures necessary to improve access to drugs in the most severely affected countries. Already contacts had been established between French hospitals and hospitals in 20 other countries, and a dozen partnerships would come into being in 2002. The initiative was intended as an additional tool to help the hardest hit countries to provide the necessary treatment to people living with HIVIAIDS. Far from fragmenting efforts, it would serve to complement activities supported by the Global Fund. Dr AGARWAL (India) said that despite the huge burden ofHIVIAIDS in India, where some four million people were thought to be infected, the Global Fund had not approved any applications from India for HIVI AIDS-related projects. India also had about two million cases of malaria, but a proposal to scale up the Enhanced Malaria Control Project to four states with 58% of all malaria cases, which would have significantly reduced morbidity and mortality due to malaria, had not been approved. The prevalence of tuberculosis was about 1.5%. A proposal to extend the Revised National Tuberculosis Control Programme to cover an additional 56.2 million population with poor socioeconomic indicators had been accepted by the Fund. Tight deadlines and the eligibility criteria had probably been responsible for many unsuccessful applications to the Fund, and he noted that more flexible criteria were under consideration. He expressed the hope that, at its next meeting, the Board of the Fund would add to its criteria the disease burden and the capacity of a country to absorb funds. Dr DUNCAN-GOFFE (Jamaica) said that countries in the Caribbean Region had the second highest prevalence rate of HIVI AIDS after sub-Saharan Africa. In view of their limited resources, they had established a Pan-Caribbean Partnership against HIVIAIDS involving both governments and the private sector. She requested a modification of the eligibility criteria for the Fund to extend its benefits to small island States such as Jamaica, which were classified as developing countries but did not fall within the prescribed per capita income range or gross domestic product. She expected the Fund to improve relationships between donors and recipient nations, to provide technical and financial support, and to reduce inequity. She looked forward to the Fund's support for projects in the Caribbean. Dr TSHABALALA-MSIMANG (South Africa) voiced her support for the Fund and for the draft resolution. She noted that 40 proposals had been approved since the Fund had been established, and that many more were in the pipeline. She expressed concern that the current resources of the Fund, which were well short of the target set by the United Nations Secretary-General, would be insufficient

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to meet the requirements for tackling the three diseases. She expressed concern also about the sustainability of the Fund; additional resources and greater accountability were needed to ensure that programmes received adequate long-term support. One of the most important principles of the Fund must be to strengthen national health systems by implt:menting integrated programmes, rather than vertical ones, against HIV/AIDS, tuberculosis and malaria. Developing countries, particularly those with the highest burden of the diseases in question, were currently underrepresented at all levels of the administration of the Fund, including the Board, the Interim Secretariat and the technical working groups. A quota system might help to solve that problem. The Fund should also provide countries with simple and clear guidelines for submitting proposals, and on the review processes involved. Proposals should be submitted through the country-coordinating mt:chanisms. She proposed that those which had not been so submitted should be returned for endorsement and resubmission. South Africa had pledged a donation of US$ 2 million to the Fund. Dr KUNENE (Swaziland) thanked WHO· and UNAIDS for their technical support during the preparation of his country's coordinated proposal. However, Swaziland had been dismayed to learn via the Internet that it had not qualified for the extra resources needed. There had been no official communication from the Secretariat of the Fund to tht:: country-coordination mechanism, making it difficult to begin the process of resubmitting the proposal. Swaziland had one of the highest rates of HIV infection in the world, but owing to fiscal constraints had been unable to launch an adequate national response. He suggested fast tracking of the proc,;:ss of resubmission and review of coordinated country proposals from the first round, and urged the Board to consider unsuccessful proposals from the first round as "proposals in the pipeline", without waiting for the September cycle. He urged better communication between the Fund Secretariat and the country-coordinating mechanisms, and requested a simplified set of guiding principles and criteria for the preparation and submission of proposals. The adjudication process should be more transparent, in line with the disease burden. WHO and UNAIDS should have a more visible role in the Board, and the Board's membership should reflect the countries most affected by the diseases concerned, especially those of sub-Saharan Africa. Dr SUAREZ OGRIO (Peru) welcomed the creation of the Fund. HIV/AIDS, tuberculosis and malaria were serious public health problems in Latin American countries, including the Andean region. Bolivia, Colombia, Ecuador, Peru and Venezuela had prepared a proposal for a regional malaria-control project. Vivax malaria was hyperendemic in Peru and affected the poorest in the population; falciparum malaria had re-emerged, and n:sistance to antimalarial drugs was appearing rapidly. The Andean group of countries also planned to submit proposals for projects to combat HIVIAIDS and tuberculosis. Greater equity was needed in the funding of projects where the problems were gravest. He expressed the hope that his group of countries would receive technical support from WHO headquarters, regional offices and UNAIDS in drafting proposals. Mrs PHUMAPHI (Botswana), speaking on behalf of the Member States of the African Region, said that the African ministers of health attending the Health Assembly fully supported the Fund, and viewed it as a unique opportunity to generate additional funds to scale up the fight against the three diseases and strengthen health systems. All countries in the region were encouraged to take advantage of the Fund. However, the African ministers were conc,erned for the future of the Fund and urged the international community to honour current pledges and to commit additional resources commensurate with the scale of the epidemic. To improve the operation of the Fund, the roles of alternate Board members and observers needed clarification. The African Union should be offered the same membership status on the Board as the European Union, and the composition of the Secretariat, the technical committees and the working groups should be more equitable, with one-quarter of the members coming from the African Region. In the light of the experience of African countrie:; with the first call for proposals, the gaps and weaknesses in the current technical review process should be identified and corrected. Procedures should be simplified and user-friendly guidelines produced on the preparation, submission and

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evaluation of proposals. Greater clarity was needed in the eligibility criteria. In addition, all proposals should be submitted via the country-coordinating mechanisms. There should be an interactive approach in communicating with countries, so that they did not have to learn the outcome of their proposals from the Internet before hearing directly from the Fund. The technical review process should respect the priorities identified by individual countries regarding the allocation of resources to prevention, treatment, care and support because those priorities were anchored in national and regional frameworks and programmes. No proposal should be considered by the Fund until it had passed through the country-coordinating mechanism. Regional proposals from recognized regional bodies, which had the advantage of harmonizing regional strategies for preventing, controlling and treating diseases, including the sharing of information and best practices, should receive the approval of the Fund's Board. The distribution of funding should ultimately reflect the burden of disease. Dr MSA MLIV A (Comoros) said that, although his country had a low prevalence of HIV (0.11 %), the number of cases had continued to increase annually since the first case of AIDS had been diagnosed. Comoros had been the first country to submit a proposal to the Fund, for a project on the prevention of HIV IAIDS among young people, and for a community-based project to control malaria. No official response had yet been received; but he had learned from unofficial sources that there were logistical and language problems with the proposal, which had been submitted in French. There appeared to be shortcomings in the management of the Fund. WHO and UNAIDS should assume a greater role, given their ability both to provide the necessary technical assistance to countries wishing to submit proposals for projects and to resolve communication problems. Professor OMASWA (Uganda) endorsed the statement made on behalf of the Member States of the African Region. Uganda was and would continue to be an active participant in the Fund. It had pledged US$ 2 million to the Fund, and would contribute in other ways to ensure its success both globally and in Uganda. Dr MAHJOUR (Morocco) said that the creation of the Fund reflected the commitment of the international community to combat HIVI AIDS, tuberculosis and malaria. Strengthened technical support from WHO and UNAIDS to countries preparing proposals was essential to ensure that they met the criteria laid down, especially the need for a national strategic plan. The country-coordinating mechanisms were valuable for discussion and consultation among all involved at the country level, including representatives of civil society. Dr THAPA (Nepal) said that HIVIAIDS, tuberculosis and malaria were among the major causes of death and morbidity in her country. The additional contribution of the G8 countries to combat those diseases at country level and the suggestion by the WHO Commission on Macroeconomics and Health that rich countries should set aside, towards saving the lives of the poor, US$ 0.01 for every US$ 10 spent were much appreciated. That suggestion applied equally to the rich in poor countries. The real test of the Fund would be its success in benefiting the poor at country level. It was important to ensure that the additional funds were not used to create vertical mechanisms and projects. Nepal's National AIDS Council was a new mechanism for mobilizing partnerships between the public and private sectors, and for improving access to high-quality services through the existing health system. Additional funds should be channelled in the same way. Because of time constraints and the complicated nature of the guidelines, none of the proposals submitted by Nepal had been accepted. WHO should provide additional technical support at country level to assist countries in preparing their proposals. Countries also needed the support of WHO in ensuring the quality of the drugs they produced for the treatment and prevention of the three targeted diseases. UNAIDS should also be associated with those activities.

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Dr PlOT (UNAIDS) said that about US$ 10 000 million annually were needed to fight AIDS. At present, about US$ 2000 million were being spent in low- and middle-income countries. The Fund was one of the mechanisms to fill the gap. The Secretary-General of the United Nations had not called for all the US$ 10 000 million to form a single fund. The money was provided by national governments, bilateral donors or international financial institutions and the Global Fund. The Global Fund was a unique opportunity to mobilize additional resources. Already, in 2001-2002 it had increased the funds available by 50%. UNAIDS and the Secretariat and cosponsors of the Fund fully supported the principles on which it had been founded., and which underpinned its framework and operations. The Fund was a new financial mechanism, not an agency, and worked in a complementary way with existing programmes and agencies, including those in the United Nations system. Its processes were country-led, and were intended to strike an appropriate balance in its support for combating the three diseases, and between prevention and treatment for HN. The Fund had received an enormous number of proposals, which showed that many countries were ready to implement programmes when funds were made available. However, as a new type of multilateral organization, the Fund had its own difficulties with respect to its governance, transparency and linkages with development; much more thought was needed on how to deal with them. The roles of UNAIDS, WHO and other agencies in the United Nations system were clear, both upstream and downstream, as outlined by the delegate of Thailand, particularly in normative issues, the fiduciary and programme function, implementation, monitoring and evaluation. The Fund needed an annual increase of 50% in its resources for fighting AIDS in low- and middle-income countries.

The meeting rose :at 12:25.

FIFTH MEETING Thursday, 16 May 2002, at 14:35 Chairman: Dr J. KIELY (Ireland) later: Dr S.P. AGARWAL (India) later: Dr J. KIELY (Ireland)

TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued) Global Fund to Fight AIDS, Tuberculosis and Malaria: Item 13.4 of the Agenda (Documents A55/8, A55/8 Add. I and A55/INF.DOC./6) (continued) Dr CASSELS (Director-General's Office) said that the Global Fund to Fight AIDS, Tuberculosis and Malaria was distinct in that all stakeholders were involved in governance and a wide range of countries from both North and South were involved as contributors. Despite the pressure to find an urgent response to an urgent problem, the clear and positive feeling had emerged that the problems were shared and that shared efforts were needed to ensure the Fund's success. As for the principles governing the operation of the Fund, it had been agreed that funds should be additional to those from other sources, which had implications for the monitoring of the Fund; they should be complementary; the Fund should focus on results; it should bring in partners from all different parts of society; it should reduce transaction costs for all parties; it should be independent; and it should remain a financing mechanism and not become a programme in itself. To put those principles into practice, however, would be difficult. An overriding theme of the Committee's discussions on the Global Fund had been the need for better communication between the Fund and the outside world, as well as within organizations, including WHO, between Board members and their constituencies, between members of countrycoordinating mechanisms, and so forth. The timing of communication was also important, to ensure that countries were the first to receive information on the outcome of their proposals. Work to create clearer guidelines and more user-friendly proposal forms would begin the following week and working groups would be formed to consider ways of improving the mechanism of the Technical Review Panel and the subjects of procurement and governance. The most urgent issue, however, was to clarify how funds would be transferred from the World Bank to countries that were due to start implementing programmes. Encouraging comments had been made on the role of WHO and UN AIDS in the governance of the Fund, in supporting its secretariat and, above all else, in supporting countries in their preparation of proposals and applications for submission to the Fund. WHO had also suggested potential candidates for membership of the Panel, for which United Nations staff would be eligible in their own right in the future rounds in the interest of ensuring the Panel's continuing independence. It was essential that the Panel should understand the development of national strategies, which often involved global partnerships supported by donors that were also contributors to the Fund. It was equally essential to structure the interaction between those involved in global programmes on AIDS, tuberculosis and malaria in a way that allowed the Panel to maintain full independence and to test its ideas and conclusions against those contributors and supporting countries. WHO was also fully committed to supporting countries that would be urgently revising their proposals during the next six weeks or preparing proposals for the next round, the date for which should be announced in June to coincide with the issue of the new guidelines. Those proposals would be considered at the meeting of -59-

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the Fund's Board to be held in November 2002 and WHO would encourage the Fund secretariat to provide as much information as possible concerning their preparation. Bearing in mind that the Fund was a financing mechanism, WHO was keen to avoid duplication of its normative role but would inform the Fund of areas in which it could set standards to be used by others. WHO was also well placed to monitor and evaluate specific programmes implemented by countries, as well as overall health development. He noted that the Fund's methods for procuring drugs and other commodities would send important signals to markets. With regard to issues of pre-qualification and fast-tracking, raised by the delegate of Thailand, WHO had operated a pre-qualification system for vaccines since the mid-1980s and more recently for HIV/AIDS medicines. In addition, it had concluded agreements with the Stop TB initiative to begin pre-qualification procedures for various tuberculosis drugs for the Global TB Drug Facility and with Roll Back Malaria for various antimalarial products and agents. More than half the approval time, which ranged between six and 12 months from receipt of the first expression of interest, depended on the action taken by suppliers to submit data and accommodate site inspections, in which connection several requests for postponement had been received from suppliers. Although WHO would take all reasonable steps to accelerate its part of the process of dossier review and site inspections, those steps also depended on the release of staff by Member States' drug regulatory authorities for that purpose. A working group was to be set up to consider strategies for increasing the resource base of the Global Fund. Much had been achieved within a short period of time, and the challenge was to ensure that the Fund worked in practice. With donor confidence, the Fund could become a highly attractive means of disbursing official development assistance, for which joint efforts were one of the best resource mobilization strategies to ensure its rapid succ(:ss. Dr HEYMANN (Executive Director) said that the Roll Back Malaria and Stop TB partnerships had helped countries to strengthen planning and prepare proposals for the Global Fund. Of the 15 countries supported by Roll Back Malaria, six had submitted successful proposals to the Fund during the first round, and he expected similar successes during the next round. By contrast, all proposals submitted by countries without WHO's support had been unsuccessful. Similarly, of the 45 countries supported by Stop TB, 24 had submitted successful applications. Over the past four months, both partnerships had worked extensively with the Fund secretariat and, in conjunction with WHO, UNAIDS and UNICEF, had produced a report that showed current baselines in disease prevalence or incidence and in activities such as high-quality treatment of tuberculosis and malaria, as well as bednet use. They were also currently finalizing standard protocols for antimicrobial resistance monitoring activities essential to drug delivery that would be provided to countries for consideration, costing and use as a standard part of any proposal submitted to the Fund. The summary of WHO's views on the most effective interventions for malaria control (document A55/INF .DOC./6) was intended to remove any confusion concerning malaria prevention and treatment and could serve as a basis for reviewing the content of proposals submitted to the Fund in that field. Dr NABARRO (Executive Director), respondi111g to the question raised by the delegate of Canada about the cost of WHO's support to the Fund, said that WHO had supported the Transitional Working Group between mid-2001 and December 2001 by handling all the administrative functions and managing the US$ 1.5 million extrabudgetary contribution for administration. For that purpose, it had contributed one full-time administrator and the equivalent of two other full-time professionals. The sum of US$ 600 000 remaining when the group had concluded its work had been used to cover support for the Fund's secretariat. No programme support costs had been charged by WHO. When the Fund had begun operating in January 2002, it had not signed any formal agreement with WHO, which had therefore provided services in good faith on a full c:ost basis. In brief, the cost of technical support to the development and operation of the Fund over the past year had amounted to US$ 800 000. Work undertaken to support countries in accessing the resources of the Fund had amounted to some US$ 3.85 million, while support to the administration of the Fund had amounted to about

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US$ 925 000, some of which should be recovered following signature of the Administrative Services Agreement between the Fund and WHO. The final net contribution by WHO to the administration of the Fund would therefore amount to some US$ 300 000. WHO would normally expect to provide such assistance to any new international health venture. The Administrative Services Agreement had been approved at the second meeting of the Fund's Board in April 2002, although two paragraphs remained under discussion between WHO and the designated member of that Board, with whom WHO was working directly with a view to imminent finalization of the Agreement. The Agreement would preserve the standing and financial integrity of WHO and the authority ofthe Director-General, which, given the Fund's independent nature, had not been easy to achieve, and provided that the cost of WHO's administrative support would be fully met by the Fund. Such full cost recovery would initially be based on expected total expenditure using a predicted service level, which would then be reviewed at annual intervals against the service actually provided. It was the wish of the Director-General that WHO should remain fully involved in the Fund and do its utmost to ensure the Fund's success by enabling countries to implement the programmes they so desperately needed. The CHAIRMAN said that he took it that the Committee wished to take note of documents A5518 and A5518 Add. I. It was so agreed. ,

Dr Agarwal took the Chair. HIV/AIDS: Item 13.5 ofthe Agenda (Resolution EB109.R6; Documents A5519 and A5519 Corr.l) Mrs ABEL (representative of the Executive Board), introducing the item, said that the Board had welcomed the development of the global health-sector strategy on HIVI AIDS and had noted the need to support countries wishing to raise the capability of their health systems to absorb new financial resources as they became available - for example, through the Global Fund to Fight AIDS, Tuberculosis and Malaria. Board members had suggested that the strategy should pay special attention to the development of primary health care services, prevention and treatment of sexually transmitted infections, access to essential medicines, blood safety and the training of health personnel. The Board had discussed issues related to HIVI AIDS under a number of other agenda items. Access to antiretroviral drugs had been discussed in the context of the essential medicines strategy, and prevention of HIV transmission to infants through breastfeeding had been discussed during the item on infant and young child feeding. Concerning follow-up to the United Nations General Assembly special session on HIVIAIDS, it had been noted that the Secretary-General would report regularly to the General Assembly on progress made. In its resolution EB109.R6 the Executive Board had recommended a draft resolution for consideration by the Health Assembly. Dr RAFILA (Romania) said that, from the beginning of its mandate in January 2001, his Government had viewed the tackling of HIV I AIDS as one of its main priorities. The virus had first begun to spread in Romania in the late 1980s, when thousands of children had become infected. After the fall of the Communist regime, the Government, faced with widespread infection, had immediately taken measures that included the provision of disposable syringes, the testing of blood and blood products, access to voluntary counselling, and the testing of pregnant women and high-risk professional groups. Public-private partnerships had helped to make possible a large-scale response, including the negotiation, with major pharmaceutical companies and involving United Nations support, of substantial price reductions. In order to ensure optimum use of resources, the Ministry of Health and Family had decided that from April 2002 antiretroviral drugs would be acquired through

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national tender. A national HIV I AIDS commission had been established, including representatives of the Presidency, the national health insurance fund, patients' associations, international organizations such as UNICEF, UNAIDS, UNFPA and United States Agency for International Development, pharmaceutical companies and nongovernmental organizations. The national strategy had resulted in access to treatment for all patients. In 1997 only 32% of the 6200 HIVIAIDS patients had been treated, only 0.5% of them receiving triple drug therapy; currently, 61% of 7214 diagnosed patients were being treated, 92% of them receiving triple therapy. Mother-to-child transmission had been reduced from between 30% and 40% in the 1990s to 1% in 2001 and the life expectancy of AIDS patients had increased from six months in the 1990s to some five years in 2001. The Ministry of Health and Family attributed that progress to the development of a consistent strategy and adequate infrastructure. The success of the public-private multilateral partnership had saved hundred of lives and significantly improved health care quality for thousands of patients. Romania was ready to share its successful experience at subregionallevel. Dr DAYRIT (Philippines) said that prevalence of HIVIAIDS remained relatively low in the Philippines. Since 1984, when the infection had first been detected, 1500 cases had been reported. Serological surveillance in the country's major cities indicated an HIV prevalence rate of about 1% in people with high-risk behaviours, particularly sex workers and injecting drug users. Total HIV infections were estimated at between 10 000 and 15 000. The Government continued to accord priority to primary prevention, working closely with nongovernmental organizations, including the strengthening of surveillance to detect infection in groups not traditionally monitored, such as returning overseas workers, and improving primary prevention, particularly among sex workers. Such measures could be used elsewhere to keep infection levels low. In that connection he asked WHO to prepare a draft resolution for consideration by the Executive Board on the organization of initiatives and development of mechanisms by which such countries could share experience, consult each other, and formulate strategies to improve surveillance methods and primary preventive measures. Dr QI Xiaoqiu (China) agreed in principle with the content of the report before the Committee. Of particular importance was the emphasis on the role of health systems in AIDS control. WHO activities had indeed promoted global implementation; the restructuring of the relevant department at headquarters was a positive step in that regard. Developing countries should be given continuous increased support through their national health systems to improve medical and biological technology and introduce more effective interventions. WHO should take into account the question of affordability, particularly with regard to antiretroviral drugs. Dr SUPAMIT CHUNSUTTIWAT (Thailand) said that Thailand's experience confirmed the significance of governmental support and policy as prerequisites for an effective national response. The country's national AIDS committee, chaired by the Prime Minister, was the forum for generating policies and plans and for securing the requisite national resources. Extensive multisectoral campaigns during the past two decades had significantly retarded the spread of infection, the infection rate in pregnant women having been reduced from 4% to 1.5% during the past decade, although the cumulative number of infected individuals remained high. With regard to the recommendations in paragraphs 1(5) and 1(7) of the resolution recommended in resolution EB109.R6, Thailand supported the idea of making prophylactic and therapeutic drugs affordable and ensuring their safe, effective use. However, he proposed that a clause should be added to paragraph 1(5) recognizing diversity in the health, social and economic contexts of the implementation of that recommendation in different countries. Thailand had gradually been increasing the affordability of antiretroviral drugs in the public sector, giving priority initially to the prevention of mother-to-child transmission of HIV. The Ministry of Public Health had included such treatment in the benefits of the universal health service scheme being implemented as part of the Government's health policy, primarily using locally produced drugs.

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The penultimate preambular paragraph of the draft resolution duly addressed the need for reducing vulnerability and preventing stigmatization and discrimination against people living with, or at risk of, HIV/AIDS. That important psychosocial aspect of AIDS should also be emphasized in the operative part of the resolution. Mr METHOT (Canada) said that the Director-General's report provided a basis for WHO to continue its efforts to fight AIDS, for which purpose a global health-sector strategy must be completed without delay. The report gave welcome attention to health systems development as a cornerstone of the health sector response. In addition, the report of the WHO Commission on Macroeconomics and Health had supported the view that health activities, to be sustainable, must be an integral part of accessible, well-functioning health systems adaptable to individual communities' needs. Canada agreed that prevention and comprehensive care, including access to treatment for opportunistic infections and antiretroviral therapies, were vital components of the health continuum. He welcomed the recently issued guidelines on expanding antiretroviral therapy in resourcelimited settings and the inclusion of antiretroviral drugs on WHO's list of essential medicines; such action would improve access to appropriate treatment. He encouraged timely implementation of WHO's work as a positive contribution to control of the HIV/AIDS pandemic, and pledged Canada's cooperation in facing the challenge of creating a global health-sector strategy. Mrs FALL (Senegal) said that the continued spread of HIV was of major concern for the developing countries, where 90% of infected persons lived. The increasing prevalence of HIV/AIDS in some countries hampered economic development, and many countries, including Senegal, had reorganized the handling of the anti-AIDS campaign. In Senegal, the necessary political commitment had been reaffirmed through the recent creation of a national council for AIDS control, with the Prime Minister and the Minister of Health as Chairman and Vice-Chairman, and involving various sectors of society, such as education, youth, civil society and persons living with AIDS, with the aim of making further progress and maintaining the country's relatively low prevalence of 1.4%; the central catalytic role of the Ministry of Health was also confirmed. Senegal supported both prevention, particularly in mother-to-child transmission of HIV, and treatment, where an initiative was in hand to improve access to antiretroviral therapy, with a State contribution of CF A francs 1000 million. A strategic plan for 2002-2006 had been drawn up, financed by a number of partners, with the objective of reducing the number of new cases and providing better patient care. She supported the resolution recommended in resolution EB109.R6. Mr ASLAM (Pakistan) said that, although designated a low-prevalence high-risk country, Pakistan had begun a national AIDS control programme in 1994. An extended national AIDS control programme had been introduced under the social action programme project, and tasks, indicators, time frame and sources had been planned up to 2003. The framework outlined strategies and interventions that would form the basis of the expanded national response to HIVIAIDS; priority areas would include vulnerable and high-risk groups, surveillance and research, sexually transmitted infections, general awareness, blood and blood product safety, infection control, and care and support. The enhanced programme would focus on targeted interventions among people with recognized high-risk behaviours who could transmit infection widely, as well as others who were vulnerable because of their specific exposure. Dr COLEMAN (Liberia) said that 90% of the people in his country lived below the poverty line. Unemployment and civil conflict, including cross-border incursions and internal displacements, had contributed to a breakdown of the health service in the regions affected. The sanctions imposed by the United Nations had further reduced the Government's capacity to deliver basic social services. As a result, the prevalence of HIV/AIDS had risen from 6.1% to 8.2% in the past 12 months. With assistance from WHO, UNFPA, UNAIDS, the United States Agency for International Development and Taiwan (China), awareness programmes were gaining momentum and general public acceptance

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of condoms had increased. He appealed to WHO, UNAIDS and other donor agencies to increase their assistance to Liberia's AIDS awareness, prevention and treatment programmes, and he expressed gratitude to the Government and people of Taiwan (China) for their various forms of assistance to the health sector, including the work of the Taiwan Root Medical Peace Corps, a nongovernmental organization that provided emergency relief to countries facing armed conflict or natural disasters, that had carried out two free medical consultation campaigns in Liberia, treating 1500 patients each time. The wish of Taiwan (China) to cooperate with WHO should be encouraged. Professor SZCZERBAN (Poland) said that, according to cumulative data from 1985 to 31 March 2002, 7450 people had been registered as having HIV infection or known to be living with HIVIAIDS in Poland; 4264, or 62%, had been infected through injecting drug use; there had been 1137 cases of AIDS with 564 deaths; but the estimated total number of people living with HIVIAIDS was 15 000-20 000. The Ministry of Health, acting through its national AIDS centre, and other governmental institutions and nongovernmental organizations had important roles in combating the epidemic. The national programme for HIV prevention and care for people living with HIVI AIDS had been presented in major health policy documents. The national AIDS centre had a monitoring and coordinating role in implementing the national programme, and cooperated with other governmental and nongovernmental agencies. Its range of activities included training courses for health care workers, preparation of educational material, social studies linked to prevention, and support for other initiatives. It also played a crucial role in the purchase of antiretroviral drugs and support for the methadone programme, and was responsible for collaboration with international organizations, particularly WHO, UNDP and UNAIDS. In addition to participation by the major ministries, over 20 main nongovernmental organizations were involved in national programme activities. The incidence ofHIV infection in Poland seemed to have been stable in recent years, suggesting that the Government's treatment of the epidemic as a main health policy priority had been correct. The current national programme would continue until the end of 2003; smooth cooperation between government institutions, and support for and from nongovernmental organizations, provided a sound basis for the programme's success. Professor VENTURA (Portugal) endorsed the resolution recommended in resolution EB109.R6, which would help to meet the targets of the Declaration of Commitment on HIVIAIDS adopted at the special session of the United Nations General Assembly in June 2001. National AIDS programmes should be strengthened by the adoption of international standards for epidemiological and behavioural surveillance and by adapting monitoring and evaluation to specific regional and country characteristics. Strategies to combat HIVI AIDS must be included in the broader context of sexually transmitted diseases and must take into account common strategies to tackle tuberculosis and viral hepatitis. There was a need, particularly in the most affected countries, to support national capacities to provide voluntary counselling and to establish testing centres and programmes for the prevention of mother-to-child transmission of HIV. Approaches to vulnerable populations should be diversified, using specific channels to contact different groups. New strategies should be found for developing primary health community structures offering prevention, care, support and treatment in a sustainable, equitable way, with universal access to antiretroviral and other fundamental drugs. There was a pressing need for new and imaginative ways of collaboration between governmental and nongovernmental organizations, and between the public and private sectors. Portugal, in cooperation with WHO and UNAIDS, was playing an important role in ensuring cooperation among lusophone countries, and in 2002 would assume the chairmanship of the UNAIDS Programme Coordinating Board. Mrs BU FIGUEROA (Honduras) said that her country greatly valued the support received from UNAIDS. Honduras had set up a national commission on AIDS research and monitoring, which included representatives of the Ministry of Health, the medical association, and the Red Cross.

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External cooperation had since improved and Honduras was consolidating its overall strategy. The UNAIDS programme in Honduras was effective, and she wholeheartedly endorsed the resolution recommended in resolution EB109.R6. Moreover, her Government wished to expand its cooperation. She supported_the Liberian delegate's call for Member States to consider the participation of Taiwan (China) as a medical partner, being convinced that it would be an active donor to UNAIDS and other programmes. Dr TUIKETEI (Fiji) said that, although the Pacific island States were only just seeing the arrival ofHIVIAIDS, the epidemic was a serious threat. Fiji had developed a two-year, multisectoral national strategic plan and programme of action on HIVI AIDS, under the chairmanship of the Minister of Health. In 2002, for the first time, specific funds had been allocated in the budget to cover HIVI AIDS activities. Seven priority action areas had been identified, including safe blood supply, the prevention and control of sexually transmitted infections, and HIV testing. The number of HIV-positive patients identified each year had risen from four in 1989 to 17 in 2001, a figure that was expected to increase threefold by the end of 2002. Fiji was vigorously implementing its HIVIAIDS activities, but was aware of the major challenges ahead, including enactment of human rights-based legislation, the procurement and use of antiretroviral drugs, and undertaking research. She requested WHO and other United Nations agencies to continue to provide technical assistance and funding; the lessons learned in other countries would help Fiji to step up the fight against HIVIAIDS, which had become everybody's business. Fiji endorsed the resolution in resolution EB 109 .R6. Dr OKAMOTO (Japan) said that the Japan International Cooperation Agency had been involved in AIDS projects since 1994, with three strategic targets based on Japan's Global Issues Initiative on Population and AIDS, namely prevention and control, care and support for patients and their families and effective control measures at national level. WHO and UNAIDS had helped to hold down the price of antiretroviral drugs, but access to those drugs should be extended to all developing countries, including those in Asia. Although WHO's recent guidelines on the introduction of antiretroviral therapy in developing countries were valuable, adherence to regimens was a problem with such drugs. WHO should devise ways and means of securing compliance, such as peer support by HIVI AIDS patient groups and directly observed treatment. It was critical, moreover, that HIVI AIDS care should be integrated into the community health system that provided primary care to the general public. Mr DOURADO QUINTAES (Brazil) endorsed the resolution contained in resolution EB109.R6. With the aim of reducing mother-to-child transmission ofHIV, he proposed the addition at the end of paragraph 2(4 )(b) of the phrase: "through reduction of HIV transmission in women of reproductive age, avoidance of unwanted pregnancies in HIV -infected women, and the provision of interventions that reduce transmission of HIV from mother to child". Dr KHAZ' AL (United Arab Emirates) called for the further development of global strategies. Since 1985, the United Arab Emirates had made good progress, including the passing of appropriate legislation. For example, the importation of foreign blood for transfusions had been stopped, all groups at risk had been examined, a monitoring system had been set up, partnerships between various health sectors had been encouraged, and care programmes had been set up for seropositive patients. In view of that experience, the United Arab Emirates was willing to take part in technical consultations. He endorsed the resolution recommended in resolution EB109.R6. Professor SMALLWOOD (Australia) said that his country supported the restructuring of WHO's HIVIAIDS department and its new focus, as collaboration with major agencies would be critical. It also supported the development of WHO's global strategy for AIDS, which complemented the Declaration of Commitment on HIVIAIDS adopted at the special session of the United Nations General Assembly. He noted that regional consultations had proved useful in preparing the strategy,

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and that regional responses would be important, bearing in mind the different stages of the epidemic. Australia was focusing its efforts on the Asia-Pacific Region. It had doubled its annual expenditure on the HIVI AIDS aid programme, and intended to make additional resources available to help Commonwealth African countries to reduce infection rates and the impact of HIVI AIDS. A meeting of regional ministers in Melbourne in October 2001 had endorsed the concept of an Asia-Pacific leadership forum on HIVI AIDS to share experiences. Dr FURGAL (Russian Federation) noted with satisfaction the increasing role played by WHO in the fight against HIVIAIDS, in which health institutions had a crucial role to play. A specific action plan and funding were needed particularly in the countries of the Commonwealth of Independent States that had seen a rapid increase in the number of cases of HIV and hepatitis. Those countries needed support in all areas, including monitoring and research. Furthermore, it was vital to strengthen coordination with other partners, especially UNAIDS, and to reinforce regional AIDS strategies. The countries of the Commonwealth of Independent States were preparing to implement the Declaration of Commitment adopted at the special session of the United Nations General Assembly on HIVIAIDS. With the support of UNAIDS and WHO, the Declaration had been adapted to the specific needs of the region and an action plan at national and regional levels had been drawn up. The plan had been reviewed by the ministers of health m January 2002 and was due for adoption at the forthcoming meeting ofheads of state. He expressed full support for the draft resolution contained in resolution EB109.R6. Ms OLIPHANT (United States of America) welcomed the broad input of the report. Much of the strategy was geared to critical issues in scaling up treatment for HIVI AIDS, tuberculosis and malaria, the same issues that the Global Fund would have to address. The critical roles of health systems, the limited capacities of many national health systems, and the need for public-private partnerships, especially at community level, were particularly important. Special consideration should be given to mother-to-child transmission of HIV and research. Complex issues must be addressed, including the impact of antiretroviral therapy on maternal nutritional status, lactation and infant nutritional requirements, and the impact of treatment on infant feeding. In a broader context, the interaction between nutritional status and the use of antiretroviral drugs in resource-poor settings should include an appreciation of some of the severe metabolic consequences of the drugs when used in the developed world. She was especially pleased to note the emphasis on accountability, monitoring and evaluation, and research in paragraph 14 of the report. Endorsing the draft resolution, she noted that the need for new technologies had been highlighted. Ms MIKKOLA (Finland) emphasized that the large resources allocated to combating the HIVIAIDS epidemic in recent years should be used in the most effective way. Although UNAIDS coordinated the work within the United Nations system, the responsibility of the health sector was unavoidable. She therefore welcomed the global health-sector strategy and expected WHO to show leadership. HIVI AIDS was a preventable disease and good results had been obtained by committed preventive work in both developing and developed countries. Without underestimating the importance of universal access to treatment, prevention should be the first priority. Investments in prevention were cost-effective and the strategy should emphasize that. WHO should also take the lead at country level. Prevention was a broad concept which included the promotion of healthy lifestyles and support to vulnerable groups. Commitment from the highest level downwards was needed, but could only be achieved with the active advocacy of the health sector. Mrs GARVAL (Denmark) said that a global response to HIVIAIDS must include prevention, care, support, treatment and efforts to prevent stigmatization and discrimination. Although the report referred to all those elements, Denmark would have preferred to see more details, such as a statement of WHO's priorities, an indication of the balance between prevention and treatment and of how the

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strategy would be coordinated with existing programmes, a timetable for finalizing the report, and the plans for bringing HIVIAIDS into the mainstream of WHO's work. WHO had a vital role to play through its normative work, technical assistance and resource mobilization. Denmark strongly urged WHO to assist Member States in developing and supporting strategies for prevention and improved access to care by increasing guidance on establishing wellfunctioning health systems. WHO had presented the first treatment guidelines for HIVIAIDS in poor settings and had endorsed the inclusion of AIDS medicines in its essential drugs list. While access to such treatment was important, alternatives to the costly antiretroviral drug therapy existed, for example prevention and treatment of tuberculosis and sexually transmitted diseases. The global healthsector strategy was a much-needed instrument. It should be comprehensive, with clear priorities and the balance in favour of prevention. Increased and efficient assistance to ensure sustainable health systems capable of combating the pandemic required a strong presence at country level. Ms BALOCH (Pakistan), on a point of order, requested the Chairman to instruct the drafting group on WHO's contribution to achievement of the development goals of the United Nations Millennium Declaration to suspend its deliberations, which were proceeding simultaneously with concurrent meetings of Committee A and Committee B, because small delegations could not follow all three. The CHAIRMAN said that the suspension of the drafting group's meeting was a matter for that body to decide. Ms BALOCH (Pakistan) said that the drafting group was a subsidiary body of Committee A and was thus subject to direction. Mr DEMBRI (Algeria) supported the proposal by Pakistan and called on the Chairman to rule on the matter. The CHAIRMAN undertook to give a ruling later in the meeting. Dr MOETI (Botswana) welcomed the strengthening and restructuring of the department of HIVI AIDS to support the critical role of WHO in combating and mitigating the impact of HIVI AIDS globally. The incidence of HIVI AIDS in Botswana was one of the highest in the world, posing an unprecedented challenge to sustainable human development. Extensive support from international partners was needed in order to meet the challenge. The measures taken by Botswana in collaboration with UNAIDS, WHO and bilateral partners included monitoring and evaluation of interventions, expanded access to free voluntary counselling and testing, a national antiretroviral therapy programme, a programme to prevent mother-to-child transmission of HIV and mobilization of civil society. His country would need additional resources to supplement its own efforts. He therefore trusted that, as one of the hardest hit, it would benefit significantly from the Global Fund and other resources in the global efforts against HIVIAIDS. He fully supported the action proposed in the draft resolution contained in resolution EB 109 .R6. Dr AKSAKAL (Turkey) welcomed the establishment of the Global Fund. For cultural reasons, the incidence of HIVIAIDS in her country was very low, with only 1325 cases in the period 19852001. Most cases had occurred in the 25- to 34-year age group, and were three times higher among men than women. Turkey nevertheless regarded AIDS as an epidemic of the future and was taking a wide range of analytical, legislative, diagnostic, treatment and educational measures. Increasing public awareness was particularly important in order to counter discrimination against, and the isolation of, people living with HIVIAIDS, which further worsened their condition.

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Dr ISMAIL (Iraq) commented that a study of AIDS-related mortality had shown an increase in patients' average life expectancy in developed countries, largely due to the use of antiretroviral drugs. WHO should help developing countries to equal that achievement. It was 15 years since the difference in performance between countries with diagnostic facilities and those without such facilities had been noted. Developing countries should finally be provided with the necessary technical facilities and assistance, focusing on HIVI AIDS prevention programmes. Mr MOLOTO (South Africa) said that, although strengthening the response of the health system to HIV I AIDS and sexually transmitted infections presented a significant challenge to developing countries, formulating an innovative global strategy required a major effort from WHO, whose HIVI AIDS department had to be able to provide a wide range of expertise and support for Member States. The global strategy must provide guidance to Member States on overcoming the stigmatization and discrimination attached to HIV infection, which acted as a barrier to seeking care. In view of the decline in the numbers of health care workers and the huge demand for health care provision, creative ways of recruiting and retaining staff, and providing care and support for HIV -infected health workers, would have to be identified. The level of literacy was an important factor. Member States needed help in disseminating information that was understandable by lay people, and in communicating culturally appropriate messages, in view of the wide range of customs, languages and dialects in developing countries. The strategy also had to include surveillance and the collation of data for planning, together with support on issues related to financing the health sector. He supported WHO's approach of strengthening health systems to ensure a sustainable response to HIVIAIDS and proposed that WHO should accelerate development of the strategy in harmony with UNAIDS. He expressed the hope that his comments and suggestions could be incorporated in the strategy. Ms R0INE (Norway) stressed the importance ofvisible and firm national leadership for success in fighting HIVI AIDS, in order to abolish taboos and break the silence hindering preventive work. Political commitment was a central principle of the Task Force on Control of Communicable Diseases in the Baltic Sea Region, which was chaired by Norway and to which the prime ministers in the region and the President of the European Commission had appointed personal representatives. Responsibility for collaboration on communicable diseases lay with national authorities, but neighbouring countries supported each other by sharing experience, organizing joint training programmes, and to some extent by funding cost-effective infrastructures. Norway welcomed the strong focus on national and local level capability in the global strategy outlined in the report. That strategy should be linked to WHO's overall work on strengthening the health sector at country level and a broad range of health specialists should be involved in its design. The relative roles of WHO, UNAIDS and other organizations in the United Nations system that were working in areas such as mother-to-child transmission of HIV and injecting drug use should be clarified. The HIVIAIDS strategy should be coordinated with that for tuberculosis, and should be consistent with the goals and recommendations adopted by the United Nations General Assembly special session on HIVIAIDS. The situation of sub-Saharan Africa was a threat to stability, security and peace in the region. Norway accorded high priority to HIVIAIDS in its assistance programmes, most of which were in African countries. However, several countries in Eastern Europe were at the epidemic level prevailing in sub-Saharan Africa eight to 10 years previously. That topic was on the agenda of a forthcoming meeting of prime ministers of States of the Baltic Sea region. Norway's national strategy for the prevention of HIVIAIDS and sexually transmitted diseases stressed the personal responsibility of all individuals for their own behaviour and lifestyle, as well as consideration for fellow human beings in order to make prevention possible. Among other challenges, the strategy highlighted the need to eradicate the stigmatization of people living with HIVI AIDS, and called for a change of attitude: people with HIVIAIDS should be able to concentrate on how to deal

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with the direct consequences of the disease without also having to defend themselves against social and work-related discrimination. She supported the draft resolution contained in resolution EB 109 .R6. Professor HOJDA (Ukraine) welcomed the active discussion on the subject of HIV/AIDS, prompted both by the global dimensions of the epidemic and the global scope of WHO's strategy. AIDS was a serious threat in his country, where the number of people with HIV infection was increasing by about 700 a month. Half of the 3000 persons with AIDS had died. Some 50 000 cases of HIV infection had been reported. There were two particular causes for concern. First, most infected people were between 20 and 28 years of age, which had serious consequences for social development, health care and national security. Secondly, Ukraine belonged to a group of countries recording one of the highest growth rates for HIV infection. A detailed national policy had accordingly been drawn up, that was fully in keeping with WHO's global strategy. Legislation had been enacted, including a basic law on AIDS prevention and social protection. Three presidential decrees had been promulgated, one of which had established a governmental commission, which was very active. The adoption of the fourth prevention programme, initiated by the President, had coincided with the United Nations General Assembly special session on HIVI AIDS in 2001. On that occasion, the President had proclaimed 2002 as the year of the fight against AIDS in the country, enabling all possible intersectoral resources to be mobilized. In the past month, with WHO support, a significant reduction in the price of antiretroviral drugs had been negotiated, which would improve access. Ukraine's efforts had been recognized by the visit of the UNAIDS Executive Director on World AIDS Day (1 December 2001 ). Ukraine would focus its future control efforts on the implementation of the Declaration of Commitment on HIVIAIDS adopted by the special session. It endorsed the draft resolution contained in resolution EB109.R6 and expressed the hope of continuing its fruitful cooperation with WHO. Dr HOLCK (Secretary), referring to the point of order raised earlier by the delegate of Pakistan, said that the drafting group on the development goals of the United Nations Millennium Declaration had suspended its deliberations and would resume its discussions after the plenary meeting. Ms BALOCH (Pakistan), on a further point of order, requested the Chairman to make a ruling that such groups should not meet when the Committee was deliberating so as to avoid the simultaneous occurrence of four or five meetings. Mr BURCI (Office of the Legal Counsel) said that, as far as he was aware, there were no rules concerning the number of meetings that could be held concurrently. However, while the Health Assembly had decided in past resolutions that there should be no more than one meeting of each of the main committees and/or plenary at the same time, it had not mentioned drafting groups or working groups of an informal nature like that on the goals of the United Nations Millennium Declaration. In practice, if the timetable so required, meetings of informal working groups had been held simultaneously. Ms BALOCH (Pakistan) asked for clear guidance as to the nature of the bodies that were meeting, which should be regarded as informal groups. The CHAIRMAN said that the group concerned was an informal drafting group working on a draft recommendation for submission to Committee A. Mr RAMOUL (Algeria), on a point of order, said that no more than two meetings of any kind should take place at the same time because of the need for transparency and to enable all Member States to participate in the Health Assembly's work. Secondly, it would simplify the Chairman's task

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if delegations were in a position to follow informal meetings, since they might otherwise be obliged to re-open discussions in the Committee. Dr HOLCK (Secretary) said that, following the plenary, only Committee A and the drafting group would be meeting. Neither Committee B nor the plenary would be in session. Mr RAMOUL (Algeria) asked whether that ruling applied only in the present instance or for the remainder of the Health Assembly. Dr HOLCK (Secretary) said that the problem was to get through the heavy agenda of 19 items. She was open to suggestions. Ms BALOCH (Pakistan) said that a suggestion had already been made, namely, that there should not be more than two meetings at a time. On that day, five meetings had been in progress simultaneously, a situation completely unacceptable to Pakistan which, as a developing country, had too few delegates to follow the work of every committee. The CHAIRMAN said that the point made by the delegate of Pakistan had been noted. Dr BRIEM (Iceland) said that the fight against HIVIAIDS required functioning health services in the afflicted countries. Such services must therefore be strengthened. Iceland welcomed the restructuring of the WHO department concerned to serve as the internal focal point for all HIVIAIDSrelated work, including the identification, development and delivery of core components of an effective health-sector response. The goal was to set the highest possible standards in order to halt transmission, improve care, treatment and support, and minimize the epidemic's impact at the global, regional and country levels. Iceland supported the revision of the global strategy for health-sector responses to HIVIAIDS, which was urgently needed. Dr TUKUITONGA (New Zealand) said that New Zealand was one of the first countries to experience a decline in AIDS incidence. A critical aspect of that success was leadership and a partnership between government, civil society and community groups, empowering communities especially the most vulnerable - to play their part in the solution. Hiding behind traditional taboos about prostitution, sex before marriage, and so on, would simply accelerate the spread of the disease. Strong partnerships should be established among those involved and the full participation of civil society, including the churches, community-based organizations and the private sector, should be sought in order to provide an effective response. Although prevention remained the most important aspect of the fight against the disease, treatment was also important. In New Zealand, it took place in various health settings, such as a general practice, sexual health centres, special units and hospices, and was backed up by care and support from voluntary groups. At the international level, New Zealand's efforts were focused on prevention in the Pacific region. To be effective, health care systems must pay more attention to the needs of the poor or marginalized groups. Dr GONZALEZ FERNANDEZ (Cuba) said that the HIVIAIDS global health-sector strategy should have been entitled "global strategy to combat HIVIAIDS", since the health sector was not the only area involved. Secondly, some time might have been gained if items 13.4 and 13.5 had been taken together. He agreed with the delegate of Denmark that action against AIDS must be coordinated. Cuba had taken note of the work done by other countries, WHO and UNAIDS, and stressed that those involved in the fight against AIDS should not be competing but cooperating and coordinating their actions so as to avoid duplication. The management of the Global Fund to Fight AIDS, Tuberculosis and Malaria should be the responsibility of either WHO or UNAIDS: a completely new structure

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would be a waste of funds and staff and reduce the amount of money available to countries needing to make use of the Fund. The global strategy reflected the main elements necessary for fighting the pandemic, in particular the need to make essential medicines available at affordable prices. Prevention and promotion activities, with input from the community and other sectors, needed to be strengthened. There was also a need for effective health services and proper laboratories to ensure safe blood and accurate diagnosis. It was also necessary to define how countries needing to do so could gain access to the Global Fund. The resources for controlling AIDS did not have to be financial alone. The VicePresident of Cuba had offered at the United Nations General Assembly special session in June 2001 to provide 4000 doctors and health personnel to create the infrastructures needed to provide medicines and follow-up. The same staff could train specialists to ensure continuity. Cuba had also offered teaching staff to set up 20 medical faculties in Africa and specialists in various fields needed for the fight against AIDS and other diseases. All such personnel could be provided by Cuba. Funds would be needed only to finance the necessary medicines and materials. The global strategy was also overdue. Some important actions and resolutions had been approved, and research into the most effective interventions was continuing, including research to find an effective vaccine. Action and funding were needed especially for the developing countries, in order to implement the most useful interventions for each country. Health ministries should adapt their policies to include the goals governments had accepted in adopting the Declaration of Commitment on HIVIAIDS in June 2001. Cuba supported the draft resolution contained in resolution EB 109 .R6. Dr UPUNDA (United Republic of Tanzania) said that his country had been much encouraged by the regional consultation process to ensure that the global strategy was based on the needs of countries and communities. It was an important tool for shaping and scaling up the health-sector response and would help countries to meet the goals and targets set out in the Declaration of Commitment on HIVI AIDS and the Millennium Declaration. WHO should continue to give priority to the further development of that strategy and to cooperation with Member States to ensure ownership and implementation. Despite the formation of national intersectoral commissions, the health sector would continue to be central to the fight against AIDS for a long time to come. His country welcomed the new partnerships being established to step up support to countries, and pledged its cooperation in the finalizing of the strategy. The meeting was suspended at 17:00 and resumed at 18:20, with Dr Kiely in the Chair.

Mrs BARTOSIEWICZOVA (Slovakia) said that, as of March 2002, the cumulative total of people with HIVIAIDS in her country had been 157, 43% of whom had contracted HIV through bisexual or homosexual transmission, 16% through heterosexual intercourse and 1% through injecting drug use; the transmission route in the remaining cases was undetermined. Fifty-three cases were in foreign nationals, mostly refugees. There had been a marked increase in the prevalence rate of syphilis, from 0.6 to 5.2 per 100 000 population. However, the reported prevalence of gonorrhoea had declined. The Government's programme to prevent sexually transmitted infections and HIVI AIDS focused particularly on the traditional behavioural risks, and on Roma in the eastern part of the country, who were especially vulnerable. Immigrants, including sex workers from other countries, posed a further problem. Her Government welcomed WHO's initiatives to combat HIVIAIDS and other sexually transmitted diseases and wished to contribute actively to them. Dr AL-MAZROU (Saudi Arabia) said that countries must redouble their efforts to prevent HIV infection and to treat people with AIDS. However, in so doing, it was essential to respect national

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traditions and adapt to the level of medical services available - points which had already been acknowledged by the governing bodies of WHO. Although the prevalence of HIV infection was not high in Saudi Arabia, the Government had allocated a large budget for specialized laboratories and medical treatment for those infected. A public awareness campaign had been introduced, aimed particularly at adolescents and young adults. The Government's current AIDS strategy included a surveillance and monitoring mechanism, advisory services and free, voluntary HIV testing. His country supported the draft resolution contained in resolution EB109.R6, and would implement all international recommendations provided that they did not conflict with the country's traditions or religion. Dr AMATHILA (Namibia) expressed her delegation's support for the draft resolution. Namibia was one of the countries most affected by HIV/AIDS. It was currently implementing its second multisectoral medium-term plan. Major activities included sentinel studies among pregnant women: such studies conducted in 2000 had shown that levels of HIV infection in the 19- to 25-year age group had remained stable for the previous four years. The Government was beginning house-to-house dissemination of information and counselling for HIV/AIDS, malaria, and tuberculosis. In March 2002, a programme for the prevention of mother-to-child transmission of HIV had been introduced. It included targeting fathers, to reduce the stigmatization of women and to encourage support from relatives on-both sides ofthe family, care and support of AIDS orphans, voluntary testing and counselling, and involvement of youth counsellors in schools. More funding would be required for all those programmes, and her country therefore hoped to receive further resources from the Global Fund to Fight AIDS, Tuberculosis and Malaria and other sources. She particularly emphasized the need to include support for AIDS orphans in national strategies and existing mechanisms, and to strengthen health systems and health infrastructure. Mr NAIK (India) said that his country's national AIDS control programme was implemented through state-level AIDS control societies and state governments. Its objectives were to reduce the spread of HIV infection and to strengthen the country's capability to respond to the HIV/AIDS problem in the long term. The programme had five components: targeted interventions for populations with high-risk behaviours; preventive interventions for the general population; low-cost care for people living with HIV/AIDS; institutional strengthening; and intersectoral collaboration. The programme had taken into account the priority areas laid down for WHO's global health-sector strategy. A nationwide HIV sentinel surveillance system had been established. Every year, in the period August-October, 320 designated sentinel sites were monitored, covering both the general population and high-risk groups. A behavioural surveillance mechanism was also in place. The Government had approved a national AIDS prevention and control policy and a national blood policy for the guidance of states and union territories. A comprehensive training programme for health professionals had been introduced, involving tertiary health care institutes. Technical resources groups had been set up in various thematic areas to provide support for programme management. Many nongovernmental organizations and other community representatives had been recruited for advocacy and intervention projects among vulnerable and marginalized groups. Another new initiative was a programme to prevent mother-to-child transmission of HIV. The Government collaborated with international organizations such as the International AIDS Vaccine Initiative to promote research and development of indigenous HIV vaccines. WHO's global health-sector strategy would further strengthen the measures undertaken by his Government. Resource constraints were the main problem faced by a developing country such as India. Even though some funding was being provided through the Global Fund and other financial institutions, the strategy should pay attention to funding problems and promote the use of the most cost-effective methods possible.

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Mrs RASETHUNTSA (Lesotho) expressed her delegation's support for the draft resolution. The problems of those who cared for people with HIVIAIDS were often not adequately addressed. Regular counselling should be provided for carers, especially health workers, to minimize the trauma of patient care. Trained health professionals were essential to any HIVI AIDS strategy; WHO should explore ways of reducing the current "brain drain" of health workers from countries with limited resources to the developed countries. WHO's efforts to encourage pharmaceutical companies to help resource-poor countries were welcome. Regrettably, her Government could not afford even highly subsidized drugs. WHO should therefore continue its efforts to ensure that antiretroviral drugs were accessible to all who needed them. Drug supply programmes should cover infrastructure, equipment and capacity-building for human resources, as well as the drugs themselves. She endorsed efforts to provide a supportive environment for young people as they tried to protect themselves and prevent the spread of HIVIAIDS. In poor countries such as Lesotho, such activities needed to be integrated into the general human reproduction programme, in order to avoid the stigma associated with HIVIAIDS. Any revision of legislation should ensure the protection of the most vulnerable groups in society, particularly women and AIDS orphans. Dr LOPEZ RAMOS (Uruguay) said that the cumulative prevalence of AIDS in her country was 5.1 %, with a mortality rate of 53%. Out of a population of 3.2 million, some 5900 cases of HIVI AIDS had been reported: 4150, people were HIV -positive, 83 7 had developed AIDS, and 93 7 people had died. Of those infected 78% were male, 68% of whom had contracted the virus through sexual intercourse and 29% through infected blood, mostly through injecting drug use. All HIVIAIDS patients were treated with antiretroviral drugs, which had reduced mortality by 50% and reduced mother-to-child transmission ofHIV from 28% to 4% between 1996 and 2001. Uruguay's national AIDS programme aimed to promote and help to ensure respect for the human rights of the people affected, including the right to health and non-discrimination based on the principles of universality, equity and quality of care. More attention needed to be given to sentinel surveillance. A system of behavioural monitoring would be particularly useful: young people were generally well informed about the risks of unsafe sexual practices, but did not always behave accordingly. Her delegation supported the draft resolution recommended by the Executive Board. Mr ARRIAGA (Mexico) said that WHO's global health-sector strategy would allow countries to share experiences and analyse their weaknesses, and was a vital element of the United Nations strategy to combat HIVIAIDS. It should pay particular attention to the increase in infection among the most vulnerable groups, especially adolescents and young people. His Government trusted that the coordination of activities between WHO and UNAIDS would continue to ensure that there was no duplication of activities. Dr ZAHER (Egypt) said that her country was currently implementing its HIVIAIDS programme for the period 2001-2005, in collaboration with WHO and UNAIDS and with the support of national nongovernmental organizations. It involved the ministries of education, tourism, social affairs and public information, and activities included safe blood initiatives and programmes to raise awareness of HIVIAIDS issues among young people and other vulnerable groups. Support and counselling were available for people living with HIVIAIDS. HIV issues were included in medical school curricula and in programmes on maternal and child health, reproductive health and sexually transmitted diseases. Research was being conducted on AIDS and other sexually transmitted diseases. Health centres were working to increase awareness among health professionals and prevent the transmission of the virus by contaminated blood. Mr SIDIBE (UNAIDS) said that the world's response to AIDS had intensified over the past year, thanks to the advocacy efforts of UNAIDS, its cosponsors and AIDS activists. The special

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session on HIVIAIDS of the United Nations General Assembly had marked a turning-point, by producing a unanimous Declaration of Commitment which was a benchmark of global accountability. The draft resolution before the Committee showed WHO's commitment to that global declaration. There was new empirical evidence of the success of HIVIAIDS prevention activities in Brazil, Cambodia, the United Republic of Tanzania and urban Zambia, especially among young people. However, the HIVIAIDS epidemic persisted or was increasing in southern and western Africa, Eastern Europe and Indonesia. Progress with regard to access to treatment was slow, but all parties recognized the significant resource gap in poor countries. The need for new partnerships had also been recognized during the debate. Since the special session, all UNAIDS' cosponsors had increased their AIDS activities, covering all sectors of society and creating strong partnerships with civil society and with people with HIVIAIDS. UNAIDS welcomed WHO's increasing involvement in HIVIAIDS activities as part of the collective effort of the United Nations system, particularly in the crucial area of access to treatment. The recent guidelines on antiretroviral therapy in resource-limited settings and quality assessment of HIV medicines as part ofthe essential drugs programme were other aspects of WHO's contribution. All those activities provided a clear baseline for accountability and the new monitoring frameworks. The common challenge for UNAIDS and WHO was to move from planning and successful but small-scale projects to effective nationwide programmes, in both low-prevalence and high-prevalence countries. Mr MASUKU (FAO) said that, as the strategy for health-sector responses to HIVI AIDS continued to evolve, the epidemic could no longer be considered solely as a health problem. Appropriate efforts had to be made to address its social, economic and institutional consequences. Increasingly, the HIVIAIDS epidemic was having a major impact on nutrition, food security, agricultural production and rural societies in many countries. AIDS-related food insecurity was affecting whole areas in many communities, and the consequent socioeconomic deterioration would eventually have a significant impact at the national level; for example, in most of the highly affected countries, up to 80% of the population subsisted on agriculture. FAO had estimated that in the 27 most affected countries in Africa seven million agricultural workers had died from AIDS since 1985, and 16 million more deaths were likely in the next two decades. In the 10 most affected African countries, the labour force was expected to decrease by between 10% and 26% over the coming years. Such a reduction, coupled with corresponding reductions in productivity, total outputs and overall economic growth, was likely to lead to a decline in national food supplies and a rise in food prices. A concurrent breakdown in other commercial enterprises could further undermine the capacity to export and generate foreign exchange. During the past decade, FAO had assessed the likely impact of HIVI AIDS on agriculture, food security and rural development and had provided support to countries to develop their own programmes. Research on the impact of HIVI AIDS on agricultural extension and farm operations had been conducted in selected countries in southern Africa and FAO was cooperating with some countries to develop AIDS-sensitive agricultural policies. In Asia, various initiatives and methodologies were successfully being applied to HIVI AIDS prevention. FAO had also assisted the Ministry of Agriculture in Uganda to incorporate HIVIAIDS considerations in its agriculture extension services. With regard to nutrition, FAO was working with WHO to produce a manual on nutritional care and support for people living with HIV I AIDS and on the development of a joint training programme. FAO was preparing guidelines that would ensure that HIVIAIDS was consistently incorporated in all its relevant field activities and emergency operations in high-prevalence areas. During the debate on HIVIAIDS at its Twenty-seventh session in 2001, the Committee on World Food Security had recognized that the following principles commonly underlay successful approaches to combat HIVI AIDS and recommended that they be adopted: dynamic leadership and political commitment at all levels; prevention of the spread of infection; prevention of HIVI AIDS in poor communities by provision of immediate assistance and development initiatives; a people-centred,

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multisectoral community-based approach to development and establishing a link between HIVIAIDS programmes and food security initiatives. Mr GIZA W (International Federation of Red Cross and Red Crescent Societies), speaking at the invitation of the CHAIRMAN, commended the global health-sector strategy outlined in document A5519. The Federation was mobilizing its global network of volunteers, who were uniquely placed to encourage behavioural changes in communities, to combat the spread of the disease. Red Cross and Red Crescent staff and volunteers currently provided support and home care services to tens of thousands of people living with, or affected by, HIVIAIDS. Through youth peer education, young people were being targeted inside and outside school settings in order to promote a safer lifestyle and prevent the spread of HIV and other sexually transmitted infections. National societies had scaled up their actions in 34 African countries and similar efforts were in the pipeline in Asia, the Caribbean and eastern Europe. Stigmatization and discrimination were two major factors driving the epidemic. On 8 May 2002, in collaboration with the Global Network of People Living with HIVIAIDS, UNAIDS and other interested partners, the Federation had launched a global anti-stigmatization campaign that would reach community level through national societies. Recent biomedical advances and past experience could be harnessed to promote the rights of people living with HIVIAIDS, prevent further transmission of the virus and mitigate the impact of the epidemic. To achieve those ends, a mechanism for coordinating the efforts of the different parties was needed, and could best be established by governments. The Federation and its member national Red Cross and Red Crescent societies were committed to taking part in such a mobilization effort. Professor IDANPAAN-HEIKKILA (CIOMS), speaking at the invitation of the CHAIRMAN, said that the updating of the 1993 CIOMS International Ethical Guidelines for Biomedical Research involving Human Subjects had benefited from the support of WHO and UNAIDS, as well as governmental contributions. Ethical issues raised by trials ofHIVIAIDS vaccines and treatment drugs, as well as new research and technological advances, mainly in genetics and human reproduction, had been among the factors that had guided the decision to undertake the project. During the revision process, several new challenges in international biomedical and health-care research had arisen. The new guidelines, to be issued in September 2002, would offer carefully balanced solutions to such key issues as the use of placebo in clinical trials and the standard of care to be provided to research subjects following the conclusion of a study. They would also address capacity-building for biomedical research and ethical review in countries with limited resources. He congratulated WHO on its new report on genomics and world health, developed by ACHR. CIOMS had begun to tackle the field of pharmacogenetics, a scientific subset of pharmacogenomics, which dealt with genetic variations in the response to drug doses and dosage regimens in individuals and patient populations, and which had become crucial in drug research and development and in the rational and safe use of pharmaceuticals. A growing understanding of the genetic mechanisms responsible for drug response, non-response or toxicity offered new opportunities for meeting the changing needs of health care systems. In 2001, at the request of health authorities and members of the scientific community, CIOMS had established an international Working Group on Pharmacogenetics and Pharmacoeconomics that would consider such issues. Dr TURMEN (Executive Director) thanked delegates for their comments, which would be reflected in the final form of the global health-sector strategy for HIVIAIDS. Document A5519 reported the progress that had been made in formulating the strategy with the participation of regions and countries. During the regional consultations, countries had made it clear that tackling HIVI AIDS was a priority that needed input from various areas, including reproductive health services, maternal and child health services and tuberculosis control programmes. A solid, integrated and coherent health-sector approach was a prerequisite for a strong, multisectoral response that addressed the underlying determinants of HIVIAIDS and the vulnerability that exposed people to infection. The

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Millennium Development Goals and the commitments made during the United Nations General Assembly special session on HIVI AIDS would be difficult to attain without effective health-sector leadership of a coordinated multisectoral response. The global health-sector strategy, within the framework of the United Nations system's strategic plan, would reaffirm the role ofthe health sector within the global effort to fight AIDS and identify its main areas of responsibility and accountability. The final version would be submitted to the Executive Board at its 111 th session. Whereas the global health-sector strategy led the way towards a wider and more effective health-sector response, there were still many areas of HIVI AIDS that needed further research, as well as additional human and financial resources. For example, WHO was working on a report, to be launched at the XIV International AIDS Conference in Barcelona, Spain, in July 2002, on the global coverage of major prevention and care interventions, so that countries would have a recognized starting point when they applied the health-sector strategy or introduced new national programmes and would be able to monitor progress over time. Such information would also be needed to monitor progress in relation to the Global Fund to Fight AIDS, Tuberculosis and Malaria and other development aid mechanisms, and to provide a basis for appropriate health services. More than 90% of the people in the developing world were unaware of their HIV status, and could not therefore be expected to use the available services. WHO was working on innovative, ethical and practical ways of expanding counselling and testing services to increase their uptake, which remained a critical limiting factor in efforts to improve programmes for preventing mother-to-child transmission of HIV and· increasing access to care and treatment. As HIV transmission was the result of a complex mixture of behaviours, settings, geographical regions and social factors, WHO was working on more effective ways of delivering crucial interventions where they were most needed. Despite the existence of effective tools for preventing HIVIAIDS, nearly a million children were infected every year. It was imperative to find ways of ensuring that the known and necessary care and information for HIV -positive women of childbearing age were made available to them. Furthermore, much more needed to be done across all WHO programmes to prevent women from being infected in the first place. The continuing work to promote the consistent use of universal precautions, to ensure blood safety, and to accelerate the development of vaccines for the prevention of HIV infection and the treatment of the disease was guided by a sound public health approach. Although antiretroviral treatments had proved to be effective in the North, they were not yet available and appropriately used in the South. Instead of the traditional individualized, clinical management approach, therefore, WHO was advocating a public health approach to the treatment and care of populations that fostered equity of access to treatment and harnessed the energies of people living with HIVI AIDS who were the agents for change and could mobilize communities. The new approach brought together care and prevention activities in a mutually reinforcing way. WHO had issued technical guidelines on antiretroviral therapy in resource-limited settings to promote the use of standardized regimens and simplified monitoring; the executive summary was available on WHO's web site in English and French. Antiretroviral drugs had also been added to WHO's model list of essential medicines - a breakthrough for the rational and safe use of such powerful and precious medicines. The CHAIRMAN suggested that the proposed amendments to the draft resolution contained in resolution EB109.R6 should be circulated to the Committee in writing, and that the draft resolution as a whole should be discussed at a subsequent meeting. It was so agreed.

(For continuation of the discussion, see summary record of the sixth meeting, section 2.)

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Quality of care: patient safety: Item 13.9 ofthe Agenda (Resolution EB109.R16; Document A55/13) Ms WIGZELL (representative of the Executive Board) said that patient safety as a specific aspect of quality of care had been discussed by the Executive Board for the first time. Board Members had expressed wide interest in the subject; they were concerned that patient safety was often neglected and that adverse events were underestimated. It had been felt that the problem needed greater attention, not least in countries where major health reforms were under way. As adverse effects often had similar causes in different areas, it had been suggested that there was scope for designing and implementing systems to reduce preventable harm and loss of public confidence, as well as the negative financial consequences. There had been support for international action, with WHO playing an important role. It had been felt that there were links between patient safety and regulatory mechanisms available to national authorities, such as accreditation. Improving patient safety was a complex system-wide effort that included three complementary actions: preventing adverse events, making such events visible when they did occur, and mitigating their effects. It had been pointed out that human resources were crucial to patient safety and quality of care, making it important to maintain a staff of properly trained health professionals. In that regard it had been suggested that WHO should establish health care quality norms and standards, and monitor their application. The resolution recommended by the Executive Board in resolution EB109.R16 called for action in areas such as the development of global norms and standards, WHO assistance to countries, promotion of evidence-based policies and mechanisms to recognize excellence in patient safety internationally, and encouragement of research. Sir Liam DONALDSON (United Kingdom of Great Britain and Northern Ireland) said that perhaps as many as 10% of all hospital patients worldwide suffered some adverse event during their care, which in some cases led to their death. Twenty-five per cent of all avoidable harm was due to medical error alone. That was not a criticism of health care, but recognition that in such a complex field error was inevitable and risks could be high. Until recently, the safety of patients was not a well understood or explicitly voiced concept. Yet in other sectors, such as the airline industry, emphasis on safety over many decades had significantly reduced the risks. There was currently a major opportunity to change the thinking on patient safety. The message had to be communicated that, while human error could not be eliminated, its occurrence could be reduced and, more importantly, so could its impact. Approaches needed to be developed systematically to analyse weaknesses and vulnerabilities and to learn from mistakes. Greater openness needed to be encouraged in health care organizations, so that the reporting of errors and adverse events by doctors and nurses were seen as good practice deserving praise and not blame. To bring about the necessary change, it had to be recognized that individuals committed unsafe actions when they worked in unsafe systems, and that by strengthening the systems, the probability of harm could systematically be reduced. Furthermore, it was essential to set up good information systems that would make it possible to analyse the underlying root causes of adverse events. Health organizations should be characterized by a culture in which the reporting of adverse events formed part of an uncompromising quest for quality, shared by governments, health personnel, patients and managers alike. He commended the draft resolution to the Committee as a step towards safer health care for patients in all countries of the world. Dr AL-MAZROU (Saudi Arabia) expressed regret that such an important topic had been raised at the end of a long meeting. He had discussed the issue with colleagues in private and public hospitals in his country and had concluded that the health system suffered from a lack of information, together with the absence of a scientific basis for the adoption of patient safety measures. It was not the medical profession that was to blame but the scientific institutions that had failed to recognize the importance of the issue. Part of

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the blame also lay with WHO. He consequently requested the Director-General to take all necessary measures to ensure that the question of patient safety was given thorough consideration and that it constituted one of the cornerstones of WHO's work. Or KIM Won Ho (Democratic People's Republic of Korea) said that adverse events had become a serious hazard in hospitals, where some 70% of such incidents resulted in short-lived disability, and 14% resulted in death. Hence safety was a fundamental principle of patient care. As the report mentioned, despite growing interest in patient safety there was still a widespread lack of awareness of the problem of adverse events. In order to ensure patient safety, the technical level of medical workers and medical equipment needed to be upgraded, and safety education improved. Two crucial factors in patient care, the devotion and sense of responsibility of the medical staff, were fundamental requirements of his country's public health policy. Or AGARWAL (India) said that in India about half a million doctors practised modem medicine, while an equal number practised Indian systems of medicine. Eighty per cent of medical care was provided in the private sector and the remaining 20% in the public sector. Under a consumers' protection act patients could seek compensation from doctors in the private sector. While quality of care was also important in government hospitals, it had to be considered in the light of the pressures to which they were subjected. Although India had institutes of excellence, where every treatment available in the world was carried out, including heart transplants, many facilities were poor. While efforts were being made with World Bank support to improve the health system, the sharing of hospital beds was not uncommon. Health care was becoming increasingly expensive and Parliament was currently considering a bill to streamline the training of paramedical personnel. Rules on biomedical risk management and environmental guidelines were mandatory for all institutions and infection control committees had been set up in government hospitals. The national health policy for 2002 acknowledged that the existing health infrastructure was unsatisfactory, owing to lack of funds and inadequately trained manpower, which had led to a serious deterioration of the quality of services. Any improvement would depend not only on greater financial resources, but on a more empathetic attitude on the part of service providers. He supported the draft resolution contained in resolution EB109.R16. Or HADDAD (Canada) said that there was growing evidence that health care was not as safe as patients, health care providers and funders would like; health care sometimes resulted in unintended harm to patients and it was unacceptable that it could inadvertently result in injury or even death. The financial cost was also important, since resources that might be used to improve health care were instead used to remedy the results of preventable adverse events. At the same time, it had to be recognized that health care was growing in complexity, with more complicated equipment, a wider range of more powerful drugs, and more people involved in treatment. Research had shown that with greater complexity, there was a greater chance of accidents: if one step in any procedure had an error rate of 1%, a five-step procedure would have an error rate of 63%. What might have seemed a minor or even acceptable level of error suddenly became major and unacceptable although some errors might be unavoidable in view of the complexity and difficulty of detection and prediction. Dealing effectively with errors and mitigating their effects was just as important as making sure that very few happened in the first place. It was significant that influential bodies were acknowledging that patient safety was crucial. Sharing information at the international level was potentially helpful to all countries, but in particular it provided a head start for countries that were beginning to address the issue. In the general enthusiasm for sharing, it was important not to lose sight of the importance of home-grown solutions. The building of a culture of safety required collaboration between many groups and organizations in various areas, and included changes to legislation and regulations; raising awareness of patients' safety and changing attitudes within the health care community; the development and availability of resources, such as clinical practice guidelines and information technology systems; the development

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and sharing of reporting systems that collected and aggregated data on risks; education and training for health care professionals and managers so as to introduce change into their practice and organizations; support for patient safety research; and finally, government involvement at all levels in supporting and committing resources to initiatives for improved patient safety. Canada supported the draft resolution and looked forward to the development of a detailed work plan. Dr HANSSEN (Norway), speaking on behalf of the Nordic countries, strongly supported the initiative on quality of care, which was an essential part of the human right to health services. WHO had an important role to play in supporting countries in developing, implementing and evaluating comprehensive national policies and programmes. His country's experience supported the call for a broad policy toolkit including organizational, economic, pedagogic and legislative means, established at local and/or national level and dependent on contextual factors such as health system design, systems of financing, and existing supervisory and monitoring mechanisms. The resolution recommended in resolution EB109.R16 did not fully reflect the implications of the report (document A55/13). Paragraph (1) should imply support for comprehensive national programmes to control and improve quality of care, rather than emphasizing the development of global norms, standards and guidelines for the definition, measurement and reporting of adverse events and near misses in health care. Norms, standards and guidelines would need to be contextrelevant and to reflect the dynamic development of health care interventions. Paragraph (3) referred to accreditation as a mechanism to establish characteristics for international benchmarking. WHO should instead promote a government stewardship role supporting national identification of appropriate mechanisms for quality control and patient safety, and take a lead in facilitating exchange of experiences and collaboration. Benchmarking international excellence in patient safety in such detail would not be effective until more knowledge from local contexts had been established and evaluated. He proposed that the paragraph be amended by inserting the words "or other means taking into account national conditions and requirements" after "for example through accreditation". He supported the request in paragraph ( 4) to encourage research into patient safety, which should be undertaken so as to reflect the diversity of health care in different countries. Dr MAZONDE (Botswana) welcomed the draft resolution since adverse events in health care delivery caused significant human suffering and avoidable financial burdens to patients, communities and governments. In Botswana performance improvement was accorded high priority in all sectors. In the health sector efforts had been made to improve delivery through a performance management system, to increase productivity through quality improvement initiatives such as total quality management, and to upgrade patient care through audits and the development of guidelines, protocols and policies. Significant progress had been made but much remained to be done in respect of prevention and the documentation of adverse events so that appropriate corrective measures could be introduced. Botswana endorsed the request to the Director-General to develop global norms, standards and guidelines for the measurement and reporting of adverse events. WHO should support national efforts to improve patient safety in health systems in both developing and developed nations. It supported the resolution recommended in resolution EB 109 .R16. Mr ZEPEDA BERMUDEZ (Brazil) welcomed the inclusion of item 13.9 in the Health Assembly's agenda. Health interventions were always intended to benefit patients and because of the poor health conditions resulting from social and economic constraints, such interventions were more frequent and more important in developing countries. The high rates of adverse events, ranging from 3% to 12%, mostly due to counterfeit or substandard medicines or faulty equipment caused financial

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loss and had serious implication for health systems. Urgent action by governments and guidance from WHO were essential. The overall performance of the health system and patient safety were among the priorities of Brazil's Ministry of Health, which placed particular emphasis on drug monitoring and pharmacovigilance through a network of drug monitoring centres. Another priority was the rational use of medicines, and an initiative involving 35 universities, the drug regulatory agency, PAHO and the national school of public health, which was a WHO collaborating centre for pharmaceutical policies, constituted a first step towards expanding the rational use of medicines within the health system. Brazil supported the resolution recommended in resolution EB109.R16 as an important contribution to the development of global standards and evidence-based policies to achieve highquality care and patient safety. (For continuation of the discussion, see summary record of the sixth meeting, section 2.) The CHAIRMAN informed the Committee that agenda items 13.10, 13.11 and 13.12 had been transferred to Committee B. (For continuation of the discussion of these subitems, see summary record of the fourth meeting of Committee B, section 4.)

The meeting rose at 20:00.

SIXTH MEETING Friday, 17 May 2002, at 9:35 Chairman: Dr J. KIELY (Ireland) later: Dr S. AGARWAL (India) later: Dr J. KIELY (Ireland)

FIRST REPORT OF COMMITTEE A (Document A55/47) Dr MSA MLIV A (Comoros ), Rapporteur, read out the draft first report of Committee A. The report was adopted. 1

TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued)

World Summit on Sustainable Development: Item 13.3 of the Agenda (Document A55/7) (continued front the second meeting) The CHAIRMAN drew attention to an amended version, prepared by a drafting group, of a draft resolution proposed by the Southern African Development Community, which read: The Fifty-fifth World Health Assembly, Having considered the report on the World Summit on Sustainable Development; 2 Recalling Principle I of the Rio Declaration on Environment and Development, namely, "Human beings are at the center of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature" and Chapter 6 on health of Agenda 21, adopted at the United Nations Conference on Environment and Development (Rio de Janeiro, Brazil, 1992); Welcoming the report of the WHO Commission on Macroeconomics and Health3 and noting the references to the resources needed to scale up the coverage of essential interventions to achieve desired health outcomes; Recognizing that sustainable development aims at improving the quality of life of all the world's present generation, without compromising that of future generations; Further recognizing that achieving this objective requires integrated action towards economic growth; the assurance that no individual or nation is denied the opportunity to benefit from development; management and conservation of natural resources; protection of the environment; and social development; Aware that these pillars are mutually supportive, creating synergy for sustainable development and good health; 1 2

See page 272. Document ASS/7.

Macroeconomics and health: investing in health for economic development. Geneva, World Health Organization,

2001.

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Bearing in mind the contribution that poverty reduction makes to health, and health to sustainable poverty reduction; that sustainable global and local environments make to health; and that viable health services uniquely make to sustainable development; Aware of the need for a comprehensive approach to health and of the intersectoral nature of health problems and solutions; Noting with concern that, despite much social and economic progress, health continues to be severely compromised in many countries by inadequacies in the implementation of required measures in all areas of sustainable development, 1. URGES Member States: (1) to address the link between health and sustainable development at the World Summit on Sustainable Development (Johannesburg, South Africa, 26 August to 4 September 2002); (2) to provide timely and effective support to the health programme as envisaged in the New Partnership for African Development (NEPAD) as a means of achieving sustainable development in Africa, and to similar initiatives in other regions; (3) to reaffirm internationally agreed development goals, including those contained in the United Nations Millennium Declaration; (4) to implement the United Nations Declaration of Commitment on HIV/AIDS and internationally and regionally agreed targets for the reduction of the disease burden; (5) to encourage countries in development to prepare and implement sustainable strategies to reduce poverty and to include in such strategies plans to address the unacceptable burden of communicable and noncommunicable diseases; (6) to encourage developed countries that have not done so to make concrete efforts towards the target of allocating 0.7% of GNP as overseas development assistance to developing countries; (7) to apply the 20:20 principle whereby not less than 20% of overseas development assistance and not less than 20% of countries' own budgets are allocated to social sector spending; (8) to dedicate funds for health research, particularly for development of new drugs and vaccines for preventing and treating diseases of poverty; (9) to adopt policies that create healthy workplaces, protect workers' health and, consistent with national and international law, prevent transfer of hazardous equipment, processes and materials; REQUESTS the Director-General: (1) to provide support to countries to implement strategies and interventions to achieve the internationally agreed development goals, including those contained in the United Nations Millennium Declaration, and scale up their efforts in health to the level required; (2) to provide technical support to countries to frame policies and to implement national commitments and action plans that promote consumption patterns at individual and national levels that are sustainable and health promoting; (3) to accelerate development of an action plan to address the ethical recruitment and distribution of skilled health-care personnel, and the need for sound national policies and strategies for the training and management of human resources for health; (4) to provide support to countries further to develop effective disease surveillance and health information systems; (5) to provide support to countries to establish and strengthen on the basis of a multisectoral approach existing programmes of action, to empower people to protect and promote their health and well-being; (6) to report to the Fifty-sixth World Health Assembly on the World Summit on Sustainable Development and on progress made in implementing this resolution.

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Mr PETTERSSON (Sweden), speaking on behalf of the drafting group, said that in paragraph 1(2), the word "African" should be replaced by "Africa's"; in paragraphs 1(6) and 1(7), the word "overseas" should be replaced by "ofticial"; and in paragraph 2(4) the words "further" and "to" should be transposed. Mr HOHMAN (United States of America) said that it had been agreed with the sponsors that paragraph 1(6) should be amended to read: "to encourage developed countries that have not done so to make concrete efforts towards the target of allocating 0. 7% of GNP as official development assistance to developing countries and 0.15% to 0.20% of GNP of developed countries to least developed countries as reconfirmed at the Third United Nations Conference on Least Developed Countries, and to encourage developing countries to build on progress achieved in ensuring that official development assistance is used effectively to help achieve development goals and targets". Or TSHABALALA-MSIMANG (South Africa), speaking on behalf of Member States of the Southern African Development Community, thanked all who had contributed to the consensus on the draft resolution. Since the United Nations Conference on Environment and Development (Rio de Janeiro, Brazil, 1992), disparities within and between countries had widened, and communicable diseases had increased in poor countries. Globalization had had a negative impact on the development of health services in such countries. At its meeting in Johannesburg, South Africa, in January 2002, the Southern African Development Community had called for concrete commitment to sustainable development, the scaling-up of interventions to reduce the impact of disease, and cancellation of the debt burden for developing countries. She urged the Committee to approve the draft resolution. The draft resolution, as amended, was approved.' HIV/AIDS: Item 13.5 of the Agenda (Resolution EB109.R6; Documents A55/9 and A55/9 Corr.l) (continued from the fifth meeting) The CHAIRMAN drew attention to a draft resolution entitled "Contribution of WHO to the follow-up of the United Nations General Assembly special session on HIV/AIDS", which incorporated amendments proposed during the fifth meeting, and which read: The Fifty-fifth World Health Assembly, Deeply concerned that the global HIV/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 2001, so that by the end of 2001, 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 HIV/AIDS adopted at the special session ofthe 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 road map towards its implementation2 as well as resolution WHA54.10 on scaling up the response to HIV/AIDS; 1 2

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.11. General Assembly document A/56/326.

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Acknowledging WHO's special role within the United Nations system to combat and mitigate the effects of HIVI AIDS, 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 HIVIAIDS; Recognizing that the full realization of human rights and fundamental freedoms for all is an essential element in a global response to the HIVIAIDS pandemic that includes prevention, care, support and treatment, reducing vulnerability to HIVI AIDS, and preventing stigmatization and related discrimination against people living with, or at risk of, HIVIAIDS; Commending the efforts of the Director-General to enhance and strengthen WHO's response to the HIVIAIDS 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 United Nations General Assembly special session on HIVIAIDS, by operationalizing the Declaration of Commitment on HIVI 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 HIVI AIDS; (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 HIV IAIDS 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 HIV-testing 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 according to the availability of resources and assuring that they are safely and effectively used in the proper context of existing systems; (6) to build and strengthen partnerships between health-care providers, both public and private, and communities, including nongovernmental 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 HIVI AIDS, on the basis of scientific evidence and lessons learned; REQUESTS the Director-General: (1) to continue to ensure that WHO plays a key role in providing technical leadership, direction and support to the health system's response to HIV, within the United Nations system-wide response, as a cosponsor ofUNAIDS; (2) to provide support to countries in order to maximize opportunities for the delivery of all relevant interventions for prevention, care, support and treatment ofHIVIAIDS; (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 HIVIAIDS, to provide support to countries, as part of their national strategies, in the areas of

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prevention, care, support and treatment in order to meet the commitments and goals agreed at the United Nations General Assembly special session on HIVIAIDS, in particular as they: (a) 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; (b) 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 pregnancies in HIV-infected women, and provision of interventions that reduce transmission from mother to child; (c) 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 for operational research on service delivery; (7) to submit a report on WHO's work on HIVIAIDS, including the global healthsector strategy to the Executive Board at its lllth session and the Fifty-sixth World Health Assembly. Mr HOHMAN (United States of America) said that he would be unable to accept the draft resolution unless the phrase "avoidance of unwanted pregnancies in HIV -infected women" in paragraph 2( 4)(b) was deleted. In response to a point raised by Brazil in the previous meeting, he said that the paragraph already adequately reflected concern to reduce HIV transmission in women. Dr CHITUWO (Zambia), Dr TSHABALALA-MSIMANG (South Africa) and Dr KORTE (Germany) stated that they wished the paragraph to be retained as it stood. Dr SUPAMIT CHUNSUTTIWAT (Thailand) recalled that her delegation had proposed a new paragraph calling for steps to be taken to end the stigmatization of people living with HIVIAIDS. The CHAIRMAN suggested that discussion of the item be suspended to allow time for informal consultations. It was so agreed. (For resumption of discussion, see page 92.) Quality of care: patient safety: Item 13.9 of the Agenda (Resolution EB109.Rl6; Document A55113) (continued from the fifth meeting) The CHAIRMAN drew attention to the draft resolution recommended by the Executive Board in resolution EB109.Rl6. Dr TUKUITONGA (New Zealand) urged WHO to promote research into adverse events in the non-hospital sector, where the risks of such events were equally high, but for which there was little information available. New Zealand was developing a national quality improvement strategy, new health and disability services legislation, and a proposed health practitioners' competency bill. He

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endorsed the draft resolution, which would enable Member States to learn from one another but said that further work was needed before mandatory international reporting on compliance with global norms and standards could be introduced. Mrs FELIU ESCALONA (Cuba) said that the risk of adverse events in health care interventions was always present: studies showed that they occurred in between 3.2% and 16.6% of such interventions, the principal causes being poor organization and operation of the health care system. Safety was a fundamental principle of patient care, requiring a wide range of measures including operational improvements, environmental safety, risk management and appropriate human resources. The effective reduction of adverse events called for concerted international action, in which WHO had a proactive role to play. There should also be systematic analysis of the quality of health care interventions, and to that end she proposed that a programme of action be implemented by WHO and its Member States including best practice and the sharing of positive experiences, with research into ways of improving the quality of health care systems. She supported the draft resolution. Mr CHOI (Republic of Korea) welcoming the report, agreed that insufficient attention had been given in the past to ensuring patient safety. He supported the draft resolution. Professor BADIANE (Senegal) said that in order to improve safety three steps should be taken. First, recommendations for good clinical practice at national or even international level should be developed; secondly, the quality of medicines and medical equipment should be guaranteed; and thirdly, information concerning adverse events should be made available. Such information could be gathered by national centres, for subsequent international distribution, and could cover such matters as the toxic effects of new medicines or of those of dubious origin, the trafficking of drugs and the harmful effects of over-the-counter products. The Internet would constitute a useful, speedy, and costeffective tool for that purpose. He supported the draft resolution. Dr OKAMOTO (Japan) said that efforts to prevent medical accidents were being intensified in Japan. WHO should assist Member States to strengthen such efforts, for instance by formulating definitions and developing standard methodologies for surveys, although account would need to be taken of the sensitivity of the information gathered. The causes of adverse events were varied and WHO's approach would have to be comprehensive. He gave the draft resolution his strong support. Dr JIRUTH SRIRAT ANABAN (Thailand) said that the promotion of patient risk management had become a critical part of Thailand's hospital accreditation programme. However, if undesirable side-effects were to be avoided, it would have to be carefully planned and implemented. There was a risk that health care providers might respond defensively in order to protect themselves, and positive attitudes towards self-assessment were essential. He proposed that the operative part of the draft resolution for the Director-General should be amended to read as follows: (1) to develop global norms, standards and guidelines for the definition, measurement and reporting of adverse events and near misses in health care by reviewing experiences from existing programmes and seeking inputs from Member countries; (2) to promote framing of evidence-based policies, including global standards that will improve patient care, with particular emphasis on product safety, safe clinical practice in compliance with appropriate guidelines and safe use of medicinal products and medical devices taking into consideration the perspectives of policy makers, administrators, health care providers and consumers in both developed and developing countries; (3) to provide support to Member States to strengthen their technical capabilities and human resources in applying the policies and standards for patient safety, in developing reporting systems, taking preventive action, and implementing measures to reduce risks;

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(4) to promote creation of a culture of safety within health care organizations, and to develop mechanisms through accreditation or other means to recognize the characteristics of health care providers that offer a benchmark for excellence in patient safety internationally; (5) to encourage research into patient safety, including epidemiological studies of risk factors, effective protective interventions, as well as associate costs of damage and protection; (6) to report progress to the Executive Board and the Fifty-seventh World Health Assembly. Mrs AYL WARD (Ireland), supporting the draft resolution, said that Ireland had recognized the importance of the issue under discussion and was implementing initiatives to ensure patient safety, including a new health strategy. Other initiatives designed to strengthen the quality of care were: a hospital accreditation programme; risk management programmes; medical indemnity reforms; greater commitment to quality and accountability on the part of regulatory bodies; and the development by training and accreditation bodies of training assessment programmes. Ms V ALDEZ (United States of America) endorsed the draft resolution. An essential element in improving quality of health care was the development of common data standards and WHO could offer Member States technical cooperation in developing their own capacities in that respect, a role that would be consistent with its efforts in health systems' performance assessment. WHO also had facilities to permit collaboration in support of research findings. She proposed that paragraph (3) be · amended to read "to support the efforts of Member States to develop mechanisms ... ". Dr FURGAL (Russian Federation) said that in many cases health care services still involved a risk to patients and to public health in general, a problem which had not been accorded sufficient attention in the past. WHO should develop and oversee the application of new health care standards to ensure quality and safety. A methodology could be developed based on the concept of bioethics, an approach supported by the WHO Regional Office for Europe. The draft resolution would be a good way of urging Member States to give patient safety the necessary attention and appealing to them to set up and reinforce a special system, including monitoring, to safeguard patient safety at all levels of health care. A provision should be included requiring the Executive Board and the Health Assembly to review progress periodically. Dr VIOLAKI-PARASKEVA (Greece) welcomed the opportunity to discuss the important subject of patient safety. A range of actions to improve performance was required, and WHO could have a role to play in raising standards through training at all levels. Attention should be paid not only to hospitals but to primary health care. She supported the draft resolution, and proposed the addition of a further paragraph urging Member States to start establishing science-based mechanisms for improving patient safety and quality of care. Ms JIMENEZ SANCHEZ (Mexico) said that, although no national study had been conducted in her country into adverse events in health care and their cost, there had been isolated studies documenting the problems and levels of dissatisfaction with the services provided by the health system. In its national health programme 2001-2006, the Government had identified quality of care as one of the three major challenges facing the health system and had launched a nationwide "crusade" to raise the interpersonal and technical standards of health care to acceptable levels. The measures envisaged under the crusade's plan of action included, on the regulatory side, streamlined regulations and innovatory mechanisms to improve the formulation, verification and enforcement of official norms, accreditation of health professionals, health institutions and training establishments, codes of ethics for doctors and nurses, a charter of patients' rights, informed consent by patients, and, on the management side, quality assurance agreements, evaluation and management of health technologies, quality performance recognition systems and health quality training. Perhaps the major cause of adverse events in Mexico was the inadequate provision of medical drugs and other supplies. High-level working groups were engaged in formulating a national

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pharmaceutical policy with a view to resolving the problem. She welcomed the possibility of participating in an international network of epidemiological research into adverse events, which would complement national action and bring Mexico's national crusade more into line with the draft resolution, which she supported. Dr KORTE (Germany) commended the draft resolution for doing justice to the importance of the training of those responsible for safety by referring explicitly to "safe use of medicinal products and medical devices". In that regard, he was pleased to offer the expertise of the Federal Ministry of Health and the Federal Institute for Drugs and Medical Devices. In Germany, training in the nursing professions was governed by the Nursing Act, and covered all relevant skills and knowledge, with special emphasis on pathology, hygiene, microbiology, epidemiology and pharmacology, guaranteeing high-quality nursing care. In addition, continuous broad-based training was taken up by a high percentage of nursing personnel. An amendment to the Nursing Act was under consideration to bring training into line with the latest standards. Germany was also engaged in establishing comprehensive quality management systems, and was keen to share its experience with WHO and other Member States. Ms NGHA T ANGA (Namibia) said that Namibia had put two strategies in place to improve patient safety and quality of care: a patients' charter spelling out patients' rights and the responsibilities of patients and health care providers; and a committee on patient care and infrastructure management to deal with patient-related problems, such as safety and security, and to improve the quality of health care. She supported the draft resolution contained in EB109.R16. Dr QI Xiaoqiu (China) said that China attached great importance to quality of care and patient safety, and wholeheartedly supported the strategy and recommendations put forward in the report. WHO should highlight the advantages to be derived from elaborating norms, international regulations and performance assessment criteria, as well as from sharing information on patient safety. Health professionals should be encouraged to draw conclusions from, and act on, that information and not to rely simply on sanctions. Consideration should also be given to norms for medical and health infrastructures, drug provision and infection control. In elaborating such norms, cooperation between developed and developing countries, as well as among developing countries themselves, should be encouraged. Mr SAM (Australia) said that he hoped that WHO's initiative on quality of care and patient safety would provide the impetus needed for greater international collaboration. Noting that the table in the report showed Australia as having a much higher rate of adverse events than the other countries listed, he pointed out that the Australian study was designed to identify all preventable errors, not just those leading to litigation. More recent international analysis showed that Australia's rates of adverse events were comparable to others', especially for serious outcomes. That should be more accurately reflected in any future report or publication. He noted also that the table provided comparative data without distinguishing between serious and preventable event rates. The purpose of the newly formed Australian Council on Quality and Safety in Health Care was to lead national efforts to improve the safety and quality of health care, with a particular focus on minimizing the likelihood and effects of error. Its current ambitious work programme included identifying a set of principles for reporting and managing adverse events. The report claimed that no initiative to reduce adverse events had been scaled up to embrace an entire health system, but the Australian Council was attempting to do just that. Australia strongly supported the adoption of the draft resolution contained in resolution EB109.R16. It saw great merit in having a global focus on definitions, standards, guidelines and risk minimization strategies related to adverse events, supported the recognition of centres of excellence in patient safety and was in favour of greater global collaboration on research.

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He expressed reservations, however, about the recommendation to introduce regulatory frameworks for reporting adverse events, because Australia's experience had shown that regulation might carry some risks of perverse incentives and unintended outcomes. Care should be exercised in managing the tension between reporting for purposes of accountability and reporting for purposes of quality improvement. What should be avoided was a regulatory framework that had the effect of driving reporting of adverse events underground for fear of sanctions. Attempts to improve quality of care in developing countries were commendable. However, there were many aspects to quality, and many possible points of intervention in health care systems. Consideration might need to be given to strengthening capacities for controlling the quality of products, environments, skills and practices at the point of entry into the system, rather than at the point of care. Inevitably there would be trade-offs between the different dimensions of quality. Australia was committed to collaboration in the field, and would welcome the opportunity to work with other member organizations on any of the recommendations. Dr LOPEZ RAMOS (Uruguay) said that, although health care, a complex process involving knowledge, technology and human interaction, was intended to benefit patients, it inevitably carried some risks of adverse reactions. The report stated with some justification that most adverse events occurred in hospitals, but laid too much emphasis on the scientific aspects of quality of care and too little on the human aspects. The report also mentioned various methods of medicines control, but omitted the role played, by the pharmaceutical industry. There should be more in-depth study of adverse events, covering training standards and the elaboration of risk management mechanisms. She proposed that paragraph (3) of the draft resolution should be amended to read "to develop mechanisms, through accreditation and other means according to the national situation, to recognize ... ". Dr OTTO (Palau) expressed his support for the activities proposed in document ASS/13, and thanked WHO, Taiwan (China), Japan and the United States of America for their assistance to his country in that field. He wholeheartedly supported the draft resolution. On the principle that action should be positive rather than punitive, he proposed that the words "quality of care and patient safety," should be inserted after "norms, standards and guidelines for" in paragraph (1 ). Dr TSHABALALA-MSIMANG (South Africa) said that the report painted a picture of the situation in developing countries and countries in transition that exactly mirrored that in South Africa. Treatment-related injuries had not yet received the attention they deserved, owing to several factors: lack of national mechanisms to measure and report adverse events; the fact that many errors did not lead to serious injury; a culture of medical practice that led many practitioners to deny or conceal errors; lack of a culture of litigation, largely due to a lack of resources; and the fact that patients were not always aware of their rights. Because in many developing countries there were no published data about reporting systems for adverse events, it was largely unknown whether most of those were the result of negligence or lack of training or were due to latent causes within the system. However, it had been accepted in South Africa that the four principles of quality assurance would apply, one of which was to focus on systems. Owing to the lack of a formal system, the cost implications of errors had never been assessed at national level. South Africa's policy on quality in health care acknowledged the importance of reducing errors and increasing patient safety, and focused on the development of systems that would reduce errors and, to some extent, eliminate their recurrence. She supported the proposal that internationally agreed definitions on adverse events and access to internationally agreed standards and guidelines should be a major strategy in addressing patient safety. South Africa strongly supported the promotion of evidence-based policies, as well as research into all aspects of patient safety. She supported the draft resolution.

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Dr HIDALGO JARA (Peru) said that patient safety was closely related to the technical competence of health personnel and the condition of equipment and infrastructure. Despite the obsolescent equipment of the medical institutions in her country, health personnel had managed in the course of an epidemic and a natural disaster to prevent the expected high casualty rate, partly because of the technical competence of the staff and the deployment of multidisciplinary teams. But much still remained to be done to establish a culture of quality within the regular health care services. She drew attention to the problems of guaranteeing safety of care to the poor and extremely poor, who could not afford access to health institutions and had no option but to purchase spurious pharmaceutical products, some of which were toxic. In her country, the high rates of maternal and infant mortality at home reflected unsafe conditions and lack of access to information about risks to health and associated preventive measures. That situation underlined the need to raise the population's awareness about risks and to adopt safe behaviour. Mrs SEPTAKOVA (Slovakia) warmly welcomed WHO's initiative, adding that the quality of health care in her country was not satisfactory. Particular problems had arisen in the diagnostic and therapeutic areas where standards were not properly enforced. A patients' charter had been in effect since 1991 but current legal protection left much to be desired, particularly with regard to sanitary conditions. A network of state health institutions was being set up, but an accreditation system conforming to European standards had not yet been finalized. The time had come to introduce a new monitoring system for patient safety as part of the new national structure. The public authorities were working with nongovernmental organizations to improve public education and information and deal with complaints from the public about health care. Ms ZOBRIST (Switzerland) expressed gratitude to the United Kingdom for having proposed the inclusion of such an important topic on the agenda of the Executive Board and of the Health Assembly. Two conferences had already been held in Switzerland on the subject and a task force had been set up to deal with patient safety. A patient safety fund sponsored by government bodies and professional associations was shortly to be established. Switzerland fully endorsed the draft resolution, together with the amendment proposed by Norway. Dr TUIKETEI (Fiji) said that safety measures, fundamental to patient care and a critical component of health care systems should include infection control management, environmental safety and risk management, occupational health and safety, safe use of medicines and equipment, standardized clinical management guidelines, good surveillance and monitoring systems for medication and adverse effects, and effective health-care waste management. However, the effective implementation of such strategies depended on Member States providing adequate resources within their health systems, including safe infrastructure and environment, adequate numbers of skilled and knowledgeable professionals, availability of safe drugs, availability of safe and functional medical equipment, and good supervisory and monitoring mechanisms. Fiji needed guidance from WHO in strengthening and developing its strategies, especially in policy formulation, programmes of action, legislation, research and other strategic interventions. She endorsed the draft resolution. Dr ZAHER (Egypt) said that in her country the Ministry of Health had established a committee for ensuring quality assurance in hospitals, medical units and health centres. It provided medical establishments with the necessary infrastructure and resources to implement quality assurance for all procedures and outcomes, and issued standards and indicators, appropriate to available means and resources, for all hospital activities. The health outcomes of all activities were analysed to ensure that they were in line with international requirements. Adverse events, including death, remained the most important measure of health outcome. Crucial steps to take to achieve quality of care in hospitals were to develop standards for various hospital departments, such as blood banks, operating theatres and health records; to decrease maternal

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and infant mortality rates; and to reduce the incidence of nosocomial infections. Efforts needed to be redoubled to improve the health system, through training of specialists and medical teams, improved working environment, sharing of experiences, robust mechanisms for monitoring implementation of quality assurance, and research. Or MuNOZ (Chile), welcoming the attention being paid to the subject, noted that in the Spanish text of the draft resolution the terms used to convey the concepts "safety" and "safe" were inappropriate and should be changed. Mention ought to be made of patients' rights and of the need to inform patients about risk. Finally, he pointed out that the role of WHO was to issue guidelines on accreditation or certification of health care providers, not on external accreditation of hospitals or health centres. Or LEGNAIN (Libyan Arab Jamahiriya) observed that adverse events leading to morbidity and disability had financial as well as physical consequences for patients. The data quoted in the report gave the impression that the number of adverse events resulting from lack of quality of care was much higher in developing countries. However, most of those countries were unaware of the problem of adverse events in hospitals because health information systems were weak, reporting was restricted by fears of liability and responsibility, and legislation was lacking. Ministries of health needed to pay greater attention to patient safety, encourage research in the field and increase international cooperation. Her country was constantly trying to improve services and quality of care for patients, but lacked technical resources. Her delegation endorsed the draft resolution. Or DUNCAN-GOFFE (Jamaica), also endorsing the draft resolution, said that quality of care had long been emphasized in her country's health care system. Instruments and procedures in place included ethical codes of conduct for health care workers, a well-developed system for reporting and investigating adverse reactions to vaccines, service agreements setting out health indicators and targets for regional authorities, and periodic clinical audits of procedures and outcomes in relation to set guidelines and standards. Most adverse events in Jamaica appeared to be associated with systemic problems, many resulting from malfunctioning equipment, some of which had been donated. Because some medical "gifts" were inappropriate and caused unintended effects, the Ministry of Health had issued guidelines to prevent such occurrences. She called on delegates to look more closely at the contribution of such donations to the incidence of adverse events. Mr ALBINSON (Consumers International), speaking at the invitation of the CHAIRMAN, said that the reporting of adverse events formed a crucial part of measures to improve the safety of medicines. Reporting systems should be global and accessible to all, and should involve the end-user, both as the reporter of the adverse event and as a partner in work towards the safe and rational use of medicinal products. He drew attention to the WHO Programme for International Drug Monitoring, operated by the Uppsala Monitoring Centre, which had 67 participating countries and a database containing over 2.7 million case records of suspected adverse drug reactions dating back to 1968 - the largest collection of such data in the world. Initially, it had been agreed to keep the data confidential, but attitudes towards confidentiality had changed and 49 countries currently allowed open access. Secrecy was not compatible with public confidence. Consumers had unique experiences of medicines, and combining those experiences with the unique data in the WHO database would advance work on safety and quality in health care. He recommended that WHO should allow free access to the database by responsible groups or individuals, and promote consumer participation in relevant aspects of work on quality of care and patient safety. Ms VIAUD (World Medical Association), speaking at the invitation of the CHAIRMAN and on behalf of the International Council of Nurses and the International Pharmaceutical Federation, said

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that adequate investment in the recruitment and training of health professionals and their involvement in health policies were crucial for ensuring quality and safety of care. The World Health Professions Alliance was concerned that cost-cutting, the global shortage of health professionals, the employment of less skilled personnel and reduced staffing levels were threatening quality of care, especially as inadequate staffing had been correlated with increased incidence of adverse events, such as bed sores and nosocomial infections, that could lead to longer stays and higher mortality rates in hospitals. It urged WHO and governments to promote the recruitment and retention of properly qualified health workers through appropriate remuneration, the provision of support services and opportunities for professional development. Associations of health professionals which could mobilize millions of members could make a real contribution to improving quality of care and patient safety, and should be supported. Dr MURRAY (Executive Director) said that the number of speakers in the debate reflected the importance accorded globally to patient safety as a critical component of quality of health care. Reference had been made to adverse events following immunization, failures of medical equipment, misdiagnosis and drug treatment in hospitals, and, as several delegates had mentioned, care outside hospitals. Several delegates had referred to governments' diverse experiences in trying to improve patient safety through fostering a culture of safety within health care organizations, the use of clinical guidelines, national standards, monitoring of adverse events and the application of that information for safer health practices and better outcomes. Others had highlighted the delicate balance between the need for better information on adverse events and the need to share that information with health care providers in such a way as to encourage improved patient safety while not being seen as punitive and thereby discouraging recognition of the problem. Resolving that dilemma was essential for progress at national and international level. He had noted the recommendations for work on definitions, norms and standards relating to patients' safety, the formulation of guidelines, and learning from shared experiences of strategies that recognized the diverse organization of health systems. WHO's work would reflect the comments and broader notions of patients' safety. The CHAIRMAN said that the proposed amendments to the draft resolution were being reconciled and consolidated into a revised text, which would be circulated and then discussed at a later meeting of the Committee. (For continuation of discussion and approval of the resolution, see summary record of the eighth meeting, section 2.) HIV/AIDS: Item 13.5 of the Agenda (Resolution EB109.R6; Documents ASS/9 and ASS/9 Corr.l) (resumed) Mr ZEPEDA BERMUDEZ (Brazil) announced that agreement had been reached on the following alternative text for paragraph 2(4)(b) of the draft resolution: "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, access to family planning information and services for HIV -infected women, and provision of interventions that reduce transmission from mother to child;". The CHAIRMAN, noting that there were no objections to that amendment, invited the Secretary of the Committee to read out the amendment proposed by the delegate of Thailand. Dr HOLCK (Secretary) said that the proposal was for the addition of a new paragraph 1(8), that would read: "to advocate the reduction of stigmatization and discrimination against people living with

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or at risk of HIV/AIDS, and to mitigate the impact of HIV/AIDS on vulnerable groups, especially women and children;". In the absence of any objection, the CHAIRMAN invited the Committee to approve the draft resolution as amended. The draft resolution, as amended, was approved! Dr Agarwal took the Chair. Global Alliance for Vaccines and Immunization: Item 13.6 of the Agenda (Document A55/10) Ms WIGZELL (representative of the Executive Board) said that members of the Board had expressed appreciation of the Global Alliance for Vaccines and Immunization (GAVI) initiative. They had been informed that GAVI's principal focus was on strengthening routine immunization services, thereby contributing to the eradication of poliomyelitis, and that the Board of GAVI had decided to allocate the resources of its Vaccine Fund to support the 74lowest-income countries. Dr MAZONDE (Botswana), applauding the success of GAVI in increasing much-needed support for immunization and improving access in countries eligible for its support, noted that a quarter ofthe world's children still lacked such access. His Government had provided funding for an expanded programme on immunization, including vaccines and the cold chain, and coverage rates had risen to relatively high levels over the past two decades. The goals of eradication of poliomyelitis and elimination of neonatal tetanus and measles had almost been achieved: no case of poliomyelitis had been reported for 11 years, and the last case of neonatal tetanus had been in 1992; the only report of measles since 1998 had been a laboratory-confirmed imported case (in 2001) and no secondary cases had been reported. Some of the gains, however, were in danger of being lost owing to pressures on the health system such as the HIVIAIDS epidemic. Although he recognized the need for GA VI to prioritize support according to agreed criteria, he proposed that the conditions for eligibility, in particular the upper limit for per capita gross national product of US$ 1000, should be reviewed. That limit might impede the introduction of new vaccines, such as those against Haemophilus injluenzae type b disease and pneumococcal infections in developing countries facing other health challenges. He proposed that other factors, such as the cost of introducing new antigens and the budgetary obligations incurred in dealing with the overall disease burden, should be included in the criteria for eligibility. That would mean that support could be given to currently ineligible countries, thus extending the public health benefits of immunization. Professor SZCZERBAN (Poland) said that, under his country's immunization programme, rates of coverage with obligatory vaccines for children under two years of age had ranged from 97.1% to 99.1% in 2000. The State financed the programme, including hepatitis B vaccine and inactivated and oral poliomyelitis vaccines, but individuals had to pay for vaccines that were merely recommended. Poland was close to eradicating poliomyelitis; no case of infection with wild-type virus had been reported since 1984. In countries where poliovirus transmission had been interrupted, WHO recommended the use of inactivated vaccine, but as it cost substantially more than the oral vaccine, Poland would be introducing it into the immunization schedule only gradually. The second and third doses of inactivated poliomyelitis vaccine would be introduced in 2003, and vaccines against Human herpesvirus 3 (varicella zoster virus), Streptococcus pneumoniae and Neisseria meningitidis infections at a later stage.

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.12.

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Dr KUNENE (Swaziland) said that, since the establishment of its expanded programme on immunization in the 1970s, Swaziland had achieved a coverage rate of 90%, one of the highest in the African Region. It had worked with UNICEF, WHO and other agencies to introduce the hepatitis B antigen and would shortly be introducing the vaccine against Haemophilus injluenzae type b infections. In line with other countries in the WHO African Region, Swaziland was on course to eradicate poliomyelitis, with no case recorded in the past five years, and tetanus had already been eliminated. It had recently collaborated with South Africa and Lesotho in launching an intercountry coordinating committee on poliomyelitis eradication. However, while commending the excellent work of GA VI, Swaziland wished to register its concern at its continued exclusion from GAVI funds due to its classification as a low middle-income country. The unfavourable economic climate prevailing over the past five to eight years had led to more than 60% of the population living below the poverty line, with a consequent decline in immunization coverage from 90% to about 70% in 2001. A heavy disease burden due to HIVI AIDS and tuberculosis had compounded the declining economic situation, and, although his Government was fully committed to funding the programme, it requested the GAVI Board to re-examine its criteria for eligibility. He expressed appreciation for the technical and financial support provided by WHO, UNICEF and Rotary International. Dr TSHABALALA-MSIMANG (South Africa) said that vaccination was one of the most important public health interventions of the age, yet many children were still dying or being subjected to life-long misery, disability and suffering from vaccine-preventable diseases. Lack of information, financial resources and health personnel often prevented vaccination campaigns from reaching worpen and children, as did social instabilities. Successful vaccination programmes required effective planning, secure funding and a supportive health system. It was difficult for low-income countries to procure vaccines, and thus high-income countries contributing to GAVI played a crucial role in saving children's lives. She called on all governments, international organizations, groups and individuals to help in providing a complete vaccination schedule for every child, in expanding the basic set of vaccines to include those against hepatitis B and Haemophilus injluenzae type b infections, in accelerating research and development, and in ensuring a sustainable vaccine supply. She also called on the private sector to promote equitable pricing policies and the sharing of expertise and other resources. Ms PORNPIT SILKAVUTE (Thailand) congratulated GA VI on its success in raising additional resources to enable children in developing countries with an annual income of less than US$ 1000 per capita to be immunized, and commended WHO, UNICEF and other partners for their indispensable role in GAVI's work. WHO's role in creating mechanisms for rapid vaccine certification, enabling the Vaccine Fund to purchase high-quality but low-cost vaccines produced in developing countries such as China, India, Indonesia and VietNam, was very valuable. That practice was one of the best ways of ensuring long-term financial sustainability and should be adopted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. WHO should also apply its success with vaccine certification to medicine certification under the Global Fund. Referring to paragraph 11 of document A55/10, she said that she was pleased that GAVI intended to expand its work to meet the needs of middle-income countries, but urged it to consider bringing the measles vaccine into its portfolio, since measles was the cause of a significant proportion of childhood morbidity and mortality in developing countries. Attention should be paid to the problem of the long-term sustainability of immunization programmes in poorer countries. Mr ABDELKERIM (Chad) welcomed the work done by GAVI, but expressed concern about the procedure for accessing GAVI funds. While external reviews of national vaccination programmes were essential, the solutions subsequently proposed should not conflict with national policies put in place as part of structural reforms. In Chad's case, for example, the external review had favoured vertical integration of the Expanded Programme on Immunization, whereas the structural reform had

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favoured horizontal integration. Integration of health services remained a major concern for both WHO and many Member States. With regard to eligibility criteria, decisions should be taken on a case-by-case basis. Dr QI Xiaoqiu (China) endorsed the measures taken by GAVI to reduce disease burdens through effective immunization programmes, and in particular, the emphasis given to safe-injection equipment, including safe disposal boxes. China was promoting the use of auto-disable syringes. GAVI's efforts to reduce the hazards of hepatitis B, which was a serious public health problem in China, and its assistance in establishing an immunization programme for children in the remotest and poorest areas were much appreciated. As of 2002, China had extended its nationwide immunization programme for newborn infants to include vaccination against that disease. Dr FURGAL (Russian Federation) said that GAVI was an impressive international partnership, whose efforts in assisting less developed countries to deal with infectious diseases were highly commendable. He endorsed the policy advocating the use of safe-injection equipment, and urged that immunization methods be further developed, particularly through the wider use of needle-less injections. Russian specialists would be happy to share their knowledge and expertise in that field. Dr LEGNAIN (Libyan Arab Jamahiriya), endorsing the report, said that she hoped that GAVI would become a permanent institution and would receive sufficient resources to extend its operations throughout the world, enabling poorer countries to combat the diseases that were hampering their development. Middle-income countries should not be overlooked, however, as they too faced problems in providing adequate immunization programmes. She suggested that a partnership be set up between developed and less developed countries with a view to establishing a Fund for the purchase of vaccines at modest prices, ensuring that all Member States benefited from an effective immunization programme. Ms BU FIGUEROA (Honduras) said that Honduras had a successful immunization programme as part of its national health strategy, with a coverage rate of 90%. GAVI's efficiency had been an inspiration to high-debt and low-income countries like Honduras. However, in October 2000 the Honduran Health Minister had submitted a project proposal which had been rejected, despite the fact that its per capita income was less than US$ 1000. She urged the GAVI Board to review its eligibility criteria. Dr TUIKETEI (Fiji) commended the work of WHO, UNICEF and other coalition partners in the Global Alliance. Fiji had achieved a reasonably good immunization coverage for all the major diseases: it had already begun administering the tetravalent vaccine and planned to add the pentavalent vaccine in 2003. It was also working towards eradicating measles, and was looking into the possibility of introducing a pneumococcal vaccine. Fiji's major problem was a lack of standard incinerators for the disposal of clinical waste and immunization consumables, and she requested the technical assistance of WHO and UNICEF in that regard. Dr CHITUWO (Zambia) thanked the Alliance for its assistance in saving the lives of millions of Zambian children, and its resultant long-term benefits both in health and in economic terms. He endorsed the call to developed countries to scale up their support for GAVI, which was not so much a vertical programme but an effort designed to strengthen national health services within countries, and expressed appreciation to WHO's Regional Office for Africa for its technical assistance in the introduction of the Haemophilus influenzae type b vaccine and the pentavalent vaccines. Ms HERNANDEZ (Venezuela) expressed great appreciation for the financial and technical support provided by GA VI in reducing morbidity and mortality from vaccine-preventable diseases,

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and emphasized the importance of safe-injection equipment and safe disposal boxes. In relation to the criteria set out in paragraph 5 of the report, Venezuela had introduced a comprehensive multi-year immunization plan, had had an international evaluation of its immunization programme and was restructuring its national immunization services committee. It would welcome technical assistance from GAVI according to its needs. Dr CHESANG (Kenya) said that, thanks to GAVI, Kenya had increased its immunization services by 16% in 2001 and had added hepatitis Band Haemophilus in.fluenzae type b vaccines to its immunization programme. GAVI had also assisted in strengthening Kenya's health system structure. The last reported case of poliomyelitis had been in 1986. Kenya had experienced a shortage of yellow fever vaccine, however, which had delayed its introduction into the immunization programme. He requested WHO to call on manufacturers to increase and maintain supplies of that vaccine. Mr ASLAM (Pakistan), endorsing the report, lauded GAVI's mission to save children's lives and protect community health through the use of safe vaccines. Pakistan was proud to have been GAVI's first beneficiary: it would be receiving US$ 35 million over the next five years, to be used to procure hepatitis B vaccine and for infrastructure support and staff training. Coverage under the Expanded Programme on Immunization was soon to be extended to the whole country.

Dr Kiely resumed the Chair and closed the meeting at 12:30.

SEVENTH MEETING Friday, 17 May 2002, at 14:40 Chairman: Dr J. KIELY (Ireland)

TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued) Global Alliance for Vaccines and Immunization: Item 13.6 of the Agenda (Document A55/10) (continued) Dr PARIRENYA TWA (Zimbabwe) said that his country, which funded vaccine use from fiscal sources, welcomed extension of the initiative to more countries. Immunization coverage was over 80% for all relevant diseases. Wild poliovirus had last been identified in 1989. Zimbabwe had applied to GA VI in 2001 for funding to strengthen its programmes and, despite some approval difficulties, hoped to have access to funds shortly. The recent alert by UNICEF to the possibility of a worldwide vaccine shortage might be attributable to a world reduction in vaccine manufacturers; GAVI was therefore urged to support efforts to promote vaccine production in developing countries. Zimbabwe was ready to introduce the pentavalent vaccine against diphtheria-tetanus-pertussis, hepatitis B and Haemophilus injluenzae type b disease and had already trained personnel for that purpose. Dr ZAHER (Egypt) said that her country's Ministry of Health and Population purchased needles and vaccines for routine immunization programmes; however, efforts were being made to improve the quality of syringes and vaccines and to make better-quality syringes more widely available. Dr CHILD (Chile) said that GAVI's central task should be to focus on the countries that did not receive adequate State support for their own immunization programmes. It should also widen the scope of its activity to look into new ways of evaluating immunization coverage. In that regard, while maintaining its focus on low-resource and low-coverage countries, its work should also include investigation of new vaccines, with case studies of their cost-effectiveness and management of programmes in middle-income countries, which might provide useful models for the rest of the world, thus stimulating horizontal cooperation. Lastly, it was important to ensure the sustainability of immunization programmes by safeguarding their priority in national health reforms. Mr LIEN (Norway) said that, although Norway, the biggest bilateral donor in the GAVI partnership, was pleased to note that GA VI seemed likely to achieve its objectives for 2005, there were some concerns. The need for multiyear planning, data quality and reporting on financial sustainability increased the burden on country capacity - a matter of critical importance not only for immunization but for the health system as a whole. The balance between infrastructure support and new vaccines would continue to require careful attention, especially with regard to global vaccine availability and the current imbalance between demand and availability of polyvalent vaccines. Likewise, the way in which new vaccines were introduced needed further study. Donor countries were responsible for ensuring consistent policies at bilateral and multilateral levels and with new partnerships such as GA VI. It was crucial that health funding through GA VI be provided in such a way as to facilitate coordination with sector-wide programmes and poverty reduction. GAVI funding should be additional to regular development assistance. Continued emphasis on low-income countries was crucial to the continuation ofNorway's support. -97-

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Dr AFRIYIE (Ghana) said that current pentavalent vaccine coverage in his country was over 80%. Ghana was developing a sustainable financial plan to cover the five-year period after the initial funding programme came to an end, and had decided on a sector-wide health approach and common basket-funding for health care, which covered immunization. As a result, however, some organizations were reluctant to make a further contribution through GAVI; he urged them to reconsider their position, as the new approach would not affect Ghana's vaccination programmes. Another area of concern was the changing profile of vaccine availability, and the disparities between the type of vaccine used in developed and developing countries, which might add to the latter's financial burdens - a matter which the Health Assembly was urged to consider. Dr ANDERSON KOUA (Cote d'lvoire) said that the new partnership had enhanced national high-level political commitment to the expanded programmes of immunization: the introduction of new and hitherto inaccessible vaccines had enabled thousands of lives to be saved. Current challenges related to injection safety, including improvements in dealing with waste and adverse reactions, and the financial sustainability of the immunization programmes. Dr SUZUKI (Executive Director) thanked delegates for their comments and the details of their countries' situations and achievements. In response, he would comment on six specific points. First, with regard to concerns about eligibility, the Global Alliance had taken a per capita ceiling of US$ 1000 as a criterion; 74 countries currently qualified. The Fund had two accounts, one for extending the availability of under-used vaccines and the other for strengthening immunization services. There were different criteria for the two. With regard to the concerns about applications, some were still being processed; in other cases the country's immunization programme was doing so well that there was no role for GAVI in terms of region-specific targets. Questions had been raised about countries above the US$ 1000 per capita ceiling; that aspect would be reviewed once the initial phase was complete. Second, hepatitis B, Haemophilus injluenzae type b infection and yellow fever were the targets for three vaccines used in industrialized countries but under-used in developing countries. It was hoped that the provision of funds to strengthen immunization services would enhance capacity to deal with other diseases too. GA VI had decided to include the disease control objective of, for example, measles, maternal and neonatal tetanus and poliomyelitis, as part of a broader objective of the Alliance but not as a target of the Vaccine Fund. Third, the GAVI partners envisaged several types of action for immunization safety. They had decided to provide auto-disable syringes to the 74 eligible countries for all routine vaccines, rather than limit assistance to vaccines covered by the Fund. Assistance would also be provided for immunization systems, including, it was hoped, measures to strengthen country capacity to ensure the introduction of incinerators and other methods to deal with sharp objects and infectious waste. Fourth, with regard to supplies, demand for yellow fever vaccine, in particular, had greatly exceeded supply and it was hoped that a Brazilian producer would be able to alleviate matters. First in order of priority was the building up of an emergency stockpile of two million doses, followed by attention to the needs for routine immunization in the worst-affected countries, and then the requirements of other countries. Fifth, with regard to new vaccines, the Task Force on Research and Development was working on vaccines against rotavirus, Neisseria meningitidis and Streptococcus pneumoniae - three agents responsible for diseases prevalent in developing countries. Fortunately, the basic technology was already in place. It was hoped that agreement would be reached at the next meeting of the Board of GA VI, in June 2002, to provide assistance for research and development activities. Sixth, concern had been expressed about the risk of burdening developing countries with a further reporting requirement. The intention was to ensure that reporting on GAVI would follow the WHO/UNICEF common reporting format to the extent possible. He stressed that GA VI was an alliance of partners committed to immunization and was intended to act as a catalyst. All partners undertook to work with countries in their national efforts.

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The CHAIRMAN said that he took it that the Committee wished to note the report contained in document A55/10. It was so agreed.

Eradication of poliomyelitis: Item 13.7 of the Agenda (Document A55/11) Ms WIGZELL (representative of the Executive Board) reported that the Board had expressed satisfaction with the significant drop in the numbers of poliomyelitis cases worldwide since 1988, and had congratulated WHO and its partners on the success to date. The representative of India had indicated India's commitment to interrupting poliomyelitis transmission by the end of 2002 and sustaining its poliomyelitis-free status through to 2005, stating that national immunization days and acute flaccid paralysis surveillance would continue during that period, and that WHO and UNICEF assistance would be necessary to ensure that India's oral vaccine supplies from bulk manufacturers were not interrupted. The representative of the Islamic Republic of Iran had suggested that the global poliomyelitis eradication initiative should focus on five priorities: assisting countries in conflict; ensuring the coverage of refugees and displac~d populations through United Nations agencies; strengthening cross-border surveillance of acute flaccid paralysis; ensuring that oral vaccines were available; and sustaining political commitment. Or ZAHER (Egypt), endorsing the report, said that only five cases of poliomyelitis, all of one strain, had occurred in Egypt in 2001, and so far in 2002 no new case had come to light. As the virus might still be present, however, national immunization campaigns would continue, as would surveillance. In 2001, over 95% of children had been immunized. Between 1998 and 2001, surveillance had been good, but had slackened in some areas in 2001. With the help of WHO, Egypt had therefore launched a plan to reinforce its acute flaccid paralysis surveillance system, with a target detection rate of two cases per 100 000 children under the age of 15. Environmental monitoring had begun in August 2000: Egypt was the only country to have established such a system, which complemented the normal surveillance system and would be used to produce guidelines for regions at risk. Or DAYRIT (Philippines) said that, although the Western Pacific Region had been certified poliomyelitis-free in October 2000, four children in the Philippines had been found to have vaccinederived poliomyelitis in 2001. Two rounds of immunization had consequently been conducted throughout the country, with a one-week door-to-door strategy, covering 100% of the target group. The experience of the Philippines showed the importance of maintaining routine immunization of infants, even in a country certified poliomyelitis-free. In the Philippines, routine oral immunization had decreased owing mainly to procurement problems. High-quality acute flaccid paralysis surveillance was important to detect circulating vaccine-derived polioviruses in good time. Since viral typing was not done within the country, it was also important to strengthen links with reference laboratories. A door-to-door strategy was an efficient approach, which had been well accepted, owing largely to wide publicity. He expressed the hope that his country's experience would encourage other countries to maintain a high level of routine immunization, together with strict surveillance. He was heartened to note that WHO would continue to provide assistance to Member States in the posteradication phase. Mr MAJOR! (Italy), noting with satisfaction that the incidence of poliomyelitis was at its lowest point ever, said that Italy had contributed to that result by providing technical assistance. There was no room for complacency, however, and the momentum must not be lost. He therefore welcomed the emphasis in the report on poliomyelitis eradication activities as a crucial part of humanitarian programmes.

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Mrs SEPTAKOV A (Slovakia) said that, although Slovakia had been poliomyelitis-free since 1960, it maintained preventive measures that were included in a strategic plan of action for the period 1998-2002. Although there had been 98% immunization coverage over the past 15 years, efforts would be maintained to improve the level, particularly in remote rural areas, and to improve surveillance to detect poliovirus; 195 laboratories were involved. In 2001, an application had been made to the European Certification Commission for poliomyelitis-free certification and a positive response was expected shortly. Mr ASLAM (Pakistan) acknowledged the assistance of the many partners in eradicating poliomyelitis in Pakistan. Only 10 cases had been reported so far in 2002, and Pakistan expected to interrupt poliovirus transmission by 2003. Two annual rounds of national immunization days had been initiated in 1994, with additional rounds added in 2001 and again in 2002. Immunization was currently undertaken on a door-to-door basis, and reservoir districts had been targeted. Surveillance for acute flaccid paralysis had been implemented nationwide in 1997, and additional officers had been hired by WHO to strengthen surveillance and immunization quality in problematic districts. The main risk factors identified were poverty and lack of education, and the resident Afghan population had been identified as a high-risk group. Efforts to achieve eradication by 2003 would be stepped up, and would include four national immunization days, campaigns targeting the reservoir districts, the involvement of political leaders, and fostering public demand for immunization and for the reporting of acute flaccid paralysis. Dr ANDERSON KOUA (Cote d'Ivoire) stated that Cote d'Ivoire had implemented an eradication initiative since 1998, including surveillance of acute flaccid paralysis. Since the last case of poliomyelitis due to wild poliovirus, in 2000, no further case had been notified. As at 31 December 2001, the incidence of acute flaccid paralysis was 2. 82 cases per 100 000 children aged less than 15 years against a target figure of two. In 2002, the intention was to put into practice an integrated system of surveillance of acute flaccid paralysis. National days against poliomyelitis would be organized for the sixth time in October and November 2002, taking a door-to-door approach and concentrating on illegal immigrants living in forest areas. Cote d'Ivoire expected to meet the microplanning plan adopted by the Inter-agency Coordinating Committee. Dr SUPAMIT CHUNSUTTIWAT (Thailand) expressed his appreciation of the progress made in Member States under the guidance of WHO and other partners. It had been over five years since the last reported case of poliomyelitis due to wild poliovirus in Thailand, and regional and global certification of poliomyelitis-free status was expected soon. His country was committed to working with other Member States, especially those of the South-East Asia Region, to complete the preeradication phase activities. He endorsed WHO's call to the international community for further funds to enable completion of the global eradication campaign. Such funding would be crucial for Member States which had to grapple with endemic poliomyelitis as well as coping with humanitarian crises. He supported WHO's efforts to define an appropriate post-eradication immunization policy which must take account of countries' diverse needs, operational systems and socioeconomic situations. Dr AGARWAL (India) said that the number of cases of poliomyelitis in India had fallen from 1934 in 1998 to 268 in 2001 and 29 up to April 2002. India was following the eradication strategies recommended by WHO, including high routine immunization coverage, national immunization days, acute flaccid paralysis sera-surveillance and mop-up immunization campaigns. The acute flaccid paralysis rate had been maintained at one per 100 000 children under 15 years, indicating good surveillance. Eradication within a year was an achievable goal. India had entered the pre-eradication phase and was setting up a national task force to oversee completion of the work. Dr OKAMOTO (Japan) said that Japan had been a keen supporter of the poliomyelitis eradication initiative, mainly through the Japan International Cooperation Agency. Progress towards

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the goal of eradication in the South-East Asia Region had been significant. Several issues remained outstanding, however, including the containment of wild viruses in laboratories and post-eradication immunization strategies and he urged WHO to address those matters. As soon as global eradication was achieved, vaccine-induced poliomyelitis could be eliminated. He called on WHO to make all eradication programmes a priority, with commensurate resources; however, it should not implement a further infectious disease eradication programme until poliomyelitis had been vanquished. Ms CHOI (Republic of Korea) said that her country maintained a surveillance system and conducted nationwide immunization, particularly of infants and children, despite being in a region that had been certified poliomyelitis-free. Cooperation between regions and WHO for the purpose of prevention, such as the maintenance of acute flaccid paralysis surveillance, was essential in order to maintain poliomyelitis-free status. Close cooperation and exchange of information between Member States, under the leadership of WHO, would be necessary to achieve the global eradication goal. Mr BRUNET (France) said that France had been certified poliomyelitis-free in December 2001, and special surveillance of circulating enteroviruses had been introduced to replace surveillance of acute flaccid paralysis, and would be supported by high immunization coverage. France was also developing surveillance of the environmental circulation of polioviruses, which would probably be widely applied in countries not affected by poliomyelitis. Exclusive use of injectable vaccine in France for many years, which had been well accepted by the population, had ensured an almost total absence of serious adverse effects, and had eliminated the risks linked to reversion of vaccine viruses to forms that could be pathogenic and even lead to epidemics. Although the situation in France was satisfactory, the globalization of trade made the problem one of world strategic significance: the fact that poliomyelitis was still endemic in some countries was a genuine problem for all countries of the world. France was continually updating its systems and was preparing a plan of action to deal with the importation of wild poliovirus. Mrs FERNANDES DE CARVALHO (Angola) said that her country was committed to eradicating poliomyelitis by 2005. Annual national immunization days had been conducted in three phases. Following a poliomyelitis epidemic in Central Africa in 2001, synchronized national immunization days had been organized in cooperation with neighbouring countries and would be repeated in 2002. The challenges facing Angola were the immunization of all children under the age of five and the strengthening and expansion of active epidemiological surveillance to accessible municipalities. Surveillance quality had to be maintained, with the cooperation of traditional authorities, churches, nongovemmental organizations and others, in municipalities that lacked health infrastructure and health personnel. The success of national immunization days should be ensured by an independent follow-up system and by strengthening the door-to-door immunization strategy. Professor HOJDA (Ukraine) fully supported the WHO strategy for the eradication of poliomyelitis. The Ukraine had long experience of the issue, and wild polioviruses had not circulated since 1994. That success was the result of immunization days launched in 1996 with the personal support and involvement of the country's President. She thanked WHO, UNICEF and Rotary International for their organizational help, which had made it possible to immunize around two million children of up to three years of age. Immunization had been planned according to a national timetable, and 98.7% coverage had been achieved. Epidemiological surveillance had been conducted since 1998, with an active acute flaccid paralysis surveillance system and a diagnostic laboratory, resulting in high accuracy. All the necessary documents had been submitted for certification that the territory was free of wild polioviruses. Ukraine's experience could be useful for other countries where the situation had not yet been resolved. Dr AKSAKAL (Turkey) said that Turkey had launched a poliomyelitis eradication programme in 1989, and since then had made considerable progress towards attaining the target. It had established

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a nationwide acute flaccid paralysis surveillance system to detect cases associated with wild polioviruses, the success of which and of supplementary immunization had strengthened political support for the programme. The last case associated with wild polioviruses, four years previously, had also been the last reported case in the European Region. Since the end of 1999, routine immunization had been strengthened by regular outreach services, and coverage had always exceeded 90%. Acute flaccid paralysis indicators had reached the level required for certification. High-risk acute flaccid paralysis cases were identified immediately and closely monitored. A national plan of action for containment had been prepared in March 2001 and implemented on schedule. A national survey had been conducted of laboratories that might potentially hold wild poliovirus-infected material. Contingency plans in the case of importation were drawn up, focusing on the timely detection of imported wild virus, for rapid response, and had been distributed to all provinces. Turkey was committed to sustaining its poliomyelitis-free status. There had been no indigenous transmission of wild poliovirus in Turkey since November 1998, and the poliomyelitis eradication programme could rapidly identify any imported cases. The European Region was to be certified as poliomyelitis-free the following month, and she thanked the dedicated staff at field and central levels for that achievement. Dr TSHABALALA-MSIMANG (South Africa) said that there had been no reported case of poliomyelitis in South Africa since 1989. It had started the countdown towards eradicating poliomyelitis in southern Africa and was collaborating with Lesotho and Swaziland in an Inter-country Certification Committee. Difficulties were being experienced in the reporting of acute flaccid paralysis and in the submission of stool specimens for analysis. Surveillance was another hurdle. Human as well as financial resources should be placed at the disposal of countries that wished to join in the advance towards a poliomyelitis-free world, including some that had been devastated by internal and external strife. Some countries were still far from achieving the target of poliomyelitis elimination, but that achievement was closer; the last mile was always the hardest and the longest. Mr ABDELKERIM (Chad) thanked all partners that had contributed funds for the eradication of poliomyelitis, allowing Chad to set up an integrated epidemiological surveillance system as an essential tool in the strategy. There had been a significant state contribution in the form of human resources. Paragraph 6 of document ASS/11 drew a distinction between "high transmission" and "low transmission" countries. Chad, which had experienced no case since 2000, was situated between two "high transmission" countries to the west and one "low transmission" country to the east. That disturbing situation called for assistance to those three countries in organizing intensive immunization days so as to meet the eradication target. Chad should also be helped to organize targeted, synchronized immunization campaigns on its frontiers with those countries, which represented 60% of its borders, and to intensify integrated epidemiological surveillance. Dr QI Xiaoqiu (China) said that his delegation agreed with the report on the eradication of poliomyelitis and with the analysis of current and future work on the problem. The rapid control and eradication of poliomyelitis in high and low transmission regions and countries would be highly significant in reaching the eradication target on schedule, and such countries should be provided with technical and financial support. In all countries, including those that had already eradicated the disease, good quality acute flaccid paralysis surveillance had to be continued and good immunization maintained, particularly to ensure that children in poor and remote areas and national minority regions received timely immunization. If necessary, supplementary immunization measures should be taken, and funding should be mobilized to ensure implementation of those activities. The international community should continue to maintain its financial and technical support for countries that had already eradicated poliomyelitis, particularly developing countries, to safeguard the successes achieved until attainment of the global goal.

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China was concerned at the outbreaks caused by vaccine-derived polioviruses in certain countries and hoped that WHO would rapidly formulate a poliomyelitis immunization strategy for the future. He welcomed the importance attached to laboratory containment of wild polioviruses and the handling of potentially infectious materials. Mr NACUV A (Fiji) said that Fiji, which chaired the Pacific subregional committee for certification of the eradication of poliomyelitis, was continuing active hospital-based surveillance of acute flaccid paralysis. In 2001, the non-poliomyelitis acute flaccid paralysis indicator had been 0.2 per 100 000 children under 15, as against 1.0 per 100 000 among persons over 15. Although there was only a low risk of importation of poliovirus among the Pacific island nations, the recent arrival of refugees highlighted the need for continued vigilance and the maintenance of good immunization levels, for which the continued support of WHO and UNICEF was needed. Dr MAZONDE (Botswana) said that a surveillance system for acute flaccid paralysis had been established in his country in 1995, making the condition notifiable. In the following year, a nationwide mass immunization campaign with oral poliomyelitis vaccine had been conducted for all children below the age of five, regardless of their immunization status. Subnational immunization days had been conducted in 1995, 1997 and 2000. Three national certification committees had been established, in line with recommendations from the African Regional Certification Commission. In preparing reports to that body, a number of system and population factors had been revealed, which would be actively addressed in order to improve coverage and strengthen surveillance. Botswana was fully committed to the 2005 target and looked for continued support from WHO. Dr SLATER (United States of America) applauded the progress made in the campaign. However, the commencement of the final stages was not a time for complacency. WHO's funding gap of US$ 275 million to the end of 2005 was a barrier to final success, and donor nations must help in resource mobilization. Victory was in sight, and leadership at the highest level of government was more important than ever. In that context, she underlined the United States' continued support for the eradication initiative, and its intention to participate in immunization activities in the developing world during 2002. Although the "post-eradication" options had not been defined, her delegation supported the findings of the Global Health Forum that there could be no artificial separation of interrupting wild virus and vaccine virus transmission. The world would either be free of circulating poliovirus or it would not. Dr FARCASANU (Romania) said that the public health authorities in Romania fully supported the WHO target for the eradication of poliomyelitis by 2005. The national strategy included routine immunization of all children with at least three doses of oral poliomyelitis vaccine. Under the national immunization plan, four-dose coverage had reached 96.8% in 2001. Mopping-up campaigns in selected risk areas had been organized, and surveillance was conducted for all children under 15; a weekly report was made to WHO of all cases of acute flaccid paralysis. An inventory of all laboratories had been completed and, currently, only the National Reference Laboratory for Enteroviruses kept potentially infectious samples of wild poliovirus. Romania was confident that the countries of the European Region would shortly be certified poliomyelitis-free. Dr KHAZ' AL (United Arab Emirates) said that no case of poliomyelitis had been reported in her country since 1992, thus demonstrating the effectiveness of the national control and surveillance programme. She commended the technical support provided by the WHO Regional Office for the Eastern Mediterranean in helping the United Arab Emirates to achieve that goal and fulfil the criteria required for certification of poliomyelitis eradication. In that connection, completion of the activities of the pre-eradication phase set out in the Global Action Plan for Laboratory Containment of Wild Polioviruses continued to form part of the national programme. Her country was fully committed to achieving the global eradication of poliomyelitis, to which end it would continue to make additional

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contributions to the eradication programme, through WHO, until the world was free of the disease. She hoped that WHO would also benefit from the experiences of countries with a view to the eradication and containment of other diseases. Mr BARBOSA DA SILVA (Brazil) commended the report and the initiatives taken under WHO's leadership to eradicate poliomyelitis. The large worldwide reduction in reported cases since 1988 was a result of well-coordinated actions, especially improved surveillance and immunization, developed in close collaboration between several agencies and Member States. With that dramatic decline, eradication by 2005 had become feasible, but efforts must be maintained in all remaining transmission areas until that was achieved. A recent outbreak in the Dominican Republic and Haiti, caused by a vaccine-derived virus, had alerted all countries in the region to improve surveillance and maintain appropriate immunization strategies. It was also important to implement the Global Action Plan for Laboratory Containment of Wild Polioviruses, for which Brazil had recently set up a task force, and, consequently, to finance the budget requested by WHO for activities in endemic areas. Mr CASTRO GRANDE (El Salvador) said that, although El Salvador had had no case of poliomyelitis for 15 years, the outbreak in the Dominican Republic and Haiti due to mutation of a vaccine-derived poliovirus had led it, on WHO's recommendation, to re-establish immunization campaigns. With the help of various institutions and 106 health brigades, the Ministry of Health intended to immunize all children under five. The campaign, which would have the backing of the police, local mayors and nongovernmental organizations, would be based on a door-to-door approach that would make it possible to detect other diseases, such as dengue fever. Dr FURGAL (Russian Federation) commented that the world was on the threshold of another great achievement, thanks to the collective efforts of governments, international organizations, the private sector and nongovernmental organizations, which had provided technical and financial support. The final goal would only be achieved by concentrating all efforts and resources to that end, even at the cost of temporarily suspending other less important issues. The last case reported in the Russian Federation had occurred six years previously, and his country had since implemented all WHO recommendations to achieve certification status. It had submitted documentation for certification as poliomyelitis-free to the European Certification Commission. Mr FARRELL (International Federation of Red Cross and Red Crescent Societies), speaking at the invitation of the CHAIRMAN, commended the partnership behind the global initiative to eradicate poliomyelitis on its remarkable progress. The International Red Cross and Red Crescent movement had joined the global initiative in September 2000 and had launched two emergency appeals for intensified national immunization days and improved surveillance. As a result, over US$ 2 million had been raised to help 14 national societies. For the 2001 campaign in Nigeria, for example, over 7000 volunteers had reached over 14 million children under the age of five through door-to-door visits. For 2002, the International Federation had provided support to the Nigerian and Niger national societies for immunization days and would work closely with other partners to coordinate national society efforts. The Federation, building on the infrastructure of staff, laboratories and surveillance for poliomyelitis, was also supporting a WHO initiative to reduce measles mortality in Africa. As a result, the International Red Cross and Red Crescent movement had strengthened its ability to tackle other public health problems, including malaria, HIVI AIDS and tuberculosis, and was ready to enhance its partnership with ministries of health and WHO to improve the health status of the most vulnerable populations throughout the world. Dr BOSHELL SAMPER (Colombia) said that, although he did not share the pessimism of virologists who thought it impossible to eradicate the disease, he considered that immunization coverage needed to be higher than 90% to prevent re-emergence of the virus. In Asia and Latin

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America, where eradication had been completed in 1994, vaccine-related outbreaks had occurred. Thus, even when eradication had been achieved it would be necessary to continue immunization in accordance with WHO recommendations. Mr HAMET (Mauritania) said that his country had been implementing a poliomyelitis eradication plan since 1995, and each year the President himself inaugurated the national immunization day. The size of the country, the existence of nomadic populations and difficulties of access suggested that pockets of wild virus might still exist. In 200 I, a case due to wild virus from the interior of the country had been discovered at Nouakchott, and another case had occurred in refugee camps near the Algerian border. Although the door-to-door strategy would have to be strengthened in order to reach the nomadic populations, that part of the Sahara was not easily accessible, and certain areas were mined. Mauritania was currently negotiating with neighbouring countries to organize demining days in June and July. Epidemiological surveillance in the country was good but needed support, especially of a logistic nature, since all immunization costs were borne by the national budget. As a country with limited means, Mauritania would welcome any partnership to strengthen its capacity to achieve the eradication of poliomyelitis. Dr SULEIMAN (Oman) expressed regret that despite WHO's efforts, there were insufficient financial resources to enable it to reach its target. It was to be hoped that the shortfall would be made up soon. Dr SUZUKI (Executive Director) thanked delegates for their useful comments, which showed their commitment to the initiative. In connection with the target of eradicating poliomyelitis by 2005, great advances had been made, as India and Pakistan had noted. In recent years, cases due to wild poliovirus had occurred in only 10 countries and, as Turkey had remarked, the European Region was expected to certify eradication of poliomyelitis in June 2002. Nonetheless, as South Africa had stated, the last mile was often the hardest and longest. The global initiative had been a joint partnership in which countries took full responsibility for their actions. As Angola had noted, cooperation was needed to address issues such as cross-border cases. He expressed WHO's gratitude to all the partners that had contributed to the work and had played a key role in maintaining political commitment in the face of a disappearing disease. On the subject of funding, to which the delegate of Oman had referred, the budget for 2002-2005 would be US$ 1000 million, with a shortfall of around US$ 80 million for the present year. If that gap could not be filled, it might be necessary to postpone certain national immunization days. One of the roles of partnership was to ensure access to immunization for every child in endemic and other countries, for no one would be free from poliomyelitis unless everyone was free. With regard to the post-certification immunization policy, referred to by China, Japan and the Republic of Korea, the occurrence of vaccine-derived cases highlighted the need to maintain high coverage, high-quality surveillance and secure containment in laboratories and vaccine-producing facilities. WHO was developing a post-certification immunization policy that would take full account of social, economic and other conditions. The Committee noted the report. WHO's contribution to achievement of the development goals of the United Nations Millennium Declaration: Item 13.2 of the Agenda (Resolution EB109.R3; Document A55/6) (continued from the second meeting)

The CHAIRMAN invited the Committee to consider the revised draft resolution entitled "Protection of medical missions from terrorism and armed conflict", which read:

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The Fifty-fifth World Health Assembly, Recalling and reiterating resolution WHA46.39 entitled "Health and medical services in times of armed conflict"; Reaffirming the need to promote and ensure respect for the principles and rules of international humanitarian law, and guided in this respect by the relevant provisions of the Geneva Conventions of 1949 and their Additional Protocols of 1977; Aware that, over the years, considerations based on [fundamental principles of humanity] international humanitarian and human-rights law have resulted in improved protection for medical personnel and for their recognized emblems during armed conflict; Deeply disturbed by recent reports of increasing attacks on medical personnel, establishments and units, [especially in times ofl during armed conflicts; Alarmed by the extent to which civilian populations are being affected by the lack of medical care as a consequence of attacks [against] directed at health and other humanitarian personnel, and health establishments, during armed conflicts; Aware of the adverse effects of such conflicts on high-priority public health programmes, such as the Expanded Programme on Immunization and control of malaria and tuberculosis; Recognizing the benefits of ceasefires brokered for national immunization days; Convinced, in accordance with international law, that it is indispensable to protect against attacks [on] directed at health personnel, hospitals, health facilities and infrastructures, ambulances and other medical vehicles[,] and communication systems [or other infrastructure which facilitates the work of health personnel] used for humanitarian purposes, 1. CALLS on all parties to armed conflicts fully to adhere to and implement the applicable rules of international humanitarian law protecting civilians and combatants who are hors de combat as well as medical, nursing and other health and humanitarian personnel, and to respect provisions that regulate the use of Red Cross and Red Crescent emblems and the protective status they have under international humanitarian law; URGES Member States to condemn all attacks [and other actions detrimental to the 2. ability ofl directed at health personnel, especially those that impede ability of such personnel to carry out their humanitarian function during armed conflicts; ALSO URGES Member States, organizations of the United Nations system, other 3. intergovernmental and nongovernmental bodies active in the humanitarian or health fields to promote actions that ensure the safety of health personnel; ALSO URGES parties to conflict and humanitarian relief organizations to assure 4. that ambulances, other medical vehicles, health facilities or other structures which facilitate the work of health personnel are utilized for humanitarian purposes only; [~]5.

REQUESTS the Director-General: (1) to [advocate] promote the protection of and respect [ofl for health personnel and establishments; (2) to liaise closely with the competent organizations of the United Nations system, including UNICEF, the Office for the Coordination of Humanitarian Affairs, the Office of the High Commissioner for Refugees, and the Office of the High Commissioner for Human Rights, together with the International Committee of the Red Cross, the International Federation of Red Cross and Red Crescent Societies [and with competent organizations of the United Nations system] and other relevant intergovernmental and nongovernmental bodies in order to promote implementation of this resolution; (3) to disseminate this resolution widely.

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Dr BOSHELL SAMPER (Colombia) noted that paragraph 4 of the report contained in document ASS/6 included a reference to the prevention not only of diseases but also of armed conflict. Colombia was concerned about the violence in the country which made it difficult and even dangerous for medical missions to carry out their work, and his delegation had therefore proposed a resolution designed to protect such medical missions during armed conflict. As a result of consultations with other interested delegations, a number of additions had been made (shown in bold) and certain phrases had been deleted (underlined and in square brackets). In response to a query from Dr BERNARD (United States of America), he confirmed that the words", as applicable" should be added at the end of the second preambular paragraph after the words "Additional Protocols of 1977", and the words ", as appropriate" should be added at the end of the seventh preambular paragraph after the words "national immunization days". Ms NELLTHORP (United Kingdom of Great Britain and Northern Ireland) proposed that the words "terrorism and" be deleted from the title. Dr BOSHELL SAMPER (Colombia) confirmed that his proposed amendments had included the deletion of those words from the title, which should read "Protection of medical missions during armed conflict". The draft resolution, as amended, was approved!

(For continuation of the discussion of the agenda item and approval of the draft resolution, see summary record of the eighth meeting, section 2.) WHO medicines strategy: Item 13.8 of the Agenda (Resolution EB109.R17; Document ASS/12)

Professor GHODSE (President, International Narcotics Control Board) raised the issue of imbalances in the availability of controlled drugs worldwide. Unfortunately, pain-relieving drugs were either not available or in insufficient supply in many countries, and his organization was seriously concerned about the shortfall. It was estimated that only 10% to 30% of patients suffering severe cancer-related pain received adequate treatment. The unavailability of opioid analgesics was due to a multiplicity of factors, and he called on governments to review procedures for facilitating patient access without jeopardizing safeguard mechanisms. His organization also proposed improving access by developing countries to narcotic drugs by encouraging preferential terms from suppliers, developing non-profit mechanisms, and urging international aid programmes to donate analgesic drugs to needy countries. An overall strategy to address the problem should be developed, in which the role of WHO would be crucial. One aggravating factor was the overprescription of psychotropic substances in many industrialized countries, with the United States of America and Europe accounting for high levels of use: although such substances had an important place in health care, there was a need for education and government action to get the balance right. Closer cooperation between international agencies would raise awareness ofthe issue and ensure more equitable global access to analgesics. Ms WIGZELL (representative of the Executive Board) reported that the Board had expressed particular satisfaction with WHO's efforts to improve access to essential medicines, including regional and international price information services and training on drug supply management and rational drug use, and welcomed the new procedures to update and disseminate the WHO Model List of Essential Drugs. The Board had also commended WHO's efforts to monitor and provide guidance on the impact of international trade agreements on access to essential medicines and welcomed the success achieved

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.13.

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at the Fourth Ministerial Conference of WTO (Doha, November 2001). Notwithstanding such efforts and achievements, however, too many people still lacked regular access to essential medicines. The Board had therefore encouraged WHO to consolidate its work on selection and pricing of essential drugs, and to focus greater attention on financing and reliable supply systems, within the overall strategy of improving access to essential drugs. The Board had recognized that continued support to countries would be needed for many years and had adopted resolution EB 109.R17. Dr KUNENE (Swaziland) expressed his appreciation for WHO's leadership in the field of pharmaceuticals and its technical guidance to Member States; it was critical to secure and expand access to essential drugs in order to save lives and improve health. With reference to the WTO Ministerial Conference in Doha, he welcomed the recognition that public health considerations should override trade aspects of WTO's Agreement on Trade-Related Aspects oflntellectual Property Rights (TRIPS), as well as the recognition of the plight, in regard to compulsory licensing, of WTO Member States that had little or no manufacturing capacity in the pharmaceutical sector. He urged WHO to accelerate its work on access to high-quality HIV/AIDS drugs and on drug quality control. He supported the draft resolution contained in resolution EB 109 .R17. Mr ZEPEDA BERMUDEZ (Brazil) noted that various international forums had recently considered the question of access to medicines to be a priority, and he highlighted the prompt action taken by his Government to dispatch medicines to neighbouring Argentina, where the political and economic crisis had led to the declaration of a health emergency. The supply of medicines was equally crucial in the event of armed conflict, natural disaster and threat of disease. The recent threat of anthrax had even led some developed countries to consider breaking patents if the prices of the patentprotected medicines needed to protect their citizens proved to be too high. With such events in mind, Brazil had proposed that the issue of access to medicines should be added to the 11 priorities listed for the biennium 2004-2005. It was both surprising and unacceptable that the issue should have since been withdrawn from that list, and he requested an explanation. The much-discussed Brazilian response to the challenges of that issue, which included the provision of universal access to antiretroviral drugs for HIVIAIDS patients, was being vaunted as a successful model. Negotiation and domestic production had lowered prices for Government procurement, while economic regulation and a law on generic brands had led to the availability of more affordable medicines in the private sector. Such examples addressed the main dimensions of access to health services and consequently to essential drugs. He welcomed the move to make the issue of international trade agreements, in particular the TRIPS agreement, a priority, with a view to protecting public health and promoting access to medicines for all. As a result, he expected enhanced monitoring of trade issues in his Region. He emphatically supported adoption of the draft resolution contained in resolution EB 109 .R17 and requested that the WHO medicines strategy remain on the agenda of the next Health Assembly and meetings of the Executive Board, and that a report be made on the progress achieved. Mr RODRIGUEZ ALV AREZ (Spain), speaking on behalf of the Member States of the European Union, said that, in many countries, access to essential medicines was the mainstay of pharmaceutical policies, which, combined with national health policies, had doubled access between 1977 and 2000, thereby vindicating the support of Member States for WHO's medicines strategy. Despite that progress, however, one-third of the global population still had no regular access to the most basic medicines. Efforts should therefore be pursued to ensure regular access through regional and national development programmes, leading to the establishment of national pharmaceutical policies that guaranteed access to safe, effective and high-quality medicines for everyone, while bearing in mind the implications of globalization. WHO had engaged in constructive cooperation with other organizations, particularly those concerned with international trade agreements, and should continue to advise Member States on the implementation of effective public health programmes that complied with their obligations under such agreements. He welcomed WHO's active promotion of the

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concept of differential pricing, which the European Union had taken into consideration in preparing a plan to combat the major transmissible diseases, such as AIDS, tuberculosis and malaria, in the developing countries. He also welcomed the important role played by WHO in emergency humanitarian aid, including recommendations on drug donations and the new emergency medical kit containing opioid analgesics. The application of simplified import-export controls was altogether reasonable in emergency situations. He urged WHO to pursue the path outlined in the successive Health Assembly resolutions which, over the years, had been remarkably effective in improving access to high-quality medicines and promoting their more rational use. Mrs TAPAKOUDI (Cyprus) said that Cyprus complied with the WHO Model List of Essential Drugs and provided medicines, including antiretroviral drugs, free of charge to people with low incomes. It endorsed the draft resolution contained in resolution EB 109 .R17. Dr ZOKUF A (South Africa) fully supported the four factors constituting the WHO medicines strategy, as they were crucial to securing and expanding access to essential drugs. His country's own approach was largely anchored on those factors. He welcomed the adoption of the Declaration on the TRIPS Agreement and Public Health at the Fourth WTO Ministerial Conference. The major diseases of poverty chosen by WHO as priority areas for 2002-2003 for making essential drugs available were equally important for South Africa, which would benefit from close collaboration with WHO. The revised procedure for updating the WHO Model List of Essential Drugs was also a useful guide for South Africa, which was currently reviewing its procedure for the inclusion of drugs on its list. In that connection, he fully supported the establishment of the WHO Essential Medicines Library, to which access should be possible via the Internet or in CD-ROM form, with a view to providing crucial information that would facilitate efforts to compile and review lists of essential drugs. He also fully supported the efforts to consolidate and update the information on international drug prices, including further work on the manual for collecting data on drug prices and price composition in low- and middle-income countries. South Africa had participated in field testing the manual, and further cooperation was expected in 2002. The main thrust of its efforts to ensure the accessibility of drugs was linked to information about their affordability, in which connection strong linkages and full participation with WHO were important. He encouraged the WHO initiative to provide independent data and technical assistance concerning international trade agreements and access to drugs, which would help countries to formulate strategies and develop informed approaches to dealing with the health implications of trade issues. The network of legal experts in that area which WHO was building as a resource would greatly assist developing countries such as his own. He therefore supported the draft resolution recommended in resolution EB109.R17, which largely embodied the elements crucial to implementation of the essential medicines strategy. Professor CANBOLAT (Turkey) said that access to safe, effective, high-quality drugs, and especially to essential drugs, should be a basic right. The price of drugs and intellectual property rights were important issues in the control of diseases such as tuberculosis, viral hepatitis and HIVI AIDS, and had been addressed by both WHO and WTO. The declaration adopted by the Fourth WTO Ministerial Conference in Do ha in November 2001 provided a solution to those problems. Although intellectual property rights were important for the pharmaceutical industry, the protection of public health was equally necessary. WHO should help to resolve the contradiction between globalization and human rights in that area. Access to essential drugs could also be assured through support for the manufacture of safe, effective, high-quality generic drugs, which would improve the balance between reimbursement systems and governmental financing of pharmaceuticals. Most countries supported patent rights and data exclusivity as being essential to the development of new drugs, but their use as pressure tools would be detrimental to research and development and access to essential drugs. WHO had an important role to play in achieving a balance between access to essential drugs and the protection of intellectual property rights.

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Dr OKAMOTO (Japan), pointing out that the WHO Model List of Essential Drugs was only a model to assist developing countries in selecting their own essential drugs, said that the crucial factor for improving access to essential drugs was reinforcement of infrastructure, including human resources, drug quality assurance and a national regulatory authority. Japan supported the ideas expressed in the report in that connection, and welcomed the revised procedure for updating the Model List. However, if interested parties were to be excluded from the final decision process in the Expert Committee on the Use of Essential Drugs in order to ensure scientific independence, that Committee should be accountable to them and its comments made public. The success of the Model List was demonstrated by the fact that 156 countries had introduced their own essential drugs list. WHO might consider using another approach, in which reliable information was provided to Member States to assist them in the selection of essential drugs. His country welcomed the inclusion of anti-HIV drugs on the list on the basis of concrete evidence but did not support the creation of a prequalification programme for HIVIAIDS drugs, owing to several uncertainties, including resources for the programme. Further clarification was needed. Japan was sceptical about the feasibility of costeffectiveness comparisons of drugs for specific diseases and was even doubtful whether such an exercise came within WHO's mandate. Dr DAYRIT (Philippines) said that his Government was committed to improving its citizens' access to essential medicines at affordable prices. Since medicines in his country were twice to 10 times more expensive than in neighbouring countries, the Government had responded by importing low-cost off-patent brands from India, which were sold at half the price of multinational products available in private pharmacies. Although, in 2002, such imports would cover only about 0.2% of the pharmaceuticals market, the Philippines hoped that its action would influence the industry to lower prices and change marketing practices. Encouragement of the use of non-branded generic products, begun 14 years previously, had not had the desired effect of reducing drug prices owing to the brand consciousness of physicians and consumers, the control of the retail trade by a few chain stores and the oligopolistic nature of the drug industry in the Philippines. His Government commended WHO's efforts to expand access to essential drugs and would appreciate technical support and guidance to review its essential drugs list and develop better drug use strategies and international procurement of essential drugs. It endorsed the draft resolution contained in resolution EB109.R17. Dr MAZONDE (Botswana) said that a regular supply of essential drugs of acceptable safety and quality at affordable prices was an important component of Botswana's national drug policy, which sought to improve access to medicines through good drug management practices, regulatory and quality assurance systems, rational drug use, use of generic drugs, an essential drugs list and treatment guidelines. An efficient drug distribution mechanism had been set up to ensure a reliable drug supply system to even the lowest-level health facilities. Owing to the current HIVIAIDS epidemic, some 110 000 people were eligible for treatment with antiretroviral drugs, at a cost of US$ 67 million, about half the total health budget for 2001. For a seriously afflicted country like Botswana, such drugs were essential, but further price reductions would be necessary to make them accessible. His country therefore welcomed the Declaration on the TRIPS Agreement and Public Health made at the Fourth WTO Ministerial Conference in Doha and endorsed the interpretation of that agreement in a manner supportive of public health and universal access to medicines, while at the same time recognizing that intellectual property rights were essential to the development of new medicines. Botswana looked forward to the implementation of the WHO medicines strategy to make necessary drugs affordable and accessible, especially for the treatment of HIVIAIDS, tuberculosis, malaria and other significant health problems. It therefore supported the draft resolution contained in resolution EB109.Rl7. Dr LOUME (Senegal) said that Senegal had established four lists of essential drugs to cover four different levels of health care: health outposts, local clinics, health centres and regional hospitals. The system had been supplemented by computer-generated charts of the most common infections so

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as to improve diagnosis and rational prescription. Senegal's efficient distribution system ensured that essential drugs were available even in the most remote health facilities. That service was backed up by a policy on generic drugs, the creation of a national quality control laboratory and the forthcoming distribution of a dictionary of medicines. WHO had a major role to play in helping countries to guarantee drug quality, especially at the time of importation. The proposed resolution would help countries to revise older lists but especially with the introduction of new drugs for diseases such as AIDS, malaria and tuberculosis. Senegal therefore strongly supported the draft resolution. Dr FURGAL (Russian Federation) noted with satisfaction the comprehensive list of measures undertaken by WHO in its medicines strategy. WHO's work in that area, including teaching materials and reports on medicines, was topical and useful to Member States, and he urged that the time required for the publication of materials already prepared be shortened. The report of the Expert Committee on Specifications for Pharmaceutical Preparations, which had been ready three years previously, had only just been published, and the final report of the Ninth International Conference of Drug Regulatory Authorities had not yet been published, even though the Conference had taken place in 1999. The latter document would be very useful for preparing and training national delegates for the Tenth Conference in Hong Kong in June 2002. The Russian Federation supported the draft resolution contained in resolution EB109.R17. Mr HOHMAN (United States of America) said that he had been pleased to note that antiretroviral drugs had been added to the Model List of Essential Drugs at the meeting of the Expert Committee on the Use of Essential Drugs in April. Nevertheless, although his Government had requested that that Committee use existing procedures for updating the Model List until the new procedures had been tested and approved by the Executive Board, that had not been done. As those new procedures had been used only partially, their effectiveness could not be determined. He applauded the move towards transparency in the conduct of the Expert Committee, including innovative use of the Internet; however, the Internet documents posted after the meeting contained some inappropriate statements concerning antiretrovirals. For example, fixed doses were promoted for drug combinations that had never been approved in those formulations by a major drug regulatory authority. He therefore requested the Director-General to conduct WHO's essential medicines programme with transparency, in an unbiased manner, with proper public disclosure of the financial interests and professional ties of all parties involved, and with the full participation of Member State drug regulatory authorities. Although the report implied that TRIPS was an impediment to expanding drug access, his Government considered it part of the solution. The Doha Declaration on the TRIPS Agreement and Public Health had sent a strong message of support for the TRIPS agreement and confirmed that it was an essential part of a wider national and international response to the public health crises affecting many developing countries. The Declaration confirmed his profound conviction that the exclusive rights provided to members under the TRIPS agreement gave powerful support to public health objectives. In that connection, his Government encouraged Member States to remove tariffs and eliminate excessive mark-ups at wholesale and retail levels for drugs against HIV/AIDS, tuberculosis and malaria, and for all products purchased with resources from the Global Fund. Responding to the implication of a comment made by the delegate of Brazil, he said that his Government had not threatened to use compulsory licensing in its negotiations with the manufacturer of a drug to treat anthrax: the arrangement reached had been based on the commercial purchase of a large volume of the drug in question. Dr MAHJOUR (Morocco) said that the issue of essential drugs was a continuing major concern. When the medicines strategy had been discussed at the previous Health Assembly, his delegation had emphasized that the essential components of a drugs policy were access, quality, safety, efficacy and rational use. A further problem was the replacement of certain effective, accessible drugs by similar

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new drugs which were more expensive. Apart from difficulties of access, that step could cause artificial market disruption, which might have serious repercussions on health and compromise the achievements of primary health care programmes. WHO should therefore negotiate with pharmaceutical laboratories a reduction in the cost of drugs for developing countries, as it had done with antiretroviral drugs, especially for drugs used in primary health care programmes and those on WHO's list. He strongly endorsed the draft resolution recommended by the Executive Board. Dr ARMADA (Venezuela), recalling that Venezuela had drawn up its first list of essential drugs 12 years previously, said that his country currently had a national pharmaceutical policy in which emphasis was placed on equitable access to drugs. A national drugs list had been drawn up and national legislation brought up to date with the introduction of a new law on medicines, listing essential drugs and encouraging the use of generic drugs. The integration of all public services into the national health service should facilitate the implementation of those instruments. Venezuela continued to suffer from the high cost of pharmaceutical products and the pressure on health workers to use the latest commercial formulations, which were not necessarily the most cost-effective. That situation resulted from conflict between commercial interests and public health. He therefore strongly supported the draft resolution, the updating of the Model List, the creation of an essential medicines library, and price survey mechanisms. He proposed that regular information should be provided to Member States on the achievements, goals and difficulties in following up the requests made to the Director-General. Ms BREMER (Norway) commended the work of WHO to expand access to essential drugs, particularly its efforts to strengthen rational selection of drugs and improve affordability. The Doha Declaration had confirmed that TRIPS did not and should not prevent WTO members from taking measures to protect public health. However, as pointed out in the Declaration, countries with insufficient or no drug manufacturing capacity might have difficulty in making effective use of compulsory licensing. WTO's Council for Trade-Related Aspects of Intellectual Property Rights had been given the task of finding a solution to the problem by the end of 2002, and Norway was participating actively in the search for acceptable options within the given deadline. On the issue of access to good-quality medicines, WHO's recently published list of HIV/AIDS drugs was a useful tool, both for international procurement agencies and for countries that lacked the requisite capacity to assess drugs and their manufacturers. She commended the work done by WHO in that area and emphasized the need to monitor the quality of the products and manufacturers already on the list and continuously update it. She welcomed the development of lists for other priority diseases, namely tuberculosis and malaria. Her delegation strongly endorsed the draft resolution. Professor HOJDA (Ukraine) said that her country's national drugs policy was based on the WHO strategy and was designed to ensure the physical and financial accessibility of essential drugs for every citizen. In the past year, the Government had introduced an essential drugs and medical supplies list, drawn up with the assistance of the Regional Office for Europe and following the classification of drugs recommended by WHO. One of the main aims of Ukraine's national drugs policy was to guarantee their quality and to ensure that they were produced according to appropriate manufacturing standards. All actions associated with the drugs policy were fully consistent with WHO recommendations. Her delegation supported the draft resolution contained in resolution EB 109.R17. Mr NACUVA (Fiji) expressed his appreciation for the report and clinical guidelines, and acknowledged WHO's role in international trade agreements in ensuring access to drugs, with reliable health and supply systems. Outlining the situation in his country, he requested WHO to assist developing Member States, to enable them to obtain access to high-quality HIVI AIDS drugs. He endorsed the draft resolution.

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Dr SUWIT WIBULPOLPRASERT (Thailand) strongly endorsed the draft resolution but expressed concern that the technical bureaucracy prevailing at WHO might hamper the successful implementation of the resolution. The launch of the Global Fund to Fight AIDS, Tuberculosis and Malaria had greatly increased the demand for technical support from WHO to help Member States to obtain a supply of high-quality generic drugs. In order to meet that demand, WHO needed to adopt a new approach and an innovative way of doing business. It had been successful in the upstream process, in providing support at global, regional and country levels. Although the Director-General had stated her full commitment to the Global Fund, the same could not be said for some of her staff responsible for technical support on quality and standards of medicines. The response from the Director-General's Office during the fifth meeting of Committee A to urgent requests for technical support on downstream implementation of approved proposals to the Fund had been to lay the blame on the countries concerned; it had been maintained that they were slow in improving the quality and standards of drug production and that WHO would do its best to accelerate its usual mechanism. That response was totally unsatisfactory: the increased demand for quality drugs could not be met by a "business as usual" approach by complacent, indifferent technical staff. Hence, it was questionable whether WHO had the leadership commitment or the capability to support the successful implementation of the medicines strategies outlined in the draft resolution. A paper in a recent issue of The Lancet had criticized WHO for losing its credibility and leadership in the area of essential drugs. Fortunately, losing a battle did not mean losing a war. WHO's infrastructure was needed to facilitate the downstream implementation of the Global Fund. To support the medicines strategy, especially in relation to standards and quality of medicines, it urgently required a major overhaul, with new thinking and an injection of fresh blood. A new mechanism, bypassing all passive bureaucratic systems, was needed to respond to the emerging, dynamic environments and demand. If no such initiative was undertaken by WHO, Member States would look to other organizations for support and WHO would permanently lose its leadership in that area. Mr METHOT (Canada) said that Canada supported WHO's continued efforts to improve access to essential drugs. Of the four components listed in WHO's medicines strategy for 2000-2003, Canada stressed the need to work collaboratively to achieve the objective of reliable health and supply systems. The provision of drugs at cost or free of charge would not solve the current problem of accessibility in the absence of a proper infrastructure and health services to deliver and monitor the often complex treatment regimens. Canada therefore encouraged international organizations and development agencies to consider that a priority in the health services sector of developing countries. His country welcomed the Doha Declaration on the TRIPS Agreement and Public Health, which emphasized the importance of intellectual property protection for the development of new and better medicines badly needed by developing and least developed countries. Canada was involved in the work of WTO's Council for Trade-Related Aspects of Intellectual Property Rights on the situation of members with insufficient or no manufacturing capacities in the pharmaceutical sector, and which were unable to make effective use of compulsory licensing under the TRIPS agreement. His country was dedicated to finding a solution to that problem before the end of 2002, as requested by the Council. It further welcomed the new procedures for selection and inclusion of medicines in the Model List, that were essential for ensuring an independent, objective selection process. While the current recommendations called for multiple lists, Canada would instead suggest that a single list be issued, with explanatory footnotes where necessary. He furthermore urged caution in the application of costeffectiveness as a criterion for selection. In future, the cost of a drug would not be a ground for exclusion if other criteria justified its inclusion in the essential drugs list. That approach might increase the accessibility of new drugs likely to be under patent. His delegation supported the draft resolution. Mr KALITE (Central African Republic) said that access to essential drugs had been an absolute priority in his country since adoption of the Bamako Initiative on primary health care. A central purchasing agency for essential drugs had been set up, and regional, prefectoral and subprefectoral centres had been created to provide information on public health and essential drugs. His country

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would appreciate support in setting up a system for quality control and for rational use of essential drugs, as well as access to antiretroviral drugs. He endorsed the draft resolution. Mr CHOI (Republic of Korea) said that WHO should assume a leadership role in expanding access to essential drugs and in providing technical assistance to Member States in obtaining access to low-cost essential drugs. There had been over-production of medicines in his country, owing to the large number of pharmaceutical manufacturers. Consequently, a list of essential drugs had not yet been established. However, a list of low-priced drugs not normally produced by the pharmaceutical industry had been drawn up and their manufacture was being encouraged by cost adjustments. His country was one of the few in Asia with the capacity to manufacture high-quality generic drugs. As such drugs were instrumental in reducing health-care expenditure, his country would continue to cooperate in strengthening technical assistance for the production of such drugs. Mr SAM (Australia) emphasized that equitable access to affordable drugs was critical to improving health status, particularly in developing countries. Recently, however, with the trade issue dominating discussion, insufficient attention had been given to the wide range of factors that impinged on access. WHO had consistently argued that the TRIPS agreement had sufficient flexibility to enable members to address public health needs, and the Director-General had committed the Organization to support governments in managing the health implications of trade agreements and to work with partners to promote public health in the consideration of trade issues. The report listed some of WHO's achievements and highlighted issues unrelated to trade that affected access to drugs, including national policies, government commitment, supply systems, sustainable financing, technology and human resources. It was encouraging to see priority given to addressing those aspects; initiation of a WHO essential drugs library gave some credence to those initiatives. Moreover, the revised procedure for updating and disseminating the Model List of Essential Drugs provided a more systematic, transparent process for drug selection. The draft resolution acknowledged activities already under way, as well as requesting the Director-General to strengthen work in specific areas. However, he remained unconvinced of the merits of the proposal to establish a global price index to benchmark costs, as it might be expensive to establish and maintain, without delivering practical benefits in terms of better access or reduced costs. Welcoming the request to WHO to continue its work on a methodology (referred to in paragraph 2(5)), he said that his delegation would appreciate the opportunity to assess the feasibility and cost-benefits of the proposal before a pricing index was established. His delegation supported the draft resolution. Mr NAIK (India) said that India had been in the front line of the developing countries' battle against the restrictive provisions of the TRIPS agreement. As a result of those efforts, the Doha Declaration had been issued, giving developing countries the flexibility to protect public health when implementing their patent laws. The Indian patent law was currently before Parliament, with amendments suggested by the Ministry of Health and Family Welfare. The amended Act would provide for safeguards, such as compulsory licensing, parallel imports and provision for governmental use in emergencies and for public non-commercial use. Other steps that needed to be taken included a rational drug prescribing system and essential drugs list; effective price control mechanisms, with continuous monitoring of patent drug prices; an increased supply of drugs through the public health system; and a review of the prescribing system followed by doctors, to promote the use of generic drugs. Access to medicines for all would remain an ideal if concrete steps were not taken to provide resources for that gigantic task. Although developing countries such as India had a fair health care infrastructure, a continuous supply of medicines was needed. The global drug supply facilities being created would have to address that problem. Whereas the Doha Declaration had emphasized the right of countries to protect public health, technical and financial support was essential for those which did

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not have adequate facilities for manufacturing drugs. WHO should continue to monitor the prices of patented medicines in the context of TRIPS. He expressed support for the draft resolution. Mrs BENAVIDES COTES (Colombia) said that developing countries were particularly interested in technical support on the issues of intellectual property rights and trade. The efforts of WHO and WTO to find solutions for Member States whose manufacturing capacities in the pharmaceutical sector were either inadequate or nonexistent were therefore welcome. She expressed the hope that the strategic fund for purchasing medicines and insecticides for particular diseases would be as effective in the Region of the Americas as the rotating Fund had been in boosting immunization campaigns. The translation into Spanish of standards and good manufacturing practices for pharmaceuticals had been a constructive step. She fully endorsed the draft resolution, which reflected the need to ensure that access to essential drugs remained one of WHO's priorities during the 2004-2005 biennium. Dr QI Xiaoqiu (China), endorsing the draft resolution, applauded WHO's medicines strategy and said that it was also the policy of the Chinese Government to improve access to essential drugs. The Model List of Essential Drugs was a fundamental document, which needed updating periodically. Some poverty-induced diseases were themselves often the causes of poverty. WHO should add hepatitis B to the diseases of poverty that were to be made priorities in 2002-2003. Traditional medicine was important in developing countries and was becoming increasingly popular in developed countries. WHO should therefore encourage Member States to broaden access to traditional medicines by including them in its list of essential medicines. Mrs ASSI GBONON (Cote d'Ivoire) said that, although much progress had been made in implementing WHO's medicines strategy, access to high-quality, affordable essential drugs remained an area of concern to developing countries, since most of them did not have well-equipped test laboratories. Regular quality control and monitoring of adverse effects were particularly important. Over 90% of drugs in Africa were imported, and it was vital that countries received WHO support for quality control, especially in the case of antiretroviral drugs. Improving access to essential drugs meant regular supplies, appropriate channels of distribution, constant geographical availability and affordability. With regard to affordability, the pharmaceutical industry had a major role to play, in partnership with developing countries. She thanked WHO for organizing an information meeting on that subject in Yaounde, and endorsed the draft resolution. Dr BUCKLE (Consumers International), speaking at the invitation of the CHAIRMAN and also on behalf of Health Action International, Medecins sans frontieres, OXFAM and The Save the Children Fund, agreed with the Director-General that much remained to be done. Access to basic health care, including access to essential medicines, was a fundamental human right. Several steps had been taken, such as the provision of information on drug prices, the prequalification process for medicines and the recent revision of the Model List. He had also noted with pleasure that the cost of drugs was no longer a barrier to their inclusion on the essential drugs list. WHO should remain involved in the issue of access to medicines, as it was too important to leave to WTO and WIPO. It should also assist Member States by advising them on ways of making health the priority when implementing intellectual property legislation. In particular, at the forthcoming meeting of the WTO Council for Trade-Related Aspects of Intellectual Property Rights, WHO should support the developing countries' call for exceptions to compulsory licensing, thus allowing the export of essential drugs produced under compulsory licences to countries that did not have sufficient production capacity. Although 10 antiretroviral drugs had been added to the list of essential drugs, the prices were still excessive; WHO should pursue its efforts to reduce them, either by stimulating competition through compulsory licensing or parallel imports, or by working towards unrestricted, systematic differential pricing. Furthermore, WHO should extend its prequalification process to include drugs for malaria, tuberculosis and other major infectious diseases. He was concerned to note the trend towards

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"partnerships" with commercial entities. As such partnerships might jeopardize WHO's independence, he urged WHO to analyse the health and social outcomes and the sustainability of such initiatives in a transparent manner, and to accelerate its work of addressing potential conflicts of interests and to involve civil society in the process. Dr NOEHRENBERG (International Federation of Pharmaceutical Manufacturers Associations), speaking at the invitation of the CHAIRMAN, said that, although access to essential drugs was crucial to improving health care, the drugs must be genuine and of high quality. Pharmaceutical companies played a central role in improving sustainable access to medicines worldwide, through research and development, partnerships, and company donation programmes. Market-based discounted pricing should be encouraged as appropriate. Partnership initiatives such as GAVI and the Global Fund were increasingly important, and industry was pleased to form part of them. Updating the essential drugs list was also important; nevertheless, in future, WHO should provide more timely information for developers and manufacturers of candidate drugs, so that they could report relevant scientific, technical and clinical experience with their products. Access to medicines also meant improving logistics and infrastructure and providing more clinics and trained medical personnel. Moreover, import duties and domestic taxes should be reduced or eliminated. He looked forward to further collaboration with WHO. Dr SUZUKI (Executive Director) thanked Member States for their support and guidance. Responding to comments about how much had been achieved and how much remained to be done, he recalled that access to crucial drugs had doubled within 20 years, yet one-third of the global population was still deprived of access to essential drugs. WHO would therefore pursue its efforts. In the context of trade agreements, WHO had noted with satisfaction that the Doha Declaration stated that the TRIPS agreement should be interpreted and implemented in a manner supportive of WTO members' right to protect public health. WHO was willing to work with countries on compulsory licensing of overseas producers in countries that had insufficient pharmaceutical manufacturing capacity, and also in analysing the public health implications of trade agreements on pricing, the pace of introduction of drugs onto the market, the extent of investment in research and development and technology transfer. WHO would strive for greater transparency in its medicines strategy and would endeavour to improve its usefulness to Member States, by enhancing the scientific evidence base and the rapidity of delivery of services, such as the essential drugs library, procedures for updating the essential medicines list and price information services. The two substantially different views expressed by Japan and Thailand on the prequalification of suppliers of antiretroviral drugs were perhaps due to failure in communication, since a similar initiative had been introduced for vaccines 20 years previously. Particularly in respect of antiretroviral drugs, WHO had cooperated with almost all the drug regulatory authorities in Member States, as well as with other stakeholders, including industry. Any company that wished to be considered for prequalification could do so. In reply to the delegate of Thailand, he said that the Director-General's commitment was reflected throughout the Organization. Downstream implementation of prequalification proposals would be expedited, as far as possible, without sacrificing the commitment to quality assurance. The process took on average six to 12 months; it might be possible to shorten the period for preparation of dossiers and on-site inspections both by enhancing capability at headquarters and by providing technical assistance to countries. In reply to Japan, he said that the criterion of costeffectiveness in the selection of essential drugs represented best practice in terms of clinical guidelines and would be used only for drugs within the same therapeutic group, as had been the practice for the past 25 years. In reply to the United States, he said that the Expert Committee's intention had been that the use of fixed-dose combinations would be recommended only if they were interchangeable, of adequate pharmaceutical quality and had been approved by regulatory authorities. The CHAIRMAN invited the Committee to consider the draft resolution recommended by the Executive Board in resolution EB109.R17.

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The draft resolution was approved. 1 Smallpox eradication: destruction of variola virus stocks: Item 13.16 of the Agenda (Document A55/21) Ms WIGZELL (representative of the Executive Board) said that the Board had discussed whether the deadline for the destruction of Variola virus stocks should be extended beyond 2002 in order to allow completion of necessary research. The potential deliberate use of biological agents had been recognized as a real threat, and the Board had agreed that further research with Variola virus was required. Such research should be outcome-focused and time-limited, with strong WHO involvement. There had been general agreement that destruction of the virus stocks was still the ultimate goal. Any extension of the deadline for destruction should be provisional and linked to approved research, which should be completed rapidly. At that stage, a consensus could be reached on the date for destruction of the stocks. WHO should continue its systematic inspection of the facilities used to store the virus. The Board had acknowledged the importance of the WHO Advisory Committee on Variola Virus Research and looked forward to receiving periodic progress reports from it. Dr FURGAL (Russian Federation) supported the recommendation that the destruction of Variola virus stocks should be delayed in order to permit further fundamental research and the development of diagnostic, treatment and prophylactic tools. The Russian Federation's research programme, conducted under the supervision and leadership of WHO, was not yet complete: work remained to be done on the sequencing of Variola virus DNA, the structures of different strains, screening of new drugs and specific analysis of viruses. Particular emphasis was being placed on new vaccines for timely single-dose immunization against smallpox and other viral infections. The research had been approved at the third meeting of the WHO Advisory Committee on Variola Virus Research. It was essential that the research should be conducted under the aegis of WHO, which would provide the necessary transparency and help to increase mutual trust among countries. Turning to the issue of the safety and security of the Russian virus stocks, he said that strict precautionary measures had been introduced in recent years. The conditions in which the virus stocks were kept were fully consistent with international standards and completely precluded any escape of the virus. WHO regularly inspected the Russian Federation's Collaborating Centre on Smallpox, and all the Organization's recommendations were fully implemented. His country categorically rejected press reports that the virus might escape from its current repository. Following the terrorist attacks on the United States of America in September 2001, the Government of the Russian Federation had considered it necessary to ask the world community to agree to maintain smallpox virus strains, in order to permit further research and the development of reliable diagnostic, treatment and preventive tools in case the virus was ever used deliberately. The Russian research programme was almost complete, and would be sent to WHO for review. On the issue of the resumption of immunization against smallpox, his country was in a position to begin producing smallpox vaccine once again and would provide assistance to WHO and Member States if called upon to do so. Deliberate use of the virus was a possibility that could not, unfortunately, ever be completely excluded. However, there was no question of resuming mass immunization. Whatever action the Government took would be agreed with WHO in advance. His delegation supported the draft resolution contained in document AS 5/21, and particularly welcomed the fact that it set no date for the ultimate destruction of Variola virus stocks. That deadline could not be set without a realistic idea of when the research was likely to be complete. It also presupposed the exclusion of any possibility of deliberate and malicious use of the smallpox virus.

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.14.

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Mr BELIZ (Panama) suggested that the existing stocks of Variola virus should not be destroyed until the research programme had developed effective methods of treatment and immunization which could be deployed on a large scale. Mr MOON (Republic of Korea) expressed his support for the recommendation to delay destruction of the remaining Variola virus stocks until the necessary research was complete. His country welcomed the draft resolution, supporting the request to the Director-General to report to the Health Assembly on progress achieved in research programmes, as the exchange of information on diagnosis, treatment and new vaccines would be crucial. Dr MuNOZ (Chile) said that his country supported the draft resolution. It was important to set a deadline for the provision of information on progress made in the necessary research. By that date, a solution would have to be found to the issue of eliminating existing stocks. Should the results of the research indicate the need to maintain a stock for subsequent study, the storage facilities should be in a highly developed technological centre, the sole purpose of which would be to conduct research for peaceful purposes. That centre should be selected by consensus by the international community. Mr LIU Peilong (China) said that large numbers of people were vulnerable to Variola virus, 400 million of them in China alone. Any unintentional leakage of the virus or deliberate use by terrorists would be catastrophic. The Chinese Government agreed with the conclusions of the Advisory Committee on Variola Virus Research that it was reasonable to delay destruction of the remaining virus stocks in order to enable further research to take place. However, the draft resolution contained in document ASS/21 did not properly reflect all the Advisory Committee's conclusions. He therefore proposed that the phrase " ... the research should be completed as quickly as possible ... " in paragraph 1 of the draft resolution should be replaced by "steps should be taken to ensure that all approved research would remain outcome-oriented and time-limited and periodically reviewed". Paragraph 2(3) of the draft resolution should be replaced by "to report annually on the progress in the research programme and relevant issues to the World Health Assembly, through the Executive Board". Dr SADRIZADEH (Islamic Republic oflran) and Mr NAIK (India) supported those proposals. Mr METHOT (Canada) said that his delegation supported the draft resolution. Regular progress reports should be submitted to the Executive Board and the Health Assembly. The WHO Advisory Committee on Variola Virus Research should be charged with making recommendations on the deadline for the destruction of virus stocks. Dr BERNARD (United States of America) said that the terrorist attacks on his country had shown that terrorists were prepared to inflict mass civilian casualties to advance their political agendas. The anthrax attacks against citizens of his country in October 2001 had broken a second barrier - that of the use of deadly disease as a weapon. United States experts considered smallpox to be the most important bioterrorist threat; the likelihood of its use was small, but growing, and the medical and public health consequences would be enormous. Retention of the current Variola virus stocks was necessary to improve understanding of the virus and to complete the development of effective protective vaccines, accurate diagnostic tests and effective therapeutic interventions, such as antiviral drugs. The need for new drugs and vaccines was particularly acute in parts of the world where many people had a compromised immune system, since for them the current vaccine was potentially lethal. His Government concurred with the recommendations that all research should be conducted in an open and transparent manner and with the approval of the WHO Advisory Committee on Variola Virus Research and that any new date for destruction should be fixed when research accomplishments and outcomes allowed for a consensus on the correct timing.

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The release of Variola virus anywhere in the world would be a critical national security issue for all countries. The United States would provide assistance, including vaccines as appropriate, for emergency post-exposure treatment in the event of an accidental or intentional release of the virus. His delegation supported the draft resolution contained in document A5 5/21, with the amendments proposed by China. Dr SUPAMIT CHUNSUTTIWAT (Thailand) said that his Government remained convinced of the merit of Health Assembly resolution WHA52.1 0, which called for destruction of all Variola virus stocks by 2002, although he acknowledged the reasons for extending the deadline for destruction put forward by the Advisory Committee on Variola Virus Research. In his Government's view, the very existence of Variola virus stocks was a matter for international concern, and strict international control and monitoring were therefore essential. The indefinite postponement of the deadline for destruction, as proposed in the draft resolution, provided less control than resolution WHA52.10 and thus offered less assurance of the safety of the global population. His delegation therefore supported the draft resolution with the amendments proposed by China. Mrs QUINTAVALLE (Italy) agreed that more research was needed to protect the world against the potentially catastrophic consequences of the re-emergence of smallpox. Live Variola virus stocks were essential for the development of antiviral drugs, an animal model to test them, new vaccines, detection and diagnostic tests and additional information on the DNA sequence of the virus. Her country therefore supported the draft resolution. Dr MAHJOUR (Morocco) supported the draft resolution as amended by China. He called upon WHO to take appropriate measures to make specific diagnostic tools and vaccines available to all countries which needed them. Mrs BU FIGUEROA (Honduras) supported the recommendation to destroy existing Variola virus stocks eventually, as described in the report. Mr MAGNUSSON (Iceland) accepted the recommendation of the Advisory Committee that research into Variola virus should extend beyond the 2002 deadline. The Advisory Committee must continue to monitor and review all research involving live Variola virus, and all approved research must remain outcome-focused and time-limited. Regular inspections of the storage and research facilities must be continued to ensure strict containment of the stocks. Iceland welcomed WHO's intention to support Member States in the event of Variola virus being used as a biological weapon, by monitoring and investigation, increasing diagnostic capacity and compilation of global inventories of vaccine stocks. His delegation supported the draft resolution. Mr KINGHAM (United Kingdom of Great Britain and Northern Ireland) said that the research reviewed by the Advisory Committee covered a number of very sensitive, important issues, which were consistent with the mandate laid down in resolution WHA52.10. The debate that had preceded the adoption of that resolution had represented a balanced view of the time that had elapsed since the last case of smallpox had been diagnosed, the level of immunity in the population, technical and scientific developments and the possibility of the natural emergence of new cases. Following the terrorist attacks on the United States of America in September 2001, the Director-General had referred to the continuing threat of smallpox. Use of the virus stocks, which were under the control of WHO, would be crucial in combating that threat. The Advisory Committee had identified the scientific basis for further work on an animal model and on antiviral drugs. Those developments were significant in that they provided measurable outputs. The recommendation that the Advisory Committee should continue to oversee the research programme was a logical step. The members of the Advisory Committee were well known for their expertise and were in a good position to ensure that research was conducted in as transparent a manner as possible and to make appropriate recommendations.

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His delegation supported the draft resolution. Dr JAACOB (Malaysia) supported the draft resolution. Extension of the deadline for the destruction of Variola virus stocks appeared to be justified by the need for more research; however, extra containment and security measures at the storage facilities were critically important in view of the increased threat of bio-terrorism. If smallpox should ever re-emerge in her country, diagnosis would be largely clinical, with confirmation by electron microscopy. The country would need to increase its range of laboratory tests, including molecular techniques and serological assays and would need WHO assistance to obtain the necessary reagents and technical expertise. There had been no smallpox immunization in her country for two decades, and some front-line health personnel and laboratory workers were not protected against the virus. WHO should provide guidelines to indicate which staff required immunization, and provide the vaccines if necessary. Mr ARRIAGA (Mexico) said that his Government agreed that the deadline for the destruction of Variola virus stocks should be extended and that the Advisory Committee should continue its work, particularly its supervision of research. Although his delegation agreed that a report on the progress made in Variola virus research be submitted to the Fifty-eighth World Health Assembly, it considered that a transparent mechanism should be established for regular reporting to Member States on progress made in the interim. Dr OKAMOTO (Japan) agreed that, since the potential threat of the deliberate use of biological agents had become a reality with the events of September 2001, research should be continued in order to respond appropriately to that threat. Existing stocks of Variola virus should therefore be maintained. The Advisory Committee should continue to oversee the research programme and to assess periodically the further need to retain the stocks, while ensuring its own neutrality and independence. High priority should be given to operational research to control the potential threat of a smallpox outbreak, and WHO should play a central role in promoting practical research to develop a global strategy, including vaccine stock for global use. He proposed the addition of a new subparagraph 2(3): "to ensure that research results and the benefits of this research are made available to all Member States". Subject to that amendment, his delegation supported the draft resolution. Dr ZAHER (Egypt) supported the research programme as proposed and submission of its results to the Executive Board so that the date for the final destruction of the remaining stocks of Variola virus could be reviewed. Strategic stocks should be retained because of the potential re-emergence of smallpox among populations that had not been immunized, such as persons under the age of20. Mr SAM (Australia) said that his delegation supported the draft resolution to extend the deadline for the destruction of Variola virus stocks to allow essential research to be completed. Like previous speakers, he strongly recommended frequent, transparent review and reporting of the research programme under the auspices of WHO. In supporting such a delay, it was to be hoped that the Health Assembly's commitment to pursuing the ultimate destruction of Variola virus once the research objectives had been achieved was not diminished. Ms SAHLI (Libyan Arab Jamahariya) supported the recommendation to defer the destruction of Variola virus stocks to enable research for humanitarian reasons to continue. However, WHO should monitor and supervise the research and the stocks to ensure that they did not fall into the hands of irresponsible elements which could use them for destructive purposes. Mr GONZALEZ FERNANDEZ (Cuba) said that his delegation agreed with the conclusions of the Advisory Committee that it was reasonable to delay the destruction of Variola virus stocks, in

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view of the promising results being produced by research into the virus strains and the fear of terrorist attacks. With regard to stocks of smallpox vaccine, he recalled the commitment made in the statement of the G7 Health Ministers' Meeting (with Mexico) in Ottawa, Canada, in November 2001 to pursue a constructive dialogue in relation to the regulatory frameworks for the development of vaccines and in particular smallpox vaccines. Regulatory systems should also be included in the review of existing Variola virus stocks. He supported the draft resolution, with the amendments proposed by China. Dr ARMADA (Venezuela) also supported the proposed amendments by China. Information on the progress of research and security measures should be made available to all countries, as should information on the worldwide availability of smallpox vaccine, the location and laboratory in which it had been produced and its effectiveness. Subject to those considerations being taken into account, Venezuela supported the recommendations contained in the report. Dr VIOLAKI-PARASKEVA (Greece) agreed that the Advisory Committee on Variola Virus Research should continue its work in an independent and transparent manner and supported the draft resolution. Referring to paragraph 27 of document ASS/21, she requested clarification of the statement "the potency of these doses is not known in all cases", since it was unclear whether it referred to the doses of smallpox vaccine available worldwide or the doses held by WHO in Geneva. Dr HEYMANN (Executive Director) assured all Member States that WHO would continue to work in a transparent manner on issues related to smallpox. The reports of the Advisory Committee, containing short summaries of the research in each technical area, were available in printed and in electronic formats. In addition, WHO would begin to publish progress reports of each research project on its web site. The next inspection of the WHO Collaborating Centre in the Russian Federation was due to take place in September 2002, and an inspection would then be conducted of the repository in the United States of America. The Organization would continue to perform other functions to maintain and strengthen the world's capacity in the area of smallpox. In reply to the point raised by Greece, he said that the reference was to the 11 0 million doses stored by Member States. The CHAIRMAN invited the Committee to consider the draft resolution contained in document AS 5/21, authorizing the retention of existing Variola virus stocks beyond the 2002 deadline. The draft resolution, as amended, was approved. 1 Natural and accidental release of biological, chemical or radionuclear agents affecting health or their deliberate use to cause harm: Item 13.15 of the Agenda (Resolution EB109.RS; Document ASS/20) Ms WIGZELL (representative of the Executive Board) reported that the Executive Board had been unanimous in its condemnation of the deliberate use of biological and chemical agents to cause harm, especially as the health consequences in civilian populations could be enormous in terms of mortality and morbidity, including potential psychological effects. Board members had stressed that the threat was shared by all and that preparedness was of international importance. WHO could assist Member States to strengthen national infrastructures and by maintaining strong global surveillance. WHO's rapid response to recent events had been appreciated. Several members of the Board had noted the importance of robust systems of surveillance and response, as outbreaks of infectious diseases would continue to occur, whether natural or deliberate, and the methods of detection and national response were similar. The health sector was likely to be the first to detect deliberately caused disease outbreaks and would remain in the front line during the response. The establishment of contingency

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.15.

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and emergency response plans required collaboration with groups such as the security and law enforcement authorities. It was therefore vital to clarify WHO's use of terms such as "verification", in the context of public health aspects of deliberate use, as opposed to the verification of compliance with international conventions or treaties. Mr COSTI SANTAROSA (Brazil) supported WHO's plan to adapt its capacity to respond to threats of deliberate use of chemical, biological and radiological agents, particularly in the light of the massive scale that would characterize a deliberate attack. With regard to the so-called deliberate use of those agents, he noted that document A55/20 recognized that a deliberate release of such agents was likely initially to be considered as a natural event, unless the agent had been spread overtly or on a massive scale. It also emphasized that WHO focused on the public health consequences of an incident involving such agents, regardless of whether it was characterized as a natural occurrence, accidental release or deliberate use; WHO's role was unchanged. Resolution EB109.R5 should be amended to reflect that understanding. WHO had an important role to play in supporting capacity building for surveillance and improving preparedness and national capabilities. Document A55/20, in paragraph 11, had interpreted resolution WHA54.14 too loosely, in asserting that it provided a mandate for WHO to facilitate joint action in cases where the public health risk might involve more than one country. The Organization should finance any new activities, as defined and agreed by Member States, in adapting its capacity to respond to the new threats against civilian populations from the regular budget and make use of its own staff. In the light of those considerations, he proposed various amendments to the draft resolution contained in resolution EB 109 .R5. The title should be amended to read "Global public health response to natural occurrence, accidental release or deliberate use of biological and chemical agents or radionuclear material that affect health". A new first preambular paragraph should be added that would read: "Underlining that the World Health Organization focuses on the possible public health consequences of an incident involving biological and chemical agents and radionuclear material, regardless of whether it is characterized as a natural occurrence, accidental release or deliberate act;". In the second preambular paragraph, the phrase following the word "including" should be replaced by "those caused by natural occurrence or accidental release of biological or chemical agents or radionuclear material as well as their deliberate use to cause illness and death in target populations". A new fourth preambular paragraph should be added that would read: "Acknowledging that natural occurrence or accidental release of biological, chemical agents and radionuclear material could have serious global health implications and jeopardize the public health achievements of the past decades;". In the following preambular paragraph, the word "also" should be added after "Acknowledging" and the words "radionuclear material" should be inserted after the words "chemical and". In paragraph 1(1), the word "humanitarian" should be inserted after "surveillance data of' and again in paragraph 2(1), between "international" and "response". Paragraph 2(4) should be amended to read: "to examine the possible development of new tools, within the mandate of WHO, including modelling of possible scenarios of natural occurrence, accidental release or deliberate use of biological, chemical agents and radionuclear material that affect health, and collective mechanisms concerning the global public health response to contain or mitigate the effects of natural occurrence, accidental release or deliberate use of biological, chemical agents and radionuclear material that affect health". Mr METHOT (Canada) said that citizens must remain confident in the ability of their governments to protect their health in the case of intentional biological, chemical and radionuclear incidents. International cooperation and the need for effective public health preparedness and response plans were essential in dealing with such incidents. He agreed with the need to strengthen public health surveillance and response activities, and supported amendments proposed by Brazil. The Global Ministerial Group on Health Security and Bioterrorism had endorsed resolution EB109.R5 in its communique following its second meeting in London in March 2002. He urged Member States to support the draft resolution, as amended.

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Dr ISMAIL (Iraq) thanked WHO for its cooperation in enabling Iraq to deal with the effects of depleted uranium weapons, and expressed the hope that the programme would be implemented promptly in the fields of surveillance, protection, awareness-raising, joint research and training. The exposure to depleted uranium to which the Iraqi population had been subjected during the aggression against it in 1991 was having long-term health consequences. Not least, there had been a conspicuous increase in the incidences of cancer, particularly leukaemia, and of congenital deformities. The brutal use of prohibited weapons against Iraq therefore constituted not only a flagrant violation of the principles of international humanitarian law, primarily the right to survival, but also threatened the lives of future generations. He thus urged adoption of the necessary measures to ensure that countries were not exposed to similar disasters in the future. Dr SADRIZADEH (Islamic Republic of Iran) said that WHO should focus on the possible health consequences of incidents involving the deliberate or other use of chemical and biological agents. In other words, it should not deviate from its humanitarian mandate by becoming involved in verification and subsequent inspection procedures, which had political and security implications. Those issues should be addressed by the relevant organizations and agencies such as the United Nations, IAEA and the Organization for the Prohibition of Chemical Weapons. His country, which spared no effort in assisting WHO to fulfil its mandate and promote global health, supported the draft resolution contained in resolution EB109.R5 as amended by Brazil. Dr SUPAMIT CHUNSUTTIWAT (Thailand) welcomed the draft resolution contained in resolution EB109.R5. Public health was the first-line response, and the best form of preparedness was built around public health capacity as well as intersectoral and international cooperation. The complexity of the issue and of the strategies for dealing with it posed an enormous challenge to both Member States and WHO. WHO should therefore pursue its endeavour to develop technical capacity and effective models for coping with such health threats, and to provide guidance and support to increase the preparedness of Member States. In that connection, greater emphasis should be placed on preventive aspects, as well as response. Mr GUNNARSSON (Iceland), speaking on behalf of the Nordic countries, Denmark, Finland, Iceland, Norway and Sweden, said that national, regional and global measures should be introduced to meet the challenge of providing a health response to the natural and accidental release of biological, chemical and radionuclear agents. The strengthening of public health surveillance was the most effective means of improving preparedness against such agents. The knowledge, experience and training available within the public health system was crucial to the effective handling of unexpected crises and incidents. He agreed that WHO should work in close cooperation with the relevant intergovernmental agencies and international organizations, whose respective roles should be clarified in order to optimize the public health response. The Nordic ministers of health had recently stepped up their cooperation in the field of health preparedness and prevention. The experience had been extremely positive insofar as their cooperation was based on established public health systems and mutual support through practical measures. The Nordic countries supported the draft resolution contained in resolution EB109.R5. Mr DEL PONTE (Switzerland) endorsed the amendments proposed by the delegate of Brazil and welcomed WHO's pre-publication report "Public health response to biological and chemical weapons". He supported the draft resolution contained in resolution EB109.R5, which gave WHO a clear mandate that was consistent with its public health role and urged strengthening of the public health response to potential epidemics of infectious diseases. He, too, welcomed the activities to strengthen the preparedness and response of Member States, in particular the WHO project on public health preparedness and response to epidemic threats.

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Mr KING HAM (United Kingdom of Great Britain and Northern Ireland) strongly supported the proposed amendments, but suggested that in the amendment proposed by Brazil to paragraph 1( 1) of the draft resolution the word "humanitarian" would best be inserted between the words "international" and "concern". The CHAIRMAN invited the Committee to approve the draft resolution contained in resolution EB109.R5, with the amendments proposed by the delegations of Brazil and the United Kingdom. The draft resolution, as amended, was approved. 1 Mr McCARTHY (Ireland) said that his country, which had strongly supported the draft resolution, had been pleased to participate in the extremely valuable and informative meeting organized in December 2001 by the WHO Regional Office for Europe to assess the risks associated with biological, chemical and nuclear attacks and to identify the planning, service and communication arrangements needed to ensure a timely and adequate response. As a result, fundamental recommendations for actions by Member States, WHO and other international agencies had been promulgated. Given its structures and technical expertise, WHO was ideally placed to inform, guide and assist endeavours within and between Member States aimed at strengthening the capacity of public health systems to deal with catastrophic events of the kind referred to in the resolution. The wide pool of relevant specialized expertise which WHO could provide was particularly crucial to small and developing countries. Dr QI Xiaoqiu (China) said that all countries had taken measures to counter bioterrorism and that China had always been opposed to any form of terrorism. In today's globalized world, it was even more important to strengthen cooperation for the prevention of harm by biological and chemical agents, in which connection health authorities had a major responsibility. In view of its leading role in the field of global health, WHO should further promote and coordinate the exchange of health information in regard to the prevention of such harm, and increase its technical and financial support to developing countries for improvement of their preventive capacities. Mr KINGHAM (United Kingdom of Great Britain and Northern Ireland) expressed his appreciation of the work carried out by WHO in the area under discussion and of the meeting hosted by the WHO Regional Office for Europe, which the delegate of Ireland had mentioned. He also strongly supported the view that the response to a deliberate release of harmful biological and chemical agents should be based on a robust and comprehensive public health system and on rigorous surveillance of infectious diseases. Where possible, it should additionally be based on contingency plans set up for natural disasters, in the interests of achieving a rapid response. International cooperation was also essential as an opportunity for learning lessons, linking surveillance systems and offering mutual support. Dr OKAMOTO (Japan) said that his country was involved in the exchange of information on technical measures to deal with the deliberate use of chemical and biological agents, in which connection it would continue its contribution to WHO for the establishment of surveillance systems. It had recently established a "syndromic surveillance system" to ensure safety during the forthcoming World Cup football matches in the Republic of Korea and Japan. In addition, it had distributed guidelines to health personnel for the diagnosis and treatment of diseases caused by biological agents. He urged WHO to take prompt action to communicate information on technical and health measures adopted by Member States with a view to tackling the deliberate use of biological and chemical

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.16.

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agents. Lastly, he requested a review of the International Health Regulations to take such issues into consideration. (For continuation of discussion of both Natural and accidental release of biological, chemical or radionuclear agents affecting health or their deliberate use to cause harm and other Technical and health matters, see summary record of eight meeting, section 2.)

The meeting rose at 20:35.

EIGHTH MEETING Saturday, 18 May 2002, at 9:20 Chairman: Or J. KIELY (Ireland)

SECOND REPORT OF COMMITTEE A (Document ASS/49) Or MSA MLIVA (Comoros ), Rapporteur, read out the draft second report of Committee A.

The report was adopted. 1

TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued from the seventh meeting)

Quality of care: patient safety: Item 13.9 of the Agenda (Resolution EB109.R16; Document ASS/13) (continued from the sixth meeting, section 2) The CHAIRMAN drew the Committee's attention to a draft resolution that had been produced on the basis of the comprehensive debate held at its fifth and sixth meetings. It read as follows: The Fifty-fifth World Health Assembly, Having considered the report on quality of care: patient safety; 2 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; 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, 1. URGES Member States: (1) to pay the closest possible attention to the problem of patient safety; (2) to establish and strengthen science-based systems, necessary for improving patients' safety and the quality of health care, including the monitoring of drugs, medical equipment and technology; REQUESTS the Director-General in the context of a quality programme: (1) to develop global norms, standards and guidelines for quality of care and patient safety, the definition, measurement and reporting of adverse events and near misses in health care by reviewing experiences from existing programmes and seeking inputs from

1 2

See page 273. Document A55/l3.

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Member States, to provide support 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 product safety, safe clinical practice in compliance with appropriate guidelines and safe use of medicinal products and medical devices taking into consideration the views of policy-makers, administrators, health-care providers and consumers; (3) to support the efforts of Member States to promote a culture of safety within health care organizations and to develop mechanisms, for example through accreditation or other means, in accordance with national conditions and requirements, 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, including epidemiological studies of risk factors, effective protective interventions, and assessment of associated costs of damage and protection; (5) to report on progress to the Executive Board at its 113th session and to the Fiftyseventh World Health Assembly. The draft resolution was approved. 1 Dengue prevention and control: Item 13.14 of the Agenda (Resolution EB 109 .R4; Document ASS/19) Dr OTTO (Palau) proposed that paragraph 1(2) be amended to read "to build and strengthen the capacity of health systems for surveillance, prevention, control and management ... ". His delegation welcomed the progress being made in the development of a vaccine. As the Philippines would argue, too, behavioural modification could play a vital role in preventing and controlling dengue and he urged WHO to make research into that aspect a higher priority. Palau greatly appreciated the assistance given by Taiwan (China), Japan, United States of America and WHO during a recent dengue outbreak, in providing much needed equipment and information. Dr ARMADA (Venezuela) proposed that the seventh preambular paragraph, after the word "depends", should be amended to read: "on the commitment of governments and on community participation in both planning of intervention strategies and implementation of control measures to prevent breeding of Aedes aegypti". He supported the amendment proposed by Palau. Dr VIOLAKI-PARASKEVA (Greece) proposed that the title should be amended to "Dengue and dengue haemorrhagic fever prevention and control" and that the phrase "and to strengthen clinical and epidemiological surveillance for dengue and dengue haemorrhagic fever" should be added at the end of the paragraph 1(3). Dr DAYRIT (Philippines) reported that outbreaks of dengue had been common in his country in recent years, especially during the rainy season. A public awareness campaign conducted before the rainy season, accompanied by community action to search for mosquito-breeding sites had led to a marked reduction of cases. Where the active participation of high-risk populations was required for disease prevention and control, effective communication of risks was vital. Indications of increasing transmission of other arthropod-borne viruses such as Japanese encephalitis virus and West Nile virus called for vigilance and further research. He therefore proposed the addition of a third subparagraph in paragraph 3, that would read: "to study the need for, and feasibility of, incorporating the surveillance

Transmitted to the Health Assembly in the Committee's third report and adopted as resolution WHA55.18.

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and research of other arthropod-home viral infections such as Japanese encephalitis, West Nile, and other emerging diseases, in the surveillance system for dengue haemorrhagic fever". Mr VOIGTLANDER (Germany) said that, as no complication-free vaccine had yet been developed against the four different dengue viruses, vector control was paramount. Specific mention should therefore be made of the chemotherapeutic agents that could reduce the viral load and hence the severity of the disease, and of the need for intensive research into the pathogenesis of severe dengue haemorrhagic fever. He therefore proposed that in paragraph 1(5), the words "and research" should be added after "development, application and evaluation". Mr MAJOR! (Italy) fully supported the draft resolution with the proposed amendments. The geographical spread and the severity of dengue and dengue haemorrhagic fever were of great concern to the public health authorities of endemic and non-endemic countries, and the possible resurgence of an epidemic of dengue fever together with the spread of the main mosquito vector could not be overlooked. Dr VAN ETTEN (Netherlands) proposed that the phrase "through integrated environmental management" should be added at the end of paragraph 3( 1). Dr GONZALEZ FERNANDEZ (Cuba) proposed that a third subparagraph should be added to paragraph 3, that would read: "to mobilize financial resources to be spent on vector control and research into vaccines". Dr LOPEZ RAMOS (Uruguay) proposed that in paragraph 1.1 the word "acquisition" should be replaced by "allocation" and that a new subparagraph (6) should be added emphasizing the importance of strengthening border health conditions for vector control and the timely diagnosis and treatment of the disease. Dr JALAL (Malaysia) said that dengue fever continued to be a public health problem in Malaysia and the South-East Asia Region. Initiatives such as public education, strengthening "search and destroy" activities in relation to breeding sites and enforcing legislation had been undertaken and a pilot project was under way, in collaboration with WHO, emphasizing community responsibility for preventive action. In view of the worsening epidemiological trends of dengue fever, WHO should accelerate research on vaccine development, pathogenesis and transmission dynamics and improvement of existing vector-control methods. Mr DOURADO QUINTAES (Brazil) said that Brazil and other American countries were facing a dengue epidemic and that dengue haemorrhagic fever was increasing the morbidity burden. The introduction of a Dengue virus type 3 into Brazil in 2002 had led to over 400 000 reported cases by the end of April 2002. The epidemic had been brought under control through massive efforts by the health authorities, but the threat of new outbreaks remained. Brazil's strategy of prevention and control included an educational campaign to encourage community participation in the elimination of insect-breeding sites; introduction of dengue control activities into health care programmes at the local level; improvement of household and environmental sanitation; appropriate patient management and diagnosis in health units to prevent deaths from dengue haemorrhagic fever; decentralization of dengue vector-control activities. Brazil supported the draft resolution and its proposed amendments. Dr TUIKETEI (Fiji) welcomed the report contained in document A55/19 and WHO's continuing support for global dengue prevention and control. The four main priorities identified in the report had been the focus of strategic interventions in Fiji since the previous major epidemic in 1998. Vector-control activities at national level were coordinated with activities at the local level in both the private and public sectors. Fiji much appreciated the technical assistance provided by Japan and WHO.

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Nevertheless, the programme still needed strengthening in the areas of research, policy modification and legal implications. She supported the draft resolution and its proposed amendments. Dr HEIBY (United States of America) welcomed the focus on the prevention of dengue and dengue haemorrhagic fever. WHO's intersectoral approach, which could be reinforced by including increased community-based partnerships, stronger surveillance systems and support for public health prevention strategies, was also welcome. As with many other public health issues, however, dengue could not stand on its own, but should be incorporated into other broader prevention strategies. WHO should continue to encourage community-based intersectoral approaches in promoting education about the disease, community action and individual behaviour change. Community ownership was vital to prevention and could facilitate sustainable cost-effective solutions. Health worker training was an important element of effective programmes and essential to technical cooperation. Member States and WHO should work together under short- and medium-term programmes to provide training opportunities for young vector-control personnel in countries infested with Aedes aegypti. He endorsed the draft resolution as it stood. Ms BU FIGUEROA (Honduras) reported that, despite considerable efforts at national level, the incidence of dengue in Honduras was high, and rising, owing to the persistence of complicating institutional and social factors such as poor environmental conditions, lack of a regular supply of drinking-water, and limited knowledge and understanding of good hygiene and sanitary practices. In the current year the number of cases of classical dengue fever was one-and-a-half times greater than in 2001 and that of dengue haemorrhagic fever, which had first appeared in 1991, six times greater. WHO should strengthen its cooperation with Honduras and other affected countries through control and prevention programmes. Dr SUPAMIT CHUNSUTTIWAT (Thailand) said that her country had been fighting dengue, a major killer of children in Thailand, for over four decades. Since vector control remained the main intervention strategy, extensive and sustained community involvement was essential, requiring strong policy support and broad multisectoral cooperation. Thailand had been actively involved in the development of a dengue vaccine for over two decades, but recognized that greater efforts and increased international collaboration were required. Once the vaccine was available, support would be needed in making it available to children, especially in poor countries where it was needed most. Thailand had been actively encouraging international cooperation in dengue, as reflected by its hosting of a recent conference in Chiang Mai. She wholeheartedly supported the draft resolution contained in EB 109.R4 and urged WHO to maintain its leadership and scale up its support to Member States in the implementation ofthe global prevention strategy. Dr ARMADA (Venezuela) supported the draft resolution with the amendments proposed, and emphasized the importance of community involvement in vector control. Since vector control was currently the principal tool available for prevention, manufacturers should play a larger role in the disposal of products such as vehicle tyres and plastic bottles. WHO could assist in the revision of current legislation as part of the prevention strategy. The legislative amendments under consideration would serve to strengthen community participation, from policy design to evaluation, and give further impetus to research. Dr ZAHER (Egypt), commending the report contained in document A55/19, stressed lack of safe water supply and the emergence of insect resistance as important reasons for the increase in the incidence of dengue. Even when a vaccine became available it would not be effective against all types of dengue. A prevention strategy was therefore particularly important and should include: elimination of mosquito vectors, clearing of stagnant water to eliminate breeding grounds, control of other vectors, and better emergency management. Local initiatives were also important and people should be made more aware of the danger ofthe presence of mosquitoes. Clearly, more medicines and drugs should be

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developed for the treatment of dengue, and further research was needed into the disease and its treatment. An evidence-based, scientifically prepared plan of preventive action was required. Mr NAIK (India) said that dengue haemorrhagic fever was considered to be the most important arthropod-borne viral disease in India. It had tremendous epidemic potential and was expanding its geographical distribution. It was expected that the risk of dengue transmission would continue to increase, owing to changes in the global climate and local weather conditions, and to increasing population density. He expressed his support for the draft resolution. Dr HEYMANN (Executive Director) said that speakers had confirmed that dengue had increased in number of cases, severity in its haemorrhagic form, and geographical distribution. He welcomed the Committee's guidance in helping WHO to intensify its activities, at the global and national levels, in the surveillance, prevention and control of dengue and dengue haemorrhagic fever. The recent broadening of the mandate of UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases to include dengue would give renewed impetus to research on vaccines and antiviral agents. Dr HOLCK (Secretary) read out the amendments proposed by Greece, Uruguay, Venezuela, Palau, Germany, Netherlands, Philippines and Cuba. The CHAIRMAN invited the Committee to approve the draft resolution as amended. The draft resolution, as amended, was approved. 1 The meeting was suspended at 10:20 and resumed at 11:05. WHO's contribution to achievement of the development goals of the United Nations Millennium Declaration: Item 13.2 of the Agenda (Resolution EB109.R3; Document A55/6) (continued from the seventh meeting) Ms COSTA COITINHO (Brazil), speaking as Chairman of the drafting group set up to consider the large number of amendments to the draft resolution contained in resolution EB109.R3, 2 said that after much negotiation, the group had reached consensus on a revised version of that draft resolution, which read as follows: The Fifty-fifth World Health Assembly, Having considered the note by the Director-General;3 Recalling the commitments made in the United Nations Millennium Declaration adopted by the United Nations General Assembly in September 20004 and the United Nations SecretaryGeneral's road map towards its implementation; 5 Recalling in particular the goals set out in the Millennium Declaration to have reduced, by the year 2015, maternal mortality by three-quarters, and under-five mortality by two-thirds, of their 1990 levels;

Transmitted to the Health Assembly in the Committee's third report and adopted as resolution WHA55.17. See summary record of the second meeting. Document A55/6. United Nations General Assembly Resolution 55/2. General Assembly document A/56/326.

2 3 4

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Recognizing that increased access to good-quality primary health care information and services, including reproductive health, is critical for attainment of the development goals contained in the United Nations Millennium Declaration; 1 Recalling and recognizing the Programme of Action adopted at the International Conference on Population and Development, commitments made at the Copenhagen Social Summit, the World Summit for Children, and the Beijing Declaration and Platform for Action and the Declaration on the Elimination of Violence against Women, and their recommendations and respective follow-ups and reports; Mindful of WHO's function, as set out in its Constitution, which includes to promote maternal and child health and welfare; Recalling that the Constitution of the World Health Organization states that enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition; Recognizing the equal rights of men and women, and noting that progress towards realization of those rights should involve 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; Welcoming the report of the Commission on Macroeconomics and Health/ which provides a useful approach to achievement of the Millennium Development Goals, and other internationally agreed development goals, including those contained in the United Nations Millennium Declaration; 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; Further recognizing that the development goals contained in the United Nations Millennium Declaration cannot be achieved without a renewed commitment of the international community, and aware of Health Assembly leadership in this context; Reaffirming resolution WHA48.10 on reproductive health: WHO's role in the global strategy,

It is understood that "primary health care services" do not include abortion except when consistent with national and, where applicable, local law, and with full respect for the various religious and ethical values and cultural backgrounds and in conformity with universally recognized human rights. 2

Macroeconomics and health: investing in health for economic development. Geneva, World Health Organization,

2001.

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URGES Member States: ( 1) to strengthen and scale up efforts to achieve the development goals of the Millennium Declaration 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 primary health care services, including reproductive health, with special attention to the needs of the poor and underserved populations; (3) to continue to advocate as public health priorities safe pregnancy, breastfeeding and childbirth, neonate, child and adolescent health and development, and elimination of violence against women; (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 strive for full coverage oftheir 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; ( 6) to support the negotiations towards an effective framework convention on tobacco control; (7) to encourage the pharmaceutical industry and other relevant partners and organizations to make essential drugs more widely available and affordable by all who need them in developing countries;

2. ENCOURAGES developed countries that have not done so to make concrete efforts towards the target of allocating 0.7% of GNP as official development assistance to developing countries and 0.15% to 0.2% of GNP of developed countries to least developed countries, as reconfirmed at the Third United Nations Conference on the Least Developed Countries, and encourages developing countries to build on progress made in ensuring that official development assistance is used effectively to help achieve development goals and targets; CALLS upon the international donor community to increase its assistance to developing countries in the health sector, taking into account the recommendations of the Commission on Macroeconomics and Health; FURTHER CALLS upon countries and other partners in development to increase their investments in the health sector, where appropriate, in line with the recommendations of the Commission on Macroeconomics and Health; 3. REQUESTS the Director-General: ( 1) to lead an international drive to generate resources and investments for research, and to improve health in developing countries, particularly in relation to neglected diseases, taking into account the recommendations of the Commission on Macroeconomics and Health; (2) to facilitate a process to consider, together with Member States, the recommendations of the Commission on Macroeconomics and Health and their followup, through intergovernmental, bilateral, national and other mechanisms, recognizing that such recommendations are based on a partnership approach between developed and developing countries, and that actions cannot be undertaken at national level without coordinated and simultaneous action at international level; (3) to report to the Executive Board at its 111th 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;

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(4) 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 lllth session and to the Fifty-sixth World Health Assembly; (5) 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 SecretaryGeneral's report to the United Nations General Assembly on progress towards attainment of the development goals of the Millennium Declaration. The drafting group recommended that the footnote concerning primary health care should end with the words "cultural backgrounds" and that the rest of the sentence should be deleted. Mr CASTILLO SANTANA (Cuba) said that the word "firme" in operative paragraph 1(6) in resolution EB 109 .RJ should be replaced by "efectivo" in the Spanish version, in line with the English. Mr STEIGER (United States of America) said that the revised text was a good compromise, reflecting much thought and productive discussion, and deserved the Committee's approval. The draft resolution, as amended, was approved. 1 Natural and accidental release of biological, chemical or radionuclear agents affecting health or their deliberate use to cause harm: Item 13.15 of the Agenda (Document A55/20) (continued from the seventh meeting) Mr MAJOR! (Italy) said that the notion of "investigations" mentioned in paragraph 11 of document A55/20 was inappropriate and the idea of WHO as a forum for discussion and joint action in relation to proliferation of biological weapons was potentially misleading, both in respect of the specific competencies of WHO, and the interrelationship between health assistance and other initiatives undertaken within the framework of the Biological and Toxin Weapons Convention (BWC) of 1972. Health and disarmament issues, although occasionally overlapping, were and should remain separate. The Fifth Review Conference of the States Parties to the Biological Weapons Convention, due to reconvene in November 2002, would continue to consider proposals from several delegations to identifY adequate procedures for investigating violations of the Convention. It was important, therefore, that neither the report nor the draft resolution should prejudge any conclusion or decision to be taken by the States Parties to the Convention. Italy further suggested that in paragraph 12 of document A55/20 a reference to the International Centre for Genetic Engineering and Biotechnology in Trieste should be added to the list of organizations cooperating with WHO in that specific field. It endorsed the need to strengthen public health surveillance and response activities, and endorsed the draft resolution as revised by the drafting group. Dr GONZALEZ FERNANDEZ (Cuba) emphasized the need to strengthen preventive action in respect of biological, chemical and radionuclear agents, including surveillance and the development of infrastructure, particularly in respect of laboratory facilities. There should be a more effective method of disseminating information on those issues, and the public should be informed in an appropriate manner to avoid an outbreak of panic. In addition, more information was needed on the most effective methods of decontamination following the release of chemical, biological and radionuclear agents, and on the safest methods for the different types of agents. Further research should therefore be carried out

Transmitted to the Health Assembly in the Committee's third report and adopted as resolution WHA55.19.

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on those agents, their effects and their possible consequences on the food chain or water supply system. Mr SAM (Australia) said that document ASS/20 provided a timely update of WHO's role in advising Member States on the most effective methods for preparing for deliberate use of chemical and biological agents. He welcomed the possibility of WHO playing a collaborative role with other international organizations. Recent experience of biological threats had demonstrated a need to strengthen laboratory, syndromic and environmental surveillance, including a need to invest in appropriate technologies and, importantly, a high level of personnel training and support. Public health services in particular should develop strong intersectoral linkages with security, defence, and emergency services. A robust, planned surveillance network both within and between countries had proved effective in responding to naturally occurring disease threats and was clearly necessary in an era of intentional threats. Australia looked forward to WHO's continued guidance and support on that issue. Dr BERNARD (United States of America) said that the realities of the new bioterrorist threat had irreversibly affected almost every social and economic sector of his nation. He acknowledged that many Member States had long suffered from deliberate attacks on their civilian populations and had also lost citizens in the tragic attacks on the World Trade Center in New York. WHO's pre-publication report "Public health response to biological and chemical weapons", demonstrated its useful work in that area. Leadership and cooperation between Member States and with WHO was the only way of countering the increasing international threat of the deliberate use of biological and chemical agents to cause harm. Dr SUAREZ OGRIO (Peru) said that his delegation appreciated the resolution. The threat posed by the deliberate use of biological and chemical agents to cause harm was of concern to all countries. As part of preparations to deal with any possible threat, Peru had recently decided to enhance its traditional monitoring and surveillance system. During the discussion on Variola virus at the Committee's seventh meeting, the fact that smallpox had been taken off the list of notifiable diseases had not been mentioned. There was an obvious need, therefore, for a consensus on epidemiological surveillance systems to ensure that all countries were alerted in good time and that the international community could respond effectively to the type of threat in question. Dr JALAL (Malaysia) welcomed WHO's assistance in strengthening national emergency preparedness, especially in the areas of risk communication and psychosocial consequences of emergencies. Malaysia had a contingency plan in place, but it required improvement, especially in the light of the recent anthrax scare. His delegation was grateful for WHO's advice and technical assistance in that regard, and appreciated WHO's role in coordinating multicountry responses and communications, especially with regard to risks of regional or global extent. Dr FURGAL (Russian Federation) said that his delegation noted with satisfaction the considerable work carried out by WHO to consolidate and coordinate the international medical community's efforts to combat new threats and enhance preparedness in response to the challenge of world terrorism. It was grateful for WHO's leadership and relevant documentation, which provided practical guidance to Member States. The Russian Federation supported the Executive Board's resolution and was prepared, in that spirit, to collaborate actively with countries and international bodies, being ready to make available Russian expertise and experience, including participation in WHO's expert groups. Dr ZAHER (Egypt) supported WHO's efforts to enhance the world's health systems in order to face natural disasters and the deliberate use of biological and chemical agents or radionuclear

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substances. Her delegation fully supported Brazil's amendments to the resolution adopted by the Executive Board, as well as that delegation's statement. Mr ASLAM (Pakistan) requested an editorial amendment to the draft resolution relating to agenda item 13.15, contained in the Committee's second report (document A55/49). In the first preambular paragraph, the word "technical" should be "chemical". Dr ANTEZANA ARANiBAR (Bolivia) said that the resolution was highly important, especially for smaller countries which lacked the capacity of larger countries for surveillance and preparedness, but would suffer no less from any disaster. Dr HEYMANN (Executive Director), welcoming the guidance and clarification provided by delegations, noted Italy's concerns about the interpretation of "investigations". WHO would continue to strengthen global, regional and national capacities in order to respond to public health risks of international importance, including those relating to natural causes and to accidental release or deliberate use of biological, chemical or radionuclear materials. At the same time, it would continue to revise the International Health Regulations so that they could better serve as a framework for all such activities. The CHAIRMAN, recalling that the resolution, as amended, had been approved at a previous meeting, 1 said that the Committee had thus concluded its consideration of agenda item 13.15.

THIRD REPORT OF COMMITTEE A Dr MSA MLIVA (Comoros), Rapporteur, read out the draft third report of Committee A.

Dr GONZALEZ FERNANDEZ (Cuba), supported by Dr ANTEZANA ARANIBAR (Bolivia), said that it was regrettable that two agenda items, namely 13.17 and 13 .18, could not be discussed - a matter that should be taken up at the next Executive Board meeting in order to ensure that they would be considered without fail at the next Health Assembly. No items on a Health Assembly's agenda should be abandoned, and it should be ensured, in future, that the workload was proportionate to the time available for deliberation. The CHAIRMAN said that that observation would be taken into account. The Executive Board itself, of course, determined the provisional agenda of the Health Assembly. Furthermore, and in answer to a related question by Professor AOUSSI EBA (Cote d'Ivoire ), he said that, if Committee B was unable, owing to time constraints, to consider items 13.17 and 13 .18, the Executive Board would be approached with a view to ensuring that they appeared on the agenda of the next Health Assembly and that the agenda of any Health Assembly would be manageable. In reply to a question by Dr VIOLAKI-PARASKEVA (Greece), he confirmed that the approval, with amendments, of Executive Board resolution EB109.R5 was reflected in Committee A's second report (document A55/49). He assured Mrs NASCIMBENE DE DUMONT (Argentina) and Mrs ROVIROSA (Mexico) that the editorial corrections they had requested to the Spanish text of the resolution would be made. Subject to those considerations, he took it that the Committee adopted its third report. The report was adopted. 2 1

Resolution WHA55.16; see summary record of the seventh meeting. See page 273.

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CLOSURE

After the customary exchange of courtesies, the CHAIRMAN declared the work of the Committee completed.

The meeting rose at 11 :45.

COMMITTEEB FIRST MEETING Wednesday, 15 May 2002, at 16:20 Chairman: Professor AM. COLL SECK (Senegal)

OPENING OF THE COMMITTEE INCLUDING ELECTION OF VICE-CHAIRMEN AND RAPPORTEUR: Item 14 of the Agenda (Document ASS/41)

The CHAIRMAN, welcoming participants, reminded the Committee that representatives of the Executive Board spoke solely in that capacity and not as members of national delegations. She drew attention to the third report of the Committee on Nominations (document A55/41i in which Mr H. M'barek (Tunisia) and Professor Pham Manh Hung (VietNam) were nominated for the offices of Vice-Chairmen of Committee B, and Dr S. Soeparan (Indonesia) was nominated as Rapporteur. Decision: Committee B elected Mr H. M'barek (Tunisia) and Professor Pham Manh Hung (Viet Nam) as Vice-Chairmen and Dr S. Soeparan (Indonesia) as Rapporteur?

HEALTH CONDITIONS OF, AND ASSISTANCE TO, THE ARAB POPULATION IN THE OCCUPIED ARAB TERRITORIES, INCLUDING PALESTINE: Item 18 of the Agenda (Documents ASS/33, ASS/33 Add.l, ASS/INF.DOC./3, ASS/INF.DOC./4 and ASS/INF.DOC./5)

The CHAIRMAN drew attention to a draft resolution on health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine, proposed by the delegations of Algeria, China, Cuba, Egypt, Indonesia, Libyan Arab Jamahiriya, Malaysia, Oman, Pakistan, Qatar, Saudi Arabia, Tunisia and Palestine, which read: The Fifty-fifth World Health Assembly, Mindful of the basic principle established in the WHO Constitution, which affirms that the health of all peoples is fundamental to the attainment of peace and security; Recalling all its previous resolutions on the health conditions in the occupied Arab territories; Convinced that the basis of negotiations and of achieving a just and lasting peace should be United Nations Security Council resolutions 242 (1967), 338 (1973), other relevant United Nations resolutions, the principle of the inadmissibility of acquisition of others' territory by force, the need for every State in the area to be able to live in security, and the principle of"land for peace";

See page 271. Decision WHAS5(4).

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Reaffirming the inalienable, permanent and unqualified right of the Palestinian people to self-determination, including their right to establish their sovereign and independent Palestinian State, and looking forward to the early fulfilment of this right; Expressing deep concern at the deterioration of health conditions as a result of the Israeli military acts against the Palestinian people since 28 September 2000, acts such as firing on civilians, deliberate extrajudicial killing, which caused hundreds of deaths and tens of thousands of injuries among Palestinians, including a large number of children; imposition of siege on Palestinian areas, thus preventing medicines and food from reaching towns, villages and refugee camps; obstruction of ambulances, injuring a number of ambulance crew members; and denial of access of injured people to hospitals, thus condemning them to death; Gravely concerned at the continued deterioration of the situation in the occupied Palestinian territory and at the gross violations of human rights and international humanitarian law, in particular, acts of extrajudicial killing, closures, collective punishments, persistence in establishing settlements, arbitrary detentions, besieging of Palestinian towns and villages, shelling of Palestinian residential districts using warplanes, tanks and the Israeli war machine, continued incursions into towns and camps and the mass killing of men, women and children living there as happened recently in the camps of Jenin, Balata, Khan Younes, Rafah, Ramallah, Gaza, Nablus, Al-Bireh, Al-Amari, Jabaliya, Bethlehem and Dheisheh; Gravely concerned at the continued violence which has caused large-scale death and injury among Palestinians, the toll of casualties having reached thousands killed and over 40 000 wounded since 28 September 2000; Emphasizing the urgent need for full implementation of the Declaration of Principles and subsequent Accords between the Palestine Liberation Organization and the Government of Israel; Expressing grave concern at the ongoing Israeli settlement policies in the Palestinian occupied territory, including East Jerusalem, and other violations of international law, of the Fourth Geneva Convention (1949) and of relevant United Nations resolutions; Stressing the integrity of the entire occupied Palestinian territory and the importance of guaranteeing the freedom of movement of persons and goods within the Palestinian territory, including the removal of restrictions of movement into and from East Jerusalem, and the freedom of movement to and from the outside world, bearing in mind the adverse consequences of the continued closure of the Palestinian territory on the health sector, hindering the vaccination programmes in particular for more than eight months, leading to high risk of infectious diseases and epidemics, whereas vaccination and immunization against infectious diseases constitute a basic right of every child in the world; Noting with deep anxiety and concern the deterioration resulting from the excessive use of force by the Israeli occupation forces against civilians, including medical teams, and its negative impact on health programmes, especially on mother-and-child-related programmes, vaccination, reproductive health, family planning, epidemic control, school health, control of drinking-water safety, insect control, mental health and health education; Deeply concerned at the serious deterioration of the economic situation in the Palestinian territory, which has become a serious threat to the Palestinian health system, aggravated by the withholding by Israel of funds due to the Palestinian Authority, including health insurance mcome; Affirming the need to increase health support and assistance for Palestinian populations in the regions under the control of the Palestinian Authority and for the Arab populations in the occupied territories, including Palestinians and the population in the occupied Syrian Golan; Reaffirming the right of Palestinian patients and medical staff to benefit from health facilities available in the Palestinian health institutions in occupied East Jerusalem; Affirming the need to provide international protection for the Palestinian people and health assistance to the Arab populations in the occupied territories, including the occupied Syrian Golan;

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Having considered the reports on health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine, 1 1. RECOGNIZES that the Israeli occupation is a serious health problem because of the serious threat it poses to the health and lives of Palestinian citizens; 2. STRONGLY CONDEMNS the Israeli military invasion of Palestinian towns and camps, which has resulted so far in the death of hundreds of Palestinian civilians, including women and children; 3. STRONGLY CONDEMNS the aggression of the Israeli army of occupation against hospitals and sick persons and the use of Palestinian citizens as human shields during Israeli incursions into Palestinian areas; 4. STRONGLY CONDEMNS firing on ambulances and paramedical personnel by the Israeli army of occupation, preventing ambulances and cars of the International Committee of the Red Cross from reaching the wounded and the dead in order to transport them to hospitals, thus leaving the wounded bleeding to death in the streets; 5. STRONGLY CONDEMNS the refusal by the Israeli occupation army to allow the burial of Palestinians, thus obliging their families to bury the bodies of their loved ones in available space around their homes and in hospital grounds; 6. AFFIRMS the need to support the efforts of the Palestinian Ministry of Health to continue to provide emergency services, deliver health and disease prevention programmes, receive further casualties in the future, and deal with thousands of cases suffering from physical and mental disabilities; 7. CALLS ON Israel to release all funds due to the Palestinian Authority, including health insurance dues; 8. URGES Member States and intergovernmental, nongovernmental and regional organizations to extend urgent and generous assistance to bring about health development for the Palestinian people and meet its urgent humanitarian needs; 9. THANKS the Director-General for her efforts, and requests her: (1) to visit the occupied Palestinian territories as soon as possible in order to examine the facts related to their health situation; (2) to reinstate a fact-finding committee on the deterioration of the health situation in the occupied Palestinian territory, which shall submit annual reports to the Director-General, and to the Health Assembly until the end of the Israeli occupation of said territory; (3) to take urgent steps in cooperation with Member States to support the Palestinian Ministry of Health in its efforts to overcome the current difficulties, in particular so as to guarantee the free movement of those responsible for health, of patients, of health workers, and of emergency services, and the normal provision of medical goods to Palestinian medical premises, including those in Jerusalem;

Documents A55/33 and A55/33 Add. I.

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(4) to continue to provide both the necessary technical assistance to support health programmes and projects for the Palestinian people, and emergency humanitarian assistance to meet needs arising from the current crisis; (5) to take the necessary steps and make the contacts needed to obtain funding from various sources, including extrabudgetary sources, to meet the urgent health needs of the Palestinian people; (6) to continue her efforts to implement the special health assistance programme, taking into consideration the health plan of the Palestinian people, and adapt it to the health needs of the Palestinian people; (7) to report on the implementation of this resolution to the Fifty-sixth World Health Assembly. The DIRECTOR-GENERAL, distinguishing the approach to the current agenda item from that of recent years, drew attention to the new information given in the supplementary report (document A55/33 Add.1) and reiterated her statement at the first plenary meeting that the current crisis in the Palestinian territories showed just what could happen when the health system and other infrastructures broke down as a result of conflict. Within any conflict, certain fundamentals, including the ability to maintain health, must be respected, and the neutrality of health staff must be upheld by all sides at all times. Restrictions should never be imposed on the movement of medical staff, patients, medicines, ambulances and other goods. Military operations should never target water and electricity supplies or waste disposal facilities. The report focused on the impact of damage to such infrastructure on people's livelihood. WHO was working with all other humanitarian organizations in the area. With UNRWA in particular, it had managed to increase the availability of medical supplies in the Palestinian territories and was working to bring in more from stocks already in place in Jordan, and to ensure their proper distribution. The documents before the Committee also showed the amount of work being carried out from headquarters and through the Regional Office, as well as the WHO Office Jerusalem, and with the health authorities in the Palestinian territories, to maintain basic services as far as possible. WHO continued to discuss, with the Israeli authorities, the possibility of a visit by a senior WHO public health specialist to help plan future action for reconstruction and rehabilitation of health services. The greatest concern remained the long-term damage to the social and economic infrastructure, for which, several years previously, there had been high hopes. The damage had been substantial; the psychological and social well-being of communities had deteriorated dramatically. People in Israel and the Palestinian territories were suffering mental and physical ill-health as a result of the conflict, and a combined effort must be made to influence all concerned to reverse the spiral of violence. The consequences of failure were unthinkable. Mr HANSEN (Commissioner-General, UNRWA) recalled that since 1950, under an agreement with the agency, WHO had provided technical supervision ofthe UNRWA's health programme. The spiral of violence and counter-violence in the occupied Palestinian territories since September 2000 had had devastating effects on formerly healthy economic and nutritional conditions. It had resulted in heavy casualties and large-scale damage to civil infrastructure, including UNRWA premises, refugee shelters, water networks, sewerage systems and power stations. Civilians on both sides of the conflict had borne unacceptable losses. Up to the end of March 2002, 1276 Palestinians had been killed, some 20% of them under the age of 18, and 30 714 had been injured. During the same period, 432 Israelis had been killed and 3690 injured. The figures did not include hundreds killed during the incursions into the West Bank in April 2002 and the sporadic attacks on the Gaza Strip, or the roughly 4000 seriously disabled persons and scores of women, children, and elderly people suffering post-traumatic stress disorders. The 303 deaths and 884 injuries recorded between 29 March and 23 April 2002 did not include the many missing persons. During the same period over 200 Israelis had been killed. Many shelters for refugees had been seriously damaged, and in the Jenin camp alone 800 families had been made homeless. By June 2001 half the Palestinian population was having to manage per capita on less

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than US$ 2 a day. The Palestinian health care system could not cope with an emergency on such a scale, the situation being made even more desperate by electricity and water cuts, shortages of medicines and blood supplies and the inability of hospital staff to reach their workplace. United Nations Security Council resolutions 1265 (1999) and 1296 (2000) strongly condemned the deliberate targeting of civilians in situations of armed conflict as well as attacks on objects protected under international law. The Security Council had further emphasized the need for combatants to ensure the safety, security and freedom of movement of personnel from the United Nations and other international humanitarian organizations. The United Nations Secretary-General had reiterated that access to humanitarian systems and protection was an essential right of refugees, displaced persons and civilians in conflict situations and should not be perceived as an arbitrary concession. Unfortunately, the movement ofUNRWA personnel, vehicles and supplies was still being restricted and UNRWA premises were being used as temporary detention sites or sniper platforms. During the incursions into the Jenin camp, UNRWA, the International Committee of the Red Cross and the Palestinian Red Crescent Society had all been denied access from 2 to 14 April 2002, and provision of humanitarian aid had been prevented until 17 April. Curfews and closures had prevented 60% of UNRWA staff in the West Bank from reaching their duty stations. Ambulances had been prevented from evacuating the wounded and had often been fired upon. One UNRWA staff member had been killed inside an ambulance; 29 UNRWA schoolchildren had been killed and 790 wounded. An UNRWA staff member had been arrested and placed in a detention centre, handcuffed and blindfolded for 56 hours, and kept without food for 52 hours. Such conditions were utterly unacceptable. All States Parties to the Fourth Geneva Convention were responsible for ensuring that humanitarian law was respected and the provisions of the Convention relative to the Protection of Civilian Persons in Time of War were observed. The most important setback for UNRWA's preventive health services was the breakdown of immunization programmes, which represented a health threat not only to refugees but to all the region's countries, since disease outbreaks recognized no borders. The appalling sanitary conditions that had resulted from the conflict were also a considerable threat to health and must be tackled if the achievements made in controlling vaccine-preventable diseases were to be maintained. He expressed the hope that everyone in the region would recognize the unacceptability of inflicting such damage on other parties. Above all, obstacles to humanitarian access should be removed and relief efforts facilitated so that the generosity of the international community in helping the victims was not wasted. Dr AL-SHARIF (Palestine) said that the latest Israeli invasion was directly responsible for the deterioration of the health conditions of the Palestinian people. Curfews and closures had made it impossible to reach health centres. The camp at Jenin had been almost completely destroyed and hundreds of its inhabitants killed. The destruction of the old city ofNablus had obliterated Palestinian culture and heritage. Israel's systematic policy of displacing the Palestinian people involved the continuous demolition of houses by Israeli tanks: more than 85 houses had been destroyed in Rafah, and many civilians had been buried in the rubble and killed, including women and children. The health of all patients with chronic conditions such as kidney failure had deteriorated, and pregnant women had been unable to visit hospitals. The blockade had prevented the delivery of medicines and vaccines to hospitals and clinics. He called on WHO to help deliver medicines and supplies. The Israeli incursions and the isolation of Palestinian villages and towns had prevented the immunization of children. Moreover, electricity cuts lasting three weeks had meant that drugs, vaccines and other biologicals requiring refrigeration had been lost. The future for health in Palestine looked bleak. There had been outbreaks of diarrhoeal diseases in Jenin, Rafah and Nablus. Previously successful health programmes sponsored by WHO, such as the eradication of poliomyelitis and prevention of measles and neonatal tetanus, were threatened with failure. There was the possibility of a measles epidemic and neonatal tetanus was on the increase because mothers, unable to reach hospital, were giving birth at home. Furthermore there had been

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outbreaks of West Nile fever, brucellosis and leishmaniasis. In addition there was the psychological damage to women and children. Remedying such health problems would require more than foreign aid: the root cause must be eliminated by the immediate withdrawal of the Israeli army of occupation, thus ending the blockade, the curfews and the isolation of Palestinian villages and towns. Mr LEVY (Israel) acknowledged that there was indeed a crisis and a breakdown in relations between Israel and the Palestinians that had been carefully nurtured in the past, including in the field of medicine, with suffering and lives lost on both sides. However, despite the significant gaps in the interpretation of the issues involved, the crisis could be resolved in a constructive manner. Medical assistance should be offered regardless of nationality or creed. Suffering was not limited to the Palestinians. Israel, too, had buried its dead, over 490 victims of terrorism, and its hospitals were treating the wounded. Even those who had suffered no physical injury had sustained psychological damage. In her address to the Health Assembly on Monday, 13 May 2002, the Director-General had said that intentional attacks against innocent civilians, as they went about their daily lives, could never be justified, no matter what the political or military context, and that she condemned such attacks, wherever they occurred. She had drawn attention to the anxiety of those searching for loved ones in the ruins of what used to be their villages or putting their children on the school bus and wondering whether they would ever see them again. He called on all Arab ministers of health present at the debate to endorse such a clear condemnation of attacks against civilians, whatever the political context. What would happen were such a situation to arise in their cities? The way to stop the violence, however, a way not to be found in political resolutions presented to organizations such as WHO, was for Mr Arafat to give an unequivocal order to his military and paramilitary police organizations to stop the violence and incitement to violence, and to crack down on terrorists. Ever since the start of the rioting, Israel had appealed to the Palestinian leadership to call for an end to the violence. Moreover, Israel had signed agreements binding the Palestinians to issue such a call. Yet there was no record of any responsible Palestinian leader doing so, in Arabic, in the Palestinian media, or condemning violence as morally wrong. On the contrary, recent documentary evidence had shown that the organs of the Palestinian Authority had diverted funds in order to purchase am1s and explosives and to send suicide bombers into Israel. Why had such funds not been used to alleviate the difficult medical situation? When Israel was forced to retaliate, those same leaders called on WHO to condemn the Israeli reaction. Genuine peace required compromise on both sides, reached by negotiation. Israel and Palestine had been close to resolving some of the issues referred to in the draft resolution before the Committee, such as self-determination, settlements and refugees. Unfortunately, in July 2000, the Palestinians had taken the deliberate decision to refuse the compromise and the violence had ensued; the onus was on those who had taken that decision. The proposed draft resolution had little to do with the work of WHO but represented a renewed attempt to isolate Israel within the United Nations. Of the many conflicts in the world, no other had been singled out for such treatment. Moreover, the draft resolution itself contained errors and showed bias. Medical teams had indeed been fired upon: 71 Israeli ambulances had been shot at, burned or stoned as they had gone to the aid of the wounded, Israeli paramedical and medical assistants had been attacked by Palestinian rioters while providing first-aid to Palestinians, and Israeli doctors had been assassinated. Israel recognized and valued the emblems that should protect all ambulances and give them immunity from being stopped. Unfortunately there had been two occasions, on 22 March 2002 and on 12 April 2002, on which Palestinian terrorists had abused the emblems of Palestinian ambulances. As a result Israel was compelled, on occasion, to stop and verify the bona fides of Palestinian ambulances. It had even had to inspect Israeli ambulances, since several had been stolen and it was feared that they might be used by terrorists on suicide missions. Restrictions on the movement of ambulances and verification that the wounded were genuine patients were therefore sometimes necessary in order to protect innocent lives.

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In recent years, public health had been one area in which Israel, Palestine and other Arab nations had worked closely together, since diseases knew no boundaries. Unfortunately, the work of the various joint committees had been frozen and little trust existed between the two sides. At a humanitarian level it was important to re-establish trust. At the Fifty-fourth World Health Assembly, the Israeli Minister of Health had called on his Palestinian counterpart to re-establish professional relationships and to re-build trust, to no avail. Yet there was a sign of hope, since the Israeli and Palestinian emergency services continued to cooperate. The debate contributed neither to peace nor to the welfare of Jews or Arabs, and he urged delegates to reject the draft resolution in its entirety. The CHAIRMAN announced that Jordan, Sudan, the Syrian Arab Republic and United Arab Emirates had requested that their names be added to the list of sponsors of the draft resolution. Mrs GABR (Egypt) said that it had been generally recognized that health conditions in the occupied Arab territories had deteriorated to an unprecedented level as a result of the systematic, excessive and arbitrary use of military force by the Israeli army. WHO, as the international organization with responsibility for health, should take urgent steps to deal with what had become a desperate situation. Hospitals, medical centres and ambulances had been destroyed and when medical teams were not forcibly prevented from carrying out their duties, they had to work in extremely dangerous conditions. Civilians, particularly women and children, had been killed indiscriminately and infectious diseases were becoming increasingly widespread. The draft resolution contained objective and practical proposals for putting an end to the excessive suffering of the Palestinian people and for improving their health conditions. She called upon the Member States to give it their support and expressed the hope that it would be adopted by consensus. Dr FARAHANI (Islamic Republic of Iran) said that emergency workers and media representatives had described the situation in Jenin and other towns in the West Bank in the wake of the atrocities committed by the Israel army as horrifying. Given the extent of the devastation, it had been unforgivable for the rescue and emergency services to have been denied access to the area for 15 days. On the basis of recent information, there could be no doubt that such actions constituted a blatant violation of international humanitarian law. The continuing Israeli military campaign in the occupied territories was an explicit violation of recent United Nations Security Council resolutions 1402, 1403 and 1405. The cancellation of the fact-finding mission to Jenin had been unfortunate. Most of those killed, injured and disabled had been between 15 and 25 years of age. The wounded had been mistreated, vehicles transporting them had been obstructed, and medical personnel had been assaulted as they delivered life-saving services. The attacks had directly and indirectly affected the health of the Palestinian population in the West Bank and Gaza Strip. Continuous closures and curfews had deprived Palestinians of access to primary health services and hospital care, health workers and ambulances had been prevented from passing through military checkpoints, and it had proved impossible to deliver medical supplies. There had been an overall decline in preventive services and the disruption of treatment had led to patients developing complications or dying prematurely. The current situation had led to a further deterioration in health conditions in the occupied territories, which had already been undermined by Israel's refusal to allow the Palestinians to establish an effective, independent health system. In view of recent events, it was incumbent on the international community to take effective measures that would put an end to the bloodshed. The Palestinians and their health institutions were in desperate need of international protection and urgent action to provide the assistance needed to save lives. In view of WHO's mandate to promote and protect health he urged the Organization to send a mission to investigate the health conditions in the occupied Palestinian territories and to examine ways of dispatching international assistance to the civilian population as a matter of urgency.

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Mr PEREZ-VILLANUEVA Y TOVAR (Spain), speaking on behalf of the Member States of the European Union, the views of which had been endorsed by Norway, emphasized the deep concern felt at the deterioration in health conditions in the occupied Palestinian territories caused by the action of the Israeli authorities. The Member States of the European Union considered that the Israeli armed forces had obligations under international humanitarian law to allow humanitarian and medical agencies to render emergency assistance. They therefore supported the appeal made by the International Committee of the Red Cross that all parties using armed force should respect international humanitarian law, particularly the Geneva Convention relative to the Protection of Civilian Persons in Time of War. The Member States of the European Union condemned the continued violence by both parties, which caused intolerable suffering for the civilian population and an enormous toll of deaths and injuries, mostly on the Palestinian side. They called for an immediate cessation of all acts of violence. A definitive and sustainable solution must be found through negotiations based on international law and United Nations Security Council resolutions. Despite the European Union's readiness to engage in good faith in a dialogue with the aim of supporting the draft resolution, it had changed its position from that in previous years because of the refusal of the sponsors to enter into substantive discussions. That was particularly unfortunate, not only because of the situation on the ground but also because it marked a complete change from the procedure adopted the previous year. As a result of that refusal, the draft resolution as presented did not fall within the competence of the Health Assembly and touched on topics that would be better dealt with elsewhere. Under those circumstances, the Member States of the European Union had no option but to abstain. Mrs LE THI THU HA (Vietnam) noted with great concern the deteriorating health conditions in the occupied Arab territories. Her country called for an end to occupation and fully supported the Palestinian people in their legitimate pursuit of the right to self-determination and the noble objectives of WHO. It therefore supported the draft resolution. Dr TSHABALALA-MSIMANG (South Africa), expressing concern for the worsening situation in occupied Palestine, said that the recent events there demanded serious attention by the Health Assembly. A peaceful settlement was possible within the foreseeable future, provided that the current climate of violence and retribution were replaced by dialogue. There had been massive violations of the rights to life, health and medical assistance in the course of the recent Israeli military incursions, allegedly taking place to combat terrorism. In a recent press release WHO had warned that the health system was in danger of collapse, and had described the shortage of medicines and antibiotics, the inability of health personnel and patients to access health facilities, the lack of food, water, electricity, access to services and access to bodies. Equally, UNFPA, the International Committee of the Red Cross and the Commission on Human Rights, in their reports on the consequences of the recent military campaign, had unequivocally expressed their concern for the grave humanitarian situation. As in many conflicts, civilians, and especially the most vulnerable groups, were the principal victims. Owing to the destruction of property and infrastructure, there was an imminent danger of the spread of epidemics, especially among children, who had been prevented from receiving vaccinations and other essential health care services. In Jenin and Nablus, where the water and electricity networks had been destroyed, the situation was particularly critical. The curfew preventing medical personnel from reaching the sick and wounded, and preventing civilians from reaching hospitals, created lifethreatening health problems. The political and security objectives of Israel could not be achieved through a campaign of violence. She urged both parties to take immediate steps to end the violence and return to the negotiating table, and welcomed the efforts of international organizations in that regard. Mr ASLAM (Pakistan) strongly supported the draft resolution and the legitimate political struggle of the Palestinian people for liberation from Israeli occupation. It was a favourite tactic of occupying powers to label freedom fighters as terrorists in order to justify their aggression. He rejected

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that approach. Tragic events were unfolding in the occupied Palestinian territories; children, women and young men were being killed and the refugee camps were in total disarray, with no water, food, medicines or nursing care. Those observations were supported by statements by the heads of the major international humanitarian agencies, quoted in document A55/33, that the increased demand for emergency medical assistance was precipitating a medical crisis and that they strongly deplored the restrictions on humanitarian access in the occupied Palestinian territory. He urged the DirectorGeneral to take emergency action to ensure that Palestinians did not fall victim to lasting physical and psychological disabilities. Mr COMENDEIRO (Cuba) agreed with the Director-General that the recent events in the occupied Palestinian territories represented the most pressing problem on the international scene. The Health Assembly's approach to the problem over the years had shown that the health and humanitarian aspects were impossible to separate from political and legal questions. Despite the ever-growing number of reports and resolutions in that and other forums on the question of Palestine, not only was there no glimmer of a solution but the situation had deteriorated to an unimaginable extent. Populations without access to primary medical care as a consequence of army blockades, obstruction of ambulances, the destruction of water and electricity supplies to hospitals and more than 2000 Palestinians killed, including over 400 children, were but some instances of the genocide being carried out by Israel. In view of the facts, no credence could be given to the arguments set forth in document A55/INF.DOC./5 in whi<:h the Israeli health authorities feigned a spirit of cooperation and simply presented the Palestinian people as terrorists. The negative effects on the health of the Palestinian people were evident, as could be seen from the Director-General's report. Before the recent events, the international community's reaction to which was unbelievably timid, the Palestinian health authorities had been making great progress, with a reduction in infant mortality and valiant efforts to establish a primary health care network in extremely adverse conditions. The real cause of the detrimental effects on human health was the illegal occupation of the Arab and Palestinian territories. An adequate health system could only be restored and developed, and effective cooperation established, when the Palestinian people exercised its legitimate right to establish an independent State with East Jerusalem as the capital, when internationally recognized frontiers were respected and when Israel ceased its aggression. Cuba, as one of the sponsors of the draft resolution, demanded firm action by the international community and WHO. Mr WESTDAL (Canada) expressed his concern at the recent tragic events in the Middle East, which affected the health of both Palestinians and Israelis. His country had made substantial contributions for development and humanitarian assistance in the region. The political situation would not be resolved by armed conflict, but rather through negotiations based on the relevant United Nations Security Council resolutions. It was regrettable that much of the time allocated to Committee B was being devoted to one geographical region and that the third meeting of Committee A had been suspended. The substantive work of the Health Assembly had been disrupted by consideration of a draft resolution on the Middle East that was not relevant to its core competence. The draft resolution was political and unbalanced and was couched in provocative language that would not help build peace and understanding. Furthermore, it called for the submission to the Health Assembly of an annual report on the situation, which could only distract that body from work on its core mandate. For those reasons, his delegation would vote against the draft resolution. Dr AL-BABILI (Yemen) asked for his country's name to be added to the list of sponsors of the draft resolution. He commended the reports provided to the Committee. It was essential for health care to be assured in the occupied territories and for the Palestinian Ministry of Health to be allowed to function effectively. Mr REN Yisheng (China) said that, since the beginning of the year, conflicts between Israel and Palestine had escalated to the detriment of regional and global peace and stability, and to the health of

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the population in the occupied territories. His government consequently condemned Israel's aggression and all violence perpetrated against innocent citizens. A policy of responding to violence by violence could only engender mutual hatred and lead to a further deterioration of the situation. The only constructive approach was to hold discussions on the basis of the relevant United Nations resolutions and the principle of land for peace. China welcomed the fact that since the lifting of restrictions on Mr Arafat's movements, Israel had recently ended the siege of the Church of the Nativity in Bethlehem. That was a positive step, and it was to be hoped that Israel would be able to respond with further effective measures towards implementing the relevant United Nations Security Council resolutions and re-starting the peace process. He urged WHO to give serious consideration to the health situation of the population in the occupied territories, in particular with regard to the needs of women and children. By implementing practical health policies and providing immediate medical assistance, WHO would be able to make a contribution towards improving the health status of the Palestinian population. Dr CHOW (United States of America) pointed out that the draft resolution followed an unfortunate pattern witnessed in many other United Nations organizations. It harshly condemned Israel for measures affecting the health of the Palestinians, but ignored Israeli suffering as a result of Palestinian actions and made no mention of the context for Israeli actions, namely the fact that they were carried out in response to terrorist attacks. Furthermore, the resolution attempted to introduce political issues for which WHO clearly had no mandate. His Government agreed that the conflict between Israelis and Palestinians had had tragic consequences and that international efforts to resolve the situation by peaceful means deserved the highest priority. It had sponsored a United Nations Security Council resolution on the urgency of access by medical and humanitarian organizations to the Palestinian population, and strongly endorsed and financially supported WHO in its efforts to provide technical assistance aimed at improving the availability of health services for Palestinians and the global community as a whole. However, a complete picture of the health consequences of the Middle East conflict must recognize that many Israeli civilians, both Jewish and Arab, had died or faced long-term health consequences because they had had the misfortune to be in the vicinity of a terrorist attack. Hence any balanced and constructive resolution would avoid language that merely inflamed emotions and attempted to pass judgment on questions on which the Israelis and Palestinians had agreed to negotiate between themselves. He expressed the hope that the Health Assembly would think carefully of the long-term interests of the Organization and the people that it served. He proposed that a roll-call vote be taken on the draft resolution and urged other Member States to join his delegation in rejecting the offensive, unbalanced and political text of the draft resolution and instead to focus on practical measures for improving the health situation of all people in the Middle East and around the globe. Dr SALLOUM (Syrian Arab Republic) said that the recent events in Jenin had been viewed with repugnance. The claim that Israel was simply responding to acts committed by Palestinians showed a lack of appreciation of the facts. Israel had occupied Palestinian territories, not to mention other Arab territories, for years. The acts that Israel considered to be terrorism were merely an attempt at self-defence. There had been no terrorism before the occupation. The health situation was growing worse by the day in the occupied territories and it was to be hoped that the draft resolution would make it possible to find a solution for the population. The Israeli delegation to the Health Assembly had claimed that its country was continually being criticized and snubbed. The reason was that Israel constituted the sole occupying force anywhere in the world, and was comparable to the former apartheid regime in South Africa. Since April 2002, there had been no health services in Jenin, and war crimes were being perpetrated against the Palestinian population. Israel was depriving Palestinians of medical assistance and the injured were being left to their fate. It had been maintained that Israel accepted the concept of a Palestinian state, yet despite support for that concept by the United States Government, Israel had refused to withdraw from the occupied territories and had rejected the notion of a Palestinian state out

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of hand. He expressed the hope that Israel would apply relevant United Nations Security Council resolutions and that it would be possible for the Committee to complete its consideration of the health issues in the occupied territories within the time allotted, so as to be able to move on to other topics. Mr BRODRICK (Australia) said that his country remained deeply concerned about the humanitarian situation in the occupied territories and strongly supported the WHO Special Technical Assistance Programme, and the work of UNRWA and other United Nations and nongovernmental organizations. His Government had recently provided extra financial assistance to UNRWA and the International Committee of the Red Cross to help relieve the suffering of those affected by the recent violence. The Health Assembly should consider technical matters and other issues that came within WHO's mandate; a debate on the political issues would not contribute to a rapid return to negotiations or a resumption of the peace process, which remained the only long-term option for improving health conditions in the occupied territories. Australia strongly regretted the politicization of a technical forum, which ought to be focused on health, and shared the view of Canada regarding the suspension of the third meeting of Committee A. Australia would vote against the draft resolution which showed a regrettable lack of balance and a focus on non-health issues. Mr EDILASHviLI (Georgia) expressed concern at the increasing risk of disease on the West Bank due to water shortages, poor sanitation and lack of waste disposal and the fact that health workers had become casualties of violence. He called upon all parties to respect the neutrality of physicians, nurses and paramedics, and allow them to carry out their duties. He welcomed the Director-General's decision to provide additional funds for the supply of emergency health kits to assist the Palestinian people. Regrettably, the text of the draft resolution was too politicized and went beyond the mandate of the Health Assembly. Health care and humanitarian issues had no borders and should be above political disagreement. Dr RAJMAH (Malaysia), speaking on behalf of the countries of the Organization of the Islamic Conference, expressed the strong support of those countries for the draft resolution, which they considered to be within the mandate of WHO, and its proposal that the Director-General should visit the occupied territories and establish a fact-finding committee to investigate the deteriorating health situation there. She called for urgent action to address the problems described by the Palestinian authorities in document A55/INF.DOC./4, in particular the decrease in health insurance coverage, shortages of medical supplies, a deteriorating environmental health situation, disruption of immunization programmes and the risk of infectious disease. She commended WHO's efforts to bring medical supplies to the occupied territories, and called for an immediate vote on the draft resolution. Dr AMMAR (Lebanon) expressed support for the draft resolution. Mr FAESSLER (Switzerland) said that the violence in the occupied territories, which was being perpetrated by both sides, prevented the health system from operating efficiently and hampered attempts at humanitarian assistance, resulting in unspeakable human suffering. It was essential that all parties respected the Fourth Geneva Convention relative to the Protection of Civilian Persons in Time of War and other provisions of international humanitarian law. The tone and content of the draft resolution went beyond the mandate of WHO. It was essential to avoid a politicized debate and to concentrate on WHO's mission of promoting health. For that reason, his country would abstain in the vote on the draft resolution. Mrs GABR (Egypt), speaking on a point of order, agreed with the delegate of Malaysia that there should be an immediate vote on the draft resolution. Mr TOPPING (Legal Counsel) said that, if it was the intention of the delegate of Malaysia to propose the closure of the debate, in accordance with Rule 63 of the Rules of Procedure of the Health

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Assembly, permission to speak against closure, if requested, could be accorded to not more than two speakers, after which the motion to adjourn the debate should be immediately put to the vote. Dr RAJMAH (Malaysia) confirmed that she wished to move closure of the debate and move to a vote immediately. Mr TOPPING (Legal Counsel) recalled that there had been a request for the vote to be taken by roll-call. The draft resolution would be approved if it received a majority of the votes of Members present and voting. Some Member States were not present, and others had had their right to vote suspended by a Health Assembly resolution. The countries which would, therefore, be unable to participate in the vote were: Afghanistan, Antigua and Barbuda, Armenia, Azerbaijan, Bosnia and Herzegovina, Central African Republic, Chad, Comoros, Democratic Republic of the Congo, Djibouti, Dominican Republic, Equatorial Guinea, Georgia, Guinea, Guinea-Bissau, Iraq, Kazakhstan, Kyrgyzstan, Liberia, Nauru, Niger, Nigeria, Niue, Republic of Moldova, Somalia, Suriname, Tajikistan, Togo, Turkmenistan and Ukraine. A vote was taken by roll-call, the names of the Member States being called in the French alphabetical order, starting with Vanuatu, the letter V having been determined by lot. The result of the vote was as follows: In favour: Algeria, Bahrain, Bangladesh, Belarus, Bhutan, Botswana, Brunei Darussalam, China, Colombia, Congo, Cote d'Ivoire, Cuba, Democratic People's Republic of Korea, Egypt, India, Indonesia, Islamic Republic of Iran, Libyan Arab Jamahiriya, Jordan, Kuwait, Lebanon, Madagascar, Malaysia, Maldives, Mali, Mauritania, Mexico, Morocco, Myanmar, Namibia, Oman, Pakistan, Philippines, Qatar, Saudi Arabia, Senegal, South Africa, Sri Lanka, Sudan, Syrian Arab Republic, Thailand, Tunisia, United Arab Emirates, Venezuela, VietNam, Yemen, Zambia, Zimbabwe. Against: Australia, Canada, Guatemala, Israel, Marshall Islands, Palau, Tuvalu, United States of America. Abstaining: Albania, Andorra, Angola, Argentina, Austria, Barbados, Belgium, Brazil, Bulgaria, Burkina Faso, Burundi, Cape Verde, Chile, Costa Rica, Croatia, Cyprus, Czech Republic, Denmark, Dominica, El Salvador, Estonia, Fiji, Finland, France, Gabon, Germany, Greece, Guyana, Haiti, Honduras, Hungary, Iceland, Ireland, Italy, Jamaica, Japan, Kenya, Latvia, Lithuania, Luxembourg, Malta, Monaco, Nepal, Netherlands, New Zealand, Nicaragua, Norway, Panama, Peru, Poland, Portugal, Republic of Korea, Romania, Russian Federation, Rwanda, San Marino, Sierra Leone, Singapore, Slovakia, Slovenia, Spain, Sweden, Switzerland, Uganda, United Kingdom of Great Britain and Northern Ireland, United Republic of Tanzania, Uruguay, Vanuatu, Yugoslavia. Absent: Bahamas, Belize, Benin, Bolivia, Cambodia, Cameroon, Cook Islands, Ecuador, Eritrea, Ethiopia, Gambia, Ghana, Grenada, Kiribati, Lao People's Democratic Republic, Lesotho, Malawi, Mauritius, Federated States of Micronesia, Mongolia, Mozambique, Papua New Guinea, Paraguay, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Samoa, Sao Tome and Principe, Seychelles, Solomon Islands, Swaziland, The former Yugoslav Republic of Macedonia, Tonga, Trinidad and Tobago, Turkey, Uzbekistan.

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The draft resolution was therefore approved by 48 votes to 8, with 69 abstentions.• Mr PEREZ DEL CASTILLO (Uruguay), speaking in explanation of vote, said that, while his delegation was concerned at the deterioration of the health situation in the occupied Arab territories, it had abstained from voting because, in contrast to previous years, far from supporting the desired goals of improving the health situation in and supplying urgently required humanitarian aid to the Middle East, the draft resolution was unbalanced and inappropriate. Had a more flexible wording been used, a solution might have been found. Mrs BENAVIDES COTES (Colombia), speaking in explanation of vote, said that her delegation had voted in favour of the draft resolution because it supported the creation of a Palestinian state. She expressed concern, however, that the sponsors of the resolution had not conducted the broad consultations required to achieve a more balanced approach. Mr VANU GOPALA MENON (Singapore), speaking in explanation of vote, said that his delegation's abstention was not related to the merits or demerits of the issue, nor was it a reflection of its support for the Palestinians in the Middle East issue. Rather, Singapore considered that the Health Assembly was an inappropriate forum in which to raise political issues. Mr ALBIN (Mexico), speaking in explanation of vote, said that Mexico had voted in favour of the draft resolution because it deplored the indiscriminate attacks that had caused deaths and suffering among the civilian population and had repeatedly asked the parties involved to respect the provisions of international humanitarian law. As the Director-General had emphasized in her opening address, within any conflict there were fundamental elements of a people's existence, including the ability to maintain its health and health infrastructure, that must be respected, and that restrictions should never be imposed on the movements of medical staff, patients, medicines, ambulances and other goods. While some points might have been discussed more appropriately in other forums and certain details been made precise, his delegation endorsed the aim and spirit ofthe draft resolution. Mr CAUGHLEY (New Zealand), speaking in explanation of vote, said that his country supported the aim of improving health conditions in the occupied territories and had supported previous WHO resolutions that focused on health issues there. His delegation's abstention was not related to its views on the current tragic situation in the Middle East. The health and humanitarian issues raised in the resolution were of deep concern to New Zealand, but WHO was not an appropriate forum for a debate of such a political nature.

Mr PIROGOV (Russian Federation), speaking in explanation of vote, said that the health conditions prevailing in the occupied Arab territories, including Palestine, were of serious concern to his country, which would do all it could to provide emergency humanitarian assistance. His delegation had abstained from voting because it considered that the draft resolution contained elements that went beyond the mandate of the Health Assembly, and amendments proposed by his delegation during consultations had been rejected. Dr FARAHANI (Islamic Republic of Iran), in an explanation of vote, said that his affirmative vote should not be construed as recognition of the Israeli occupying regime.

Transmitted to the Health Assembly in the Committee's first report and adopted as resolution WHA55.2.

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Mr W ABAIAT (Vanuatu), speaking in explanation of vote, said that, while Vanuatu supported the aims of the draft resolution, it had abstained because some of the points raised went beyond WHO's mandate.

The meeting rose at 19:05.

SECOND MEETING Thursday, 16 May 2002, at 12:05 Chairman: Professor A.M. COLL SECK (Senegal)

FIRST REPORT OF COMMITTEE B (Document ASS/43) Dr SOEPARAN (Indonesia), Rapporteur, read out the draft first report of Committee B.

Ms BLACKWOOD (United States of America), noting that there was no reference to the rollcall vote that had been taken the previous day on the draft resolution contained in the report, asked whether there was any legal requirement that such a reference be made. Mr TOPPING (Legal Counsel) said that in accordance with Rule 75 of the Rules of Procedure of the World Health Assembly, the results of the roll-call vote would be included in the summary record of the meeting. The report was adopted. 1

FINANCIAL MATTERS: Item 15 ofthe Agenda

Financial report on the accounts of WHO for 2000-2001, report of the External Auditor, and comments thereon made on behalf of the Executive Board; report of the Internal Auditor: Item 15.1 of the Agenda (Documents ASS/25, ASS/25 Corr.l and ASS/25 Add.l, ASS/37 and ASS/38). Dr KARAM (representative of the Executive Board), speaking as Chairman of the Administration, Budget and Finance Committee, introduced the report and audited financial statements for the financial period 1 January 2000-31 December 2001 (documents ASS/25, ASS/25 Corr.l and ASS/25 Add.l) and said that the significant increase in extrabudgetary funds in 1998-1999 had been sustained in 2000-2001, with resources reaching US$ 1500 million. The higher level of payment of assessed contributions had contributed to a 99% rate of implementation of the regular budget, which had remained static. Expenditure for all other sources of funds had been 141% of the original budgeted amount owing to a significant increase in voluntary contributions. That increase required WHO to continue to upgrade and improve its management and information systems. The Organization's liquidity remained strong. The level of internal borrowing continued to fall, and, at 31 December 2001, had stood at US$ 56 million as against US$ 94 million at the end of the previous biennium. The Committee had stressed the importance of Member States paying their assessed contributions in a timely fashion. Lastly, the period 2000-2001 had marked a transition towards results-based budgeting. The following biennium, 2002-2003, would be the first for which WHO would be reporting on the basis of a fully developed results-based budgeting system.

See page 274.

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Mr FAKIE (External Auditor), introducing his report (document A55/25), said that, although he had expressed an unqualified audit opinion and was pleased to note the 92% collection rate, he remained concerned at the high level of assessed contributions outstanding from previous periods, amounting to US$ 82 million. More information was needed on the administrative and support costs associated with the management of extrabudgetary funds. No governance structure for information technology had been defined, and thus decision-making had not been properly coordinated: excessive use of short-term consultants to perform crucial functions gave cause for concern. The current financial system should not be replaced with a new one until those concerns had been addressed. Ms WARANY A TEOKUL (Thailand) said that she had noted with concern the view expressed in the report that the difference of 73% between extrabudgetary and regular budget funds might lead to disproportionate administration and support costs, and supported the External Auditor's call for an integrated planning process. Referring to paragraphs 16 and 18 of the report of the Internal Auditor (document A5 5/3 7), she urged WHO to strengthen national capacity in respect of the Tobacco Free Initiative by adequate financing of programme activities, and to help put mechanisms in place to ensure the quality of products procured through quality assurance and pre-qualification systems. Lastly, she would like the Director-General to ensure that resources were consistent with WHO's policy on maintaining synergy between those resources and regular budget funds. Mr TASAKA (Japan) expressed the hope that WHO would continue its efforts to improve the efficiency and effectiveness of its budget, and requested information on the indicators to be applied in the new results-based budgeting system, so that delegates could properly assess that system. Mr STONECIPHER (United States of America) commended the creation of the Department of Information Technology and Telecommunications, and of the new global management system to improve control of computer systems and information technology strategy. WHO should continue its efforts to further strengthen programme evaluation. Mr ROKOVADA (Fiji) joined in welcoming the increase in receipts of extrabudgetary funds, as well as the increase in the rate of payment of assessed contributions. However, the rise in arrears was a cause for concern and Fiji, having already paid its assessed contributions for 2002 in full, urged other Member States to settle any arrears promptly. He was concerned by the statement in paragraph 27 of the report of the internal auditor (document A55/37) that the relationship between the WHO Centre for Health Development in Kobe, Japan and headquarters required improvement, and asked how the Centre was financed. Ms VAN GINNEKEN (Netherlands) said that while she was pleased to note the significant increase in the rate of collection of assessed contributions, the high level of long-term arrears remained a matter for concern. She stressed the importance of making payments in full, on time and without conditions, as well as of improving the effective management of unliquidated obligations. Mr BRODRlCK (Australia) welcomed the largely positive reports of the External and Internal Auditors, and drew particular attention to the comment in paragraph 13 of the report of the Internal Auditor concerning the concept of accountability. Australia was a strong supporter of results-based budgeting, which delivered efficiency, transparency and accountability in the work of international organizations. He congratulated WHO on the progress achieved so far, and looked forward to further progress, particularly with regard to reporting and evaluation. Mr MACPHEE (Canada) said Canada, too, was concerned at the high level of outstanding contributions and urged that prompt payment be made. The sharp increase in extrabudgetary funding

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would have an impact in terms of financial management, and he looked forward to continued scrutiny of that management in future reports. Dr EL-TAYEB (Egypt) asked for clarification regarding the distribution of the increased extrabudgetary funds received. The Office for his Region, which was in urgent need of resources to support effective noncommunicable disease programmes, had received only some 10% of the funds concerned. Mr BAQUEROT (Executive Director), in reply to the question raised by Japan, said that information on the implementation of the 2000-2001 budget would be provided at the forthcoming session of the Executive Board. The indicators linked to the new results-based budgeting system related, however, to the preparation of the 2002-2003 budget, rather than to the 2000-2001 biennium. In response to the question from Fiji, information on sources of extrabudgetary funding for the Centre in Kobe could be found on page 104 of document A55/25 Add.l. He would be discussing the question of the Centre's operational relationship with headquarters on his forthcoming trip to Japan. He assured the Australian delegate that the Secretariat would take the comments of the External and Internal Auditors fully into account. Lastly, he informed the delegate of Egypt that most extrabudgetary funds were earmarked by donors for specific areas of work or specific regions. Dr EL-TAYEB (Egypt) suggested that it would be useful to have more information at an early stage on how extrabudgetary funds were to be distributed, so that regions which were not destined to receive such funds could be allocated proportionately more resources under the regular budget. The CHAIRMAN invited the Committee to consider the draft resolution contained m paragraph 8 of document A55/38. The draft resolution was approved. 1

The meeting rose at 12:55.

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.3.

THIRD MEETING Thursday, 16 May 2002, at 14:45 Chairman: Professor A.M. COLL SECK (Senegal)

FINANCIAL MATTERS: Item 15 of the Agenda (continued)

Status of collection of assessed contributions, including Members in arrears in the payment of their contributions to an extent which would justify invoking Article 7 of the Constitution: Item 15.2 of the Agenda (Document AS 5/26) Dr KARAM (representative of the Executive Board), speaking as Chairman of the Administration, Budget and Finance Committee (ABFC), introduced that Committee's second report (document AS 5/26). The Board had noted that the rate of collection of assessed contributions for 2001 at 31 December 2001 had been 87%. For 2002, the rate at 31 March 2002 had been 26% and by 30 April2002 33%, compared with 52% at 30 April2001. ABFC had heard that since 31 March 2002, the date of the report, a further 10 Members had paid their 2002 contribution in full and seven had made part payments. Therefore, a total of 64 Members had made full payments for 2002, 32 had made part payments and 97 had not yet made any payment. The total of arrears for previous years currently stood at US$ 126 million, compared to US$ 117 million at the same time in 2001. In respect of Members in arrears to an extent that would justify invoking Article 7 of the Constitution, three groups of Members had been considered by ABFC. The first group consisted of 23 Members whose voting privileges had been suspended at previous sessions. The second comprised six Members whose voting privileges had been suspended from the opening of the Fifty-fifth World Health Assembly, in pursuance of resolution WHA54.5. Of those Members, Belarus had indicated that it would be making a payment of US$ 345 100, which, if received, would be sufficient for its voting rights to be retained. The third group consisted of four Members whose voting rights would be suspended from the opening of the Fifty-sixth World Health Assembly unless payments were made before that time. ABFC had recommended a resolution for consideration by the Health Assembly, which was set out in paragraph 13 of the report, in respect of those countries, namely: Argentina, Gabon, Paraguay and the Solomon Islands. ABFC had concluded that the proposals received from Azerbaijan and the Dominican Republic requesting special arrangements to pay their arrears in instalments and to have their voting rights restored could be recommended to the Health Assembly. Recommended resolutions to that effect were contained in Annexes 2 and 3 of document ASS/26. A request had been received from Somalia for the waiving of its prior arrears. While ABFC had noted the difficult circumstances facing Somalia, it had not felt able to recommend the proposal since it would set an undesirable precedent. The amount owed was not large by comparison with the arrears of other Member States, and many other Member States also experiencing difficult circumstances had made significant efforts to meet their obligations. The Health Assembly had seldom adopted a resolution exonerating a Member State from payment, and in all such cases the resolutions had followed a precedent established by the United Nations. The ABFC had urged Somalia to make a request for rescheduling its arrears under the provisions of resolution WHA54.6, which could be considered at a future Health Assembly.

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Mr BOUKOUBI (Gabon), referring to paragraph 7 of the second report of the ABFC (document A55/26), announced that Gabon had settled its arrears, totalling US$ 208 000, in full, and had also paid part of its contribution for 2003. That situation should be taken into account during consideration of the resolution recommended by ABFC, in paragraph 13 of document A55/26. Ms WILD (Comptroller) said that, since 10 May 2002, a further US$ 1.5 million had been received from Member States. Cote d'Ivoire, Ethiopia, Mongolia, Rwanda and United Arab Emirates had paid their contributions for 2002 and a part-payment for 2002 had been received from Bolivia. Estonia had paid its contributions for 2003, and part payments for 2003 had been made by Mongolia and Rwanda. Sufficient payments in respect of prior arrears had been received from Belarus and the Democratic Republic of the Congo for the provisions of Article 7 no longer to apply. The contributions received so far from Comoros and Guinea had not been sufficient to lift the provisions of Article 7, but it was understood that further payments were to be made. Gabon and the Solomon Islands had both made sufficient payments in order to be deleted from paragraph 7 of document A55/26; as just indicated, Gabon had also made a part payment for 2003. The CHAIRMAN drew attention to the three draft resolutions recommended by ABFC in document A55/26, noting that the draft resolution set out in paragraph 13 should be amended by deleting the names of Gabon and the Solomon Islands from paragraph (2). Dr AUSTIN (Guinea) informed the Committee that Guinea had paid US$ 56 346, the value date for which was 16 May 2002. It should be received by the end of the Health Assembly and therefore Guinea should be removed from the list of Members given in paragraph 6 of document A55/26. Mr ROKOV ADA (Fiji) said that, as he had mentioned during the previous meeting, Fiji had paid its contribution in full for 2002. Although there had been some difficulty in sending the payment, it had been made two months previously, and his delegation was therefore concerned still to be listed as having its contribution outstanding. He requested the Secretariat to check whether the payment had been received. Mr DEDRYVER (France) noted that the amounts outstanding had clearly decreased, but nevertheless invited Member States to settle their arrears in full and unconditionally. Around 30 Member States had not made any payments in 2000 and 2001, and he wondered what efforts were being made by the Secretariat, particularly regarding the reform of the scale of assessed contributions, to resolve the problem. Ms WILD (Comptroller) said that, although it was understood that two amounts had been paid by Guinea, they had not yet been received by WHO. With regard to Fiji, the records would be checked and the delegation informed later that day of the outcome. Mr BAQUEROT (Executive Director), replying to the question raised by France, said that the Secretariat was in constant contact with the Member States concerned in order to convince them to settle their arrears. The possibility of making payments in local currency had been discussed with some countries and it was thought that some arrears might be settled in that manner. Dr GEZAIRY (Regional Director for the Eastern Mediterranean) wished to bring the problems of the Eastern Mediterranean Region to the attention of the Committee. Somalia had a transitory Government which had been unable to pay even Ministers' salaries, so would not be able to pay assessed contributions to the United Nations or WHO. The civil war had been so prolonged that there was no hope of Somalia regaining its voting rights, even if payments were spread over 10 years. Substantial extrabudgetary resources were being mobilized for Afghanistan, which was still in a very difficult situation. Other Member States were also experiencing difficult economic situations but they,

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at least, had governments whose members were paid salaries and that were collecting taxes, even if the amounts were small. The CHAIRMAN invited the Committee to consider the draft resolution recommended by ABFC in paragraph 13 of document AS 5/26, with the proposed amendment. The draft resolution, as amended, was approved. 1 The CHAIRMAN invited the Committee to consider the draft resolution on arrears in payment of contributions: Azerbaijan, contained in Annex 2 of document A55/26. Ms NELLTHORP (United Kingdom of Great Britain and Northern Ireland) welcomed the efforts made by the Secretariat and Azerbaijan to settle the outstanding arrears. She proposed that in paragraph 2 ofthe draft resolution the word "should" be amended to ''will". The draft resolution, as amended, was approved? The CHAIRMAN invited the Committee to consider the draft resolution on arrears in payment of contributions: the Dominican Republic, contained in Annex 3 of document A55/26. The draft resolution was approved? Miscellaneous income: Item 15.3 of the Agenda (Resolution EB109.R19; Documents A55/27 and A55/INF.DOC./2) Dr KARAM (representative of the Executive Board) said that at its 109th session the Executive Board had considered a report by the Secretariat on projections for miscellaneous income for 2002-2003. The Fifty-fourth World Health Assembly had approved the use of up to US$ 52 million from the Miscellaneous Income Account to finance the regular budget for the financial period 2002-2003. The amount of miscellaneous income available at that time had been estimated at about US$ 35 million, with a projected shortfall of some US$ 17 million. In order to reduce the shortfall, the Director-General had appealed to those Member States that were to benefit from the use of miscellaneous income to complement the amounts of their assessed contributions for 2002-2003, in accordance with resolution WHA54.17, to agree to forgo that assistance. In January 2002 five Member States had responded to that appeal. At that time, the revised estimate of miscellaneous income available for 2002-2003 had indicated a projected shortfall of US$ 13 million. The Board had also considered the arrangements in respect of the financial incentive scheme and had noted that, in accordance with resolution WHA41.12, interest earned in 2001 would be applied to Member States as a credit to their accounts in 2004-2005. In January 2002, the projected amount of interest earned and available for the financial incentive scheme had been estimated at some US$ 15 million. It had been proposed that Member States' accounts should be credited in 2002-2003 with their respective shares of the interest earned in 200 I instead of waiting until the 2004-2005 biennium. That would allow for a speedier completion of the transition to the new scheme. In resolution EBI09.Rl9, the Board had recommended that the proposal be adopted by the Fifty-fifth World Health Assembly.

1 2 3

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.4. Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.5. Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.6.

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Mr SABHARWAL (India), referring to the report on miscellaneous income in document A55/INF.DOC./2 in which a revised estimated shortfall of some US$ 11 million was indicated, sought clarification on paragraph 8, which stated that should the shortfall persist the Director-General would review implementation plans for the regular budget to make any adjustments that might be necessary. He wished to know how the Director-General would proceed with such adjustments, and whether there would be consultations with Member States. In the interests of transparency, Member States, at least, should be kept informed of any developments, including her proposals, and efforts should be made to meet the shortfall by reducing administrative expenses, rather than cutting health promotion programmes, particularly in developing countries. Mr BAQUEROT (Executive Director) replied that the situation was being carefully monitored and would become clearer by January 2003. The financial regulations provided for the DirectorGeneral, in the event of the shortfall, to review the implementation plan for the regular budget and make necessary adjustments. She would of course give careful consideration to the type of adjustments to be made. Referring to the suggested cut in administrative expenses, he said that out of a total budget for General management at headquarters of some US$ 80 million, of which half was linked to ongoing costs, such as heating and electricity, a saving of US$ 11 million would represent about 20% of the remaining budget, which would prove difficult to achieve. The CHAIRMAN invited the Committee to approve the draft resolution contained in resolution EB 109 .R 19 on miscellaneous income, together with the amendment proposed in paragraph 4 of document A55/27 that an additional paragraph be inserted. The draft resolution, as amended, was approved. 1 Revolving and other long-term funds: Item 15.4 of the Agenda (Resolutions EB109.R20 and EB109.R21; Document A55/28)

Dr KARAM (representative of the Executive Board), introducing the item, said that the Executive Board at its 109th session had considered a report by the Director-General, on the status of four funds: the Real Estate Fund, the Information Technology Fund, the Revolving Sales Fund and the Security Fund. Regarding the Real Estate Fund, the Board had noted that initial five-year plans had been developed that would form the basis on which the Director-General would make proposals for funding for the Real Estate Fund for future bienniums. The Board had been informed that the project for the construction of a new building to provide accommodation for WHO and UNAIDS was progressing well and that the Swiss authorities had continued to provide support. He drew attention to the draft resolution recommended in resolution EB 109 .R20 on the Real Estate Fund, in particular to the provision that, should WHO's share of the estimated expenditure exceed Sw.fr. 27.5 million by over 10%, authority for additional expenditure would be sought from the Health Assembly. In respect of the Information Technology Fund, the Board had recognized that the replacement of the 25-year core administrative systems had become a priority and that the process was entering the 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. Regarding the Security Fund, the Board had fully supported the Director-General's decision to establish a fund to guarantee WHO staff security and safety worldwide and had adopted decision EB 109(8) in that regard. The Board had considered proposals relating to the Revolving Sales Fund and had concluded that all the Fund's operations should be presented under one account, as reflected in the draft resolution recommended in resolution EB109.R21.

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.7.

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The CHAIRMAN invited the Committee to consider the draft resolution recommended m resolution EB109.R20 on the Real Estate Fund. The draft resolution was approved. 1 The CHAIRMAN next invited the Committee to consider the draft resolution recommended by the Board in resolution EB109.R21 on revolving and other long-term funds. The draft resolution was approved. 2 Assessments for 2003: Item 15.6 ofthe Agenda (Document A55/29) Dr KARAM (representative of the Executive Board), introducing the item, said that the Board had considered the information on the assessments for 2003 and the comments thereon by ABFC, and had agreed to recommend that the Fifty-fifth World Health Assembly should maintain the assessment for 2003 as adopted in resolution WHA54.17, while taking steps to prepare for the biennium 2004-2005. The Committee endorsed the recommendation. The CHAIRMAN said that he took it that the Committee wished to recommend that the Executive Board be requested to review questions related to assessments for 2004-2005 at its 111 th session in January 2003 and to make appropriate recommendations to the Fifty-sixth World Health Assembly. It was so agreed.

SECOND REPORT OF COMMITTEE B (Document A55/45) Dr SOEPARAN (Indonesia), Rapporteur, read out the draft second report of Committee B. The report was adopted. 3

STAFFING MATTERS: Item 16 of the Agenda

Human resources: annual report: Item 16.1 of the Agenda (Document A55/30) Mr BAQUEROT (Executive Director), introducing the report (document A55/30), explained that in response to requests made at the Fifty-fourth World Health Assembly a diversity management policy had been formulated, which aimed at recruiting more women and members of staff from unrepresented or underrepresented countries, and at developing support systems to allow staff to reach their full potential. A proactive recruitment strategy was being introduced; it comprised a targeted recruitment network allowing the Organization to access the databases of other organizations, an 1 2 3

Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.8. Transmitted to the Health Assembly in the Committee's second report and adopted as resolution WHA55.9. See page 274.

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electronic recruitment project allowing candidates to apply and be screened online, briefing kits for worldwide distribution, and accountability guidelines for managers responsible for selecting staff. The Organization had also adopted a number of measures to make the working environment more congenial and had integrated ongoing development of staff in the performance management development system launched in January 2002, which helped to assess staff performance. Additional resources had been committed to ensure the full implementation of the strategy. The CHAIRMAN drew attention to a draft resolution on increased representation of developing countries in the Secretariat and in expert advisory panels and committees proposed by the delegations of Algeria, Benin, Chad, China, Cuba, Ethiopia, Libyan Arab Jamahiriya, Malaysia, Oman, Pakistan, Palau, Qatar, Somalia, South Africa, Swaziland, Syrian Arab Republic, United Republic of Tanzania, and Vanuatu, which read: The Fifty-fifth World Health Assembly, Guided by the Purposes and Principles of the Charter of the United Nations, in particular the principle of the sovereign equality of its Member States; Reaffirming the principle of equitable participation of all Members of the Organization in its work, including that of the Secretariat and various committees and bodies; Bearing in mind Article 35 of the Constitution, which upholds the principles of efficiency, integrity and internationally representative character of the Secretariat, and adherence to the principle of geographical representation in recruitment of the staff; Recalling its resolution WHA4.51 adopting the Staff Regulations of the Organization and its subsequent resolutions amending these regulations; Recalling its resolution WHA50.15 on recruitment of international staff in WHO: geographical representation; Further recalling its resolution WHA35.10 approving the Regulations for Expert Advisory Panels and Committees and its subsequent resolutions amending these regulations; Concerned that the developing countries are underrepresented in the Secretariat, in the professional category, including at headquarters; Also concerned at the limited representation of developing countries on expert advisory panels and committees, 1. UNDERLINES that the Secretariat of WHO is a common secretariat for all Member States and should therefore reflect the composition of its membership, a majority of which are developing countries; 2. STRESSES, in this context, adherence to the principle of equitable geographical representation and gender balance at all levels in the Secretariat, especially at headquarters, in order to improve its representative character; 3. EMPHASIZES the principles of transparency, nonselectivity and objectivity in appointments both in the Secretariat and to expert advisory panels and committees; 4. UNDERLINES that country quotas for appointments in the Secretariat should, in principle, be based on geographical balance, population criteria, and balance between developed and developing countries, and not on financial contributions to the Organization; 5. REQUESTS the Director-General to ensure that the principles of equitable geographical representation, gender balance and a balance of experts from developed and developing countries are respected in making appointments in the Secretariat and in establishing expert advisory panels or expert committees;

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6. FURTHER REQUESTS the Director-General to seek the concurrence of the concerned Member State when appointing experts to advisory panels, to circulate information on all appointments made to these panels to Member States through a publicly available document, including on the Internet, and to encourage developing countries to send nominations for the panels; 7. DECIDES to amend the Regulations for Expert Advisory Panels and Committees in light of this resolution, as per the Annex to this resolution; 8. REQUESTS the Director-General to submit a report to the Fifty-sixth World Health Assembly on implementation of this resolution, including different alternatives to the current representation formula in the Secretariat.

ANNEX

AMENDMENTS TO THE REGULATIONS FOR EXPERT ADVISORY PANELS AND COMMITTEES Amendment to Regulation 3.1 Add at the end: Information on all appointments made to these panels shall be circulated to all Member States. The Director-General shall encourage the developing countries to send nominations for the panels. Amendment to Regulation 3.2 Replace the last sentence with the following: He shall encourage nomination of experts from developing countries and from all regions and shall be helped in this task by Regional Directors. Amendment to Regulation 4.2 Replace with the following: As a general rule, the Director-General shall select from one or more expert advisory panels the members of an expert committee on the basis of the principles of equitable geographical representation, gender balance, a balance of experts from developed and developing countries, representation of different trends of thought, approaches and practical experience in various parts of the world, and an appropriate interdisciplinary balance. The membership of expert committees shall not be restricted by consideration of language, within the range of languages of the Organization. The CHAIRMAN said that it had been proposed than an open-ended working group should be established to discuss the text of the draft resolution, which would then be considered by the Committee at a later meeting. It was so agreed.

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Mr BRODRICK (Australia) suggested that, given the scope of the draft resolution, the Secretariat be requested to attend the discussions with a view to providing advice. It was so agreed.

Mr BASIT (Pakistan) expressed the hope that, in scheduling the meeting of the working group, consideration would be given to the difficulties of small delegations in participating in concurrent meetings. Mrs HERNANDEZ (Venezuela) drew attention to the fact that document A55/30 did not cover staff movements after 3I December 200 I and expressed concern about the low or virtually nonexistent representation of Latin American countries among staff members in P6, D 1 or more senior posts. Tables 4(a) to 4(f) appeared to indicate that most countries in the region were well-represented; in fact, in the majority of cases that condition was fulfilled by just one member of staff. Only 8% of professional staff from the Americas held P6, D1 or higher positions, the lowest percentage of all regions. Of the 24 officials in question, only four came from countries other than the United States of America and Canada. A mere 1I% of Member States from the Americas had at least one staff member in a P6, D I or higher post. Few of those States had officials in PS posts, but 70% had staff in P4 or lower positions. WHO officials should of course be of the highest calibre. However, since countries in the Latin American region had plenty of highly-qualified persons in the health profession, it was surprising that they were so poorly represented in WHO. The WHO Secretariat must be constituted on the basis of equitable geographical representation. Dr TASAKA (Japan) expressed concern that many countries were still underrepresented or unrepresented. While he welcomed the measures taken so far to improve the situation, he urged the Secretariat to make further efforts to ensure that all Member States were equitably represented. Mr ROKOV ADA (Fiji) requested clarification regarding the location and functions of the three Fijian nationals who, according to the entry for Fiji in Table 4(f) of the report, worked for the Organization. He also asked for clarification of the criteria used to determine whether a country was overrepresented, underrepresented or unrepresented, and if the figure shown in the table was incorrect, of Fiji's representation in the light of those criteria. Mrs ALLEN-YOUNG (Jamaica) commended the decision to implement the diversity management policy. She shared the concerns expressed by the delegate of Venezuela regarding the underrepresentation of countries in the Americas, as the Caribbean countries appeared to be even less represented than countries in other areas of the Region. She therefore looked forward to the full implementation of the diversity management policy. Ms MAFUBELU (South Africa) said that, as a sponsor of the draft resolution to be discussed by the working group, her country wished to emphasize the urgent need to tackle the current significant and worrying underrepresentation of developing countries and women in the Secretariat, as well as in expert advisory panels and committees, and the underrepresentation of women in the Secretariat, especially at the higher levels. As long as the criteria used for establishing country quotas for appointments in the Secretariat were based on financial contributions and not on geographical balance or on a balance between developed and developing countries, the latter would remain seriously underrepresented. The pattern of underrepresentation was repeated within the expert advisory panels and committees, in whose work the particular perspectives of developing countries should be represented and the specialized local knowledge of their experts should play a vital role. South Africa therefore fully supported the draft resolution and urged Member States to adopt it in its entirety.

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Mr MOON (Republic of Korea) urged the Secretariat to take appropriate measures to ensure that Member States that were underrepresented compared with their status in terms of their financial contribution were represented within reasonable ranges through cooperation with the governments of underrepresented and unrepresented nations. He requested clarification of the number of long-term WHO staff who were nationals of the Republic of Korea. To his knowledge, that number was three, but, according to the report, there were five. Mr SABHARWAL (India) requested clarification of the criteria used to determine desirable ranges of representation. If the main criterion was the level of financial contribution, the system clearly and unfairly favoured the developed countries and needed to be revised. Mr BAQUEROT (Executive Director), replying to points raised during the debate, expressed the hope that the Secretariat's efforts to promote diversity in recruitment would result in a more equitable geographical representation. He informed the delegate of the Republic of Korea that the Secretariat would contact his delegation to clarify the number of staff members who were nationals of that country. With regard to the criteria used to establish desirable ranges of recruitment, he recalled that in 1997 the Health Assembly had adopted resolution WHA50.15, paragraph 3 of which requested the Director-General to modify the method of calculating desirable ranges by revising the number of posts used in the calculation to 1450. As indicated in a report to the Fifty-third World Health Assembly (document A53/INF.DOC./3), four criteria were used to establish ranges. The first criterion was membership of WHO. The second related to a Member State's contribution and laid down a specific number of posts per 1% contributed; the larger the contribution, therefore, the larger the number of posts. The third element was population, with an adjustment for each one million of population. The fourth was an upper and lower limit for each desirable range; once a factor, based on membership, contribution and population, had been established, a coefficient of 15% was used to establish the upper and lower limits. Finally, a minimum lower limit of one and a maximum limit of eight staff members had been established for the lowest possible range. Table 4, column 1, of document ASS/30 provided information concerning the respective range of each country. Or OMI (Regional Director for the Western Pacific), responding to the question from the delegate of Fiji, said that the three Fijian nationals currently working for the Organization were at the P4, PS and 01 levels. The first was working in Papua New Guinea as a medical officer, the second was currently on secondment to the UNFPA office in Fiji, and the third was working as Director of Administration and Finance in the African Region. (For continuation of discussion, see summary record of the fifth meeting, section 3.) Amendments to the Staff Regulations and Staff Rules: Item 16.2 of the Agenda (Resolutions EB109.R13, EB109.Rl4 and EB109.Rl5; Document ASS/36 1)

Or KARAM (representative of the Executive Board) said that the United Nations General Assembly had approved, with effect from 1 March 2002, a revised base/floor salary scale for the professional and higher categories that incorporated an increase of 3.87% through the consolidation of post adjustment on a "no loss - no gain" basis. Pursuant to that decision, the Director-General had proposed, in accordance with Staff Regulation 3.1, that the Executive Board should recommend to the Fifty-fifth World Health Assembly a modification of the salaries of staff in ungraded posts. The modification called for similar adjustments to the Director-General's salary, bearing in mind the terms of paragraph Ill of her current contract. The Health Assembly was therefore invited to consider the

See document WHA55/2002/REC/!, Annex 1.

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draft resolution recommended in resolution EB I 09.R13 on salaries of staff in ungraded posts and of the Director-General. The Board had confirmed amendments to the Staff Rules concerning, inter alia, contractual reform and the system for performance management and development, which were set out in Annex 2 to document EB 109/2002/REC/1. To ensure consistency between the Staff Regulations and the Staff Rules, and to include reference in the Staff Regulations to conditions concerning the eligibility of Regional Directors for reappointment, the Board had also recommended to the Health Assembly that Staff Regulation 4.5 should be amended. The revised text of the amendment was contained in document A55/36. The Health Assembly was therefore invited to consider the draft resolution contained in resolution EB109.R15 on amendments to the StaffRegulations. Mr STONECIPHER (United States of America) said that his delegation had many questions concerning the various amendments to the Staff Regulations, in particular whether the International Civil Service Commission had reviewed and endorsed those amendments. He understood that the Secretariat had prepared a statement to address those issues. Mr BAQUEROT (Executive Director) said that a number of questions had been raised by Member States during and following the Board's consideration of the matter. With regard to the endorsement of contractual arrangements by the International Civil Service Commission (ICSC), he had written to the Chairman of ICSC in April 2002 to seek his views on the implementation of timelimited contracts by WHO. The Chairman had subsequently confirmed, in a letter dated 29 April2002, that the arrangements were fully in line with common system practice. Comparing the previous and revised versions of Staff Rule 420.1, he explained that there was a marked difference between the existing career service appointments and the new service appointments to be introduced. The only similarity was that neither had a specified termination date, as opposed to fixed-term or temporary appointments. Service appointments were strongly performance driven, in accordance with the objectives of the recently introduced performance management and development system. The new contracts could also be terminated by the Organization at any time, subject to due cause and process, for reasons connected with the availability of funding, skill mix or profile considerations. The appointments could not be considered as a job for life, and were more in line with the type of rolling contracts frequently encountered in the private sector. A proposal had been made to delete the reference to permanent appointments in Staff Regulation 4.5. In response to a question regarding the justification for the use of term-limited appointments, he said that, strictly speaking, short-term work would continue to be covered by short-term contracts. However, the use of successive short-term contracts for continuing work was simply not good employment practice. Circumstances would arise, nevertheless, in which the immediate establishment of a fixed-term position would be inappropriate, for instance, owing to the unpredictability of funding. To accommodate such concerns, term-limited contracts had been designed to provide for enhanced conditions of service, compared to those currently applicable to short-term staff. The limitation to a maximum of four years' service under temporary contracts would act as an incentive for managers to plan their workforce needs more thoroughly, and to create posts whenever they were strictly necessary and feasible. The service allowance for term-limited contracts in WHO lay well within that for United Nations appointments of limited duration, which had been approved by the United Nations General Assembly. The variations in the design of the allowance and in the application of WHO term-limited contracts simply reflected the operational needs and funding realities of the Organization. Specific criteria were being put in place to ensure the consistent implementation of the service allowance throughout WHO. The discretion in setting the amount of service allowance was no different from that used to determine the step at which a staff member might be recruited within a given grade under a fixed-term contract. He confirmed that the enhanced termination indemnity would not apply to all staff under the new separation procedures: it would only be payable when a post of indefinite duration, or any post

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held by a staff member with a service appointment, was abolished or came to an end. In any event, efforts must first be made to reassign the staff member, in accordance with the process shown under Staff Rule 1050. In all other cases, if the Director-General deemed it appropriate, she could decide to enhance the termination payment due by up to 50%. Consequently, the enhanced indemnity was payable only in very specific cases, and even then, only when other solutions had proved impossible. Maternity leave benefit was not the same for temporary staff as for fixed-term staff. The former were entitled to eight weeks paid leave, with a possible further eight weeks unpaid leave, whereas the latter were entitled to a full 16 weeks paid maternity leave. Under the current health insurance arrangements for short-term staff, appointments of less than one year entitled staff members to benefit from limited health insurance coverage, but their spouses and children remained outside the scope of those provisions. If they fulfilled certain criteria, shortterm staff were entitled to request full insurance coverage, but again their families were not covered. Under the new arrangements, after one year, temporary staff could request full insurance cover for themselves and eligible family members, namely, spouse and children under 18 years of age. In such cases, during intervals when the staff member was not employed, he or she must agree to pay the required contribution, including the Organization's share, personally and for each insured family member.

The meeting rose at 17:00.

FOURTH MEETING Friday, 17 May 2002, at 09:50 Chairman: Professor A.M. COLL SECK (Senegal)

STAFFING MATTERS: Item 16 of the Agenda (continued)

Amendments to the Staff Regulations and Staff Rules: Item 16.2 of the Agenda (Resolutions EB109.R13, EB109.R14 and EB109.R15; Document ASS/36 1) (continued) Mr STONECIPHER (United States of America) said that, despite the explanations given by the Executive Director at the Committee's previous meeting and the letters from the International Civil Service Commission, many of his delegation's questions remained unanswered. The correspondence between the Organization and the International Civil Service Commission had fallen short of stating that the full text of the proposed amendments had been reviewed and found to be compatible with the United Nations common system, and quite clearly only the proposed changes to the contractual arrangements had been addressed, not the amendments to the Staff Rules as set out in document EB 109/27 Add.1? Furthermore, only limited information had been received regarding the rationale for many rule changes. There was no indication, for example, as to why term-limited appointments would automatically start at pay step three rather than step one, why the required duration of service for an end-of-service grant was being reduced from 10 to five years, and why two months' paid plus two months' unpaid maternity leave should be offered to temporary employees on short-term contracts. There was no indication, either, of the financial implications of the proposed changes or how they were to be funded. The issues were extremely important and had ramifications for the entire common system, and unless sufficient time could be allowed for a constructive and detailed discussion, preferably in a different forum, the United States would be unable to support the proposals. Mr TOPPING (Legal Counsel) explained that the changes to the Staff Rules had been made by the Director-General, confirmed by the Executive Board and then been reported to the Health Assembly. If there was no further action, they would enter into force on 1 July 2002. There was one change to the Staff Regulations that was inconsequential, and he wondered whether, as the Rules had already been confirmed, it might not be more appropriate to ask for further study and that they should then enter into force as foreseen. Mr CHERNIKOV (Russian Federation) rejected the Legal Counsel's interpretation. He said that it had been clear from the documentation submitted to the Executive Board in January 2002 that there was a direct link between amendments to the Staff Regulations and those to the Staff Rules, and that, to enable the new types of contract to enter into force, changes would have to be made to the Regulations. As his delegation understood it, therefore, if the resolution was not adopted, the amendments to the Staff Rules would not be implemented.

1 2

See document WHASS/2002/REC/1, Annex 1. See document EB109/2002/REC/l, Annex 2.

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Mr AITKEN (Senior Policy Advisor), responding to the concerns of the delegation of the United States, confirmed that the full text of the changes as they were adopted would be transmitted to the International Civil Service Commission and that the Secretariat would report regularly to the Executive Board on the progress of the implementation of the new rules, including the need for any adjustments that might be necessary. Mr STONECIPHER (United States of America) said that his delegation would not oppose the draft resolution on the understanding that answers would be received from the International Civil Service Commission, that items would be amended, if necessary, should they not comply with the United Nations common system, and that the Organization would use its usual diligence in sensibly refining its rules and regulations and keep Member States regularly informed of the situation. The CHAIRMAN invited the Committee to approve the draft resolution contained in resolution EB109.R15. The draft resolution was approved. 1 The CHAIRMAN invited the Committee to consider the draft resolution contained in resolution EB109.R13. The draft resolution was approved. 2 Appointment of representatives to the WHO Staff Pension Committee: Item 16.3 of the Agenda (Document ASS/31) The CHAIRMAN invited the Committee to appoint one member and one alternate member to the WHO Staff Pension Committee in accordance with the rotational schedule explained in document ASS/31. In the absence of objections she would take it that the Committee wished to convey the following draft decision to the plenary. Decision: The Fifty-fifth World Health Assembly reappointed Mr L. Rokovada, delegate of Fiji, as member of the WHO Staff Pension Committee, and Mr M. Chakalisa, delegate of Botswana, as alternate member, the appointments being for a three-year period. 3

COLLABORATION WITHIN THE UNITED NATIONS SYSTEM AND WITH OTHER INTERGOVERNMENTAL ORGANIZATIONS:Item 19 of the Agenda (Document AS 5/34) The Committee noted the report contained in document A55/34.

International Decade of the World's Indigenous People (Documents ASS/35 and ASS/35 Add. I) Mr SABHARWAL (India) recalled that the issue of indigenous people within United Nations human rights fora had arisen as a result of the international community's concern for the situation of original inhabitants who had been dispossessed and marginalized by settlers from overseas. India, along with other countries, had consistently emphasized the need for a definition of the term 1 2 3

Transmitted to the Health Assembly in the Committee's third report and adopted as resolution WHA55.21. Transmitted to the Health Assembly in the Committee's third report and adopted as resolution WHA55.20. Decision WHASS(lO).

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"indigenous people" to ensure that the interests of genuine indigenous people did not suffer for lack of clarity. It would be unfair to ask an organization such as WHO to identify the groups concerned without a clear definition. In addition, disparities in health standards might well result in specific groups being disadvantaged. It was important that any disparities should be removed at the national level, and that WHO should only become involved at a country's request and address the problems as part of the overall health strategy. It was the responsibility of Member States to ensure that the health needs of indigenous people and other disadvantaged groups were met, and to seek the assistance of WHO if necessary. Dr ASAMOA-BAAH (Executive Director) confirmed that in defining and taking that area of work forward the Organization would be guided by that approach. Mrs SOSA MARQUEZ (Mexico) drew attention to the fact that in the documents some internationally used expressions, such as indigenous peoples, had been changed, and terms that indicated ethnic factors, indigenous populations or marginalized ethnic groups had been used. In considering such changes it was important to bear in mind the uniqueness of indigenous peoples and the specific nature of their health-related problems that did not necessarily derive from marginalization or disadvantage. Her delegation therefore urged WHO, in dealing with issues relating to indigenous peoples, not to consider them as a more vulnerable or marginalized group and, more particularly, not to consider their health problems as being solely poverty-related. As part of Mexico's current national plan for the development of indigenous peoples, considerable improvement had been made in the health care infrastructure. Coverage had been extended and the views of those people had been reflected in the extreme poverty alleviation programme. Health, education and nutrition were now part of the programme, as were social security issues and solidarity programmes, from which 30% of the country's indigenous population benefited. Mr LIEN (Norway) said that in 2001 his Government had finalized a plan of action for health and social services for the Sami population, aimed at making existing services more accessible in terms of language and cultural responsiveness, rather than establishing separate services. He expressed the hope that the Norwegian plan of action would serve as an inspiration to other countries. It included the improvement of mental health services in Sami areas and significant data collection on health and living conditions in those areas, that would be used as a basis for research and policy adjustments. The plan of action would also highlight, for the benefit of municipalities, regional authorities and Stateowned hospitals, the fundamental importance of language and cultural responsiveness. It had been developed in close cooperation with representatives of the Sami people, their organizations and the Sami Parliament, demonstrating that cooperation with indigenous peoples' representatives was the best foundation for appropriate policy-making. His delegation looked forward to following the progress of the work of WHO in that area. Mr MACPHEE (Canada) said that Canada welcomed the Organization's pragmatic and focused approach in identifying the major challenges and priorities for a global plan of action to improve the health of indigenous people. The need for an integrated approach and long-term political commitment at the national level reaffirmed Canada's own experiences in working in partnership with indigenous people to address their unique health needs and perspectives. As the Decade of the World's Indigenous People came to a close, it was crucial that governments should continue to work closely with indigenous people to address critical health challenges as part of a comprehensive development strategy. Canada looked forward to the results of the continued consultations on that strategy. It welcomed WHO's participation in and contribution to the interagency support group to the Permanent Forum on Indigenous Issues and urged the Organization to ensure the availability of sufficient measures for that purpose. The Committee noted the reports contained in documents A55/35 and A55/35 Add.l.

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REVIEW OF WORKING METHODS OF THE EXECUTIVE BOARD: Item 17 of the Agenda (Resolution EB109.R7; Document A55/32)

Mrs ABEL (representative of the Executive Board), introducing the item, said that the progress report in document A55/32 covered the Board's deliberations at its 109th session in January 2002 and two meetings of the Ad hoc open-ended intergovernmental working group to review the working methods of the Executive Board. At its third meeting on 10 May 2002, the working group had reviewed submissions received from Member States, the group's future programme of work and its reports to the Executive Board and Health Assembly. On the basis of an informal paper by the Chairman of the working group, a number of issues and positions set out in the submissions had been clarified, including the scope of the working group's mandate to determine the size of the Executive Board. On the question of the group's future programme of work, it would be proposed to the Executive Board that the Chairman of the working group would distribute by mid-June 2002 a document comprising the Member States' submissions, according to the themes outlined in the agreed list of topics, including the issues raised at the third meeting. The Secretariat would provide a paper on the cost implications of the proposals. It was also proposed to convene two informal intersessional meetings before the 111 th session of the Executive Board, the first in August 2002 and the second in November 2002, of which all Member States would be advised. That information would be reported to the Executive Board at its 110th session after the closure ofthe current Health Assembly. Mr SABHARWAL (India) recalled that in the course of the working group's discussions his delegation had proposed that, in compliance with resolution WHA54.22, in order to achieve increased transparency and participation, the working group should review, inter alia, the terms of reference and composition of the committees of the Executive Board to reflect equitable geographical representation and gender balance; the criteria for the appointment of experts and committee members; the Executive Board's rules of procedure so as to render them more harmonious, effective and efficient, thus ensuring improved participation by Member States in its proceedings, working groups and drafting committees; and measures to ensure transparency of the retreats for members of the Executive Board. It should consider measures to improve the Executive Board's interaction with the Health Assembly and the Secretariat to strengthen their respective roles in accordance with the Organization's Constitution. India would continue to participate actively in the meetings of the working group. However, there was a need for greater participation in the Board's proceedings. To that end, without overlooking the need for efficiency, the Rules of Procedure of the Executive Board should be amended to facilitate participation by non-members, particularly on issues vital to their countries or regions. The question of accountability was of great importance: it was essential that all important decisions taken by the Board should be submitted for approval to the Health Assembly. With regard to the committee system, the principle of equitable geographical representation should be applied, so that intergovernmental committees and working groups properly reflected the broad representative character of WHO, and a greater number of Member States, whether or not they were Executive Board members, could be nominated to serve them. Professor ZELTNER (Switzerland), speaking in his capacity as Chairman of the Ad hoc openended intergovernmental working group, thanked the Member States for their contributions to that process and noted that they had shared many of the same questions and ideas on how to proceed. It was his aim to carry forward that work for the Executive Board to its January 2003 session to enable it to submit its proposals to the Fifty-sixth World Health Assembly. Mr DING Zhizhuang (China), expressing concern over the lack of substantive progress in the working group, said that his delegation looked forward to receiving the Chairman's document on Member States' submissions, so that substantive discussions could begin. In improving the working methods of the Board and its subsidiary bodies, it was essential to enhance transparency and

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efficiency, ensure equal parttctpation of Member States, and fully reflect their views and recommendations on world health matters. The Board should avoid politicization. It was duty bound to abide by the Constitution of WHO, as well as the Health Assembly resolutions and decisions. It should be fully aware of its terms of reference, and refrain from conduct that violated the principles of the United Nations Charter. The Board should also avoid political proposals that were unrelated to health matters and would lead to confrontation between Member States, jeopardize the spirit of cooperation in the Board and waste valuable time. With regard to document distribution, it was not unusual for many important conference documents to be distributed immediately before a meeting, and many relevant documents were either unobtainable through the Organization's web site or were unavailable in all working languages. It was essential, therefore, to improve the efficiency of the conference services. The CHAIRMAN took it that the Committee noted the report. It was so agreed.

The CHAIRMAN drew attention to the draft resolution contained in resolution EB109.R7. Mrs ABEL (representative of the Executive Board), introducing the draft resolution, said that after a thorough discussion, ranging from the need to use WHO's resources wisely to the well-being of Executive Board members travelling to Geneva, the Board had decided to recommend that the travel of Board members should be based on WHO staff travel standards rather than on resolution WHA30.10. Mr STONECIPHER (United States of America) said that despite the helpful replies to his delegation's questions since the item had last been discussed, his delegation remained concerned about the need for business class travel. Although the increased costs were small, they nevertheless represented an additional expense for the Organization and there was no indication of cost efficiency efforts to offset that increase. He expressed the hope that delegations would be kept informed on a regular basis of any long-term savings. The draft resolution was approved. 1

TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued from the fifth meeting of Committee A)

Infant and young child nutrition: Item 13.10 ofthe Agenda • Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes (Document A55/14) • Global strategy for infant and young child feeding (Resolution EB109.Rl8; Document A55/15 2) Mrs ABEL (representative of the Executive Board), introducing the item, said that at the 109th session of the Executive Board, several members had emphasized the importance of the International Code of Marketing of Breast-milk Substitutes as a means of promoting exclusive 1 2

Transmitted to the Health Assembly in the Committee's third report and adopted as resolution WHA55.22. See document WHASS/2002/REC/1, Annex 2.

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breastfeeding for the first six months of life and continued breastfeeding until the second year, and of protecting infants and young children from malnutrition. Recommendations made in respect of the draft global strategy had been incorporated into document AS 5115. Dr SADRIZADEH (Islamic Republic of Iran) proposed that a new subparagraph 4 should be added to paragraph 2 of the draft resolution in EB109.R18 that would read: "to ensure that the introduction of micronutrient interventions does not replace or undermine support for sustainable practice of exclusive breastfeeding and optimal complementary feeding, and 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 World Health Assembly resolutions". Mrs AKMAN (Turkey) said that the health and nutritional status of mothers and children could not be considered separately. In addition to the global Baby-friendly Hospital Initiative and the active promotion of breastfeeding and safe complementary food, Turkey had launched a baby-friendly primary health care programme to monitor maternal nutrition, teach breastfeeding techniques and identify problems. Reliable data from that programme would be collated and made available nationwide. Mr TASAKA (Japan) said that, while apprectatmg the importance of and need for the International Code of Marketing of Breast-milk Substitutes, his delegation expected it to be based on scientific evidence and full recognition of the differences in health policy between Member States at each stage of its implementation. Mr CHAKALISA (Botswana) expressed his country's wholehearted commitment to the provision of adequate infant and young child nutrition through programmes launched in collaboration with international donor agencies and the private food industry. At present, nutrition counselling and nutrient supplements were available to the vulnerable populations, including children under five and pregnant and lactating women. A programme on prevention and control of micronutrient deficiencies had been established, and regulations on the marketing of breast-milk substitutes were expected to be in place by the end of 2002. The national programme to prevent mother-to-child transmission of HIV covered infant and young child feeding guidelines, the training of health workers and counselling. These and other government programmes had brought down the moderate malnutrition rate from 30% in the early 1980s to 10% in 2000. Dr RAFILA (Romania) noted that, as in other post-communist countries of Eastern Europe, national data had indicated increased malnutrition and its consequences in women and children. The situation had been attributed to a marked decrease in breastfeeding due, in part, to the lack of appropriate support and advice from caregivers, peer-support groups and medical professionals. The inappropriate substitution of liquids, such as tea, for milk had, in the past, led doctors to prescribe milk substitutes for infants. However, new legislation was to be introduced in an attempt to reverse the trend. Some maternity hospitals had been accredited as baby-friendly, and additional financial resources allocated. Breastfeeding support had been incorporated into the training of nurses and midwives. Other promotional programmes for breastfeeding would be continued and expanded. Dr KOUNANDI (Cote d'Ivoire) emphasized the importance of ensuring that the results of WHO's work were consistent with the spirit and the letter of instruments already adopted, in particular, the International Code of Marketing of Breast-milk Substitutes and subsequent resolutions. The moderate malnutrition rate of infants and young children in Cote d'Ivoire was 24.4% and the severe rate was 8.4%. Of the 90% of mothers who breastfed their children, 85% continued up to the age of two years. Exclusive breastfeeding had risen from 4% in 1998 to 11% in 2000, prompted, undoubtedly, by the Government's strong political will. A national child health programme that

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included the promotion of breastfeeding had been set up and a nutrition programme was in place. A bill on breast-milk substitutes was currently before parliament and was expected to be passed shortly. Dr ZHANG Deying (China) said that China recognized the importance of the global strategy on infant and young child feeding, and the respect for and promotion and protection of the universallyaccepted human rights that it embodied, particularly the right of the child to adequate, safe and nutritious food. The promotion of breastfeeding and optimal feeding practices for young children would ensure healthy survival. Legislation on maternity and infant care had been adopted to encourage the promotion of breastfeeding. In collaboration with WHO and UNICEF, baby-friendly hospitals had been established, and regulations endorsing the International Code of Marketing of Breast-milk Substitutes had been introduced. UNICEF had implemented a successful project to alleviate vitamin A deficiency in children under the age of five. As a result of those measures, there had been a marked increase in breastfeeding and a remarkable improvement in the nutritional status of children. In some areas, however, 90% of women were in paid employment and had difficulty in breastfeeding continuously for six months. Efforts would continue to redress that situation. Mrs MADZIMA (Zimbabwe) said that her country welcomed the global strategy for infant and young child feeding because it provided fresh information, strengthened existing targets and addressed new challenges. The strategy would help governments to secure progress in the fields in question. Her Government reaffirmed its commitment to the achievement of existing goals, including those set by the International Conference on Nutrition in 1992 and the Codex Alimentarius standards, as well as its commitment to the attainment of good health through adequate and appropriate infant and young child feeding practices. In order to give positive guidance on infant and young child feeding practices to compensate for the lack of a definition of inappropriate feeding in the global strategy, she proposed that a new paragraph should be inserted between the second and third preambular paragraphs of the draft resolution that would read: "Recognizing that infant and young child mortality can be reduced by exclusive breastfeeding for the first six months of life and continued breastfeeding with frequent complementary feeding with safe and appropriate/adequate amounts of local foods up to the age of two years and beyond". Resolution WHA54.2 was based on a wide range of studies and hence there was no point in re-opening the debate about the optimal duration of exclusive breastfeeding. She further proposed the deletion of the reference to civil society and the international community in the last preambular paragraph, and of the phrase "and to work together closely for this purpose" at the end of the same paragraph, as it was governments' responsibility to promote the optimal feeding of infants and young children. She supported the amendment proposed by the Islamic Republic of Iran. Ms BUIJS (Netherlands) said that, while document ASS/14 provided an overall picture of the enormous problem of malnutrition, including the growing number of children affected by obesity, there was only one very short paragraph on the Code's implementation. More precise and more clearly presented information might have been expected. Furthermore, as reporting occurred at two-yearly intervals, it would be useful to Member States to chart progress on the Code and resolutions. Her country welcomed the draft global strategy on infant and young child feeding as it built on important earlier initiatives and was consistent with the International Code and relevant resolutions. It supported the amendments proposed by the Islamic Republic of Iran and Zimbabwe, and requested the Organization to supply the requisite funds to develop and produce a new international reference for assessing health, growth and nutritional status on the basis of the multicentre growth reference study referred to in paragraph 23. Ms VALDEZ (United States of America) said that document ASS/14 gave an accurate description of the global burden of the major forms of malnutrition and the particular challenges each form represented. Improved nutritional status for infants and young children was of the utmost priority

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for all Member States. However, much more research was needed on the role of nutrition in mother-tochild transmission of HIV, as well as on the impact of antiretroviral drugs on lactation and infant nutrition and on malnourished pregnant or lactating women. She applauded the process that had led to the global strategy and commended the painstaking step-by-step approach (document A55/15) as a model for other relevant WHO programmes. As stated in the briefing note submitted to the regional committees in July 2000, successful international strategies all shared common features: careful preparation, a clear scientific basis, widespread ownership, and acceptance by both governments and other stakeholders. The global strategy had all those qualities. Nevertheless, in paragraph 48 of the strategy, under the section "Supporting policy development and promotion", the words "are consistent with" in the fourth bullet should be replaced by "give full consideration to" in order to bring the text into line with paragraph 4 of resolution EB 109.Rl8. Similarly, the phrase "are given full consideration" should be used in the fifth bullet. Dr MHLANGA (South Africa) said that his country was facing the simultaneous dual challenge of overnutrition and undernutrition. Inappropriate eating habits combined with physical inactivity were leading to overnutrition, while overzealous marketing of inappropriate foods, together with the low prices of those foods, made them tempting. Unfortunately, the problems would be handed down from one generation to the next. It was particularly important to address women's health and nutrition per se, and not merely as a means of safeguarding the well-being of children. Member States should therefore make the nutrition of both women and children a priority. In many cultures, men tended to be given food first and the rest of the family had to be content with what was left over. His delegation was in favour of the amendments proposed by Zimbabwe and endorsed the views of the Islamic Republic oflran, the Netherlands and Turkey. Dr BORWOM NGAMSIRIUDOM (Thailand) advocated expanding the programme to prevent mother-to-child transmission of HIV by including antiretroviral treatment for post-parturition HIVpositive mothers. That measure would extend the life of mothers, help to prevent malnourishment and increase survival among infants and young children. His delegation was concerned that the global strategy paid insufficient attention to the increasing problems of obesity in developing countries. Micronutrient deficiency could be overcome if legislation made it compulsory to fortify all table salt with iodine. His country endorsed the global strategy and supported the draft resolution contained in resolution EB109.Rl8. Dr CONOMBO KAFANDO (Burkina Faso) said that, in the countries in her region, poor hygiene and a shortage of drinking-water were not conducive to the use of substitute products. Breastfeeding was the only way to improve the health of infants and very young children; it also strengthened the bond between mother and child. In Burkina Faso, 97.8% of mothers breastfed their infants and the Government had taken steps to implement the International Code of Marketing of Breast-milk Substitutes and the Baby-friendly Hospital Initiative, and to promote breastfeeding in order to combat malnutrition. While supporting the draft resolution, she proposed that the expression "civil society" should be deleted as it could be misleading, and that a new paragraph should be inserted after the third preambular paragraph that would read: "Recognizing that infant mortality can be reduced by exclusive breastfeeding during the first six months, combined with the introduction of safe, appropriate, complementary local foods and continued breastfeeding up to the age of two or beyond". She further proposed the addition of a new operative paragraph 2( 4) that would read: "to ensure that the introduction of micronutrients does not replace or erode the practice of exclusive breastfeeding and the optimal introduction of complementary foods and that the marketing of nutritional supplements complies with the protective provisions of the International Code of Marketing of Breastmilk Substitutes and with subsequent resolutions of the Health Assembly".

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Dr ARMADA (Venezuela) said that his country was pursuing a social policy that placed emphasis on the nutrition of lactating mothers and of infants in the belief that adequate nutrition was essential for better health. His Government had applied the International Code as part of a general policy of encouraging breastfeeding and it had been incorporated in new legislation, currently before Parliament. His delegation endorsed the global strategy, but considered that one of its objectives should be the improvement of maternal health and nutrition, and that reference to the mother-child relationship should be supplemented by mention of fathers, whose support was of fundamental importance to good breastfeeding practices. His delegation endorsed the draft resolution and the amendments proposed by Zimbabwe. Mrs MUXI (Uruguay) said that the implementation of the global strategy would not only promote, protect, and support breastfeeding, but would also make it possible to give effect to the International Code ofMarketing of Breast-milk Substitutes and Health Assembly resolutions. Uruguay had introduced rules protecting breastfeeding in 1997, had updated them in the light of scientific evidence and Health Assembly recommendations, and was advocating exclusive breastfeeding for the first six months. Uruguay had established a national Codex committee and played an active part in the technical meetings of the various international committees and forums, so as to ensure that decisions taken at the national level were consistent with those of WHO and other international bodies. She therefore proposed that the words "by means of adequate labelling" should be inserted in paragraph 4 of the draft resolution after the words "at an appropriate age", and that the word "consistent" should be replaced by "in accordance". She further suggested the inclusion of a footnote referring to resolution WHA54.2, paragraph 2(9). Her delegation supported the amendments proposed by the Islamic Republic oflran, the Netherlands and Zimbabwe. Mr JHA (India) said that his country endorsed the global strategy, but feared that renewed debate about infant feeding might dilute previous Health Assembly resolutions on that vital issue. His delegation was concerned about the use of the expression "commercial groups" in paragraph 2(4) of the draft resolution, since commercial enterprise was profit-driven and therefore unlikely to be prepared to collaborate with governments to protect, promote and support breastfeeding. Since the draft resolution appeared to allow scope for commercial interests and a conflict of interests, his delegation proposed that the word "commercial" should be deleted from paragraph 2(4) and the phrase "in the spirit of resolution WHA49 .15" should be inserted at the end of that paragraph. In addition, the draft resolution should contain a global public health recommendation to the effect that exclusive breastfeeding should last for six months and be accompanied by the provision of safe and appropriate complementary foods, with continuing breastfeeding up to two years of age or beyond. Mrs TIHELI (Lesotho) said that her delegation attached great importance to the health of infants and young children. Malnutrition, diarrhoea, acute respiratory infection and other preventable childhood diseases continued to pose great challenges to the health system of her country. The HIV I AIDS pandemic had further complicated the situation. Lesotho was currently experiencing a serious food shortage and, as was so often the case, vulnerable groups such as women and children were worst affected. Wasting was estimated at 16% and total energy deficit was put at 60%. She therefore called for further assistance to resolve the problem. Nevertheless, an estimated 58.1% of mothers exclusively breastfed their children for six months and her Government was working hard to improve that figure. The provision of micronutrients for lactating mothers should be considered in that connection. Her delegation supported the amendments proposed by India, the Islamic Republic of Iran and Zimbabwe, and proposed, in addition, that in paragraph 2(1) the phrase "as appropriate to national circumstances" should be deleted, that "taking into account" should be replaced by "while respecting positive", and that the phrase "and to reduce the risks associated with obesity and other forms of malnutrition" should be added at the end of the paragraph. With those amendments Lesotho could support the draft resolution.

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Mr KINGDON (Australia) welcomed the comprehensive overview of the Organization's activities and countries' progress in protecting and supporting infant and young child feeding and the updated information on advances in the implementation of the International Code of Marketing of Breast-milk Substitutes. Australia had taken a number of initiatives to improve the nutrition of mothers and infants in recognition of the fact that sound nutrition in the early years contributed to better health in adulthood. The Code was actively being implemented in Australia, where the marketing of infant formula products was monitored through a voluntary agreement, known as Marketing in Australia of Infant Formulas' Manufacturers and Importers Agreement, which was designed as a self-regulatory mechanism to protect the public from the inappropriate marketing of such products. Since the introduction of that Agreement, the number of complaints had declined. Procedures were in place to monitor compliance with the Agreement and to advise the Government accordingly. Australia would continue to collaborate in the context of the Agreement. He expressed concern about the large number of amendments being proposed to the draft resolution and suggested that they would be better handled by a drafting group. Mrs DE HOZ (Argentina) said that her country had a long history in the area of maternal and child health and had developed optimum nutrition strategies for mothers and infants. Breastfeeding was promoted and supported, and was at the heart of a strategy geared to providing equal opportunities to all infants born in Argentina. Much work had been done on the Baby-friendly Hospital Initiative and, more recently, on baby-friendly health centres. The International Code of Marketing of Breast-milk Substitutes was in force and was subject to periodic monitoring in collaboration with UNICEF and WFP. In that connection document A55/14 did not provide sufficient information on the progress made in implementing the Code. Since 1998, Argentina's legislation on infant and young child nutrition had recommended exclusive breastfeeding for the first six months and continued breastfeeding up to two years. As a result of those and other measures, statistics for the year 2000 showed that 75% of babies were breastfed until six months and most continued to be breastfed until two years of age, or beyond. In the interests, therefore, of optimizing the text of the resolution, Argentina supported the proposals by Uruguay and Zimbabwe. In addition, to make it clear that the global strategy would have the same transparency and independence as resolution WHA49.15, it proposed that in paragraph 2(4) the word "commercial" should be deleted and the words "in the spirit of resolution WHA49.15" added at the end. Mrs FELIU ESCALONA (Cuba) stressed that Member States must understand that the development of young children shaped the future of new generations and would reduce the morbidity and mortality rates of that group. The underdevelopment of children was as much a health risk factor as lifestyle, environment and poor health services. Governments and society as a whole should be committed to protecting the new generation at the initial stages of their lives. It was particularly important that Member States should at all levels ensure that inadequate feeding became a thing of the past by promoting breastfeeding and the health and nutrition of mothers. The strategy was comprehensive and had been updated with modern scientific evidence. Member States that had not yet implemented it should create an environment in which they could do so. WHO for its part should devise an evaluation and follow-up system and report to the Health Assembly every three years. Cuba supported the draft resolution contained in resolution EB 109.R18 with the proposed amendments. Ms AROSEMENA (Panama) said that it was crucial that the sovereignty and independence of national governments should be maintained in implementing the International Code of Marketing of Breast-milk Substitutes and subsequent relevant Health Assembly resolutions in conformity with their respective social and legal frameworks. She therefore proposed that in the fourth bullet of paragraph 40 of the global strategy (document A55/15), the words "in accordance with national

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measures" should replace "adopted to give effect to both". A consequential amendment should then be made in the last phrase of paragraph 44 so that it would read:" ... subsequent relevant Health Assembly resolutions in accordance with national measures". Dr MOHAMAD TAHA (Malaysia) said that Malaysia had adopted and adhered strictly to the national code of ethics for infant formula products, and protected and supported breastfeeding. In order to ensure effective implementation of the International Code of Marketing of Breast-milk Substitutes, WHO should take action against the manufacturers and distributors of industrially produced infant foods that violated the codes of practice, increase scrutiny of the marketing practices of manufacturers of feeding bottles and teats, and urge and assist Member States to implement the Code nationally to improve compliance. His delegation supported the draft resolution contained in resolution EB 109.R18 with the amendments proposed by the Islamic Republic of Iran, Panama and Zimbabwe. Ms BLAKER (Norway), speaking on behalf of the five Nordic countries, Denmark, Finland, Iceland, Sweden and Norway, welcomed the progress made to ensure adequate nutrition for infants and young children. She also welcomed the reference to human rights in paragraph 3 of the global strategy annexed to document A55115, and the public health recommendation to protect, promote and support exclusive breastfeeding for the first six months, as well as the essential message of the strategy, that there was a need to develop comprehensive national policies on infant and young child feeding, including the responsibilities of different sectors of society. Such policies should incorporate follow-up of special activities, such as the Baby-friendly Hospital Initiative, and implementation of the International Code of Marketing of Breast-milk Substitutes. Specific policies should also be integrated into overall national food and nutrition policies and should be broad in scope, covering such aspects as maternity leave in the context of maternity protection. More information was needed on the diet of infants and young children and the nutrition-related health problems of mothers and children; more research was also needed on HIV and breastfeeding in order to guide future policy. As nutrition in resource-limited countries differed significantly from nutrition in richer countries, recommendations should take into account access to safe drinking-water and hygienic conditions. With regard to the multicentre growth reference study discussed in paragraph 23 of document A55114, she emphasized the importance of the new international reference curve for assessing the nutritional status and health of children and, consequently, for promoting child health and development globally. Its implementation should be given top priority by WHO and Member States. The Nordic Countries supported the global strategy on infant and young child feeding and the draft resolution as it stood. Dr DA YRIT (Philippines) said that document A55/14 contained insufficient information on the implementation of the International Code of Marketing of Breast-milk Substitutes and suggested that a more thorough report should be provided. In addition, the Executive Board should devise a mechanism for monitoring implementation of the Code. The global strategy on infant and young child feeding (document A55/15) was confusing. The section "Exercising other feeding options", for example, referred to instances when breastfeeding was not possible without clearly explaining what they were. An appendix containing the necessary explanations should therefore be provided. In the case of babies unable to take breast-milk at all or only able to take milk from a wet nurse, acute discernment was needed together with thorough training of health workers. Furthermore, while the document was not sufficiently specific on the subject of the desirable nutritious indigenous foods, it was too specific in its statements on industrially-processed complementary foods. Such details might best be included in a technical appendix. In sum, there was little to guide a country such as his own through the implementation ofthe Code.

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As the strategy stood, therefore, it could undermine breastfeeding by not stating clearly the situations in which it was not possible; it could inadvertently promote industrially-processed complementary foods; and it could weaken previous efforts to protect breastfeeding from commercial interests by not providing adequate guidance on implementation of the Code. His country found it difficult to endorse the strategy as drafted. Dr AL-KATTAMI (United Arab Emirates) stated her country's total commitment to the implementation of the International Code of Marketing of Breast-milk Substitutes. There were 17 baby-friendly hospitals in her country, four of which were recognized internationally. Several meetings had been held between the Ministry of Health and a visiting WHO expert on breastfeeding issues. A project had subsequently been established to promote breastfeeding and measures had been adopted to ensure full implementation of the International Code. The Ministry of Health was in the process of setting up a committee to promote implementation of the project, with interministerial and intersectoral collaboration to ensure follow-up and enactment of appropriate legislation. Dr KOUNANDI (Cote d'Ivoire) said that, in addition to its general comments, his delegation wished to propose some amendments to the draft resolution. First, a new paragraph should be added after the fourth preambular paragraph that would read: "Recognizing that infant morbidity and mortality could be reduced by exclusive breastfeeding during the first six months and continued breastfeeding up to two years and beyond with the introduction of safe and appropriate local, complementary foods". The words "civil society and the international community" and "and to work together closely for this purpose" should be deleted from the last preambular paragraph. The resolution called on the responsibility of governments, not of civil society and the international community, and reference to them might open the door to commercial and industrial interests that were diametrically opposed to those of the Health Assembly. Paragraph 2(1) should be amended to read: "to adopt and implement the global strategy, taking into account positive local traditions and values as part of the overall nutrition and child health policies and programmes in order to ensure optimal feeding for all infants and young children and reduce the risks associated with all forms of malnutrition, including obesity". In paragraph 2(2), the word "public" should be inserted before "sectors", as it was mainly the public services that would be collaborating with governments. In paragraph 2(4), the word "commercial" should be replaced by "community" in order to prevent the food-processing industry from funding activities or programmes linked to the global strategy, bearing in mind their repeated violations of national and international instruments protecting breastfeeding and child health. In paragraph 4, the word "labelling" should be inserted before "consistent with the policy of WHO". Cote d'Ivoire strongly supported the draft resolution contained in resolution EB109.Rl8 with the amendments proposed, including the proposed new subparagraph on micronutrient deficiencies. (For continuation, see summary record of the fifth meeting, section 2.)

The meeting rose at 12:35.

FIFTH MEETING Friday, 17 May 2002, at 14:40 Chairman: Professor PHAM MANH HUNG (VietNam) later: Professor A.M. COLL SECK (Senegal)

THIRD REPORT OF COMMITTEE B Dr SOEPARAN (Indonesia), Rapporteur, read out the draft third report of Committee B. The report was adopted. 1

TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued from the fourth meeting)

Infant and young child nutrition: Item 13.10 ofthe Agenda (continued from the fourth meeting) • Childhood nutrition and progress in implementing the International Code of Marketing of Breast-milk Substitutes (Document A55/14) (continued from the fourth meeting, section 2) • Global strategy for infant and young child feeding (Resolution EB109.R18; Document A55/15 2) (continued from the fourth meeting, section 2) Dr EL-TA YEB (Egypt) supported the amendments proposed by Cote d'Ivoire, India, Islamic Republic of Iran, Lesotho, Uruguay and Zimbabwe to the draft resolution contained in resolution EB109.R18. Mrs PIERANTOZZI (Palau) endorsed the comments made by India and Zimbabwe with regard to nutrition for mothers. Documents A55/14 and A55/15 were welcome, but did not give enough information on the progress made in implementing the International Code of Marketing of Breast-milk Substitutes, as stated by previous speakers. The proposed global alliance for improved nutrition was only a short-term solution. Malnutrition was a complex problem that could not be solved simply by adding single nutrient supplements to food. Furthermore, the activities of the companies involved in the global alliance might undermine breastfeeding. She therefore supported the amendments proposed by the Islamic Republic of Iran and Zimbabwe. WHO should assist Member States in combating the undesirable influence of private companies on the implementation of health standards. She could not support the amendment proposed by the delegate of Panama. She acknowledged the contributions made by UNICEF in assisting Palau with training and the establishment of a baby-friendly hospital. Mr DEBRUS (Germany) supported the draft resolution as it stood, and opposed many of the proposed amendments, in particular, the proposal by Lesotho to delete the phrase "as appropriate to 1

See page 275. See document WHASS/2002/REC/1, Annex 2.

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national circumstances" from paragraph 2.1. The draft resolution should remain in the form adopted after extensive deliberations in the Executive Board. He welcomed the reference to the joint responsibility of governments and society as a whole in the promotion of breastfeeding and the adequate nutrition of young children. A recent study in Germany had revealed that, although children were being breastfed for longer than before, the rates still declined drastically from an initial 60% to just over 10% among children aged six months. That indicated a need for improved coordination of assistance for mothers with breastfeeding problems, and for the regular collection of data on breastfeeding trends. Or PENDAME (Malawi) explained that the implementation in Malawi of the recommended strategies on breastfeeding, baby-friendly hospitals, the International Code of Marketing of Breastmilk Substitutes and micronutrient supplementation were hindered by the extent of food insecurity at the household level, and low income, which prohibited the purchase of breast-milk substitutes by women with HIV/AIDS. He supported the draft resolution and called on WHO to carry out further analysis in the light of the circumstances he had highlighted, with a view to drawing up specific strategies for countries like Malawi. Or MOHAMED (Kenya) endorsed the comments made by India and Zimbabwe. He preferred to refer to the first six months of life, rather than to the first four months, as in the second preambular paragraph of the draft resolution, and wanted a more explicit reference to a six-month breastfeeding policy. He suggested replacing the word "commercial" in paragraph 2(4) with either "private", "community" or "private and community". He warned of the danger of using the word "substitute" rather than "supplement", given the need to guard against inappropriate use of substitutes. Breastfeeding and substitutes were not mutually exclusive. Mr CICOGNA (Italy) agreed that the two guiding principles for elaborating the global strategy should be enhanced participation and the need to take account of the best available scientific and epidemiological evidence. Implementation should be tailored to suit the specific needs of individual countries, and should build on past achievements. Given that the strategy was a guide for action, the proposed appointment of national breastfeeding coordinators and multisectoral committees should be presented as suggested options, and countries should be given the opportunity to consider alternatives in the light of their individual circumstances. He strongly supported the proposal by the delegate of Australia that a drafting group be convened to revise the draft resolution. The text recommended by the Board was well-balanced incorporating the outcome of fruitful and extensive discussions in previous Health Assemblies, as well as in the Board itself. He was confused by the numerous amendments proposed and could not support them without the clarification provided by a drafting group. Or ABDALLAH (United Republic of Tanzania), indicating her support for the global strategy on infant and young child feeding, said that her country had introduced a national programme on infant and young child nutrition, based on a multisectoral approach. The national code of marketing of breast-milk substitutes had enjoyed legal status since 1994. The global strategy would be a useful tool in strengthening those efforts. She supported the draft resolution, and the amendments proposed by the delegates of Cote d'Ivoire, India, Islamic Republic of Iran, Lesotho and Zimbabwe. Or AL-JABER (Qatar) supported the proposal by the delegate of Lesotho that paragraph 2(1) should be amended by deleting "as appropriate to national circumstances". The aim should be to develop a universal standard, not to emphasize national differences. He did not support the suggestions made by Panama. Mrs BENAVIDES COTES (Colombia) said that her Government had been stepping up efforts to promote healthy and nutritious food for infants and young children with the implementation of the

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national food and nutrition plan, for the period 1996-2005, and the plan for the protection and support of breastfeeding, for the period 1998-2008. National practice was firmly based on the principle that breastfeeding should take place for the first six months of life and food supplements used for the first two years. Welcoming the global strategy for infant and young child feeding, she stressed the importance of a multisectoral approach, for instance, by promoting collaboration with the ministries of agriculture and education, but she expressed concern about several proposed amendments to the draft resolution. It was inadvisable to alter a text that had emerged from an extensive and participatory process involving Member States, intemational organizations, nongovernmental organizations, medical professionals and representatives of the food industry. By adopting the Millennium Declaration of the United Nations, heads of state and government had committed themselves to establishing solid links with the private sector and civil society organizations in the promotion of development and the elimination of poverty. Such interaction had already enhanced efforts to combat health problems, for instance, by the donation of specific drugs, or by assistance with vaccination programmes, and agreements reached with publishers had led to free or low-cost Internet access to medical journals for schools and research centres in developing countries. She therefore supported the draft resolution as it stood. Mrs MWEWA (Zambia) explained that malnutrition was a leading cause of morbidity and mortality among children under the age of five in her country. Consequently, her Government was taking various steps, such as reviewing the Code of Marketing of Breast-milk Substitutes, reviving baby-friendly hospital initiatives, providing counselling on breastfeeding and infant and child feeding, reassessing the period for maternity protection, implementing growth monitoring, commercially fortifying sugar with vitamin A, and developing protocols for malnourished children. She supported the draft resolution with the various amendments proposed. Dr SULEIMAN (Oman) expressed support for the draft resolution with all the proposed amendments. He commended all those associated with the WHO multicentre growth reference study, the results of which would shortly be available for analysis. The study would make a significant contribution in the context of comparing data on breastfeeding and growth rates in different areas of the world. Dr TUIKETEI (Fiji), stressing the fact that malnutrition mainly affected the most vulnerable groups in society, said that strategies adopted by many governments had proved inadequate, since they failed to address the underlying factors behind nutritional problems. It was essential to tackle the root causes: poverty, low family planning coverage, low immunization rates, unsafe water supply, poor sanitation, low literacy level and an absence of relevant policy guidelines. In Fiji, strategies and programmes were pursued in close collaboration with the private sector and local communities in order to increase their effectiveness. Activities at national level included the fortification of flour with iron, provision of vitamin A supplements, integrated management of childhood illnesses, monitoring of nutritional status of children in clinics and schools, promotion of baby-friendly hospitals, preparation of legislation concerning the code of marketing of breast-milk substitutes, and strengthening of health promotion. She supported the proposal by the delegate of Australia that a drafting group be established to consider the draft resolution. Mr DUARTE CARDOSO (Brazil) endorsed the draft global strategy on infant and young child feeding and supported the draft resolution. In view of the many amendments proposed, he suggested that a revised text should be circulated before the draft resolution was discussed further. Mr EL ABASSI (UNICEF) said that the draft global strategy was a major step forward, based on factual data, field experience and dialogue between all parties concerned with child development and survival. UNICEF was pleased with its fruitful collaboration with WHO in the complex and difficult drafting process.

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Exclusive breastfeeding to the age of at least six months and optimal infant and young child feeding were crucial not only to growth and survival, but also to psychosocial and cognitive development. Pregnant women must receive adequate nourishment in order to reduce the number of low birth-weight babies. An adequate supply of micronutrients, given in the form of, for example, iron, iodine and vitamin A supplements, for both children and mothers had a considerable impact on the health and development of the child. It was important to put an end to the confusion over the breast-feeding of infants in regions and countries affected by HN/AIDS, by adhering to the relevant recommendations of the Fifty-fourth World Health Assembly. UNICEF would increase its support to countries for the implementation of the global strategy and the International Code of Marketing of Breast-milk Substitutes and would continue to work with WHO to develop implementation tools and methodology for all aspects of the global strategy. The 4% increase in exclusive breastfeeding in recent years had prevented at least one million infant deaths; that progress should be sustained. Ms ALLAIN (Consumers' International), speaking at the invitation of the CHAIRMAN, said that the key role played by the International Code of Marketing of Breast-milk Substitutes and the subsequent relevant Health Assembly resolutions had been highlighted by recent warnings of contamination of powdered infant formula with Enterobacter sakazakii and the death of a five-day-old bottle-fed boy in Belgium - examples of the risks of artificial feeding in all countries and settings. There was an urgent need for adequate labelling of infant formula, with a clear warning of the risks involved in artificial feeding, and for independent testing of product safety. The International Code and associated resolutions and the draft global strategy were of universal importance. The International Baby Food Action Network (IBFAN), of which her organization was a founding member, would fully support the global strategy when it was adopted, but it was important to know what other parties would be involved in its implementation. Involvement of the commercial sector might lead to conflicts of interest and undermine everything the global strategy sought to achieve. Despite the current enthusiasm for partnerships with the private sector, her organization was wary: it had seen too many cases of industry interference. For example, at the current Health Assembly an infant formula manufacturer had written letters to ministers of health in an attempt to reduce the effect of the International Code. Public relations material distributed in Latin America had implied that the International Code was fully observed when that was not, in fact, the case and company information targeted at mothers contained conflicting information. She welcomed the role assigned to commercial enterprises in the draft global strategy (document ASS/15, Annex, paragraph 44), which stated that their conduct should conform to the International Code and its associated Health Assembly resolutions and national measures. Commercial enterprises should fully respect that provision in order to avoid conflicts of interest. IBF AN had worked with governments and WHO to protect and promote breastfeeding for over 20 years, and its contribution had been acknowledged by the Director-General of WHO. She was concerned to note, however, that only one paragraph in document ASS/14 had been devoted to the implementation of the International Code (paragraph 20). Such treatment did not do justice to the efforts of Member States or IBF AN. Ms LA VIOLLE (La Leche League International), speaking at the invitation of the CHAIRMAN, said that the optimum feeding practices defined in the draft global strategy- exclusive breastfeeding for the first six months of life, supplemented by appropriate local foods until the age of two years or more- might seem a challenge to some, but the 30 000 volunteers of her organization, in 63 countries, had achieved it themselves and helped other mothers to do so as well. La Leche League International would inform its trained volunteers about the global strategy and encourage them to assist WHO and Member States if called upon to do so. Her organization was willing to share the resources of its Centre for Breastfeeding Information with health professionals and policy-makers. It endorsed the International Code of Marketing of Breast-milk Substitutes. It did not accept funding from companies that violated the International Code, and did not allow them to exhibit at its local,

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national, or international events. It called on Member States to respect Health Assembly resolution WHA49.15, designed to ensure that financial support from commercial sources for health professionals did not create conflicts of interest, and urged Member States and WHO to make use of the grass-roots expertise of organizations such as her own. Dr BRONNER (International Association of Infant Food Manufacturers), speaking at the invitation of the CHAIRMAN, welcomed the draft global strategy as an important contribution to future initiatives in the critical area of infant and child nutrition. She welcomed the all-inclusive approach of the global strategy and the draft resolution which acknowledged the constructive role that infant food manufacturers could and did play. Her organization was willing to participate in publicprivate partnerships to improve infant and young child feeding and supported the full implementation of the International Code of Marketing of Breast-milk Substitutes. The members of her organization devoted considerable resources to research on paediatric nutrition and the development of nutritionally balanced processed foods. Her organization therefore welcomed the scientific process advocated in the draft global strategy and looked forward to contributing constructively to it. She supported the Director-General's view that interested parties should meet to try to resolve the outstanding issues blocking implementation of the International Code, in particular the lack of clearly defined government regulations, inadequate and non-transparent enforcement mechanisms, and confusion about the scope of the International Code. Ms LEHMANN-BURI (International Lactation Consultant Association), speaking at the invitation of the CHAIRMAN, thanked WHO for undertaking the enormous task of creating a sciencebased global strategy on infant and young child feeding, which could be expected to reduce morbidity and mortality among mothers and their babies. In her organization's opinion, the preamble of the draft resolution proposed by the Executive Board should specify that exclusive breastfeeding was recommended for the first six months of life, in accordance with Health Assembly resolution WHA54.2. The invitation in the draft resolution to industrial and commercial enterprises and their associations to help implement the global strategy should be linked to a requirement that such assistance should be consistent with the International Code and relevant subsequent Health Assembly resolutions. Her organization had the expertise to provide practical, clinical and evidence-based technical support for the implementation of the draft global strategy, and was ready to assist in the effort to improve the health and nutrition of infants and young children. Dr TURMEN (Executive Director) thanked participants for their supportive and pertinent comments. She also expressed her appreciation to all those involved in the preparation of the draft global strategy, which was the fruit of four years of collaborative efforts between WHO, UNICEF, Member States and other parties in a science-based national, regional, and global consultative process. At the 109th session of the Executive Board in January 2002, some Member States wished to make further contributions to the draft. A circular letter had accordingly been sent to all Member States asking for further comments, which had been incorporated. The next step was to determine how the global strategy should be applied in the specific conditions prevailing in each country. WHO would support Member States in that endeavour. The draft global strategy built on past achievements and reaffirmed Member States' commitment to attaining the goals of the Innocenti Declaration on the Protection, Promotion and Support of Breastfeeding, the implementation of the Baby-friendly Hospital Initiative and the more widespread observance of the International Code of Marketing of Breast-milk Substitutes. However, the draft global strategy went further: it called for a comprehensive policy on infant and young child feeding; for support from all relevant sectors; for promotion of complementary feeding combined with continued breastfeeding; for guidance on feeding in exceptionally difficult circumstances; and for consideration of new measures to revitalize the International Code and subsequent relevant Health Assembly resolutions. The strategy took an integrated and comprehensive approach and stressed that the measures it described should be implemented as soon as possible.

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Some speakers had referred to the lack of information in document ASS/14 on the implementation of the International Code at national level. That report was intended to reflect only the developments since the previous report, and there had been little new information because most Member States had already reported at least once. Other parts of the report, such as those relating to the Baby-friendly Hospital Initiative (paragraphs 14 and 15), gave some information about developments at a national level. However, such reports were restricted in length, and document ASS/14 was already longer than the norm. The draft giobal strategy reiterated the importance of implementing the International Code and called upon governments to decide what new measures were needed to improve its implementation. Further information from Member States should, therefore, be forthcoming in the future. The four-year development of the draft global strategy had included a technical consultation involving the world's leading experts in paediatric nutrition, held in March 2000. WHO and UNICEF had then produced the first draft of the global strategy, which had been discussed in seven national and six regional consultations, involving over 100 Member States, during 2000 and 2001; eight nongovernmenta1 organizations and six international organizations had also been consulted. Regular reports had been submitted to the regional committees, the Executive Board and the Health Assembly. She was therefore surprised at the concerns raised by the delegate of Philippines, in particular, since that country had made a valuable contribution to the draft global strategy in a country consultation in Manila in December 2000 and a senior-level consultation in Kuala Lumpur, and had endorsed the draft global strategy as recently as April2002. Once adopted, the global strategy would provide a platform for further action by WHO and Member States. The CHAIRMAN said that, in the absence of any objection, he took it that the Committee wished to establish a drafting group to consider the draft resolution contained in resolution EB 109 .R 18 and to resume its consideration of item 13.10 once the drafting group had completed its work. It was so agreed.

(For approval of the draft resolution, see summary record of the sixth meeting, section 3.) Diet, physical activity and health: Item 13 .11 of the Agenda (Resolution EB 109 .R2; Documents ASS/16 and ASS/16 Corr.l)

Mrs ABEL (representative of the Executive Board), introducing the draft resolution contained in resolution EB109.R2, said that the Executive Board had reviewed a report on diet, physical activity and health, which had highlighted the increasing burden of noncommunicable diseases in both developed and developing countries. The Board had noted the transition in many countries from a high degree of physical activity in daily life towards physical inactivity, unbalanced nutrition and obesity. That trend was due to global social and economic changes, including growing urbanization and changes in work and modes of transport. The Board had welcomed the initiative to develop a global strategy on diet, physical activity and health, noting the limitations of purely national efforts. The draft resolution called upon Member States and WHO to develop global and national strategies on diet and physical activity in the context of health promotion and disease prevention, and requested the Director-General to submit a progress report on integrated noncommunicable disease prevention to the Health Assembly in May 2003. Mr COSTI SANTAROSA (Brazil), recalling that Brazil had sponsored resolution EB109.R2, said that the timetable that had been proposed would not allow adequate time for the issues to be properly analysed. He therefore proposed that submission of the progress report should be postponed until 2004 and that paragraph 2(4) of the draft resolution should be amended accordingly. He

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expressed appreciation for the Director-General's visit to Brazil on the occasion of World Health Day 2002. Dr LARIVIERE (Canada) said that Canada had adopted three objectives to help its citizens improve their health: to promote physical activity as fundamental to health and well-being; to encourage the integration of physical activity into daily life; and to reduce barriers to physical activity. To attain the objectives, the Government was working with civil society to create working and social environments that made it easy and fun to be physically active. A lack of physical activity, an unhealthy diet and excessive food energy intake were contributing to obesity and overweight; almost half the population were of a weight associated with higher health risks. Disparities in nutritional wellbeing among vulnerable population groups were being given priority attention. Of particular concern were adolescents who were at risk of experiencing serious problems related to diabetes and cardiovascular disease in later life. Considerable progress had been made in identifying the nature of the problem, but much better solutions were needed to address it. Solutions would only be found through research and the sharing of collective experiences in collaboration with WHO. Following the successful launch of World Health Day in Brazil, Canada wished to propose that the draft resolution contained in resolution EB109.R2 should be amended by the insertion of an additional operative paragraph to read: "FURTHER URGES Member States to celebrate a Move for Health Day each year to promote physical activity as essential for health and well-being". If the proposal was acceptable, the Director-General might be asked to select an appropriate date. Mr CASTILLO SANTANA (Cuba) observed that lifestyles were closely linked to the cultural, social and culinary values of a community. It was therefore difficult to identify appropriate health actions and introduce healthy eating habits that would be acceptable to different peoples. In this respect health promotion strategies should be adapted to the needs of every Member State, taking into consideration future generations. Such changes could, of course, only be introduced when the population had access to appropriate food and the possiblity for physical activity, always bearing in mind that throughout the world, there were children and adolescents suffering from undernutrition as a result of a lack of basic foodstuffs. Careful thought should be given to formulating an appropriate strategy and to helping the very poor. The strategy should take account of the culinary traditions of different countries and the capabilities of each Member State and should seek to overcome current inequalities. Health promotion activities must be geared towards achieving substantial changes in lifestyles, building on the positive experiences gained so far. In paragraph 8 of document ASS/16 reference was made to the joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases, which had taken place in January/February 2002 and to its report, which had been reviewed in April 2002. He understood that the report, due to be published by the end of 2002, included a list of conclusions and recommendations which, inter alia, dealt with issues related to national policies and other aspects that were potentially outside the scope of a purely technical study. He urged the Organization to ensure that the consultation process was transparent; it would be unsatisfactory if such an important and far-reaching piece of work encountered difficulties as a result of a lack of information. Mrs KOMODIKI (Cyprus) commended WHO's efforts to develop effective strategies for the prevention of noncommunicable diseases, using relatively low-cost measures relating, in particular, to diet, physical activity and smoking. In Cyprus, chronic diseases, particularly cardiovascular diseases, were emerging as the main public health problem, which was not surprising since some 38% of men smoked, one-quarter of the population was obese, one-third had high cholesterol levels and only 8% of the population took regular exercise. However, Cyprus had benefited from the sharing of knowledge and experience with other countries through the countrywide integrated noncommunicable diseases intervention (CINDI) programme, which had assisted in the strengthening of national capacities and the development of preventive programmes. All countries should have a similar opportunity.

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Mrs KRISTENSEN (Denmark) strongly supported WHO in taking a leading role to counteract the alarming development of overweight and obesity. In formulating the proposed global strategy a multidisciplinary and multisectoral approach would be imperative. Denmark had decided to focus on the manifold hazards and negative consequences of obesity during its forthcoming Presidency of the European Union. Consequently, a conference on obesity would be held on 11 and 12 September 2002 in Copenhagen with the aim of developing and facilitating a broad integrated approach to the problem. Although document A55/16 contained important international findings, many questions remained unanswered: for example, what needed to be done to change risky behaviour among vulnerable groups, and what determined individual preferences for certain types of food? The determinants and mechanisms behind dietary habits and physical habits were highly complex, and evidence-based strategies would be required in order to instigate changes in behaviour. It was not enough to consider diet and physical activity as a simple balance over which individuals had control. She therefore proposed that the draft resolution be amended by adding two subparagraphs after paragraph 2(1) to read as follows: (2) "to support further research on effective implementation of different means leading to healthier lifestyles", and (3) "to ensure that a multidisciplinary and multisectoral approach is a governing idea of the global strategy'', the remaining subparagraphs to be renumbered accordingly. Mr KINGDON (Australia) strongly supported the development by WHO of a global strategy on diet, physical activity and health and the establishment of a stronger evidence base of what worked and did not work in that area. More needed to be learned about the effectiveness and cost-effectiveness of interventions in order to address the alarming decline in physical activity and in the quality of people's diet worldwide. International collaboration and the sharing of experiences would be beneficial in undertaking research in that regard. Australia had increased its efforts in that area in recent years. Current activities included: the "Eat Well Australia 2000-201 0" strategy and the accompanying "National Aboriginal and Torres Strait Islander Nutrition Strategy and Action Plan 2000-201 0"; the development, dissemination and review of evidence-based dietary guidelines targeting children and adolescents, adults and the elderly; the development and implementation of a national action plan for 2000-2005 to increase the consumption of fruit and vegetables, and a recently published review of physical activity interventions for a range of settings and population groups. Australia looked forward to collaborating with WHO and the Member States, and to sharing experiences and information as the new global strategy developed. Consultation with industry and other stakeholders in devising the strategy would be critical to its successful implementation. Ms V ALDEZ (United States of America) said that, as part of its agenda to prevent disease through better living, the United States Department of Health and Human Services was implementing initiatives to encourage daily exercise, greater consumption of fruit and vegetables and avoidance of tobacco use. Obesity was recognized as a major public health problem, and environmental changes and research to support evidence-based interventions to help such disorders were being encouraged. The development of public-private partnerships was a key element of that work. The benefits of physical activity extended beyond chronic disease prevention and weight control. The positive effect of preserving independence for older adults was particularly significant as the global population aged. Economic analyses of the costs of inactivity and the savings associated with physical activity provided further support for its promotion. Physical activity also complemented other important national policy issues, such as tobacco control, urban safety, environmental issues and transportation. In promoting good nutrition, the food industry could be an important collaborator. Bringing industry into the discussion as a willing partner in research and in seeking solutions to the crisis could be a positive factor. She looked forward to the report of the joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases, but urged WHO to allow sufficient time for the review process and to obtain contributions from a range of stakeholders, including the scientific research community, industry, nongovernmental organizations and professional health societies. Clarity about

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the scientific basis for the recommendations, such as specific recommended intake levels and the process used in developing them, would enhance the report's effectiveness and facilitate wider adoption. The United States hoped that Member States would have an early opportunity to provide comments on the draft report before its finalization. WHO should focus, in particular, on strategies for implementation at the country level. Care should be taken to ensure that any recommendations were based on sound scientific evidence. Further research was needed to determine the relative importance of different dietary components, including fruit and vegetables, fat, salt, antioxidants, fibre, calcium and potassium and on the appropriate balance between calorific intake and physical activity. Better monitoring of scientific data and more research were needed in a broad spectrum of related areas. She cautioned against extrapolating research data from developed countries to developing countries. The draft resolution represented a good first step in the right direction. Dr BORWOM NGAMSIRIUDOM (Thailand) indicated that a recent study on the burden of disease in Thailand had demonstrated that noncommunicable diseases related to diet and physical inactivity were responsible for 3 5% of years of life lost among men and 49% among women, of which 9% and 13%, respectively, were due to cardiovascular diseases. Policy-makers had therefore introduced additional primary prevention and healthy lifestyle measures, including, "Exercise for Health" for 2002 and beyond, in line with WHO's "Move for health" campaign. Moreover, the benefits of a healthy diet had been widely publicized through the media. His country's experiences in that area might be useful in formulating the proposed global strategy on diet, physical activity and health. He warned that dietary supplements were increasingly being promoted in a way that was misleading, and surveillance and proper regulation were needed; slimming aids, in particular, were no substitute for physical activity. Collaboration with industry was needed to ensure balanced information and accurate labelling. He supported the draft resolution. Mrs ALLEN-YOUNG (Jamaica) observed that the prevalence of obesity in her country was significant, particularly among women. The Ministry of Health had developed an aggressive health promotion strategy aimed at reducing the risk factors for noncommunicable diseases to address the problem. The strategy, which would be further developed and extended in the future, included: innovative health-education and health-promotion strategies, incorporating local culture, music and indigenous cuisine; well-located and well-timed health fairs that underlined all the risk factors for chronic diseases and emphasized the benefits of integrating healthy eating and exercise in the daily routine; collaboration with transnational fast-food companies to encourage them to produce healthy menus; and employment of behavioural change officers to serve as counsellors and workers in health centres and the community. She supported the draft resolution. Professor GRABAUSKAS (Lithuania) said that several national research projects in Lithuania, including the monitoring of health behaviours, clearly demonstrated that lifestyles were dynamic, changing direction rapidly and either able to promote health or to increase the risk of ill-health. Data from the Finbalt Health Monitor programme, which had been in operation since 1992, had shown that nutritional habits in Lithuania had changed for the better: the challenge was to ensure that such positive changes could be sustained in the long term. If carried out properly, the monitoring of health behaviours through mechanisms like the Finbalt Health Monitor was both feasible and effective. In the European Region, 30 Member States participating in the CINDI programme had decided to use the Finbalt methodology to evaluate their national programmes. Another option might be to use the methodology developed by WHO as part of its STEPwise surveillance approach. Finally, as a sponsor of resolution EB 109 .R2, Lithuania supported Brazil's request that submission of the report be postponed until2004. Mr TASAKA (Japan) said that Japan was also suffering under the burden of noncommunicable diseases. In order to prolong healthy life expectancy and improve the quality of life, Japan had drawn up a new 10-year plan that placed emphasis on primary prevention, the improvement of health

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promotion, and the introduction of numerical goals through an evidence-based approach that would enable progress to be monitored and assessed. To ensure the success of the campaign, his Government had recently submitted legislation to the Japanese Parliament that focused on the provision of information, harmonization of health services for each life stage, and strengthening of the health promotion infrastructure. With regard to food labelling, he asked whether WHO had participated in the recent meeting of the Codex Committee on Food Labelling. Mr CHAKALISA (Botswana) said that Botswana, like many developing countries, had attained high levels of urbanization, resulting in an increase in diseases such as hypertension, heart disease, stroke, cancer and diabetes. Documentation on the prevalence of risk factors for noncommunicable diseases, such as an unhealthy diet, obesity, smoking and lack of exercise, was scanty. However, one study had shown that one in three women of child-bearing age was obese, and that obesity was more frequent in urban areas. The Government had integrated various nutrition and health promotion activities into its programmes, and national days, such as World Health Day and Diabetes Day, were celebrated. The prevention of noncommunicable disease risk factors had been incorporated into a plan of action for nutrition, which had been developed with the generous support of WHO and FAO. Physical activity had been included in the curriculum of primary schools and diet information made available at educational institutions. He supported the draft resolution and looked forward to the formulation of a global strategy. Developing countries needed support from WHO in carrying out population-based surveys on the prevalence of lifestyle risk factors. The findings would then be used as a guide for formulating national policy programmes and communication strategies. Ms PAYDEN (Bhutan) said that in developing countries, where there were huge resource constraints, physical activity could play a major role in public health. Unlike other resources, physical exercise was easily accessible, straightforward and cheap. Her country had celebrated World Health Day 2002, with its theme "Move for health", in all educational institutions. In order to further disseminate that concept, the Minister of Health was to embark on a 560-kilometre walk across the country, talking to students and villagers on risks to health and preventive measures. Dr AL-KA TTAMI (United Arab Emirates) stressed the importance of establishing the risk factors for noncommunicable diseases and expressed her support for the draft resolution. Her country had set up awareness-raising programmes, particularly with respect to healthy food. Physical training should be part of the public health policy in all countries. She proposed that WHO's findings on nutrition and healthy lifestyles should be put on the WHO web site and made available to all Member States. Mr UUTELA (Finland) said that chronic diseases were major causes of mortality and loss of quality of life in all societies of the world and could continue to be for the foreseeable future. Hence, every evidence-based attempt to prevent chronic disease should be implemented. Finland endorsed the views expressed in document ASS/16 and agreed that healthy changes in diet and physical activity promoted cardiovascular and general health. Thanks to a consistent public health policy, cardiovascular mortality had been substantially reduced in the past three decades in Finland and recent studies had indicated that healthy life expectancy had increased as much as life expectancy, through a reduction in smoking, changes to a healthier diet and increased physical activity. Health education had originally been the main national instrument used to influence diet, but a real breakthrough had been achieved only after a consensus had been reached between health, agricultural and trade policymakers, together with enterprises and the media, on a healthy nutrition policy. "Healthy" was increasingly used as a sales promotion argument. Occupational life in modem societies had changed dramatically, with people expending less energy. Hence it had been recognized that everyday life had to be made more energy-consuming. On

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that assumption, a multisectoral national programme had been drawn up, based on the principle that physical activity was important for the mental, social and physical health of persons of all ages. Finland welcomed the efforts of WHO in promoting a healthier diet and increased physical activity with a view to the attainment of a better state of health worldwide. It welcomed the opportunity to contribute to WHO's programmes and supported the draft resolution, together with the amendments proposed by Brazil, Canada and Denmark. Mr ZIDAR (Slovenia) strongly supported WHO's initiative in tackling unhealthy diet and lack of physical activity as major preventable risk factors for chronic noncommunicable diseases. In April 2002, Slovenia had organized an international conference on Promoting Health through Healthy Nutrition and Health Enhancing Physical Activity (Radenci, Slovenia, 18-21 April 2002), which had been attended by participants from 15 countries, as well as representatives of the European Union and WHO. The ensuing Radenci Declaration recognized the international agreement on the scientific evidence for the health benefits of healthy nutrition and physical activity and the prevention of related illness, and set out a number of goals for the promotion of well-being, prevention of various chronic diseases and improvement of quality of life. It also emphasized the need for training of public health professionals, more and better data on food intake and the pattern of physical activity in the population, innovative ways of tackling those issues across the whole lifespan, and further research into the effectiveness of promotion efforts in those areas. Such efforts had to be intersectoral and multidisciplinary, using an integrated multilevel approach and focusing on supporting lifestyles changes. Different approaches were needed for different settings and sections of the population. Lack of action would increase the burden of disease and subsequent economic and environmental costs for future generations. The conference had accordingly appealed to public health professionals, academic institutions, civil society and nongovernmental organizations, industry and commerce, the media, political decision-makers, and international bodies to take up the challenge, so as to have a positive impact on health worldwide. Dr MHLANGA (South Africa) expressed support for the draft resolution. While lifestyle diseases could be prevented by already-identified, cost-effective initiatives, it would not be easy for countries to implement appropriate interventions. South Africa had set up dietary programmes and had established that an integrated approach was needed, covering the total lifespan and including the educational and faith-based sectors. Ultimately health was the responsibility of each individual. Mr JUGNAUTH (Mauritius) said that cardiovascular diseases, diabetes and cancer were the major health problems in Mauritius, linked to lack of physical activity and inadequate dietary habits. He consequently welcomed WHO's initiative in developing a strategy on diet, physical activity and health. There was sound scientific evidence, together with national experience in many countries, to show that remarkable progress could be made at the population level by influencing not only behaviour, but also the environmental factors leading to unhealthy lifestyles. Countries such as his own, where noncommunicable diseases had rapidly increased, needed support from WHO in efforts to make living environments conducive to maintaining physical activity and a healthy diet. His country therefore supported the draft resolution, together with the amendment proposed by Canada. Dr ZHANG Li (China) said that WHO's policy was of particular practical significance for developing countries and that he accordingly supported the draft resolution. His Government had encouraged adolescents and children to participate in World Health Day 2002 activities with its theme of "Move for health", and to increase their participation in sports. As it had been recognized that an unhealthy diet and inadequate physical activity were linked to chronic diseases, all governments should implement educational campaigns to change people's dietary habits. In his country, the rural areas had limited access to health-related knowledge, so that there was a particular need for such campaigns, which would require WHO support.

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Mr HAN Dae Song (Democratic People's Republic of Korea) voiced his support for WHO's global strategy, since diet and physical activity were crucial in reducing the occurrence of chronic diseases and, more importantly, enabling people to enjoy a longer life. However, while about 20% to 50% of the world's population risked an early death as a result of obesity, many others died prematurely of malnutrition. WHO should intensify its cooperation with other international organizations, nongovernmental organizations and developed countries in an attempt to narrow that gap. In connection with World Health Day 2002, his country was waging a media campaign to enlighten people to the positive significance of physical activity. He supported the draft resolution. Mr ROKOV ADA (Fiji) said that everyone was aware of the increasing economic and health burdens of noncommunicable diseases, especially in developing countries. Such diseases were the most common cause of morbidity and mortality in adults in Fiji. Diabetes, hypertension, cardiovascular diseases and cancers accounted for 75% of all hospital admissions and use of health services, as well as 65% of the country's pharmaceutical budget. Prevention strategies had been developed, but had not adequately addressed the situation. Fiji was consequently extremely grateful to WHO for supporting the research on noncommunicable diseases currently being undertaken in the country; results from the national survey would help the country to review and adjust its strategies. He supported the draft resolution together with the amendment proposed by Canada. Mr DEBRUS (Germany) said that information on the effects of unhealthy nutrition or eating habits was crucial to the development of new strategies or recommendations that could be adapted to the special circumstances in each Member State. He considered that greater emphasis should be given to obesity in children and to the effects on health of stress. The combating of stress was also crucial for an awareness of healthy eating behaviour, and he assumed that that issue was also covered in WHO's programmes. In Germany the Centre for Health Education and Health Promotion adopted a triple approach, covering diet, physical activity and stress control. He supported the draft resolution. Mr SHRESTHA (Nepal) proposed that the "Move for health" initiative should be continued, with a view to reducing the burden of noncommunicable disease. Nepal would also favour action, through workshops and projects, to sensitize high-risk populations to the need for physical activity. Dr PAVLOV (Russian Federation) welcomed the attention being given by WHO to the interaction between nutrition, physical activity and health and to the proposed global strategy in that area. However, further efforts to improve the diagnosis and treatment of noncommunicable diseases alone would not greatly affect mortality figures. The only way to improve the situation was to change behaviour and lifestyles and to convince people of the need to take care of their own health and that of those around them. He urged WHO to assist Member States in developing strategies for a more rational approach to physical activity and health. The need to find economically viable ways of achieving better levels of health was particularly relevant given the lack of resources in low-income countries. Many Member States were already working extensively in the field of preventive medicine and had accumulated a great deal of positive experience that could be made available to WHO. In his country, for example, practical measures had recently been taken to provide greater opportunities for participation in physical activities and sports, and a national programme had been set up to provide physical education for children and young people. Interest in such issues should be maintained both globally and nationally. Mrs LE THI THU HA (VietNam) said that her country was currently facing the dual burden of communicable and noncommunicable diseases. Recent surveys had shown that the prevalence of hypertension and diabetes had increased almost 10-fold in some urban areas over the past 10 years. The contributing factors included changes in lifestyle, cigarette and alcohol consumption and physical inactivity, as well as a lack of knowledge and understanding on the part of the population. With WHO's support, Viet Nam had devised a national policy of prevention and control of

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noncommunicable diseases, which it was hoped would make further resources available for health education. It had also recently conducted a mass media campaign encouraging people to consume more fish, fruit and vegetables in their daily diet. She supported the draft resolution with the amendment proposed by Canada. The CHAIRMAN emphasized the important role of immunological research in determining the mechanisms that were responsible for many chronic diseases and in the development of medicines to prevent them, and urged WHO to encourage such research. Several countries, including his own, were accumulating considerable research experience in that area. Mr HOLMAN (New Zealand) said that in New Zealand physical inactivity was second to smoking as a modifiable risk factor for poor health. Some 54% ofNew Zealand adults aged 15 or over were overweight and of those 17% were obese. Nutrition and obesity played a major role in all three leading causes of death: ischaemic heart disease, cancer and stroke; they were also a major determinant in other conditions, from diabetes to dental decay. The impact of those conditions fell disproportionately on Maori and Pacific peoples and those of lower socioeconomic status. While on an international comparative basis New Zealanders generally had a balanced diet, there was considerable scope for reducing health inequalities by improving lifestyle choices including diet. However, policies aimed at changing habitual behaviours must be sensitive to sociocultural contexts and address underlying social inequalities. New Zealand had developed an integrated strategy involving various government agencies to provide information, advice and evidence to district health boards on crucial interventions related to appropriate diet and adequate physical activity. He welcomed WHO's efforts to develop suitable tools for the measurement of risk factors for chronic diseases and noted that the WHO STEPwise approach to surveillance was designed to enable all countries to participate in that important task. Dr PARIRENYATWA (Zimbabwe) said that, like most developing countries, Zimbabwe had experienced high levels of socioeconomic change, which had effected dietary patterns and physical activity. Growing urbanization had changed modes of transport, work and food supply, which, in turn, had significantly contributed to an increase in noncommunicable diseases. His Government recognized the importance of changing dietary patterns in order to stem that increase, and endeavoured to promote a low-fat, high-vegetable-content diet based on indigenous foods. However, the major problems facing his country were food scarcity, malnutrition and poor micronutrient content. He supported the draft resolution with the amendment proposed by Canada. Mrs HERNANDEZ (Venezuela) said that for many years cardiovascular diseases, cancer and diabetes had been major causes of death in Venezuela. The Government had, therefore, with the assistance of nongovernmental organizations, developed and implemented multidisciplinary policies to prevent and control cardiovascular diseases by encouraging healthy lifestyles, including a healthy diet and physical activity. The socioeconomic determinants of noncommunicable diseases, which were unequally distributed among the population, were known. As indicated in the draft resolution, it was important to ensure the development of effective managerial mechanisms and to strengthen collaboration with public and private institutions and nongovernmental organizations. The support of international organizations would be required in that regard. Dr AFRIYIE (Ghana) said that noncommunicable diseases were rapidly increasing in Ghana. The prevalence of diabetes had risen from 0.2% in 1958 to 4% in 2000; and hypertension and its complications, particularly strokes, accounted for I 0% of deaths in urban centres and were the second leading cause of adult deaths in such areas. Ghana, like most developing countries, was in epidemiological transition. While the burden of communicable diseases had been reduced, the increase in life expectancy, the adoption of Western-style dietary habits and unhealthy lifestyles had led to the emergence of noncommunicable diseases. The rapid growth in consumption of fast foods in Ghana

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was an example of the negative impact of globalization. His country had developed a national policy and strategy for the control of noncommunicable diseases, which included strengthening public education, introducing legislation to counter common risk factors, such as drug and tobacco use, monitoring morbidity and mortality patterns, standardizing diagnostic and management structures and procedures, and developing health education materials on physical activity and diet. Ghana had followed its celebration of World Health Day 2002 by instituting a monthly national health walk to encourage the habit of walking. He supported the draft resolution as amended by Canada and urged WHO and other partners to implement the policies recommended therein. Dr AKSAKAL (Turkey) said that it was essential to develop programmes using a lifespan approach in order to establish dietary habits conducive to promoting health and preventing the burden of noncommunicable diseases that affected all countries. She therefore endorsed WHO's strategies for tackling the issue and supported the draft resolution. It was vital to develop and implement nutritional programmes, train health personnel and the public, coordinate the activities of different organizations and cooperate with international organizations. Turkey had implemented community education programmes on nutrition and physical activity, mother and child nutrition, breastfeeding promotion, and combating micronutrient deficiencies. Moreover, since 1923, Turkey had held a national day for youth and sports. Dr HANSSEN (Norway) welcomed the leading role being taken by WHO, in cooperation with other international organizations, to counteract the alarming development of overweight and obesity, and looked forward to the development of a global strategy on diet, physical activity and health. He stressed the importance of a multidisciplinary, multisectoral and evidence-based approach. He supported the draft resolution, with the amendments proposed by Denmark, which would assist the implementation of the suggested initiatives. Dr EL'ISMAILI LALAOUI (Morocco) endorsed the analysis of the links between diet, physical activity and health in document A55/16. His country's Ministry of Health had adopted a programme to counteract noncommunicable diseases, which included studies of the risk factors for those diseases, and a multisectoral strategy to combat smoking. Mrs POSADA (Mexico) welcomed the Organization's initiative to develop an overall strategy on diet, nutrition and prevention of chronic disease. To overcome the challenges posed by noncommunicable diseases, which affected all socioeconomic groups, healthy lifestyles should be promoted through encouragement of physical activity and sound dietary habits. She supported the draft resolution. Ms RUNDALL (Consumers International), speaking at the invitation of the CHAIRMAN, welcomed the report. Referring to public-private partnerships, she sought assurance that WHO would not be drawn into an unhealthy association with the food industry, which used the United Nations system and nongovernmental organizations, inter alia, to promote highly profitable but unhealthy foods that placed a strain on national and family economies in terms of import, purchasing and health service costs. In the light of the lobbying powers wielded by the food industry, the Organization's checking procedures and strategies should be reviewed. It was essential that governments, and United Nations and nongovernmental organizations working in the public interest, should support the establishment of sound national policies to counteract the influence of companies that used health claims to project a healthy image for unhealthy products. It was also necessary to guard against the confounding research supported by the food industry and the marketing of unhealthy foods to children. Her organization would strongly support the development of a WHO code on marketing to children and schools. Lastly, she urged WHO to instigate independent research into the impact of marketing on poor people in order to promote food systems that were sustainable, indigenous, equitable and environmentally friendly.

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Ms HUGUES (International Council ofNurses), speaking at the invitation of the CHAIRMAN, welcomed WHO's strategies to promote nutrition and physical activity. Her Council, which comprised national nurses' associations in 124 countries, was deeply concerned by the growth of sedentary lifestyles, unhealthy diets, and alcohol and tobacco use, especially among young people. Today's nurses played an important role in health promotion and disease prevention and saw themselves as active partners with other health professionals in risk reduction. Lifestyle diseases represented a global public health problem, and it was therefore essential that nurses contributed to national health strategies. For its part, the Council would continue its efforts to strengthen the health promotion and disease prevention components of nursing education, research and practice. It was also committed to helping to mobilize members of professional associations to participate in healthy lifestyle initiatives, including national nutrition and physical activity campaigns. In turn, it looked to WHO and governments to invite nurses to join activities for disease prevention and health promotion. Mr AHNLUND (Inter-African Committee on Traditional Practices affecting the Health of Women and Children), speaking at the invitation of the CHAIRMAN, commended WHO's initiative to link health, diet and physical activity and urged it to continue to encourage national partnerships with nongovernmental organizations. The experience of his Committee showed that health could be improved through government-led policies, often implemented in partnership with nongovernmental organizations, that recognized the contribution of all, including women, traders, entrepreneurs and cooperatives, to the economy. Women produced more than 50% of all food grown and ensured the presence of fruit, vegetables and pulses in diets. Moreover, they often carried the multiple burden of producing the food, caring for the family and maintaining the home. WHO support for the development of national plans of action on diet, physical activity and health would encourage support for sound agricultural practices and for rural and farming women. It was important to address the broad determinants that affected health choices. In that connection, he expressed the hope that the draft resolution would bring about renewed support for the education of children, young people and women, which could include instruction on healthy diets and lifestyles. In Kerala, India, the education of women had been cited as a major factor in increasing life expectancy to 70 years, compared with the Indian average of below 60. Education was an obvious area for successful collaboration with nongovernmental organizations. He welcomed the draft resolution as a sound basis for moving forward. Dr YACH (Executive Director) thanked delegates for the support expressed for the draft resolution and welcomed the information provided on specific health initiatives and simple yet effective ways of communicating with the public. He acknowledged that dynamic changes were occurring in disease risks and outcomes. Rising levels of diabetes and hypertension were probably initial indicators of a larger epidemic of cardiovascular disease and cancer yet to come. In response to calls by Australia and Denmark for further evidence on which to base policies, he explained that WHO was working in close collaboration with the International Union for Health Promotion and Education and the Centers for Disease Control and Prevention in Atlanta, Georgia (United States of America) as well as other groups around the world, to strengthen the global evidence base for the effectiveness of health promotion strategies, including cost-effectiveness components. Some results of that work ought to be available at the World Conference on Health Promotion and Health Education in Melbourne, Australia, in 2004. It was, however, impossible to ignore the view expressed by most Member States that action must be taken even before the availability of conclusive evidence. There were clear messages on measures that could be taken with immediate effect, particularly in relation to physical exercise, healthy eating and tobacco use. Many of the specific components of healthy diets were already mentioned in the 1989 publication Diet, nutrition, and the prevention of chronic diseases: report of a WHO Study Group (WHO Technical Report Series, No. 797), currently being revised. It was crucial to develop more effective communication, as well as a more multisectoral approach. Governments should accept considerable responsibility for steering the public towards healthier lifestyle choices. Several speakers had referred to the importance of sound surveillance and the WHO

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STEPwise surveillance approach, which was designed to monitor progress on risk factors and related interventions. Success depended on policies that were sensitive to local cultural and social realities, particularly in relation to eating and physical activity, and he welcomed the good examples described by previous speakers. Several delegates had drawn attention to the double burden of under- and overnutrition. Thankfully, the core components for addressing chronic diseases also had a positive impact on other aspects of child and adolescent health, including communicable diseases, and could even influence violence and injury control. In reply to the delegate of Japan, he confirmed that WHO had participated at the recent meeting of the Codex Alimentarius Commission, informing the Commission of the progress made in developing diet and nutrition guidelines, and requesting the Member States of the Commission to submit comments on the draft version. WHO had also stressed the role of labelling within a broader set of policies designed to enable consumers to make informed choices on healthier eating. WHO hoped to strengthen collaboration with the Codex Alimentarius process with regard to the development of those policies. He agreed with the delegate of Germany on the central importance of children and adolescents. In that context, the comments made in document ASS/16, paragraph 18, should be read in conjunction with the information provided on child and infant feeding (document ASS/14); both documents emphasized the importance of a lifespan perspective. He noted the concerns voiced about possible adverse commercial influences on WHO policy, and expressed the commitment of the Organization to strengthen protection against conflict of interests, whether real or perceived. Many of the comments, concerning marketing had been dealt with by the Director-General in her opening address to the Health Assembly and at a consultation in April 2002, the outcome of which would be communicated to Member States shortly. In response to the questions raised by Cuba and the United States of America, he said that the final version of the report of the joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases was being prepared as a publication in the WHO Technical Report Series by the expert group concerned. Its findings would be taken into account by WHO when the Organization considered its policy on diet and nutrition. The draft report could be consulted on the WHO web site, and the final date for comments by any interested party was 15 June 2002. After that date, all comments would be reviewed by the Chairinan and Vice-Chairman of the group and the final version would be prepared and circulated to all members of the expert group. Publication was scheduled for the first quarter of 2003. Preparations for the formulation of the global strategy on diet, physical activity and health referred to in the draft resolution contained in resolution EB 109 .R2 were intended to involve a thorough process of consultation with the various stakeholders. Tentative plans had evolved for discussions with the food industry, including a high-level meeting to be convened by the DirectorGeneral, and consultations with consumer groups, health professional bodies, and other United Nations organizations were envisaged. A draft document would be developed for discussion by the Executive Board in January 2004, as recommended in the amendment proposed by Brazil. It was hoped that it would be dispatched to Member States in October 2003 to allow adequate time for the preparation of comments. Dr BEHBEHANI (Secretary) read out the amendments to the draft resolution contained in resolution EB 109 .R2 proposed by the delegates of Canada and Denmark. In line with the proposal made by the delegate of Brazil, paragraph 2(4) would be amended by replacing "1llth session and the Fifty-sixth World Health Assembly" with "113th session and the Fifty-seventh World Health Assembly". The draft resolution, as amended, was approved. 1

Transmitted to the Health Assembly in the Committee's fourth report and adopted as resolution WHA55.23.

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Ageing and health: Item 13.12 of the Agenda (Documents A55/17 and A55/17 Add. I)

Mrs ABEL (representative of the Executive Board), reporting on the Board's discussion of the challenges presented by rapid population ageing, said that members had noted that the United Nations Second World Assembly on Ageing (Madrid, 8-12 April 2002) offered a unique opportunity to propose policies to ensure healthier, longer lives in all regions of the world. WHO's participation in the preparatory work for that Assembly had focused on policy recommendations that built on resolution WHA52. 7 on active ageing, adopted during the United Nations International Year of Older Persons in 1999. It focused on how the determinants of health throughout life influenced the development of disease and disabilities at older ages, and how people could remain healthy for as long as possible. The active ageing approach recognized the usefulness of healthy older persons to their families, societies and development in general. Ms BERAUN ESCUDERO (Peru), providing statistical data on the rapidly ageing population in her country, said that acute respiratory infections constituted the main cause of mortality among persons over 65 years of age followed by cerebra- and cardio-vascular diseases and neoplasms. Peru was entering a period of epidemiological transition, in which significantly different causes of mortality were emerging in older people of differing socioeconomic status. Chronic, degenerative diseases were prevalent among the wealthy classes, while the health problems traditionally associated with disadvantaged groups were exacerbated by poor access to health services. It was important to develop policies designed to ensure the physical, psychological and social well-being of older people, as well as to facilitate their integration into the national community. To that end, her Government was preparing to implement a national programme for older persons, which would provide an essential care package aimed at protecting health and quality of life. Or EL'ISMAILI LALAOUI (Morocco) said that, in his country, family solidarity was an important aspect of care for older persons. An ageing population was bound to have an impact on the overall morbidity rate, which made it imperative for governments to ensure that their populations had adequate health insurance. Ms PHUMAPHI (Botswana) explained that her country was currently hosting a WHO pilot project to develop an integrated response of health care systems to rapid population ageing. Her Government had been prompted to take part by the increasing incidence of noncommunicable diseases, the added burden on older persons owing to the HIVI AIDS crisis, and the predicted rise in the proportion of older persons, given the high mortality rates in the 20-49 age group. The promotion of good health and social welfare for the elderly would be critical to the capacity of her country to respond to the challenges posed by the epidemic, combined with an ageing population. In response to concerns about the growing neglect of older persons in the context of evolving family values, her Government had made efforts to analyse the current situation in Botswana. Noncommunicable diseases such as hypertension, cancer and diabetes had become more prevalent, and there had been a marked rise in morbidity and mortality from cardiovascular diseases and cancer over the past 20 years. An in-depth study would be conducted later in 2002 to assess the health care system, with a view to developing appropriate intervention strategies. In future, the Ministry of Health would collaborate with other ministries to enhance multisectoral participation in health. WHO should give due emphasis to such collaboration at international and national levels to ensure a more holistic approach. Or ORDONEZ (Cuba) elucidated three fundamental concepts behind the technical and health issues at the centre of the debate: the achievable standard of living provided by the government of each country; the lifestyle of each individual, family and community; and quality of life, which was the product of a combination of standard of living and lifestyle. The creation of basic support services for older persons, physical activity, mental health and genetic factors were crucial elements that

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required further analysis. He endorsed the three priorities established at the Second World Assembly on Ageing in Madrid: older persons and development; the promotion of health and well-being, and the support of governments and civil society. He emphasized the importance of creating multisectoral and international alliances to address those issues. In Cuba, comprehensive care for the elderly was a fundamental pillar of the national health care system, contributing to an average life expectancy of 76.2 years. A programme to promote regular physical exercise among older persons, started in 1984, had grown to involve more than 300 000 people across the country. He endorsed the International Plan of Action on Ageing 2002, adopted at the Madrid Assembly, which he hoped would be fully implemented. Dr MASSE (Canada) said that Canada had welcomed the close collaboration during the preparation of the policy on ageing and health and the consistency and complementarity between that policy and the recommendations on diet, physical activity and health. WHO should continue to take a leading role in order to ensure the timely implementation of the International Plan of Action on Ageing 2002. Mr UUTELA (Finland) said that in the light of the changing age structure of the population, and the social, economic and cultural changes in both the developed and developing world, the question of ageing should be approached from the point of view of the skills, knowledge and experience that the elderly had to offer. Health services needed to be based on an understanding of the prerequisites for health and functional capacity at the physical, mental and social levels, and to support the active participation of the elderly themselves, as well as the whole community, in changing the environment, attitudes and service structure to take account of their needs and capabilities. In order to reduce the burden of disabilities, chronic diseases and premature mortality, the wider target of supporting independent living and using and improving the functional capacity and ability of elderly people should be given greater priority. Further research on changes due to ageing and on ways of developing favourable structures in both health and social services and other infrastructures in the community were also needed. WHO and other international organizations should encourage the necessary cooperation at the community level. He suggested that a report be prepared, for submission to the Fifty-sixth World Health Assembly, on the progress made in implementing the actions proposed in resolution WHA52.7. Dr LOPEZ RAMOS (Uruguay) noted that, among Latin American countries, Uruguay had one of the oldest populations, with 17% over the age of 60. Moreover, the number of people over the age of 75 was projected to grow in the next few years. There would consequently be a corresponding increase in the number of people requiring health services that were currently not equipped to deal with such a situation. The results of a multisectoral study on ageing and health that had been carried out with technical assistance from PAHO, had shown that 50% of the population over the age of 7 5 suffered from some form of disability, compared with 10% in other countries with similar societal structures. Elderly people who were poor and with a low level of education experienced the worst health and had most difficulty accessing health services. She acknowledged the efforts being made by the Organization to ensure that the proposals in resolution WHA52.7 were implemented. Bearing in mind the relevance and importance of the subject to governments, society as a whole, health systems and the health of individuals, Uruguay suggested that, in addition to the Committee noting the report, WHO should be asked to report to the Fifty-eighth World Health Assembly on the progress made in implementing the International Plan of Action on Ageing 2002 and resolution WHA52.7. WHO should also be active in devising and implementing strategies, as well as in ensuring that they were followed up, and provide the relevant information to the Health Assembly. Mr TASAKA (Japan) said that, over the past 20 years in Japan, the proportion of people over the age of 60 years had increased from 13.5% to 23.5%, and that the elderly population consisted of more women than men. As a result, Japan had passed a law on ageing in 1995 and followed it up with

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a framework policy on ageing in 1996, which included setting up an insurance scheme for the elderly. The latter had been implemented in 2000; those enrolled in the scheme had access to assistance from the social services, as well as to medical care, according to need. The policy was based on respect for elderly people. Dr VIOLAKI-PARASKEV A (Greece) said that the ageing populations of the developing and developed countries would increase significantly, and, in iurn, would create serious health, economic and social problems. Governments would therefore need to formulate appropriate policies that would ensure that the elderly would enjoy healthy, good quality lives. To that end, she called upon WHO to establish a research programme on ageing and health and undertake activities, in collaboration with the United Nations and other international organizations, to ensure that the International Plan of Action on Ageing was implemented. She expressed support for Uruguay's suggestion that a report on the progress made in the implementation and follow-up of resolution WHA52.7 and the International Plan of Action on Ageing should be submitted to the Fifty-eighth World Health Assembly. Dr VAN ETTEN (Netherlands) recalled that the countries that had participated in the Second World Assembly on Ageing had recommended that the focal points for ageing within the United Nations system should be strengthened. WHO's life course and active ageing programme was one of those focal points and an excellent example of an integrated, horizontal health approach. With WHO's policy framework in place and the International Plan of Action on Ageing adopted, monitoring and follow-up had become extremely important. The World Assembly on Ageing had decided that existing channels should be used for that purpose, so it would be appropriate for the Health Assembly to undertake the task of reporting on the health component of ageing. He supported the proposals by previous speakers that a report be submitted to the Fifty-seventh or Fifty-eighth World Health Assembly. Mr HOLMAN (New Zealand) observed that in his country the trend towards an ageing population had been less rapid than in other countries with only 12% of the population over 65, although by 2051 the proportion would have risen to 25%. He congratulated WHO on its document entitled Active ageing: a policy jramework; 1 it provided a comprehensive, systems-focused guide to planning for an ageing population at the national level that would be valuable for both developed and developing countries. Document A55117 correctly affirmed that the health sector had a major role to play in the multisectoral implementation of national approaches to positive ageing. New Zealand's positive-ageing strategy identified the actions that needed to be taken by almost every government department in support of its goals. Approaches to active ageing would require a reorientation of current health systems from their focus on acute care to a continuum of care from health promotion and disease prevention to the appropriate treatment of chronic diseases, provision of community support and long-term and palliative care. WHO, through its ageing and life-course programme, could play a valuable role in facilitating information sharing between countries in that area. Mrs HERNANDEZ (Venezuela) said that, even though population ageing was not such a serious problem in her country as in some of its neighbours, devising and implementing an appropriate policy for elderly people was nevertheless a major challenge. The existing policy on ageing focused on positive interventions to deal with the structural and other factors that were instrumental in reducing the quality of life: seeking practical solutions, protecting social rights, and striving for equality. The policy took account of social needs in overall terms rather than focusing on specific groups, providing equal opportunities to enable people to lead fully independent lives. Its operational mechanisms consisted of a network of state and social institutions in whose establishment both the elderly and the community participated. It had proved to be an effective way of satisfying needs through a combined

Document WHO/NMH/NPH/02.8.

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effort that went beyond the provision of services alone. Venezuela had actively participated in the Second World Assembly on Ageing and supported WHO's initiatives to improve the quality of life of the elderly, and the inclusion ofthe economic, social and cultural determinants in the policy on active ageing. However, greater attention should be given to the gender and ethnic dimensions. Dr KANITTA BUNDHAMCHAROEN (Thailand) endorsed WHO's policy framework on active ageing. As the proportion of elderly people worldwide continued to grow rapidly, providing integrated services to meet their needs was a challenge, especially for developing countries. In particular, it would require sustainable financing and, in that regard, strategies that emphasized comprehensive health care provision, from disease prevention early in life to care at the end, were of special interest. One area of concern, particularly for developing countries, was the migration of young people from rural agricultural areas to the cities, with the elderly being left behind. As a result, the pool of care providers was diminishing. Policies to encourage rural development and self-sufficiency were essential if young people were to remain in rural areas. In developing countries, pension and social security schemes were often rudimentary and it was up to governments to provide health services for the elderly living close to the poverty line. Focusing on prevention and healthy living would substantially cut health care costs for that group. The elderly in communities with a high prevalence of HIV/AIDS were facing a triple burden of providing care for adult AIDS patients, looking after orphans who were often infected with HIV, and working to generate income. Such a situation could have a serious effect on the mental state of older carers, often women, who needed to be singled out for special attention. Care provided by family members should not be a substitute for an effective health system, and any policy on ageing should aim at achieving a balance between institutional and community care. Thailand had been providing universal access to health care for its elderly population for more than 15 years. Its second national long-term plan on ageing highlighted comprehensive intersectoral strategies, including health security, income security, social participation, transportation, and other social services for the elderly, in line with WHO's policy framework. Mr GUNNARSSON (Iceland), endorsing WHO's activities on ageing and health, agreed that the basic approach to ageing and health should focus on prevention and reducing the burden of disabilities and premature mortality. Such an approach should have exercise and healthy nutrition as its cornerstone, as well as universal and equal access to health care services. The strengthening of health promotion, primary health care and rehabilitation services would deliver better health in old age. The cost of such basic services should be regarded as an investment in better health. It was also important to develop interventions and treatments to reduce the number of people afflicted by dementia, and research in that field should be given priority. Areas for improvement included healthcare information systems and community care, where cooperation between primary health care, social services and the hospital system needed strengthening. In addition, the growing demand for institutional care had to be met, although focusing on prevention should improve the situation to some degree. Creative and innovative solutions would have to be found to plug any gaps in financing. Mr DEBRUS (Germany) said that Germany was participating in the regional discussions on the formulation of a global action plan on ageing, which would culminate in the United Nations Economic Commission for Europe Ministerial Conference on Ageing (Berlin, 11-13 September 2002), at which a regional implementation strategy was expected to be adopted. The participation of WHO and ILO in the dialogue was greatly valued. Mr VARELA (Argentina) reminded the Committee of the mandate given to the United Nations and its specialized agencies by the Second World Assembly on Ageing to formulate strategies for implementing the International Plan of Action on Ageing 2002 and to ensure that they were in line with the objectives laid down in the Millennium Declaration and the follow-up to the principal relevant United Nations conferences. In that respect, and as several speakers had already mentioned,

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the Executive Board might usefully consider the issue of ageing and health at its forthcoming sessions and request a report on the progress made in implementing resolution WHA52. 7 and the International Plan of Action, for consideration at a future Health Assembly. Dr MHLANGA (South Africa) recalled that several previous speakers had referred to the challenges facing elderly people. Consequently, the elderly should be included in the target group for all sustainable development and poverty reduction initiatives. Having spent their lives bringing up their own children, they frequently found themselves having to care for orphans left by their children, in particular, in countries affected by HIVIAIDS. The elderly were also often the victims of mental and physical abuse by a society without respect that no longer valued them. He endorsed the WHO active ageing policy framework and the International Plan of Action on Ageing 2002, and requested WHO to continue to provide technical assistance to enable countries to implement those policies. Mr MAJOR! (Italy) said that the proportion of the over-60s in the population was growing everywhere in the world, a fact that had implications for the quality oflife of the elderly, the incidence of chronic and noncommunicable diseases and disability, and the health services. He requested further information on the role WHO would play with regard to the International Plan of Action on Ageing 2002. Mr HOHMAN (United States of America) welcomed WHO activities in relation to some of the major aspects of the International Plan of Action on Ageing 2002. His country was enthusiastic about the Plan and pleased to see that the hard work done in Madrid was already bearing fruit in the form of a policy framework. The Second World Assembly on Ageing had provided countries with an excellent opportunity to re-examine ageing at the national and international level and to reaffirm their commitment to improving the health of older persons. Healthy lifestyles were vital, if the burden of disabilities, chronic disease and noncommunicable disease was to be lightened. The United States strongly supported the establishment of health promotion targets for older persons. A strong primary health care system and a continuum of care would help older populations to remain active and independent. In his country, care within the family was highly valued and attempts were being made to improve support for informal caregivers through the National Family Caregiver Support Program. Thorough scientific research was crucial for the development of sound policies. Such research had revealed that ageing itself was not the cause of disease, disability and frailty. The challenge facing health authorities was therefore to maintain and accelerate the downward trend in disability and to reduce rates of illness among the ever-increasing numbers of older people. His Government fully supported research into ageing and the increasing budget allocation in that area. It also supported WHO's activities as a convenor and facilitator of such research and in circulating information on ageing. The sharing of experience would assist governments in research, monitoring and planning and would enable them not to repeat mistakes. He requested the Director-General to report back after two years on the WHO follow-up to the International Plan of Action on Ageing 2002. Dr ASAGBA (Nigeria), commenting that ageing was a normal biological process, said that in Africa, the elderly traditionally played an active part in the community, but that modernization, education, urbanization and migration were undermining that traditional role. In many countries, ageing was widely perceived as a time of mental and physical decline and loss, and persons over the age of 60 years were considered to be economically unproductive. Retirement usually led to a sharp drop in income and living standards and it became difficult for older people to afford basic clothing, housing or good health. In Nigeria, care for the elderly was being provided to a lesser and lesser extent by families owing to rapid social changes and the downturn in the economy, a situation that was exacerbated by tribal conflict and the emergence and re-emergence of certain communicable diseases, despite all the advances achieved in the twentieth century. Nonetheless, life expectancy had increased in Nigeria and the elderly population was growing. Ageing issues had therefore forced their way into the national consciousness and a national plan of action for the elderly had been formulated, whose

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main objective was to secure the participation of older persons in all aspects of national life, to ensure their access to health services and to sustain their creativity and participation in society. The plan, implemented at central, state and local levels, was a national response to the Declaration of the Fourth Global Conference on Ageing (Montreal, 1999), in that it sought to ensure the well-being of the elderly and took into account physical, mental, social, spiritual, cultural and environmental factors. Her country had also formulated a draft policy on the care of the elderly. She looked forward to receiving support from the international community for implementation of those activities. Mr SAM (Australia) said that his country supported an approach to ageing that dealt with the underlying causes of chronic disease and postponed the onset of disability. His Government's policy was consonant with the WHO active ageing policy framework and the International Plan of Action on Ageing 2002. Australia therefore commended WHO's development of the framework. His country was trying to prepare for the significant changes that would occur in its population in the next 50 years through the national strategy for an ageing Australia and other initiatives at national, state and regional levels. The prevention and effective management of chronic, noncommunicable diseases was a high priority, since such illnesses were prevalent among older people and were responsible for about 70% of the total burden of chronic disease. He endorsed the recommendations of the Second World Assembly on Ageing and the recognition given to the important role of carers. The most significant fact emerging from recent reports, however, was the need to commence action immediately. Mr DUARTE CARDOSO (Brazil) endorsed the WHO policy framework on active ageing and the recommendations of the Second World Assembly on Ageing. Under WHO's leadership, the implementation of the International Plan of Action on Ageing 2002 would heighten the capacity of national health systems to respond to the increasing challenge. Ageing already constituted a major problem in Brazil, as the rise in the number of persons over the age of 60 years was having an adverse impact on the public health care system. The Brazilian Ministry of Health had embarked on many of the policies outlined in the WHO policy framework and had introduced a national health programme on ageing. Immunization had successfully prevented influenza among the over-60s in recent years, and the Ministry was also carrying out epidemiological research in order to analyse mortality and morbidity trends among the elderly more accurately. Nevertheless, there was still a need to combat communicable diseases, as death rates from tuberculosis were higher among older people; similarly, more effective initiatives related to mental health were required. Health information systems should cover questions related to ageing. Physical activity should be promoted in accordance with the WHO "Move for health" initiative. Mr KAMMEYER (International Federation of Medical Students' Associations), speaking at the invitation of the CHAIRMAN, said that his Association recognized the impact that older persons were having on socioeconomic and health matters and consequently applauded WHO's leadership in recognizing active ageing as an important global health issue. The world population was ageing and elderly persons were the primary consumers of health-care resources. Current medical education did not sufficiently cover the needs of older persons and health professionals were therefore inadequately prepared to face the challenge of ageing. His Association had been active in several initiatives designed to remedy that situation, such as a joint study with WHO on teaching geriatrics in medical education that had provided fresh insight into the manner in which ageing was covered in medical education worldwide. Together with the International Pharmaceutical Students' Federation, the Association had launched the International Students Network on Ageing and Health. He called upon the international community to sustain the involvement of older persons in the formulation of policies regarding their own autonomy and social productivity, and to promote an awareness of lifestyles leading to physical, social and mental well-being. As a body representing the next generation of physicians, the Association understood the importance of activism in ageing and health issues and

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accepted the leading role it would play in that dialogue. It fully supported WHO's initiatives in those fields. Ms KHANNA (World Vision International), speaking at the invitation of the CHAIRMAN and on behalf of the three nongovernmental organization committees on ageing (Geneva, New York and Vienna), members of the Conference of Non-Governmental Organizations in Consultative Relationship with the United Nations, said that the time had come to cater for the needs of the elderly and very elderly who represented an increasing section of society, even in developing countries. The Declaration and International Plan of Action on Ageing 2002 adopted at the Second World Assembly on Ageing were evidence of governments' firm intention to give the elderly universal, equal access to physical and mental health care and of their acknowledgement that new policies would have to be adopted to meet the growing needs of an older population. The three nongovernmental organization committees on ageing stood ready to collaborate with WHO and governments at the national level in order to ensure that the implementation of the Plan of Action was not delayed and that citizens' needs were taken into due account. Dr KINGMA (International Council of Nurses) said that data clearly showed that, throughout the world, the proportion of people aged 60 and over was growing faster than any other age group, a demographic shift which had profound implications for future health-care systems and services. The health sector would need to enhance capacity building of health personnel and pay renewed attention to the promotion of physical and mental health, the prevention of disability, provision of rehabilitation and palliative care, and support for the grieving process. Health-sector staff would be called upon to provide crucial support services. A critical mass of qualified health professionals and personnel would be required in order to guarantee the sustainable development of care for the elderly. Her organization was greatly concerned by the acute shortage of geriatric nurses. The stigma and discrimination on the grounds of age in many countries had contributed to the low prestige of personnel providing services for older persons. Such negative attitudes must be eliminated. If good-quality staff were to be recruited and retained, they would have to be offered a safe working environment, job satisfaction, just remuneration and access to continuing education. It was clear that professional goals would not be met without staff with the right knowledge, skills and ethical attitudes. It was therefore regrettable that the International Plan of Action on Ageing 2002 did not address the critical issue of human resources. Her organization supported the WHO active ageing policy which offered a comprehensive framework for the requisite structural changes, and would continue to work with WHO to improve the quality of care offered to older persons at all levels of the health system. In addition, it would encourage an adaptation process ensuring that health-care environments were age-friendly and offered good working conditions for personnel. Dr YACH (Executive Director), responding to the comments made, said that ageing should be regarded as a triumph of development and not as a burden, although the gains in the quality of life and life expectancy were not shared equally. The rate of ageing was increasing rapidly all over the world. Active, healthy ageing was possible, provided that a life-course approach to risk factor control was adopted. Many aspects linked to the prevention of noncommunicable diseases were synonymous with the promotion of healthy ageing. A new WHO report on the shift from acute to chronic care was due to be published shortly. 1 WHO would build on its excellent collaboration with a number of organizations to give effect to recommendations to strengthen research programmes into ageing and health. It would be necessary to give some thought to the optimal periodicity for reporting on progress in the implementation ofthe International Plan of Action on Ageing 2002 and resolution WHA52.7. In the meantime, the focus would clearly be on improving the implementation process at country level.

1 Innovative care for chronic conditions· building blocks for action- global report, World Health Organization, Geneva, 2002, 112 pp.

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The Committee took note of the report. Professor Coli Seck took the Chair.

STAFFING MATTERS: Item 16 of the Agenda (continued from the fourth meeting)

Human resources: annual report: Item 16.1 of the Agenda (Document A55/30) (continued from the third meeting, section 3) Mrs BERGER (Switzerland) said that she regretted to announce that, despite the best efforts of the working group, it had proved impossible, owing to the short time available, to arrive at a consensus on a revised text of the draft resolution on increased representation of developing countries in the Secretariat and in expert advisory panels and committees put before the Committee at its third . I meetmg. The CHAIRMAN said that a series of amendments had been proposed to the draft resolution by several delegations and invited the delegate of Australia to present those amendments. Ms BALOCH (Pakistan) speaking on a point of order, said that the draft resolution proposed by her delegation and others should be formally presented to the Committee by the sponsors before the introduction of proposed amendments. The CHAIRMAN invited the delegate of Pakistan to present the draft resolution on behalf of the sponsors. The amendments would be considered thereafter. Ms BALOCH (Pakistan) stated that Egypt, Indonesia, the Islamic Republic of Iran, United Arab Emirates and Zimbabwe had asked to join the sponsors of the draft resolution. The aim of the draft resolution was to increase equitable representation in the Secretariat. Many developing countries and countries in transition were underrepresented, especially in the professional category and at headquarters. The current formula for determining representation, based on membership of WHO, population and financial contribution, unfairly penalized developing countries. The draft resolution emphasized the principles of transparency, fairness in selection, objectivity, competence and merit in appointments to the Secretariat and to expert advisory panels and committees, and underlined equitable geographical representation, membership, population criteria and the balance between developing and developed countries in establishing country ranges. It also proposed amendments to the Regulations for Expert Advisory Panels and Committees that had been drafted in close consultation with the Secretariat and were aimed at improving the representation of developing countries and women in those groups. The text of the draft resolution had been circulated by the sponsors with the expectation of constructive negotiations. Regrettably, owing to a lack of flexibility on the part of some delegations that had participated in the drafting group, it had not been possible to reach agreement on the text; those opposing the draft resolution had not sought to amend it but to submit new proposals that ran counter to the spirit of the original. The sponsors had accepted the following proposed amendments, from various sources. The title would be amended to read: "The need for increased representation of developing countries and countries in transition in the Secretariat and expert advisory panels and committees". In the third preambular paragraph, the text following the word "Constitution" would be deleted. In the seventh and

See summary record ofthe third meeting of Committee B, section 3, page 158.

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eighth preambular paragraphs, in paragraphs 5 and 6, and in the proposed amendments to Regulations 3.1, 3.2 and 4.2, set out in the Annex to the draft resolution, the words "and countries in transition" would be inserted after "developing countries". In paragraph 3, "nonselectivity and objectivity" would be replaced by "fair selection, objectivity, competence and merit". Paragraph 4 would be amended to read: UNDERLINES that country ranges for appointments in the Secretariat should, in principle, be based on membership, equitable geographical representation, population criteria and balance between developed and developing countries, with less emphasis on financial contributions to the Organization. In paragraph 6, "to seek the concurrence of the concerned Member States" would be replaced by "to consult with health authorities concerned". In the amendment to Regulation 3.2 contained in the Annex to the draft resolution, "He" should be replaced by "He/she". Stressing that the sponsors had serious difficulties with the current criteria and that the matter was extremely important to them, she expressed the hope that the changes would be acceptable to those who wanted a democratic Secretariat. The sponsors would continue to strive towards that goal as long as was necessary. Mr BRODRICK (Australia) introduced a series of amendments proposed by his delegation and that of the United Kingdom of Great Britain and Northern Ireland, supported by the other Member States of the European Union, and by Bulgaria, Canada, Czech Republic, Fiji, Hungary, Japan, Latvia, Lithuania, New Zealand, Norway, Palau, Poland, Republic of Korea, Slovenia, Switzerland, Tuvalu, United States of America and Vanuatu. The proposals had been tabled that afternoon, even though the draft resolution had been circulated only the previous morning, a circumstance that had raised several difficulties. All Member States supported the objective of increasing the representation of developing countries in WHO, but responsibilities should be taken seriously and delegates should tread warily when significant proposals were submitted at short notice and without previous review by the Executive Board, a concern that had been raised in the past by some of the draft resolution's sponsors. The work of the drafting group had resulted in some helpful amendments despite the lack of time for consultation, but fundamental concerns remained. The amendments were as follows. The third preambular paragraph would read: Guided by Article 35 of the Constitution, which states that the paramount consideration in the employment of staff shall be to assure that the efficiency, integrity and internationally representative character of the Secretariat shall be maintained at the highest level, with due regard being also paid to the importance of recruiting staff on as wide a geographical basis as possible; The seventh preambular paragraph would read: Concerned that many countries, including developed and developing countries and countries in transition, continue to be unrepresented and underrepresented in the Secretariat, and in many cases in the professional category, including at headquarters; In paragraph 1, "in accordance with the principles of Article 35 of the WHO Constitution", would be inserted after "UNDERLINES" and "countries in transition" would be inserted after "developing countries". Paragraph 2 would read: STRESSES, in this context, the importance of equitable geographical representation and gender balance in the Secretariat in order to achieve a suitably representative character".

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In paragraph 3, "nonselectivity" would be replaced by "fair selection". Taking into account current work within the Secretariat that alleviated the concerns of some delegations, paragraphs 4, 5 and 6 would read: 4. UNDERLINES the importance of the Secretariat urgently pursuing all measures to ensure that all Member States are represented in the Secretariat in accordance with the desirable ranges set out in resolution WHA50.15. 5. REQUESTS the Director-General to ensure that the principles contained in Staff Regulations 4.2 and 4.3 on appointment of staff members are strictly applied, and notes that particular attention is needed to increase geographical distribution and gender balance, as well as the representation of unrepresented and underrepresented States. 6. INVITES the Director-General to take into account views expressed by the concerned Member States when appointing experts to advisory panels, to circulate information on all appointments made to these panels to Member States and to encourage developing countries and countries in transition to send nominations for the panels. In view of the lack of time available to consider and consult about the amendments to the Regulations for expert advisory panels and committees proposed in the Annex to the draft resolution, he proposed that paragraph 7 of the draft resolution and the Annex be deleted. It was crucial that the Executive Board consider the matter under discussion. As the sponsors of the draft resolution had indicated that they would continue to press for its adoption, the discussion could continue in that forum. He therefore proposed that paragraph 8 be amended to read: REQUESTS the Director-General to submit a report to the 111 th session of the Executive Board on the implementation of this resolution. A new paragraph would then be added that would read: DECIDES to include this item on the agenda of the Fifty-sixth World Health Assembly. He expressed regret that there had been insufficient time for those amendments to be circulated and the hope that they would be circulated in writing as soon as possible. Ms BALOCH (Pakistan) stated that she had noted with interest the proposals made by the delegate of Australia, but rebutted them as amendments. They ran counter to the basic premise of the draft resolution, that was to change the existing formula on the basis of which appointments were made in the Secretariat, and represented a new proposal that maintained the status quo, and introduced elements, such as reference to the Executive Board, that were not in the original text. She was not prepared to consider an entirely new proposal during discussion of the draft resolution, and asked the Chairman to act on that basis. Mr TOPPING (Legal Counsel), responding to a request for advice from the CHAIRMAN, referred to Rule 67 of the Rules of Procedure of the World Health Assembly which stated that a motion was considered an amendment to a proposal if it merely added to, deleted from or revised part of that proposal. A motion that constituted a substitution for a proposal was to be considered as a proposal. Normal practice would be to consider and decide on each amendment in turn. As indicated in Rule 68, when two or more proposals were moved, the Health Assembly should vote first on the proposal deemed to be furthest removed in substance from the proposal first presented. Should the amendments presented by the delegate of Australia be considered to be a proposal, they would be voted upon first. Rule 52 provided that, unless decided otherwise by the Health Assembly, no proposal

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could be discussed or put to the vote unless copies of it had been circulated to all delegations at least two days previously. However, the Rule did permit the discussion and consideration of amendments, even though they had not been circulated or had only been circulated the same day. Pakistan appeared to have asked for a ruling on whether the Australian intervention constituted a proposal or an amendment. The Chairman was entitled to take views from the floor before making a ruling on that point. Professor ABOUO-N'DORI (Cote d'Ivoire) maintained that Legal Counsel ought to have ruled, as a jurist, on whether the intervention of the delegate of Australia represented a proposal or amendments. Mr BARCIA (Portugal) suggested that time be allowed for further interventions, starting with the substance of the argument, in order to facilitate the Chairman's decision. Ms RODRIGUEZ CAMEJO (Cuba) firmly supported the request by Pakistan for the Chairman to decide. Having, correctly, sought and received the advice of the Legal Counsel on whether Australia had presented a new proposal or amendments, the Chairman should invite two protagonists to speak for each view and then decide. Ms BALOCH (Pakistan), maintaining that she had asked for a ruling, said that, if the Chairman was not yet ready to take a decision, the Cuban suggestion was the way forward. Mr TOPPING (Legal Counsel) confirmed that the Chairman could seek views before making a ruling. The Rules of Procedure did not limit the number of speakers. Mr MACPHEE (Canada) sought clarification as to whether it would be more acceptable for delegations to make individual amendments; in order to save time, Canada had been willing to support the presentation by Australia of a collection of amendments. As the document setting out the draft resolution was dated 16 May 2002, he asked whether Rule 52 had been satisfied. Professor ABOUO-N'DORI (Cote d'Ivoire), considering that the discussion should be brought to a close, argued that the delegate of Australia had introduced a new proposal, not amendments. Ms BALOCH (Pakistan), on a point of order, expressed her concern at the course being followed. It was understandable that each delegation wanted to express a view on a procedural move, but as she understood it, when a motion was moved by a delegation, there should follow two interventions for and two against. The advice given by the Legal Counsel had not been clear in that respect. Under Rule 64, therefore, she moved that the debate on the item should be suspended, with no further discussion, and that the meeting should proceed to action on the draft resolution. The CHAIRMAN ruled that the intervention by the delegate of Australia constituted the presentation of a new proposal and not amendments. The Committee would therefore consider the draft resolution introduced by Pakistan. She suggested that the debate should be resumed the next morning. Mr MACPHEE (Canada), speaking on a point of order, requested a response to his question concerning the date of circulation of the draft resolution. If Rule 52 had not been satisfied the Committee should not be considering the draft resolution. Mr TOPPING (Legal Counsel) explained that, in practice, Rule 52 had been interpreted not to mean strictly 48 hours; for instance, a document submitted on a Thursday afternoon could be

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discussed the following Saturday morning. The document setting out the draft resolution, having been issued the day before the current meeting, did not meet the two-day requirement. Replying to a further point of order by Ms BALOCH (Pakistan), the CHAIRMAN confirmed her view that Australia's intervention constituted a new proposal but recognized the problem of the interpretation of Rule 52. Nevertheless, she stressed that the matter had already been discussed and that that was part of the process; the validity of the original document was not in question. The discussion would be resumed the next day. Ms BALOCH (Pakistan), again on a point of order, emphasized that Rule 52 clearly gave the Chairman the discretion to permit discussion and consideration of amendments even though they had not been circulated or had been circulated the same day. She therefore appealed to the Chairman to allow immediate consideration of the draft resolution. Mr BARCIA (Portugal) pointed out that procedural considerations were hindering a democratic debate on a major, strategic matter for the Organization. He could not agree to a vote without the opportunity to intervene on such an issue. It was his understanding that there would be an opportunity for democratic expression on the matter, before a vote. He was prepared for the vote to be lost, but not to take part in a travesty of democratic debate. Mr BOTZET (Germany) supported the position of Portugal. A thorough discussion of the proposals was necessary. Interrupting the previous speaker to raise a point of order, Mr RAMOUL (Algeria) said that the matter had been sufficiently discussed. Pakistan's proposal had been available the previous day, 16 May 2002. The delegate of Pakistan had been clear: the Committee should proceed immediately to a vote and, in conformity with the Rules of Procedure, start with the proposal of Australia, then the text originally proposed. He requested that the Chairman close the debate and proceed to a vote. Mr BRODRICK (Australia) said that as two days had not yet elapsed since the circulation of the original proposal, he would prefer the debate to be deferred. The meeting was suspended at 20:35 and resumed at 20:50.

The CHAIRMAN invited the Committee to consider the two proposals. The proposal presented by Australia should be considered first, as it was the second one to be submitted, then the Committee could vote on the proposal presented by Pakistan. Dr MHLANGA (South Africa) asked whether the Committee would be provided with the text of the proposal presented by Australia. Dr SUWIT WIBULPOLPRASERT (Thailand) observed that, in accordance with Rule 52 of the Rules of Procedure of the World Health Assembly, the Chairman might permit consideration of amendments that had not been circulated or only circulated the same day, but not proposals. If the Chairman had decided that Australia had submitted a proposal, not an amendment, it could not be considered. Further, if it was decided to defer consideration of Pakistan's proposal until the following day, the provision that proposals should be circulated at least two days in advance, as set out in Rule 52, would be satisfied. Ms BALOCH (Pakistan) agreed with the previous speaker that, as the proposal of Australia had not been circulated, the Committee should not consider it. The draft resolution proposed by Pakistan and the other sponsors had been circulated the previous day, and should be considered. The sponsors

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of the draft resolutions were prepared to consider both proposals, however, and were ready to vote on them immediately, despite reservations about the legal interpretations that had been provided. Mr HOHMAN (United States of America), speaking on a point of order, requested the Chairman to clarify her ruling on conformity of the debate with Rule 52 of the Rules of Procedure. Mr RAMOUL (Algeria) said that when a request for action was made under a point of order it was usual to put that proposal to the Committee immediately. He did not understand, therefore, why, following his request for closure of the debate, the floor had been given to another delegate. He reiterated his request that the Committee proceed directly to a vote. Mr TOPPING (Legal Counsel) said that the Chairman, with reference to Rule 52, had invited the Committee to agree to proceed to consider both proposals. He had understood that that suggestion had received some support and, therefore, that the Committee had agreed to follow that course. He further understood that the delegate of Algeria had then requested closure of the debate. If that were so, the Chairman could give the floor to two speakers opposing that request, then the Committee would proceed to a vote on the matter. Should no delegate wish to speak against closure of the debate, that would indicate agreement to close the debate. Since it appeared that the Committee had previously agreed to consider both proposals, if it agreed to close the debate it should vote first on the proposal presented by Australia. If that proposal was rejected, the Committee could vote on the proposal submitted by Pakistan. He understood that the amendments introduced by the delegate of Pakistan had been made on behalf of all the sponsors and, in accordance with Rule 67, would therefore automatically be incorporated in the proposal. Mr HOHMAN (United States of America) requested a response to his call for clarification concerning conformity with Rule 52. Mr TOPPING (Legal Counsel) said that, as he had indicated earlier, Rule 52 stated that no proposal could be put to the vote unless copies of it had been circulated to all delegations at least two days previously, except as might be decided otherwise by the Health Assembly. The Committee had apparently decided otherwise, namely, by agreeing to proceed to a vote on the two proposals, including that presented by Australia, which was not available in writing. Mr HOHMAN (United States of America) observed that the assumptions of the Legal Counsel could not dictate the decision of the Committee. His understanding of Rule 52 was that the Committee had to comply with the "two-day" provision unless it decided otherwise. He maintained therefore that the Committee was currently not in conformity with Rule 52. Mr TOPPING (Legal Counsel) concurred that it was for the Committee to decide how it wished to proceed. The Chairman might wish to ask the Committee whether it agreed with her suggestion to consider the two proposals. If the Committee did not agree, it should proceed to a vote on that suggestion. The CHAIRMAN suggested that she should proceed as indicated by the Legal Counsel. Mr HOHMAN (United States of America), on a point of order, moved the adjournment of the meeting under Rule 61. In accordance with Rule 64, his motion should take precedence over any other, except that of suspending the meeting. Ms BALOCH (Pakistan) requested that the Committee proceed to a vote on the motion proposed by the delegate of the United States of America. According to Rule 63, two speakers could

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speak in favour of, and two against, the motion, after which the Committee should proceed immediately to a vote. Mr TOPPING (Legal Counsel), after reading out Rule 61 and referring to Rule 64, confirmed that a motion for adjournment of the meeting took precedence over a motion for closure of the debate. With regard to the voting procedure, he explained that the Chairman would shortly request those delegates in favour of adjournment to raise their name plat~s. Ms BALOCH (Pakistan), on a point of order, requested a roll-call vote. Mr TOPPING (Legal Counsel), referring to the voting procedure for a roll-call vote, explained that the names of Members entitled to vote would be read aloud, starting with the Member drawn by lot. Those that were absent would be called a second time. Mr BARCIA (Portugal) requested clarification on what the Committee was being asked to vote on and the implications of that vote. Mr TOPPING (Legal Counsel) replied that the Committee was being asked to vote on whether to adjourn the meeting. A "yes" vote meant that the Member was in favour of adjourning the meeting; a "no" vote, that the Member opposed adjournment. The decision would be made by the majority of those present and voting; an abstention would not be counted in the tally of Members present and voting. The following Members were not entitled to vote or were not present at the Health Assembly: Afghanistan, Antigua and Barbuda, Armenia, Azerbaijan, Bosnia and Herzegovina, Central African Republic, Chad, Comoros, Djibouti, Dominican Republic, Equatorial Guinea, Georgia, Guinea-Bissau, Iraq, Kazakhstan, Kyrgyzstan, Liberia, Nauru, Niger, Nigeria, Niue, Republic of Moldova, Somalia, Suriname, Tajikistan, Togo, Turkmenistan, and Ukraine. Dr OWAlNAT (Libyan Arab Jamahiriya), rising to a point of order, questioned the conduct of the meeting. Voting appeared to be shifting from one motion to another in a rather disorganized manner. Ms BALOCH (Pakistan), on a point of order, asked for confirmation that those delegates in favour of the motion of the United States of America to adjourn the meeting should vote "yes", whereas those against it should vote "no". The CHAIRMAN confirmed that the subject of the vote was the adjournment of the meeting. If the decision was to continue the meeting, the Committee would then proceed to vote on the proposal of Australia, followed by that of Pakistan. Mr HOHMAN (United States of America), speaking on a point of order, requested that the vote proceed without comment on what might happen afterwards. A vote was taken by roll-call, the names of the Member States being called in the French alphabetical order, starting with Oman, the letter 0 having been determined by lot. The result of the vote was as follows: In favour: Andorra, Australia, Austria, Belgium, Bulgaria, Canada, Cyprus, Czech Republic, Denmark, Fiji, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Latvia, Lithuania, Netherlands, New Zealand, Norway, Palau, Poland, Portugal, Republic of Korea, Slovakia, Spain, Sweden, Switzerland, United Kingdom of Great Britain and Northern Ireland, United States of America, Yugoslavia.

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Against: Algeria, Argentina, Botswana, Brazil, China, Congo, Cote d'Ivoire, Cuba, Democratic Republic of the Congo, Democratic People's Republic of Korea, Egypt, Ethiopia, Ghana, Guinea, India, Indonesia, Islamic Republic of Iran, Jordan, Libyan Arab Jamahiriya, Malaysia, Mali, Mexico, Myanmar, Nepal, Pakistan, Peru, Philippines, Saudi Arabia, Senegal, Sierra Leone, South Africa, Sri Lanka, Thailand, Tunisia, Turkey, United Arab Emirates, United Republic of Tanzania, Uruguay, Venezuela, VietNam, Zimbabwe. Abstaining: Belarus, Russian Federation. Absent: Albania, Angola, Bahamas, Bahrain, Bangladesh, Barbados, Belize, Benin, Bhutan, Bolivia, Brunei Darussalam, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Chile, Colombia, Cook Islands, Costa Rica, Croatia, Dominica, El Salvador, Ecuador, Eritrea, Estonia, Gabon, Gambia, Grenada, Guatemala, Guyana, Haiti, Honduras, Israel, Jamaica, Kenya, Kiribati, Kuwait, Lao People's Democratic Republic, Lebanon, Lesotho, Luxembourg, Madagascar, Malawi, Maldives, Malta, Marshall Islands, Mauritania, Mauritius, Federated States of Micronesia, Monaco, Mongolia, Morocco, Mozambique, Namibia, Nicaragua, Oman, Panama, Papua New Guinea, Paraguay, Qatar, Romania, Rwanda, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Samoa, San Marino, Sao Tome and Principe, Seychelles, Singapore, Slovenia, Solomon Islands, Sudan, Swaziland, Syrian Arab Republic, The former Yugoslav Republic of Macedonia, Tonga, Trinidad and Tobago, Tuvalu, Uganda, Uzbekistan, Vanuatu, Yemen, Zambia. The proposal was therefore rejected by 41 votes to 35, with 2 abstentions. Mr BARCIA (Portugal) said his delegation had never before known a debate of major importance in an international organization to be closed before it had even begun. It was deplorable that, apart from the delegations that had sponsored the draft resolution or proposed amendments to it, no delegation in the chamber, including his own, which had asked for the floor at the beginning, had been able to make a substantive contribution. He wished to know the quorum necessary to enable a vote to take place and whether that quorum had been attained. Mr TOPPING (Legal Counsel) replied that the quorum required for a formal vote was 93. He took the position, however, as at many previous Health Assemblies, that a Committee could not question the quorum after the vote, only before. He had considered that there was a quorum in the room before the voting commenced. In any event, the results of the vote showed that 85 Members had not responded and had been marked absent; subtracting 85 from the total membership of 191 gave 106. Of the names of the countries he had read out which were either not present at the Health Assembly or did not have the right to vote, six were not present. Consequently, another six Members could be subtracted from the total, giving 100. Thus, the results of the vote could not in any event be used to argue that a quorum was not present. As to the further procedure, having rejected a motion for the adjournment of the meeting, the Committee should proceed to a vote on the motion for the closure of the debate. Dr OWAi'NAT (Libyan Arab Jamahiriya) said that the Committee was familiar with both the draft resolution and the proposal presented by Australia. In order to save time, it should vote on the two proposals straight away. Ms BALOCH (Pakistan), speaking on a point of order, asked for clarification of the Legal Counsel's statement that the meeting would proceed to vote on the closure of the debate. As she understood it, before the proposal to adjourn the meeting, which had been rejected, the Committee had been considering whether to hold a vote on the proposal presented by Australia. In her view, consideration of that matter should not continue.

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Ms MACMILLAN (New Zealand), on a point of order, asked whether there was the necessary quorum for a vote. Ms BALOCH (Pakistan), on a further point of order, asked which of the applicable rules of procedure the delegate ofNew Zealand wished to invoke. Mr TOPPING (Legal Counsel) said that a proposal to adjourn the meeting had been rejected. The next matter to be considered was the earlier proposal by the delegate of Algeria that the debate should be closed. No decision had yet been taken on that point. The question of a quorum was governed by Rule 85 of the Rules of Procedure of the World Health Assembly which stated that onethird ofthe members of a committee constituted a quorum but also that a majority ofthe committee's members must be present for a question to be put to a vote. Accordingly, the presence of 62 delegations in the room was requested in order to hold a meeting at all, and 93 delegations must be present for a formal vote to take place. The matter currently before the Committee was the vote on the closure of the debate. The delegate ofNew Zealand had asked for a formal confirmation that a quorum was present, and a count of the number of delegations present would be made. Ms RODR:iGUEZ CAMEJO (Cuba), speaking on a point of order, pointed out that many delegates from developed countries had deliberately left the room so that the quorum would not be attained. Such behaviour was both unconstitutional and unacceptable especially from countries that so frequently advocated democracy. If such behaviour continued, her delegation would request a vote on every single draft resolution brought before plenary for adoption. Dr OWAINAT (Libyan Arab Jamahiriya), on a point of order, expressed dismay at the conduct of the meeting and agreed that the developed countries were not behaving correctly; leaving the room was not the right way to deal with the issue before the Committee. He proposed that a vote should be taken among the Members still present in the room. Mr RAMOUL (Algeria), on a point of order, said that the behaviour of his colleagues from the developed countries betrayed their real attitude towards draft resolutions that were of importance to the developing countries. If it was possible, under the Rules of Procedure, to take a vote on the original draft resolution with the number of members currently present in the room, that should be done straight away. If not, the developing countries should systematically reject all the remaining draft resolutions before the plenary for adoption the next morning, without discussion. Ms NELLTHORP (United Kingdom of Great Britain and Northern Ireland), speaking on a point of order, said that her delegation had remained in the meeting room. She believed that some delegations had left the room because they felt that they had not had a democratic opportunity to discuss the proposal presented by Australia. The proposal had been put forward in good faith and with a willingness to negotiate on the original draft resolution presented by Pakistan. Most delegations had not even had an opportunity to look at the Australian proposal. It had been suggested that discussion of the Australian proposal should be delayed, in order to allow for translation into the six official languages of the Health Assembly and to allow time for study. That proposal had been rejected by the sponsors of the original draft resolution. Accordingly, those delegations that had left the room felt that their democratic rights had not been respected. Ms BALOCH (Pakistan), speaking on a point of order, asked whether there was a quorum. Mr TOPPING (Legal Counsel) said that 52 delegations were in the room, which was below the quorum required for conduct of the Committee's business. He saw no alternative but to adjourn the meeting.

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Ms BALOCH (Pakistan), speaking on a point of order, asked for the meeting to be suspended for a few minutes, since more delegations were expected to arrive soon. Mrs GARV AL (Denmark), speaking on a point of order, said that her delegation, too, had stayed in the meeting room. However, she felt extremely uncomfortable at the rowdy behaviour of the Committee. Her delegation had remained because it felt that it had been deprived of the right to comment on the draft resolution and its proposed amendments. The democratic principles normally adhered to in a meeting had been grossly violated, and she expressed the hope that, in future, the proceedings would be much more orderly and worthy of the Health Assembly. Mr REN Yisheng (China), speaking on a point of order, pointed out that the discussion of the draft resolution proposed by Pakistan and other countries had begun many hours earlier. The fact that Australia had presented a proposal, whether it counted as an amendment or as a new proposal, showed that Australia had indeed participated in the debate. It was unjust to say that countries had not been allowed the opportunity to discuss the draft resolution. He was reminded of the events which had taken place at the United Nations World Conference against Racism, Racial Discrimination, Xenophobia and Related Intolerance, held in Durban, South Africa in September 2001. Those same countries that had walked out of the present meeting had held up the debate at the World Conference. A vote had been taken on some draft resolutions after those countries had left, and they had subsequently challenged the quorum, just as they had tried to do at the current meeting. Their behaviour was not democratic. Dr BODZONGO (Congo) said that the Chairman had ruled that the proposal presented by Australia was a new proposal rather than an amendment to the original draft resolution. The Committee should decide on the draft resolution, and the meeting should be suspended for a few minutes in the hope of attaining a quorum. Countries had had ample opportunity to discuss both proposals during the day. The current situation was an attempt to undermine the debate. Mr RAMOUL (Algeria), speaking on a point of order, said that the farce that the Committee had just witnessed showed a lack of respect for the Chairman and for the delegations participating in the work of the Committee since the start of the day. His delegation intended to demand a vote on every report of the Committee, challenge every consensus reached and demand a vote on every single proposal put to the plenary the following day. Even if it lost the votes, it would go on fighting the established order that other colleagues wished to retain. The CHAIRMAN said that, in the absence of a quorum, the meeting would be suspended. The meeting was suspended at 22:15 and resumed at 22:30. The CHAIRMAN announced that, as there was still no quorum, she was obliged to adjourn the meeting. She expressed great disappointment at the turn of events, especially as she had endeavoured to conduct the Committee's business in the most democratic way possible and ensure ample opportunity for everyone to speak. She had agreed to chair Committee B in the hope that all sides would show the maximum of understanding. What had happened was unacceptable and offensive to herself and her country, Senegal, which was on the path to democracy and fought for democracy. She thanked the delegations that had remained in the room and assured them that she would do everything possible to ensure that democracy prevailed. The Committee would reconvene the following morning to consider the remaining draft resolutions. Ms BALOCH (Pakistan), speaking on behalf of the sponsors of the draft resolution, thanked the Chairman for her guidance and patience during the Committee's deliberations. It was unfortunate that some delegations had decided to leave the room. She agreed with the Chairman that their action had

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been an insult not only to the sponsors of the draft resolution, but to the Chairman, the Committee and the Health Assembly as a whole. Ms RODRiGUEZ CAMEJO (Cuba), endorsing the expression of thanks to the Chairman, said that the only response that the developing countries could make to the challenge to democracy was to show a united front and fight together for the interests of the developing countries at the Health Assembly. Mr BRODRICK (Australia), thanking the Chairman for her hard work and perseverance, expressed regret that the debate, which many of the delegations that had left the room had been keen to hold, had not taken place. He said that he looked forward to a successful outcome the following day.

The meeting rose at 22:35.

SIXTH MEETING Saturday, 18 May 2002, at 11:55 Chairman: Professor AM. COLL SECK (Senegal)

STAFFING MATTERS: Item 16 of the Agenda (continued)

Human resources: annual report: Item 16.1 of the Agenda (continued) The CHAIRMAN drew attention to a draft resolution on the need for increased representation of developing countries and countries in transition in the Secretariat and the expert advisory panels and committees, which was a revised version of a draft resolution introduced at the third and fourth meetings of the Committee. The draft resolution was proposed by the delegations of Algeria, Benin, Chad, China, Cuba, Egypt, Ethiopia, Indonesia, Islamic Republic of Iran, Libyan Arab Jamahiriya, Malaysia, Oman, Pakistan, Palau, Qatar, Somalia, South Africa, Swaziland, Syrian Arab Republic, United Arab Emirates, United Republic of Tanzania, Vanuatu, and Zimbabwe, and read: The Fifty-fifth World Health Assembly, Guided by the Purposes and Principles of the Charter of the United Nations, in particular the principle of the sovereign equality of its Member States; Reaffirming the principle of equitable participation of all Members of the Organization in its work, including that of the Secretariat and various committees and bodies; Bearing in mind Article 3 5 of the Constitution; Recalling its resolution WHA4.51 adopting the Staff Regulations ofthe Organization and its subsequent resolutions amending these regulations; Recalling its resolution WHA50.15 on recruitment of international staff in WHO: geographical representation; Further recalling its resolution WHA3 5.10 approving the Regulations for Expert Advisory Panels and Committees and its subsequent resolutions amending these regulations; Concerned that the developing countries and countries in transition are underrepresented in the Secretariat, in the professional category, including at headquarters; Also concerned at the limited representation of developing countries and countries in transition on expert advisory panels and committees, 1. UNDERLINES that the Secretariat of WHO is a common secretariat for all Member States and should therefore reflect the composition of its membership, a majority of which are developing countries; 2. STRESSES, in this context, adherence to the principle of equitable geographical representation and gender balance at all levels in the Secretariat, especially at headquarters, in order to improve its representative character; 3. EMPHASIZES the principles of transparency, fair selection, objectivity, competence and merit in appointments both in the Secretariat and to expert advisory panels and committees; 4. UNDERLINES that country ranges for appointments in the Secretariat should, in principle, be based on membership, equitable geographical representation, population criteria, - 211 -

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and balance between developed and developing countries, with less emphasis on financial contributions to the Organization; 5. REQUESTS the Director-General to ensure that the principles of equitable geographical representation, gender balance and a balance of experts from developed and developing countries and countries in transition are respected in making appointments in the Secretariat and in establishing expert advisory panels or expert committees; FURTHER REQUESTS the Director-General to consult with health authorities 6. concerned when appointing experts to advisory panels, to circulate information on all appointments made to these panels to Member States through a publicly available document, including on the Internet, and to encourage developing countries and countries in transition to send nominations for the panels; 7. DECIDES to amend the Regulations for Expert Advisory Panels and Committees in light of this resolution, as per the Annex to this resolution; 8. REQUESTS the Director-General to submit a report to the Fifty-sixth World Health Assembly on implementation of this resolution, including different alternatives to the current representation formula in the Secretariat.

ANNEX Amendments to the regulations for Expert Advisory Panels and Committees Amendment to Regulation 3.1 Add at the end: Information on all appointments made to these panels shall be circulated to all Member States. The Director-General shall encourage the developing countries and countries in transition to send nominations for the panels.

Amendment to Regulation 3.2 Replace the last sentence with the following: He/she shall encourage nomination of experts from developing countries and countries m transition and from all regions and shall be helped in this task by Regional Directors.

Amendment to Regulation 4.2 Replace with the following: As a general rule, the Director-General shall select from one or more expert advisory panels the members of an expert committee on the basis of the principles of equitable geographical representation, gender balance, a balance of experts from developed and developing countries and countries in transition, representation of different trends of thought, approaches and practical experience in various parts of the world, and an appropriate interdisciplinary balance. The membership of expert committees shall not be restricted by consideration of language, within the range of languages of the Organization.

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The CHAIRMAN drew attention to a further draft resolution on increased representation of developing countries in the Secretariat and in expert advisory panels and committees proposed by the delegations of Australia, Bulgaria, Canada, Czech Republic, Fiji, Hungary, Japan, Latvia, Lithuania, New Zealand, Norway, Palau, Poland, Republic of Korea, Slovakia, Slovenia, Switzerland, Tuvalu, United Kingdom of Great Britain and Northern Ireland, United States of America, and Vanuatu, which read: The Fifty-fifth World Health Assembly, Guided by the Purposes and Principles of the Charter of the United Nations, in particular the principle of the sovereign equality of its Member States; Reaffirming the principle of equitable participation of all Members of the Organization in its work, including that of the Secretariat and various committees and bodies; Guided by Article 35 of the Constitution, which states that the paramount consideration in the employment of staff shall be to assure that the efficiency, integrity and internationally representative character of the Secretariat shall be maintained at the highest level, with due regard also being paid to the importance of recruiting the staff on as wide a geographical basis as possible; Recalling its resolution WHA4.51 adopting the Staff Regulations of the Organization and its subsequent resolutions amending these regulations; Recalling its resolution WHA50.15 on recruitment of international staff in WHO: geographical representation; Further recalling its resolution WHA3 5.10 approving the Regulations for Expert Advisory Panels and Committees and its subsequent resolutions amending these regulations; Concerned that many countries, including developed and developing countries and countries in transition, continue to be unrepresented and underrepresented in the Secretariat, and in many cases in the professional category, including at headquarters; Also concerned at the limited representation of developing countries on expert advisory panels and committees, I. UNDERLINES, in accordance with the principles of Article 35 of the WHO Constitution, that the Secretariat of WHO is a common secretariat for all Member States and should therefore reflect the composition of its membership, a majority of which are developing countries and countries in transition; 2. STRESSES, in this context, the importance of equitable geographical representation and gender balance in the Secretariat in order to achieve a suitably representative character; 3. EMPHASIZES the principles of transparency, fair selection and objectivity in appointments both in the Secretariat and to expert advisory panels and committees; 4. UNDERLINES the importance of the Secretariat urgently pursuing all measures to ensure that all Member States are represented in the Secretariat in accordance with the desirable ranges set out in resolution WHA50.15; 5. REQUESTS the Director-General to ensure that the principles contained in Staff Regulations 4.2 and 4.3 on appointment of staff members are strictly applied, and notes that particular attention is needed to increase geographical distribution and gender balance, as well as the representation of unrepresented and underrepresented States; 6. INVITES the Director-General to take into account views expressed by the concerned Member State when appointing experts to advisory panels, to circulate information on all

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appointments made to these panels to Member States, and to encourage developing countries and countries in transition to send nominations for the panels; 7. REQUESTS the Director-General to submit a report to the Ill th session of the Executive Board on the implementation of this resolution; 8. DECIDES to include this item on the agenda of the Fifty-sixth World Health Assembly.

Mr BRODRICK (Australia), recalling the discussions at the previous meeting, said that an informal meeting had taken place earlier that morning between representatives of the two groups of interested parties, also attended by the Director-General, with a view to reconciling the different points of view. Various proposals had been discussed in an attempt to reach a consensus on the draft resolution considered at the previous meeting, after which it had been agreed that the representatives would return to their groups in order to ascertain whether the proposals were acceptable. Unfortunately, since the draft resolution had been circulated only two days previously and in view of the importance that the countries that had proposed amendments attached to the issues involved, it had not proved possible for his group to accept the proposals. The sponsors of the second draft resolution mentioned by the Chairman, to which the Member States of the European Union should be added, remained committed to the wording proposed in that draft. Ms BALOCH (Pakistan) said that the sponsors of the first draft resolution and the delegates of several other developing countries were cognizant of the importance of the Health Assembly, the Organization itself and the need to make them a success. That principle had been the basis of the work of the sponsors throughout the negotiations. It was regrettable that certain delegations had insulted the Health Assembly, the Chairman and the Director-General by walking out of the previous meeting. The sponsors had arrived at the informal meeting referred to by the previous speaker with open minds and the clear intention to make progress. They had been approached by the Chairman and the Director-General, whom they all respected, with the request to show some movement, and had agreed to discuss the matter further. The informal meeting had been held in the Chairman's office with two representatives from countries sponsoring the second draft resolution and two from those sponsoring the original draft resolution and the revised version of that resolution. A consensus proposal had been suggested that could have brought the two sides together. That proposal contained some elements that were not acceptable to the original sponsors as they shifted the focus from many of the important issues that they had wished to highlight. Nevertheless, all the developing countries, which had met beforehand, and the sponsors of the draft resolution presented by her delegation had agreed to accept each and every amendment that had been proposed. They were in full agreement on accepting the compromise proposal. Unfortunately, the other party was not. That was their prerogative and her group could only say that it showed their lack of seriousness and lack of commitment to achieving consensus. Her group had discussed all possible eventualities. Given that there was no consensus, the only way to progress was to put to a vote the first draft resolution mentioned by the Chairman. Disappointed that a large number of countries in transition had simply walked out of the room during the previous meeting, the sponsors had decided to propose the deletion of all references to countries in transition throughout the text. The following countries had asked to be included as sponsors of the draft resolution: Bangladesh, Barbados, Cote d'lvoire, Gambia, Jordan, Senegal and Thailand. The names of Palau and Vanuatu should be removed from the list of sponsors. Mr RAMOUL (Algeria) said that he would not waste words on the shameful episode of the previous evening. The sponsors of the original draft resolution had been requested to join the informal meeting already mentioned in order to find a solution to the problem. The subject of the original draft resolution had been raised well in advance, contrary to statements suggesting that there had been insufficient time to prepare comments. Unfortunately, the result of the informal meeting had only

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confirmed the attitude of those who thought that the democratic operation of an institution was valid only when it served their own interests. He called for an immediate vote on the first draft resolution mentioned by the Chairman, together with the new amendments introduced by the delegate of Pakistan. Ms RODRIGUEZ CAMEJO (Cuba), referring to the previous meeting, regretted the insulting attitude taken by the developed countries once it had appeared that the common interest of the developing countries would prevail. She thanked the Chairman for her continued efforts to re-establish dialogue and trust among the members of the Committee, to which, unfortunately, not all countries had been prepared to respond. The informal meeting had been held in the hope that Member States would display flexibility and a constructive spirit. The sponsors of the original draft resolution and a large group of developing countries had indicated that they were prepared to accept the compromise text proposed by the Chairman, which had been prepared jointly with the Secretariat and representatives of the opposing parties. However, regrettably, there had been a negative response from the other group of countries. In other words, those countries were opposed to negotiation and dialogue. That left, therefore, no option but to turn to the first draft resolution mentioned by the Chairman, which was a revised version of the original draft resolution and which defended the interests of the developing countries. She called on all developing countries to support that draft resolution. Dr OTTO (Palau) said that Palau had joined the sponsors of the original draft resolution because it believed in its underlying principles. He had expected a democratic debate on the issue in which all pertinent opinions could be voiced, and was disappointed that that had not taken place. Palau had been prepared to accept the amendments presented at the previous meeting by Australia. It had, however, proved impossible to reconcile those amendments and the original text. Palau had maintained the opinion that further efforts should have been made to consider the amendments with a view to reaching a compromise. As a result it had been removed from the list of the sponsors of the first draft resolution. Palau still supported the principles underlying the original draft resolution but had decided to join the sponsors of the proposed amendments. Mr SELIM LABIB (Egypt) said that he regretted the current situation and pointed out the negative repercussions of the position adopted by some Member States the previous day in an attempt to thwart the adoption of a fair draft resolution submitted by developing countries. The position of those Member States could not be justified; it was a discredit to the political dialogue being conducted in all international forums. He appealed to all delegations to make every possible effort to progress beyond a dangerous situation. A fresh start should be made and a position adopted that was more in tune with socioeconomic balance and the rules of justice. The aims of the sponsors of the draft resolution introduced by Pakistan were legitimate. They wished to establish fair treatment of developing countries without jeopardizing the interests of other countries. They had been patient and were still trying to reach a consensus on the draft resolution. The developing countries were as deeply committed to their position as other countries were to theirs. He requested the Chairman to respond to the request from Pakistan and Algeria that a vote be taken. Mr BARCIA (Portugal) said that, since the debate had turned to questions of substance, he wished to make the statement that, for procedural reasons, he had been prevented from making at the previous meeting. Ms BALOCH (Pakistan), rising to a point of order, said that with all due apologies to the delegate of Portugal and others who wished to speak, there was not enough time left to hear the views of 191 delegates, and that a vote should be taken. Referring to the list of sponsors of the first draft resolution mentioned by the Chairman, she indicated that the Democratic People's Republic of Korea and Sudan should also be added to the list.

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The CHAIRMAN said that she would allow the delegates who had already requested the floor to speak before the vote was taken. Dr SALLOUM (Syrian Arab Republic), rising to a point of order, said that there had been two requests for an immediate vote and he asked the Chairman to move immediately to the vote in accordance with the Rules of Procedure. Mr TOPPING (Legal Counsel) said that the closure of the debate had been moved, according to Rule 63 ofthe Rules of Procedure. Under that Rule, the Chairman was entitled to give the floor to two speakers objecting to the closure. In the event of an objection, a vote would have to be taken on that motion. Mr BARCIA (Portugal) objected to the proposed closure of the debate since there had been no proper opportunity for a debate. Ms BALOCH (Pakistan) said that, as she understood it, the delegate of the Syrian Arab Republic had asked for a vote to be taken as quickly as possible and not for closure of debate. She had no objection to other speakers taking the floor, provided a vote was taken directly afterwards. The CHAIRMAN -said that it was her understanding that the Syrian Arab Republic had, in fact, asked for the debate to be closed and a vote to be taken. Committee B would therefore proceed to a vote. Dr SALLOUM (Syrian Arab Republic), rising to a point of order, said that he had not asked for a closure of the debate, but rather that a vote should be taken as soon as possible. The misunderstanding had arisen as a result of the interpretation by the Legal Counsel, whose contribution during the discussions had given serious cause for concern. In reply to a request by the CHAIRMAN to reiterate clearly his earlier proposal, he said that he had proposed that the list of speakers should be closed but that those who had already indicated a wish to speak be allowed to do so. Mrs lORD ACHE (Romania) and Mr GRBESA (Croatia) asked for their countries to be added to the list of sponsors of the second draft resolution. Mr REN Yisheng (China) observed that almost a whole working day had been devoted to one agenda item without a solution being found. The Committee should therefore proceed to a vote immediately. Mr BARCIA (Portugal) said that he could not support the proposal to close the debate as to do so would be contrary to democratic principles and the traditions of the Organization. The systematic recourse to procedural moves had been unacceptable. While he fully endorsed the increased participation of developing countries in the work of WHO, the problem could not be solved merely by radically changing the selection criteria so that, in effect, demographic representation would be the sole indicator. To take such a step would be both mistaken and irresponsible; its first victims would be many of the Member States who might have voted in favour of the resolution. Moreover, it represented a clear politicization of the expert committees whose principal qualification for membership should be scientific ability, and would once again call into question the credibility of WHO's expert advisory panels and committees. Mr PEREZ-VILLANUEVA Y TOVAR (Spain), speaking on behalf of the Member States of the European Union, expressed regret that the draft resolution had elicited so much acrimony, resulting not only in a failure to reach consensus but also in open confrontation. The correct procedure in all the international organizations, including WHO, should be to have a wide-ranging constructive debate

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before proceeding to a vote. The countries he represented had always encouraged the Organization's efforts in favour of the countries that most needed help, through the provision of political and financial support. Given the political implications of the revised draft resolution, a Committee of the Health Assembly was not the appropriate forum in which to raise a fundamental change in the rules and regulations that applied to the Secretariat, some of which were laid down in the Constitution. The CHAIRMAN expressed her understanding that the Committee, as requested by Pakistan and other delegations, wished to vote on the proposal introduced by Pakistan and, responding to a point of order raised by Mr MACPHEE (Canada), confirmed that an explanation of the vote could be given after the vote had been taken. Ms BALOCH (Pakistan) requested a roll-call vote. Mr TOPPING (Legal Counsel) said that the following Member States would not be called either because they had had their vote suspended in accordance with prior Health Assembly resolutions, or because they were not represented at the Health Assembly: Afghanistan, Antigua and Barbuda, Armenia, Bosnia and Herzegovina, Central African Republic, Chad, Comoros, Djibouti, Georgia, Guinea-Bissau, Equatorial Guinea, Iraq, Kazakhstan, Kyrgyzstan, Liberia, Nauru, Niger, Nigeria, Niue, Republic of Moldova, Somalia, Suriname, Tajikistan, Togo, Turkmenistan and Ukraine. The vote would be on the first resolution mentioned by the Chairman at the start of the meeting. Those in favour should say "yes" and those against "no". The resolution would be approved if a majority of those present and eligible to vote voted "yes". Those abstaining would not be counted in the process of determining those present and voting. Ms BALOCH (Pakistan), rising to a point of order, wished it to be clear that the Committee was about to vote on the draft resolution with the amendments she had introduced earlier. The CHAIRMAN confirmed that that was the case. A vote was taken by roll-call, the names of the Member States being called in the French alphabetical order, starting with Vanuatu, the letter V having been determined by lot. The result of the vote was as follows: In favour: Algeria, Angola, Bahrain, Bangladesh, Barbados, Benin, Bhutan, Bolivia, Botswana, Brunei Darussalam, Burkina Faso, Cameroon, China, Colombia, Congo, Cote d'Ivoire, Cuba, Democratic People's Republic of Korea, Democratic Republic of the Congo, Dominican Republic, Egypt, Ethiopia, Gabon, Gambia, Ghana, Guinea, India, Indonesia, Islamic Republic of Iran, Jamaica, Jordan, Kenya, Kuwait, Libyan Arab Jamahiriya, Madagascar, Malaysia, Mali, Mauritius, Morocco, Myanmar, Nepal, Oman, Pakistan, Philippines, Qatar, Saudi Arabia, Senegal, Seychelles, Sierra Leone, Singapore, South Africa, Sri Lanka, Sudan, Syrian Arab Republic, Swaziland, Thailand, Tunisia, Turkey, United Arab Emirates, United Republic of Tanzania, Venezuela, VietNam, Zambia, Zimbabwe. Against: Australia, Austria, Belarus, Belgium, Bulgaria, Canada, Croatia, Cyprus, Czech Republic, Denmark, Fiji, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Latvia, Lithuania, Luxembourg, Netherlands, New' Zealand, Norway, Palau, Poland, Portugal, Republic of Korea, Romania, Russian Federation, San Marino, Slovakia, Spain, Sweden, Switzerland, United Kingdom of Great Britain and Northern Ireland, United States of America, Yugoslavia.

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Abstaining: Argentina, Brazil, Chile, Costa Rica, El Salvador, Honduras, Mexico, Nicaragua, Paraguay, Peru, Uruguay. Absent: Albania, Andorra, Azerbaijan, Bahamas, Belize, Burundi, Cambodia, Cape Verde, Cook Islands, Dominica, Ecuador, Eritrea, Estonia, Grenada, Guatemala, Guyana, Haiti, Kiribati, Lao People's Democratic Republic, Lebanon, Lesotho, Malawi, Maldives, Malta, Marshall Islands, Mauritania, Federated States of Micronesia, Monaco, Mongolia, Mozambique, Namibia, Panama, Papua New Guinea, Rwanda, Saint Kitts and Nevis, Saint Lucia, Saint Vincent and the Grenadines, Samoa, Sao Tome and Principe, Slovenia, Solomon Islands, The former Yugoslav Republic of Macedonia, Tonga, Trinidad and Tobago, Tuvalu, Uganda, Uzbekistan, Vanuatu, Yemen. The draft resolution, as amended, was therefore approved by 64 votes to 41, with 11 abstentions.' Mrs QUINT AV ALLE (Italy), speaking in explanation of vote, expressed her disappointment that such an important issue had not been the subject of a thoughtful and in-depth discussion. Italy had participated in the drafting group that had met to consider the original draft resolution and would have liked to see the discussion that had been initiated there resumed on the basis of the amendments that certain countries had drawn up in a very short space of time. In the absence of such a discussion, there should not have been a vote. Undoubtedly the issue was sensitive and it was right and proper for WHO and the Member States to ensure a more equitable geographical representation, but the resolution in its current form was not acceptable. Not only did it contain two contentious proposals, which should have been amended, but it also required further work. Certain aspects relating to ways of improving the current situation, which needed explanation by the Director-General before a decision could be taken, were not included. Italy had therefore voted against the resolution. It would have voted similarly on any resolution relating to a serious issue that had not been adequately discussed. Mr MACPHEE (Canada), speaking in explanation of vote, said that Canada had been unable to support the resolution as drafted. The principles of geographical representation were already enshrined in article 101 of the United Nations Charter and in the WHO Constitution, in particular, in Article 35. Canada considered that elements of the resolution as approved, in particular paragraphs 4 and 7 and the Annex, were inconsistent with the principles of the United Nations Charter and the WHO Constitution and, furthermore, would seriously jeopardize the Director-General's prerogative to manage the Organization's human resources. He regretted that the Committee had not been given the opportunity to give adequate consideration to the resolution and its implications for the Organization, and the United Nations system. Ms BLACKWOOD (United States of America), speaking in explanation of vote, expressed dissatisfaction at the outcome of the matter and at the imposition of a vote. The resolution was illconsidered and did not benefit the interests of either the developed or developing countries or the work and integrity of the Organization as a science-based, technical agency. The issues and their ramifications, which were profound, had not been debated. The Constitution remained the supreme document guiding WHO and that would not change with the resolution. Neither would the policies relating to country ranges, which were part of the United Nations common system practices, nor the scientific focus of WHO, with the paramount considerations of merit and technical expertise, irrespective of country of origin. She had listened to the position of the developing countries but, given that it had been impossible to discuss the matter adequately in the time available, the United States stood by its view that it should be referred to the Executive Board for detailed discussion.

Transmitted to the Health Assembly in the Committee's fifth report and adopted as resolution WHA55.24.

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Mrs BERGER (Switzerland), speaking in explanation of vote, said that her delegation had voted against the resolution to express its dissatisfaction with the procedure that had been followed rather than with the content of the resolution. Although it was generally agreed that a better geographical balance needed to be established in the Secretariat, what had been proposed not only affected WHO's organizational framework, but that of the whole United Nations system. It was therefore regrettable that it had not been possible to hold a thorough debate within a realistic time frame, which might have allowed a compromise to be reached. The present polarization could only harm the Organization and would certainly not allow solutions to be found that were compatible with the interests of all Member States. Mr TASAKA (Japan), speaking in explanation of vote, said that it was generally recognized that geographical underrepresentation in the Secretariat affected not only developing countries but also developed countries, some of which were major financial contributors. However, he had understood that measures were being developed that would help to resolve the problem and it might be worth waiting to see what transpired. With regard to the expert committees, membership should be exclusively on the basis of merit and not according to country of origin. His delegation had therefore voted against the resolution. Mr WEEKES (Barbados), speaking in explanation of vote, said that his delegation would have preferred to be associated with a resolution that had been arrived at on the basis of a consensus among all the Member States. The quality of decision-making in Committees A and B and in the Health Assembly as a whole was enhanced when all countries participated in the decisions. More extensive participation by experts from the developing countries would strengthen the decision-making process and lead to more widespread improvements in health throughout the global population. Thanking the developed countries for their financial and technical support, he nevertheless maintained that their position of strength brought with it responsibilities. He therefore urged them to take account of the special needs of the developing countries, where it was often felt that local experts were better placed to articulate local needs. Finally, it was not the end of the debate. Delegates should return to their countries and reflect on the issues, so that agreement on the appropriate level of participation of the developing countries and countries in transition could be reached by the next session of the Health Assembly. Barbados had voted in favour of the resolution because it was the only resolution that advanced the cause of the developing countries. However, he requested that his country's name be removed from the list of sponsors. Mr V ARELA (Argentina), speaking in explanation of vote, said that, although his delegation supported the principles reflected in the resolution just adopted, it had abstained since a subject that would have such important repercussions on the Secretariat's functioning should not have been put to the vote but dealt with through discussion and consensus. Mrs POSADA (Mexico), speaking in explanation of vote, said that her delegation had abstained because, although it agreed with the spirit and purpose of the text, it would have preferred the resolution to have been approved by consensus, in the spirit of collaboration that had always prevailed at previous Health Assemblies. It was important to foster a constructive approach at all times. Mr FULLER (United Kingdom of Great Britain and Northern Ireland), speaking in explanation of vote, said that his delegation supported the concept of equitable geographical representation in the Secretariat, and had proposed a number of amendments because of certain problems it had foreseen. As a result of the text approved, countries with small populations would be worse off than before if the proposals were implemented. Furthermore, the method used in calculating desirable ranges for post distribution was in line with the criteria adopted in the United Nations common system, from which WHO should not depart. A third problem was that such texts should be considered by the Executive Board before being tabled at a Health Assembly.

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The United Kingdom remained committed to working constructively within the Health Assembly in order to meet WHO's agreed objectives, and would continue its strong support and financial contributions with a view to alleviating poverty and improving health conditions in the developing countries. The extent to which those objectives would be furthered by the sort of proceedings just witnessed was another matter, however. He asked the Director-General how she intended to take forward the proposals contained in the text just approved. Mr CHERNIKOV (Russian Federation) explained that his delegation had voted against the resolution for several reasons. It understood the problem and had played a constructive part in negotiations on the text, submitting some amendments. However, the sponsors had declined to accept many of those amendments. The method of conducting negotiations had been unacceptable. With regard to the substance, he reiterated his earlier remarks that paragraphs 4 and 5 were meaningless since the balance between two groups of States was mentioned but nothing was said about the third group, those with economies in transition. The Secretariat would not and could not take such provisions into account. Mr COSTI SANTAROSA (Brazil), speaking in explanation of vote, expressed solidarity with the principle of better representation of developing countries in all international organizations. His delegation had abstained not for substantive but procedural reasons. Such an important topic should have been the subject of lengthier discussion. His delegation had not been consulted before the presentation of the draft resolution by the sponsors, although it would have been willing to participate from the very beginning. Decisions had been hampered by the absence of any well-established regional consultation mechanisms, and the belated presentation of the draft had not contributed to an adequate debate. Dr CHRISTIANSEN (Norway), speaking in explanation of vote, said that the alternative to a disruptive and confrontational vote would have been to conduct deliberations among Member States in the interval between the current and the next session of the Health Assembly, a procedure he had proposed in the drafting group. His delegation fully subscribed to Article 35 of the Constitution and to the principles of equitable geographical representation and gender balance in the Secretariat and would support efforts to achieve them, but had voted against the resolution because it did not contain any of the constructive amendments proposed by a number of Member States including his own. An unfortunate precedent had been set that might have consequences for other United Nations organizations. Ms MACMILLAN (New Zealand), speaking in explanation of vote, said that New Zealand strongly supported the concept of equitable geographical representation. The complex issues raised in the resolution deserved serious consideration. As there had been no opportunity for consultation before the Health Assembly or for a substantive discussion that might have led to consensus, New Zealand had voted against the resolution. Mrs BIGI (San Marino), speaking in explanation of vote, associated her delegation with the statement by the Swiss delegation. She said that she hoped that questions regarding equitable geographical distribution could be dealt with in future without any North-South polarization. Mr GUNNARSSON (Iceland), speaking in explanation of vote, supported some of the ideas in the resolution but was disappointed that the matter had not been resolved in a more cooperative manner. Holding a vote before a meaningful discussion on the issues involved was undemocratic and ran counter to the goals of WHO. Iceland had therefore voted against the resolution. Mr SOLANO ORTIZ (Costa Rica), speaking in explanation of vote, said that his delegation shared the concern for equitable geographical representation within the Organization but considered

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that the matter should have been resolved by consensus. He regretted the absence of negotiation between the regional groups; the Latin American group had been virtually excluded from negotiations. Ms BALOCH (Pakistan), speaking on behalf of the sponsors, said that, contrary to the view expressed by a previous speaker, countries with small populations would not be placed at a disadvantage by the resolution. Less importance should be attached to financial contributions in determining ranges. The vote clearly reflected the need for change in the system. Developing countries felt that they were underrepresented in the Secretariat, particularly at the higher levels. Approval of the resolution was not a decision to change the current formula; the report that the Director-General had been asked to prepare would form the basis for a full discussion of all the issues involved. She thanked all the sponsors for their support. The DIRECTOR-GENERAL, replying to the delegate of the United Kingdom, said that she was sure that all those present would have time to reflect on the manner in which delegates had expressed themselves. Before the next Health Assembly, all Members would have learned more about the complexities of the many issues involved in achieving the equitable solution desired by all delegations. It was one thing to talk about the goals of equitable gender and geographical representation, but applying the formula meant the use of mathematics. The debate had shown that the Secretariat did not face an easy task in analysing all the issues involved and preparing a report, but it would be done. The report would provide good background information and a more extensive overview that would make it easier to arrive at a consensus.

ORGANIZATION OF WORK

The CHAIRMAN announced that consideration of items 17, 18 and 19, which had been transferred from Committee A, would be deferred until the Fifty-sixth World Health Assembly.

3. TECHNICAL AND HEALTH MATTERS: Item 13 of the Agenda (continued from the fifth meeting, section 2) Infant and young child nutrition: Item 13.10 of the Agenda (continued from the fifth meeting) The CHAIRMAN reminded delegates of their previous discussion of the draft resolution contained in resolution EB109.Rl8, following which a working group had been formed to incorporate the proposed amendments. WHO had taken note of the suggestion to harmonize the wording of the global strategy with that of the draft resolution. She invited the Committee to consider the amended draft resolution which read: 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;

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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 psychomotor 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; Recognizing that infant and young-child mortality can be reduced through improved nutritional status of women of reproductive age, especially during pregnancy, and by exclusive breastfeeding for the first six months of life, and with nutritionally adequate and safe complementary feeding through introduction of safe and adequate amounts of indigenous foodstuffs and local foods while breastfeeding continues up to the age of two years or beyond; 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; 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 held 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 providiQg 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 to renew their commitment to protecting and promoting the optimal feeding of infants and young children, 1. 2. ENDORSES the global strategy for infant and young-child feeding; URGES Member States, as a matter of urgency: ( 1) to adopt and implement the global strategy, taking into account national circumstances, while respecting positive 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, and to reduce the risks associated with obesity and other forms of malnutrition; (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;

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to define for this purpose, consistent with national circumstances: (a) national goals and objectives, (b) a realistic time line for their achievement, (c) measurable process and output indicators that will permit accurate monitoring and evaluation of action taken and a rapid response to identified needs; (4) to ensure that the introduction of micronutrient interventions and the marketing of nutritional supplements do not replace, or undermine support for the sustainable practice of, exclusive breastfeeding and optimal complementary feeding; (5) to mobilize social and economic resources within society and to engage them actively in implementing the global strategy and in achieving its aims and objectives in the spirit of resolution WHA49.15; 3. CALLS UPON other international organizations and bodies, in particular ILO, FAO, UNICEF, UNHCR, UNFPA and UNAIDS, to give high priority, within their respective mandates and programmes and consistent with guidelines on conflict of interest, to provision of support to governments in implementing this global strategy, and invites donors to provide adequate funding for the necessary measures; 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, including through adequate labelling, 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 provide support to Member States, on request, in implementing this strategy, and in monitoring and evaluating its impact; (2) to continue, in the light of the scale and frequency of major emergencies worldwide, to generate specific information and develop 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.

(3)

The draft resolution, as amended, was approved!

FOURTH AND FIFTH REPORTS OF COMMITTEE B

Dr SOEPARAN (Indonesia), Rapporteur, read out the draft fourth and fifth reports of Committee B. The reports were adopted. 2 1 2

Transmitted to the Health Assembly in the Committee's fifth report and adopted as resolution WHA55.25. See page 275.

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CLOSURE

After the customary exchange of courtesies, the CHAIRMAN declared the work of the Committee completed.

The meeting rose at 13:55.

PARTII SUMMARY RECORDS OF THE MINISTERIAL ROUND TABLES

ROUND TABLES: RISKS TO HEALTH: Item 11 of the Agenda (Document A55/DIV/5) Salle VII, Tuesday, 14 May 2002, at 9:40 Chairman: Dr C.P. THAKUR (India)

The CHAIRMAN said that health was recognized as a key factor in the economy. Research had revealed a link between certain types of disease and different economic levels: thus, protein-energy malnutrition and the consequences of unsafe sex were prevalent in low-income countries, and high blood pressure and cancer in high-income countries. India had both groups of problems. The health parameters at the southern state of Kerala were almost equivalent to those of Sweden, with a high risk of ischaemic heart disease, while in the least developed northern areas there was a high risk of infectious diseases due largely to unsafe drinking-water. The number of HIV infections due to unsafe sex had risen from one in 1986 to some four million by the year 2002, although that rate of increase was declining as a result of wide-ranging programmes. Subclinical malnutrition still existed, and lifestyle diseases and cancer were on the increase. It should be the joint responsibility of all to help fight the disease burden of the developing countries. He introduced the facilitator, Dr J. Koplan (Emory University, Georgia, United States of America). Dr KOPLAN (Facilitator) said that risk factors were important because of the increased interest in prevention. Different types of risks affected low- and high-income countries, with some overlap for low- and medium-income countries. In the past, only those people at greatest risk had been targeted, but the modem, more cost-effective approach was to try to lessen the risk for whole populations. More attention was being paid to risk perception and communication. It was a natural tendency, whether for psychological, cultural or emotional reasons, to attach greater weight to some risks that in fact posed less of a threat than others. One purpose of the analysis in the report was to indicate the relative importance of risks for different country groupings and then to communicate that knowledge to populations, so that they would be aware of the true situation. Major risks to health existed for all regions. They were known, increasing and sometimes largely unchecked. The discussion should show which factors were important and why, and what interventions were worthwhile. Dr MUBARAK (Iraq) said that, although Iraq was encountering unique health problems owing to the extended imposition of sanctions, it had made immense efforts to reduce risk factors through prevention. Certain problems had arisen because of the country's inability to use its own resources, and as a result the incidence of communicable diseases in particular had increased markedly. Intensive vaccination and public awareness campaigns had been undertaken, with the participation of civil society, local government, the media and education authorities. Despite those efforts, diseases that had previously been eradicated had reappeared, and the incidence of noncommunicable diseases had increased owing to the nonavailability of diagnostic and screening facilities. Iraq's inability to import the necessary drugs and equipment, notably equipment to improve drinking-water supplies and sanitation, had led to an increase in mortality and morbidity. Prevention remained the main problem confronting health services. He called on the international community to help Iraq, and in particular to give attention to the health problems caused by the use of shells tipped with depleted uranium. Iraq, as one of the first countries to suffer the effects of such weapons, had welcomed the Organization's efforts to establish a -227-

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joint panel on diagnosis and curative methods. Unfortunately, few results had been achieved, even though the situation was comparable to a natural disaster calling for rapid intervention. Dr SUJUDI (Indonesia) said that one risk facing his country was the threat to health services resulting from a lack of human and financial resources. Training and education programmes were being undertaken in order to improve capacities, and public, private and community resources were being mobilized in order to improve the financial situation. Another risk was posed by emerging diseases, poor sanitation and the reluctance to modify traditional behaviour patterns in favour of a healthier lifestyle. In response to that challenge, Indonesia had introduced a "health paradigm" in the year 2000, focusing on health promotion and disease prevention, and incorporating measures to promote healthy cities, districts and villages. Initiatives taken had been designed to strengthen the environmental protection and sanitation programme, encourage health promotion and increase awareness. A tobacco-free initiative had been launched, and a questionnaire on noncommunicable diseases had been incorporated into the national household survey. Support from WHO would be needed to ensure the success ofthose initiatives. Dr HONG Sun Huot (Cambodia) said that the three main health risks for his country were protein-energy malnutrition, unsafe sex and tobacco use. Protein-energy malnutrition was a major concern, as 45% of Cambodian children were underweight for their age. The proportion of children who were exclusively breastfed up to the age of six months was still low, and efforts were being made to promote exclusive breastfeeding. Impressive progress had been made in remedying vitamin A deficiency by linking distribution of the micronutrient to supplementary immunization activities. The nutrition programme of the National Mother and Child Health Centre undertook iron supplementation. To counter iodine deficiency the government cooperated closely with the private sector for the production and sale of iodized salt. A behavioural surveillance survey in 2000 had revealed that 25.1% of all adults aged 20 to 25 and 21.6% of those aged 25 to 30 had had sex with female sex workers in the previous year. With government support for 100% condom use programmes, the proportion of use by high-risk groups had risen to 90% in 2000 and HIV prevalence rates had fallen. To combat tobacco use, efforts were being made to promote tobacco-free workplaces, ban smoking in pagodas and regulate tobacco advertising. An inter-ministerial committee had also been created for tobacco control. Dr GAMKRELIDZE (Georgia) considered that some health risks were typical of both developing and developed countries. According to document A55/DIV /5, Georgia would appear to be among the high-income countries in terms of tobacco use, alcohol consumption, high cholesterol, and high blood pressure, while in terms of protein-energy malnutrition and unsafe sex it would appear to be a low-income country. The gradual increase in poverty in his country had had a direct impact on health indicators and was giving rise to increasing concern. State investment in health had fallen some 15% to 20% below the level of the 1980s, tending to bring the country more into line with low-income countries where health risks were concerned. Action would have to be taken, notably to eradicate the causes of poverty, and annual per capita public expenditure on health would need to be increased at the very least by US$ 40 to US$ 50. In addition, part of Georgia's foreign debt should be written off. Mr JACKLICK (Marshall Islands) said that his country's adoption of the concept of primary health care had had a great impact on a wide range of health problems, and had provided an entry point for specific services to address them. Education was the most effective tool in efforts to assess health care risks. The Ministry of Health had had some success in creating awareness of risks to health, but faced problems in effectively measuring change. The Bureau of Primary Health Care had cooperated in various intervention programmes, in areas such as reproductive health, family planning, maternal and child health, and dental health for school-age children. Risk management had focused on those risks that were scientifically understood, such as those associated with diabetes, cancer and diarrhoea! diseases. Much work had been done to identify the causes of those risks following a cholera

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outbreak in 1999 that had revealed the importance of adequate monitoring, population-wide intervention, and communication of risks to the public. The health status of the population had dramatically improved in recent years, thanks to the tireless work of health care professionals and the technical and financial assistance rendered by regional and international organizations. Valuable assistance had also been received from Taiwan (China). Mr SAVVIDES (Cyprus) emphasized the dramatic impact of poverty reduction on health and longevity. About eight million lives could be saved if existing effective interventions could be applied in low-income countries. Even though the greatest risk to the poor came from communicable diseases, the incidence of noncommunicable diseases was significantly increasing in the poorer countries. The impact of infectious diseases had been significantly reduced in Cyprus, owing to general social and economic development and the use of specific preventive and therapeutic measures, but chronic diseases, especially cardiovascular diseases, had emerged as a new public health problem. The response to health risk factors in his country had focused on better community participation, appropriate legislation, intersectoral collaboration and health sector reform. The most important requirement was to change the focus of the health care system from treatment to health promotion and disease prevention. That called for accurate quantitative information on the impact of the various risk factors, as otherwise policy might be driven by pressure groups or by emotional reactions. He looked to The, world health report 2002 to fill in the gaps in knowledge of the various analytical and management tools that could be used for that purpose. Professor SMALLWOOD (Australia) strongly supported WHO's approach to defining the burden of disease and measuring the risks of major disease and injury as important preconditions for effective prevention. Australia was well placed to measure risks and to communicate them to the community. However, much remained to be done, particularly in dealing with the risk factors driving the epidemics of obesity and diabetes. Huge gains could be made if the correct interventions were applied to counter ischaemic heart disease, stroke and diabetes. Campaigns against tobacco-smoking had been effective, except among younger women. Some of the difficulties in such campaigns were how to allocate resources and how to strike a balance between health care and prevention. The issue of health inequalities was very important for Australia, and, while he agreed with the WHO approach of improving the health status of the whole population, he was concerned that the disadvantaged might be left behind in that process, thereby increasing inequalities. Strong political leadership, by not only health ministers but also heads of government, was needed in order to bring about change. Another important aspect was the motivation of the community: if people were to be asked to change their behaviour, they had to be persuaded that risks to their health were serious. Mr DAY ARA TNE (Sri Lanka) said that Sri Lanka faced most of the health risks that were prevalent in countries at a similar stage of socioeconomic development. Poverty, with its link to unhealthy living conditions, lack of education and reduced access to health care, clearly posed the most serious risk to health, resulting in shorter life expectancy and disability in old age. As a result of measures taken by successive governments, mortality rates had fallen, especially among infants and children, but it had become a matter of some concern that quality of life indicators were failing to keep pace with survival indices, owing largely to the emergence of new risks to health. Tobacco use, substance abuse and particularly alcoholism were major preventable causes of many noncommunicable diseases. Two decades of internal armed conflict, with civilian deaths and the displacement of about a million people, had also exposed the population to many risks, with both psychological and physical consequences and brought additional burdens including malnutrition, infectious diseases and stressrelated illnesses. The development of many children might be adversely affected by their experiences

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during the conflict. The individual skills in the community and of care workers needed to be developed to address those challenges, and health care structures and facilities would have to be reoriented. The support of WHO in training Sri Lanka's health workers under the "Health as a Bridge to Peace" initiative was consequently invaluable. In addition to those problems, Sri Lanka's formerly sound health infrastructure was under severe strain owing to resource constraints. An intersectoral approach to health policies has been adopted, and a national commission would soon be established along the lines of WHO's Commission on Macroeconomics and Health to foster greater investment in health and promote integrated development approaches designed to eliminate poverty. Further technical support from WHO would be required in that endeavour. Poorer countries would not be able to make the necessary changes alone: they needed the world community to share its knowledge and resources with them. WHO should help to develop good surveillance and early warning systems and prioritize the risks that affected populations as a whole as well as specific, high-risk groups. It should also help to formulate appropriate and effective policies to minimize and eliminate risks, and lead the way in finding cost-effective technology and control measures that would enable countries to counter the risks they faced. Mr HLAVACKA (Slovakia) said that Slovakia was one of central Europe's transitional economies. Its child and adult mortality rates were low. The major causes of disease were high blood pressure, high cholesterol, tobacco use, alcohol consumption, high body mass index and physical inactivity. The monitoring and surveillance of risks to health were well organized through a network of state health institutes, specialist centres and reference laboratories, supported by comprehensive legislation that had recently been harmonized with that of the European Union and included a ban on tobacco advertising, a high tax on tobacco products and severe restrictions on alcohol advertising. Those mechanisms provided a good basis for implementing population-wide interventions for major risks, with the aim of lowering exposure levels. To that end, the redirection of resources from treatment to prevention was an important but difficult policy to maintain in view of the preference of politicians for tackling visible dangers that required access to high-technology curative medicine. The situation was exacerbated by pressure from the pharmaceutical industry, whose business was cure rather than prevention. Possible solutions included more effective risk communication, especially via the media, and a common approach to the pharmaceutical industry to secure support for prevention, but they could only be achieved on a global basis. Global efforts were also needed to ensure that the effect on lifestyles of national legislation to ban tobacco advertising and restrict alcohol advertising was not compromised by the international media, as was currently the case. Professor COLL SECK (Senegal) said that her country was making great efforts to tackle such behavioural risks as unprotected sex, alcohol and drug use, traffic accidents and tobacco use, particularly among young people. Less easy to address were the risks associated with traditional customs, such as female circumcision and the taboos that prevent women going for antenatal checks and to specialized maternity units, resulting in extremely high maternal mortality rates. Risks associated with lifestyle, such as lack of activity and over-eating, unusual in a poor country, existed among the urban populations, causing diabetes and high blood pressure. Malnutrition and diarrhoea! problems (but not cholera, of which there had been no case for several years) caused by environmental factors such as the lack of drinking-water, proper sanitation and hygiene were common. Malaria accounted for 30% of health consultations. The extent of all those risks was unknown, although some behavioural, hospital and demographic studies had been done. The renaming of Senegal's Ministry of Health as the Ministry of Health and Prevention gave a strong signal of the increasing importance of prevention in her country's strategy. Campaigns had been launched against diseases such as diabetes. Senegal also had a national multisectoral HIVI AIDS programme, and no-smoking schools were being established. Cooperation with other sectors had increased, as had early warning systems for dealing with epidemics.

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Mr KARA MOSTEPHA (Algeria) said that, while there had been an increase in life expectancy and a marked improvement in morbidity and mortality rates in Algeria, the main causes of infant mortality were still acute respiratory insufficiency and diarrhoea! diseases, and the main causes of maternal mortality, high blood pressure and haemorrhage. Water-borne diseases were a major health problem in Algeria. Violence and trauma, which had been declared a leading worldwide public health problem by the Forty-ninth World Health Assembly, 1 also needed to be addressed. Algeria was making considerable efforts to reduce tobacco use, and had recently introduced a tax on tobacco to fund health measures. It was essential, however, that efforts made in terms of national legislation were backed up at international level, particularly in the current programme ofwork of WHO. The problems under discussion were not simply health problems, and could not be addressed by health ministers or health services alone. They also needed to be tackled by nongovernmental organizations, individuals and user groups. Elected representatives in particular had a significant role to play, for instance to ensure that hospitals were not left to deal with a host of non-medical problems. Dr VIT (Czech Republic) said that health services accounted for some 7.3% of his country's gross domestic product. Health care was financed mainly from compulsory health insurance, with State funds chiefly allocated to financing selected investment projects and certain costly health projects. A few costs were covered directly by patients. Since 1990, in contrast to most other post-communist countries, the Czech Republic had seen an improvement in its health indicators. The infant mortality rate, in particular, which had stood at 4 per 1000 in 2001, was comparable with that of the most highly developed countries of the European Union. Cardiovascular diseases remained the predominant cause of death, followed by cancer, and injuries and poisoning. Infectious diseases remained a potential threat, particularly in view of the increasing migratory trends. Immunization programmes had been successful, and some diseases such as diphtheria and poliomyelitis had practically been eradicated. In 1997 immunization of newborn infants against tuberculosis had again been made compulsory, and in 2001 immunization had begun against hepatitis B and Haemophilus injluenzae type b infection. As a result of an increase in cases of salmonellosis, due mainly to violations of the health and safety regulations relating to the preparation of food, recorded during the 1990s, a new food safety strategy was being developed. The number of cases of HIV infection and AIDS had increased, as had drug use, especially among young people. Against that background a high-quality health care system was vital. As part of its health care quality programme in 2001 the Ministry of Health had established a centre for health and quality system management responsible for coordinating the health care sector with the State administration, government bodies, the public, and international and national organizations. Dr BORST-EILERS (Netherlands) said that document ASS/DIV/5 clearly showed that a major challenge for all countries was to build a health risks policy on a firm basis of evidence, a difficult task in view of the factors other than scientific evidence that needed to be taken into account. One of the most difficult issues was the discrepancy between objective scientific risk assessment and the public's perception of risk: behavioural risks, such as smoking and dangerous sports, were tolerated by the public, but risks perceived as being the result of government policy, such as food-related health incidents, were not. To be successful risk management had to bridge that gap. An effective risk policy consisted of three elements: risk assessment, which needed to be transparent; risk communication, with scientifically-based and open transmission of the facts to the public; and risk management, in which decisions were the responsibility of politicians. Regulatory authorities such as national food authorities should be independent of political influences. Ideally, governments should list and prioritize the major health risks to their populations on the basis of years

Resolution WHA49.25.

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of life lost. The cost-effectiveness of interventions should then be assessed, an area in which WHO might be able to provide solutions. The first major preventable cause of death in the Netherlands was lifestyle-related disease, which caused 10 000 premature deaths per year, and the second was medical error. Accidents in the home, followed by road traffic accidents and accidents in the workplace were also major causes. Uncertain and variable risks, such as unsafe food, caused preventable illness, and bioterrorism could not be overlooked. With regard to the discussion points suggested in document ASS/DIV/5, smoking, drinking, drug use, body weight and physical activity of children were closely monitored, and information and prevention campaigns were adapted accordingly. The Netherlands cooperated with the European Union's infectious disease surveillance system. Scarcity of funds was a major impediment to an effective prevention policy, as politicians preferred to allocate funds to curative and care programmes that produced short-term results. To overcome that problem, her Government had decided to set aside a fixed percentage of its health budget solely for prevention. With regard to enhancing government institutions, the Netherlands had recently established a national food safety authority and was strengthening its health inspectorate, which was responsible for monitoring patient and product safety and was devising a risk assessment system with which WHO might help. Dr EL NASSER {Jordan) said that the pressure on Jordan's limited natural and economic resources, and particularly its medical resources, as a result of humanitarian disasters, conflicts and economic sanctions in neighbouring countries had had a psychological and social impact on the population. Morbidity had increased and endemic diseases had become chronic. As in other countries, the causes were physical inactivity, obesity, smoking and bad diet. There were also unseen risks, such as airborne pollutants and the mismanagement of medical effluents, medical errors and the risks associated with ageing. Measures such as the redirection of health policies to give greater priority to prevention through primary health care, increasing public awareness and new legislation had been taken to address the problems, and efforts had been made to increase the country's technical and health manpower and intersectoral coordination. However, in relation to smoking and alcohol consumption, conflicts of interest caused particular difficulties. Mr SOTHINATHAN (Malaysia) said that despite Malaysia's well-developed primary health care facilities, noncommunicable diseases that were partly hereditary but largely associated with lifestyle were a particular challenge. It had launched a lifestyle campaign in 1991, focusing on safe food, exercise, mental health and the importance of healthy families, and targeting a wide range of noncommunicable diseases and risks such as malnutrition. Malaysia also worked with WHO and other countries of the South-East Asia Region on tobacco-control initiatives, and had already passed legislation to curb tobacco use. Another concern was the health impact of electromagnetic fields created by the frequent use of mobile phones, and in view of the large amount of conflicting information available new efforts should be made at the international level to determine the degree of risk they posed. There was also concern about major food hazards including microbiological contamination, pesticides, veterinary drugs, environmental pollutants and food adulteration, all of which could be reduced by ensuring food safety from farm to table. Food safety measures based on scientific principles should be developed in cooperation with the relevant agencies at national and international levels. Malaysia's National Food Safety and Nutrition Council defined food safety policies, ensured optimum use of resources, and provided a mechanism for dealing with food safety challenges. Further technical support would still be required from WHO and FAO to increase capacity building. Dr COLEMAN (Liberia) stated that Liberia's infant mortality rate was 144 per 1000 births and its maternal mortality rate was 780 per 100 000. The proportion of people with access to safe drinking-

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water was 35% in urban areas and 15% in rural areas, while the figures for good sanitation were 20% and 4%, respectively. Immunization coverage against the preventable childhood diseases had risen from 23% in 2001 to 55% in 2002 thanks to support from GAVI. The most prevalent diseases were malaria, malnutrition, measles, respiratory tract infections and diarrhoea! diseases. The major risks to health were lack of access to health care due to poor infrastructure; growing poverty; the high rate of illiteracy and cultural taboos; and increasing instability in the north-western region of the country, which had led to large numbers of internally displaced persons, a breakdown of the health system and lack of access to drinking-water and good sanitation. However, monitoring systems had been set up with the assistance of WHO and were starting to produce positive results in respect of epidemics such as cholera and yellow fever. There was an urgent need to strengthen the capacity of the Ministry of Health to apply broadbased social-mobilization techniques that had already proved to be useful in a country in which 70% of the population was illiterate and cultural taboos were strongly upheld. It was imperative that resources should be mobilized both locally and internationally for personnel training and the rehabilitation of the health system. He expressed gratitude to agencies including WHO and donors including Taiwan (China) for support. Dr LOPEZ RAMOS (Uruguay), noting that her country had an ageing, mostly urban population and had completed the epidemiological transition, outlined some epidemiological and demographic data for Uruguay. The crude birth rate was one of the lowest in the world, and the crude mortality rate had remained stable for some four decades. Life expectancy at birth was 73 years. Maternal mortality and the infant mortality rate had fallen steadily, the latter to 14 per 1000 in 2000, largely owing to improved public health services. The main causes of death were age-related and noncommunicable diseases, such as circulatory diseases, neoplasms, traffic accidents (the leading cause of death for people younger than 34 years) and violence. Tobacco use and alcohol consumption were major risk factors. Communicable diseases, in particular acute respiratory infections and diarrhoea} diseases, were the principal causes of admission of children to hospital. The incidence rate of meningitis due to group A and C meningococci had markedly declined after immunization campaigns but at the same time cases of illness due to group B organisms had increased. Such had been the decline in incidence of measles that a policy for eradication had been implemented. Emerging or re-emerging diseases were being seen, such as AIDS, leptospirosis and hantavirus disease, and environmental changes had led to problems such as lead poisoning and contamination of wheat with the mycotoxin deoxynivalenol. Despite Uruguay's good statistics, a high level of literacy, and educational campaigns directed at vulnerable groups, the country was not free of risks to health. Its health sector strategy was still based on access to clinical care, despite efforts since the Alma Ata declaration. The population had not translated a culture of self-care into behavioural changes; no matter how clearly the risks had been identified, their magnitude was inadequately perceived. The recent economic downturn had affected the development of families and communities. Uruguay's health system was a complex, mixed system with a substantial private component; it accounted for 10% of the gross domestic product, but was not equitable. The private sector, which served a minority of the population and those who were wealthiest, consumed 70% of those resources; the remainder was distributed in the public sector which served the neediest, and then on the basis of the curative model. The country lacked a system for prioritizing risk factors and costs that would enable it to establish adequate financing, thereby limiting both prevention and treatment. The Ministry was reorganizing the health services, and, in order to formulate appropriate health policies, was strengthening surveillance systems for both risk factors and diseases, directing resources to prevention, setting a common approach for the pharmaceutical industry, and improving food safety. Recognizing the multiple causes of illness, it had to optimize intersectoral coordination, including civil society, and establish a suitable institutional framework. Its response to sustainable development needed promotion of a social, economic, cultural and environmental policy on a human scale, with communication making an important contribution.

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Mrs ALLEN-YOUNG (Jamaica) said that life expectancy in her country was 72.2 years for females and 69.9 years for males, and the infant mortality rate was 24 per 1000 live births. As a result of the Government's access-oriented policy for the past three years, with a strong primary care focus, 82% of the population had access to drinking-water and almost the entire population had access to satisfactory means of sanitation and waste disposal. The current immunization coverage was 90%. However, recent economic, demographic and social changes had affected the health of the population, shifting the epidemiological balance from communicable to noncommunicable diseases. Many risks were lifestyle-related such as obesity and smoking. The four leading causes of death in hospitals were diseases of the circulatory system, nutritional and endocrine diseases, neoplasms, and respiratory diseases. HIVI AIDS was becoming an increasing threat. The Ministry of Health had an effective surveillance system, which provided the data on disease prevalence, on which health policy was formulated. The current prevention strategy was to establish a health promotion and protection division within the Ministry of Health, formulate policies to reduce risk, such as the promotion of healthy food and a ban on tobacco product advertising, encourage healthy lifestyles and employ behavioural change officers to work with young people to promote abstinence, condom use and delay in the first sexual contact. An intersectoral approach had been taken to HIVI AIDS, whereby the problem was seen as related to national development and not merely to health. The same approach had been taken to accident prevention through advertisements encouraging safe driving. Dr MODESTE-CURWEN (Grenada) said that the shift of emphasis in primary health care programmes to prevention rather than treatment had led to an immunization coverage rate of 95% in recent years; by law, unvaccinated children could not be admitted to schools. Safe drinking-water was available to some 98% of the population. Comprehensive scientific data on the various risks to health were unavailable owing to a lack of resources, but many of the factors cited in document A55/DIVI5 could be observed in Grenada. Following a series of consultations, health care practitioners had been commissioned to compile a list of common injuries on which a subsequent educational programme would be based. In the area of occupational hazards, farmers had been identified as a high-risk group because of their indiscriminate use of pesticides and herbicides mainly due to a lack of information on the risks involved. The high incidences of skin lesions and respiratory pathologies had led the country to approach PAHO for assistance. Other occupational risks had also been observed, such as the risk to mental health in stressrelated jobs. Many workers requested consultations with psychologists, who formerly only worked with the mentally ill, and efforts were being made to expand those services. A workers' health and safety programme had been launched, but still required technical assistance. In view of the rising incidence of hypertension, diabetes and high cholesterol, a wellness programme had been launched, with wellness clinics for people with obesity, hypertension and diabetes. They were instructed in proper diet and exercise and on how to monitor themselves, and were then encouraged to go back to their communities to educate their peers. In that way, responsibility was being placed in the hands of the people themselves. Collaboration at national level was crucial if risks to health were to be reduced, scientific investigation and information were necessary to guide efforts, as was political will. Above all, communities needed to be sufficiently motivated. Mrs DREIFUSS (Switzerland) pointed out that the main causes of death in her country were cardiovascular diseases, cancer, accidents, violence and suicides, the latter being particularly prevalent among men up to the age of 44. Accidents and suicides in particular could be avoided and there could be improvements in the areas of mental health and psychiatric care where current taboos were often an obstacle to treatment and recovery. Greater efforts should also be made to identify risks among the various groups in society. Multiethnic societies such as Switzerland should address the risks according to age-group, sex and origin,

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having particular regard to the correlation between poverty, poor integration, the status of "foreigner" and lower employment opportunities. The distinction between behavioural and environmental risks should also be taken into account. Electromagnetic fields, genetically-modified crops and the use of certain products, such as antibiotics, in livestock were areas in which society was demanding prompt government action. Budgetary allocations for treatment rather than prevention also caused concern. Most costs borne by the population through the insurance systems were care-related, and health care sometimes discouraged preventive measures. It was extremely important to evaluate prevention - which approaches were successful and why, whether vulnerable groups had been reached and how? The tobacco industry still seemed to be making a greater impact on the population than the health authorities; states needed to send a credible message and avoid conflicts of interest with the tobacco companies. Some success had been achieved in Switzerland with HIV/AIDS. The government had issued a strong, simple message through target groups and the use of relay points, such as nongovernmental organizations, that the public had readily accepted. Such methods should continue to be used. Dr CHITUWO (Zambia) said that the mission of the Ministry of Health in his landlocked, sparsely populated country was to provide cost-effective care, as close to the family as possible. Zambia suffered from a high incidence of potentially preventable and treatable diseases, and from an increasing burden of noncommunicable diseases such as diabetes and hypertension. The statistics were discouraging: life expectancy had declined between 1980 and 1996, from 50.4 to 46.2 years for men and 52.2 to 44.7 years for women. The average maternal mortality rate was 649 per 100 000 live births and the under-five and infant mortality rates had risen to 197 per 1000 births and 109 per 1000 respectively, in 2000. The causes for such high mortality rates included malaria, complications associated with HIVI AIDS and high poverty levels - 75% of the population lived below the poverty line. Malaria was a major risk for infants below the age of five and was also responsible for 30% of hospital admissions. Furthermore, the incidence of tuberculosis had more than pentupled since 1970 to 500 cases per 100 000 in 2000. Diarrhoea! diseases, pneumonia and malnutrition also contributed to the high infant mortality rate. An essential factor to be considered was accessibility to drugs, although rural health centres were able to distribute drugs in health kits containing essential medicines. Access to safe water was crucial and in rural areas women in particular had to walk long distances to find water. However, sanitation had improved and 66% of the rural population had pit latrines, while almost all urban dwellers had adequate facilities. Monitoring and surveillance of public health was satisfactory in Zambia. There had been a concerted effort to make the region poliomyelitis-free, with a house-to-house campaign to encourage the immunization of all infants. Unfortunately there were many impediments to the implementation of population-wide public health interventions including poverty, inadequate education, a high national debt, refugees, particularly those from Angola and the Democratic Republic of Congo, and the brain drain: Zambia was currently losing a dramatic number of health care workers including nurses, pharmacists, environmental and mental health technicians. There had also been a dramatic decline in the number of doctors, from 1600 in 1997 to 400 in 2001. Such losses inevitably constituted a handicap in the implementation of a national health programme. Zambia's government, which had been in office for only four months, was determined to strengthen the health delivery system through decentralization and cooperation, particularly to combat hunger and drought. Its policy was one of zero tolerance for corruption, and transparency and accountability at all levels. Dr SEKATLE (Lesotho) said that poverty, a level of unemployment in excess of 30%, the HIV/AIDS pandemic and unemployment due to retrenchment in the South African mines were all risks to health in Lesotho. Poverty contributed to the prevalence of malnutrition, which in turn increased the burden on Lesotho's health system. A recent assessment had revealed alarmingly high rates of malnutrition that caused high levels of stunting, iodine and vitamin A deficiency and anaemia;

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it had also indicated an unacceptable rise in goitre and diabetes. The situation was exacerbated by the famine that had hit many South African countries, the causes of which were difficult to define. Another major risk to health was unsafe sex, which contributed to the high prevalence of sexually transmitted diseases, particularly in the age group 15-30 years, and over 20% of the population was infected with HIV. There had also been an increase in teenage pregnancies and maternal mortality. With regard to health strategies in her country, tuberculosis and diabetes were treated virtually free of charge, but the primary health care system once generally regarded as a role model, had been badly affected by the AIDS pandemic and the emigration of many trained health workers. The Government believed that a multisectoral approach was needed to reduce poverty and intended to work closely with the ministries of agriculture, finance, planning and communication, and the media to fight disease and promote a physically active and healthier lifestyle. Dr MARTIN (St Kitts and Nevis) pointed out that most of the health risks in his country were associated with lifestyle, including unsafe sex and lack of physical activity. Poor family structures had also contributed to the increasing prevalence of sexually transmitted diseases, such as HIVIAIDS, and noncommunicable diseases such as cardiovascular ailments, diabetes and cancer as well as of violence. Other challenges to the health system were limited financial resources and dengue. As a means of combating the various risks, a health promotion unit had been set up to educate the population and promote physical activity. Collaboration was encouraged with the private sector, which was considered to have a fundamental role in the health domain; a partnership with the press had been initiated, with monthly press releases. St Kitts was also cooperating with other countries in the region in a partnership to combat health risks. In that context, he voiced his gratitude to the people of Taiwan (China) for their contribution to his country's health sector. Dr TANGI (Tonga) said that, whereas in the 1960s and 1970s communicable diseases had posed the greatest risks and had been countered by vaccination campaigns and an adequate clean water supply, over the past 30 years there had been a dramatic increase in noncommunicable diseases such as diabetes and obesity, for which his country had being unprepared. For the past three years, therefore, large-scale public education campaigns had been conducted to encourage people to opt for a healthy lifestyle. Mr VAEVAE-PARE (Cook Islands) pointed out that his small country shared health problems due to communicable and noncommunicable diseases with both developing and developed countries. The country was fortunate in having eradicated or controlled poliomyelitis, tetanus and infantile diarrhoea! diseases. However, it faced the risks of emerging and re-emerging diseases, such as HIV/AIDS and tuberculosis, and conditions such as obesity, diabetes, hypertension and cardiovascular complaints, cancer - especially cervical and breast cancer - and motor vehicle accidents resulting from alcohol abuse. The Government was consequently vigilant in promoting health awareness and involving communities and special groups in the partnership process with the aim of making quality health care accessible to all its people. Mr RASMUSSEN (Denmark) said that, while the leading causes of disease varied from country to country, certain risk factors clearly remained constant. It was easily predictable from the discussion, for example, that there would be an increase in tobacco-related diseases in developing countries if no action was taken within an international framework. In that connection, he agreed with the Minister of Health of Slovakia that international broadcasting minimized the effect of national legislation and that an international ban on tobacco advertising was therefore essential. From the Danish perspective, the most important risks to health were smoking, alcohol abuse, unhealthy eating habits, too little physical activity, and traffic and work accidents. He agreed with previous speakers that a multisectoral approach was required, integrating local communities in

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preventive work. As prevention proved most effective at the local level, schools, civil society, private organizations and enterprises had an important role to play in health promotion. Dr KOPLAN (Facilitator) remarked on the enthusiasm for WHO's interest in and approach to risk factors, and the general consensus that WHO and the Health Assembly should constitute a role model for healthy behaviour and health promotion, for example by providing a smoke-free environment. The disease burden of countries had been dramatically presented, including a range of pressing - and indeed depressing - issues affecting both low- and high-income countries. The risks affecting the former included unsafe water, infections (malaria, tuberculosis and HIV), unsafe sex, micronutrient deficiencies, and infrastructural problems. In the higher-income sector, there was increasing emphasis on noncommunicable diseases, injuries, mental health issues, unsafe sex and occupational health. Broadly speaking, those risks could be grouped into environmental and lifestyle categories, together with a genetic contribution. Trends appeared to show that lower and higher income risks were increasingly mixed together within the same country, calling for a complex approach to interventions. Further issues of general concern included ageing populations, and increasing pressure for expensive treatment that drained resources away from prevention in the public health sector. There was a universal need for greater financial resources, and a better balance between expenditure on treatment and prevention. More reliable surveillance data were required on risk factors in order to help to determine the progress made and better communicate the risk. Decision-makers should be made aware of health priorities, so that they could invest and intervene once the major risks had been identified. With regard to primary health care, there had been general agreement that improvements should focus not only on individual activities, but also on the public health aspect of prevention, looking at communities as a whole, with a view to formulating policies on the basis of sound data. Progress had been mentioned, particularly in relation to tobacco control campaigns, including bans on advertising, the creation of tobacco-free schools, and the elimination of tobacco sponsorship of sports programmes. There had been moves to find alternatives so as to ensure healthier fast food and some countries had created posts for officers responsible for behavioural health change. The most important advance was that all countries shared one vision and one sense of values, regardless of their individual differences, and a conviction that more resources should be devoted to prevention in combating health risks.

The meeting rose at 12:35.

Salle XII, Tuesday, 14 May 2002, at 9:30 Chairman: Dr M.M. DAYRIT (Philippines)

The CHAIRMAN, opening the debate, introduced the Facilitator, Dr K. Balakrishnan, Head, Environmental Engineering Group, Chennai, India. Dr BALAKRISHNAN (Facilitator) said that major risks to health were estimated using an approach that provided a standardized framework for assessing and comparing the impact of certain risk factors, based on criteria that included likely contribution to disease burden, high evidence of causality and availability of data. Annex 1 to document ASS/DIV/5 listed the current disease burden

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due to a selected set of risk factors across country groupings with different levels of adult and child mortality. The table presented an assessment of the current proportion of burden due to the cumulative effect of past exposure to each risk factor, not of future benefits that might derive from removal of that exposure. Focusing on risk factors instead of disease outcomes for quantifying the disease burden allowed potential intervention strategies to be identified and analysed for cost-effectiveness. Having an objective indicator such as an exposure variable for measuring risk also made it possible to substantiate the decline of all the major factors to the lowest observable levels. For example, the figure in the document showed that the risk of coronary heart disease decreased in line with decreases in blood pressure, cholesterol and body mass index to below levels currently accepted as guideline values. Such findings provided an additional impetus to designing interventions that aimed at reducing overall population exposure rather than the exposure of high-risk population subgroups. Finally, the availability of comparable quantifiable estimates facilitated risk communication between all stakeholders, thereby enabling a framework for effective management to be established. Recognition of those elements of risk analysis would allow countries substantially to improve the life expectancy of their populations. Or PAZ ARGANDONA (Bolivia) said that the risk factors listed in document A55/DIV/5 were linked to the prevailing social, economic, technological and political climate in countries, which in turn was determined by national laws, notably those promulgated by ministries of health. The latter, therefore, had an important role to play in predicting and reducing health risks. However, WHO could also help by providing information, as well as the resources and tools needed for implementing the required measures and for establishing cooperation between Member States, particularly developing countries. There was a danger that the basic principles of the health-for-all strategy, such as universal coverage and equal access by all to care on the basis of need, might be sidelined as attention and resources were increasingly directed towards large-scale development plans. If health were at the centre of development, he wondered whether there were concomitant national and equitable international flows of resources to those at greatest need. The evidence suggested otherwise, and he considered that to be an important risk to health, vividly exemplified in the negotiations of WTO and the Do ha Declaration on the TRIPS Agreement and Public Health (November 2001 ). Mrs BARTOS (Romania), noting the changes in tobacco-related morbidity and mortality in Romania since 1989, related that a recent survey had revealed the major extent of the health risk that tobacco consumption posed in her country. Attempts were being made to legislate against the advertising and promotion of tobacco products, but existing restrictions were still rather informal: the health ministry would have to cooperate with other ministries, and with civil society, in order to achieve results. Romania supported the initiative of the WHO framework convention on tobacco control, which it regarded as a launching-pad for future international negotiations. Preparations for its national negotiating position had led to the establishment of an interministerial group which was currently working on a national action plan for tobacco control. A loan from the World Bank had helped the Government to finance a three-year smoking prevention project. The Ministry of Health and Family had a national programme for health promotion and education for health, with extensive health-promotion services and a network of health-promotion schools which would be expanded through the training of teachers in education for health. Mr ABDULLAH (Maldives) said that, in addition to the risks identified in document A55/DIV/5, environmental pollution posed a serious threat. It was therefore important for WHO, other international organizations and Member States to address health problems related to the environment, particularly in view of the World Summit on Sustainable Development to be held in Johannesburg later in the year. Many health risks had universal causes, including poverty and unhealthy lifestyles,

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that could be reduced if countries were to pool their resources to improve health education. He also underlined the need to improve workplace health. In response to the threat posed by tobacco use, his Government had introduced various measures to discourage smoking, including a vigorous school-health programme, and four islands had declared themselves tobacco-free areas. However, he said that he was saddened to see the number of health workers, including WHO personnel, who continued to smoke, since it was imperative to set a good example. Mr GUNNARSSON (Iceland) said his Government was making every effort to strengthen systems for monitoring health risks and assessing the effectiveness of its interventions. Early-warning systems for infectious diseases, as well as for chemical and nuclear incidents, were being enhanced through cooperation with other Nordic countries, the European Union and WHO. Effective information systems were an essential part of such endeavours, because risk reduction strategies could only be formulated on the basis of sound research and understanding. Mobilization of resources could be facilitated by better prioritization of public funding, as well as by partnerships with the private sector. Risk communication had been greatly improved, thanks to media collaboration, but further research into risk reduction policies was still required. Iceland's well-documented and manageably sized population made it ideal for monitoring, surveillance and outcome research programmes, and the Government was willing to share its experiences with others and to cooperate with them in assessing risks to health. Mr JUGNAUTH (Mauritius) said that the enjoyment of good health was a fundamental human right and a benchmark for measuring progress towards poverty reduction and hence enhancement of socioeconomic status. Ministers of health needed to ensure that health became a major political issue at the highest level of government. In his country, communicable diseases had largely been brought under control, thanks to the success of the immunization campaign, with coverage of almost 100% and which included vaccines against hepatitis B and from 2002 Haemophilus injluenzae type b infections. A strict surveillance system for infectious diseases was in place, including screening and follow-up of visitors from regions where communicable diseases were endemic. Low birth weight remained a problem, and progress had been made in halving the infant mortality rate to the target of 10% by 2005. Noncommunicable diseases continued to be the leading cause of mortality, and the focus of prevention. The new approach adopted by his Government focused heavily on prevention since, in his experience, doctors often paid more attention to curative measures. Efforts to combat noncommunicable diseases were being decentralized: a single unit within the Ministry building had been replaced by units throughout the regions, supplemented by the establishment of a mobile screening unit travelling from village to village. Within the framework of efforts to improve community participation, a health promotion campaign had been launched through the media. Some difficulties had, however, been encountered. The public, regarding television purely as a means of entertainment, was reluctant to watch health promotion programmes. With regard to screening, an estimated 65% of cases of diabetes (whose prevalence in Mauritius was the second highest in the world) remained undiscovered, sometimes because diabetics deliberately deceived doctors by controlling their sugar intake on the days before testing. It was important to try to change such attitudes, and he would welcome suggestions as to how to get the message across to target groups. Mr HUTTON (United Kingdom of Great Britain and Northern Ireland) welcomed the emphasis placed on risk factors, but pointed out that the issue was complex, ranging from lifestyle factors such as smoking and diet to factors largely outside personal control, such as environmental pollution and infectious diseases. The management of those risks required strong political will. He stressed the importance of better communication as part of an effective strategy. An appropriate relationship needed to be established between governments and the people they served, based on openness and the sharing of information, even if that endangered the government's own

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popularity. In his country, the failure of the government to maintain such a relationship during the bovine spongiform encephalopathy crisis had led to a loss of public confidence in both the government and its scientific advisers. There should be full disclosure of information from an early stage, even when scientific uncertainty remained, and that information should be independently validated, to prevent vested or commercial interests taking precedence over the interests of public health. That approach should lead to the empowerment of individuals to establish their own health priorities. Since public understanding of health risks remained limited, health education should be provided in schools from an early age. Finally, it was essential to strike the right balance between giving people the information to make their own decisions and taking legislative measures to reduce risk. Mr OLANGUENA A WONO (Cameroon) said that it should be recognized that poverty posed the greatest health risk in developing countries, and WHO and ministers of health should take the lead in calling for more investment in health. Most of those countries, in which infectious and parasitic diseases were the leading sources of morbidity and mortality, were in a period of epidemiological transition. The scourge of HIV/AIDS had been followed more recently by the emergence of several new risks, such as cardiovascular diseases and diabetes. To manage those risks, each country needed to define its epidemiological profile and analyse the risk factors, but also a completely new approach, designed to attach greater importance to prevention and going beyond the traditional recourse of formulating new programmes, capacity building, and mobilization of resources. What was really important was to encourage individual and collective commitment. Health promotion could not be achieved by ministries of health or governments alone, but required the involvement of individuals, communities, enterprises, religious groups, the media and nongovernmental organizations. A more global approach would lead to better-structured partnerships and a better understanding of health problems in the context of economic growth and development. In his country, the Ministry of Health had had to mobilize support from other sectors, including the private sector, for the campaign to combat HIV/AIDS, the prevalence of which had increased by 22% over the past 10 years to a rate of 11%. It was imperative to strengthen the capacity of health systems to respond to fresh challenges, notably the problems caused by influxes of refugees. Besides epidemiological surveillance and research, subregional cooperation was needed to deal with, for example, the health risks created by massive transboundary movements resulting from the construction of the Chad-Cameroon pipeline. Or GONZALEZ GARCIA (Argentina) said that, while the background paper (document ASS/DIV/5) provided some useful ideas for determining priorities, particularly with regard to analysis, management and communication, it nevertheless had several shortcomings. It reflected a vision of public health rooted firmly in the developed world. It stressed the importance of communication processes for changing lifestyles, but failed to take into account that, in most countries, lifestyle choices were neither a priority nor a possibility for the majority. Consequently, the State needed to assume responsibility for improving the lives of its citizens through the effective management of public health policy. That entailed combating poverty, which was the root cause of many health problems. In his country, there had been a sharp increase in poverty in recent months, with the proportion of the population living below the poverty line reaching 50%. That situation was not unique, but he expressed concern for the consequences, since in the Russian Federation the economic crisis had led to a drop of seven years in average life expectancy. It was important to press for a speedy international response to the phenomenon, for traditional health policies were insufficient. Many health risks were global in character, and therefore necessitated a global response. For example, the tobacco and alcohol sectors were global industries, to such an extent that they could be described as exporting health risks. In the same way as policies on medicines, policies on cigarettes should be globalized, and the situation monitored at international level. Governments should also be required to consider the global implications of their policies, in order to avoid spreading poverty to other parts of the world. For instance, the protectionism of

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agricultural policies in Europe and the United States of America contributed to the poverty of developing countries, which were unable to compete in agricultural markets. Mr NGEDUP (Bhutan) warned that the issue of risks to health was as complex as life itself, and the number of those risks was limitless. Rather than adding to the list, he wished to draw attention to the shortcomings of the approach thus far. For instance, tobacco consumption was not confined to smoking, since in many parts of the world the habit of chewing tobacco was equally life-threatening. More emphasis should be given to risks arising principally in the developing world, and regional differences should be emphasized. Since lifestyle changes would take decades to achieve, health education should be given in schools from an early age. Professor TAG-EL-DIN (Egypt) said that it was difficult to discriminate between the causes of disease and diseases themselves. For example, high blood pressure was not only a disease but a risk factor for other conditions. Referring to the tables contained in document A55/DIV/5, he pointed out that certain causes of disease had been overlooked, in particular psychological factors, especially in middle- or high-income countries. While high blood pressure had been shown to be prevalent in such countries, it could also be prevalent but undetected in low-income countries. Another major health risk in low- and middle-income countries was unsafe water and food, which led to infection and hence to disease. Infectious diseases remained; for example, many individuals infected with hepatitis A, B or C viruses went on to develop liver disease. Respiratory tract diseases were also prevalent and major causes of morbidity and mortality. Indoor pollution, such as smoke, chemicals, deodorants, and house dust caused respiratory tract illnesses, including asthma and chronic airway obstruction, in certain countries. Parasitic infestations, including malaria, were also major causes of disease, as were pharmaceutical agents, chemicals, insecticides, and pesticides, which could remain latent for long periods. Late detection or diagnosis in low-income countries was an important factor, leading in many cases to chronic disease or high rates of morbidity or mortality. Likewise, improper diagnosis and management due to lack of facilities, expertise or experience were a major cause of disease. Professor ONGERI (Kenya), observing that the health risks listed in document A55/DIV/5 concerned the middle- and high-income groups, called for the balance to be redressed. Poverty was the major cause of the high prevalence of disease in Africa, where 56% of the population lived below the poverty line. He suggested that government health budgets should be commensurate with the burden of disease in a country: that was not currently the case in Kenya. Illness prevented individuals from earning a living, creating a vicious circle linking poverty and disease. Communicable diseases had a high incidence in Africa, where the child mortality rate was high owing to poor maternity care. Vulnerable groups should therefore be taken into consideration when assessing health risks. In a new trend in the region metabolic disorders such as diabetes were increasing, particularly among those in gainful employment, which had produced a situation difficult to control. He suggested that WHO should draw up price guidelines and recommended drug dosages for Member States, and that education and social health insurance schemes should be part of health measures. Finally, he advocated an internal audit system to deal with health problems related to food standards. Dr AFRIYIE (Ghana) drew attention to the detrimental effect on health of certain political decisions, in particular economic policies. He called for governments to include in their economic projections vigorous public health analyses. Another factor related to risks was the loss of health resources through the brain drain of trained doctors, nurses and pharmacists to countries offering higher salaries. He urged the Health Assembly to adopt a more direct approach in setting certain minimum doctor-patient and nurse-patient ratios. Once ratios fell below that minimum in a country, governments concerned should discourage employment agencies from actively recruiting health staff for overseas positions.

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Mrs NELESONE (Tuvalu) indicated that a consensus to combine efforts to minimize risks to health, along with a stronger commitment on the part of Member States, was essential in order to reduce their impact. The underlying causes of such risks had to be understood in order to be dealt with. He urged participants to take into account the problems facing marginalized groups suffering from poor nutrition, inadequate water supplies and sanitation, especially in developing countries. Increased globalization had brought a rise in the incidence of diabetes and heart disease, and marginalization of rural communities had led to higher infant mortality rates. Like other developing countries, Tuvalu was experiencing an increase in lifestyle-related diseases, and HIV infection was already established. In order to minimize risks, he advocated a holistic approach with greater emphasis on health promotion. Mr BEASSOUMAL (Chad) expressed the hope that the round table discussions would enable health ministers to formulate precise and constructive ideas for better measuring, identifying and reducing risks to health in Member States. The main health risks in Chad were protein-energy malnutrition, poor sanitation, unhealthy lifestyles, unsafe sex, alcoholism, tobacco use, and unwanted pregnancies - other risks being poorly evaluated, while the main obstacles to interventions aimed to reduce those risks were poverty, ignorance, illiteracy and tradition. The government did not currently have an effective surveillance system, but was determined to strengthen the services provided by the ministries of health, social affairs, education, water and the environment, communications, planning and rural development, and to allocate more resources to prevention. In collaboration with the media, it had launched a major campaign of communication and social mobilization to increase public awareness of risks to health. Professor SZCZERBAK (Poland), commenting that one debate would not suffice to cover the whole subject of risks to health, said that the pattern of diseases in Poland was similar to that in most other European countries: some could be ascribed to affluence, while others were caused by poverty. One specific problem was tobacco consumption. Poland had hosted the third European Conference on Tobacco and Health; the ensuing Warsaw Declaration for a tobacco-free Europe constituted an important instrument for combating the risks inherent in smoking. Not enough attention had been paid to the role of the media in heightening popular awareness of health risks. Communication of misleading messages was as dangerous as the risks themselves. He suggested a special conference or workshop on the contribution of the media. He remarked that the participants in the round table were ministers of disease rather than health, because they concentrated all their thoughts and energy on curative measures. Since the majority of health determinants lay outside the health sector, creating a platform for intersectoral cooperation might prove more successful in reducing risks to health. A message to that effect from the meeting would be useful. Mr NACUV A (Fiji) said that the road to good health required continued efforts to change the habits and behaviour ofyoung people. A focus on education was vital. Health, especially reproductive health, and the dangers of smoking should be made part of the school curriculum, and there should be close cooperation with ministers of education to ensure a good legacy for future generations. Referring to paragraph 6 of the Secretariat's report on the World Summit on Sustainable Development (document ASS/7), he agreed that health should play an integral part in development because it affected infrastructures and settlement patterns. He concurred with the Kenyan Minister that health should be given more prominence in national economies: in Fiji, the health budget represented only 8% of the total budget, whereas education account for 22%. Increasing the share of the budget devoted to health was a challenge that would have to be met by all participants in their capacity as politicians and ministers of health, since otherwise they would be unable to eliminate some of the risks they had been discussing. If no such improvement were achieved, the round table would be a futile exercise.

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Dr PARIRENY ATWA (Zimbabwe) said that risks to health were wide-ranging. The main problems encountered in his country were frequent droughts and cyclones, which endangered food security and entailed the risk of precipitous malnutrition and disease. His Government was therefore examining the possibility of building more dams and storing grains in silos. Another danger stemming from globalization was that poor nations might be marginalized. The big monopolies had swallowed local firms, and the dominant position of drug manufacturers would sooner or later jeopardize health. Arrangements should be made to repatriate trained staff from developing countries, or to pay those countries compensation for the skilled personnel they had lost through the brain drain. UNICEF had issued a warning about a worldwide shortage of vaccines. That shortage would constitute a major risk to health, and the round table should provide a platform for exploring the issue further. Health sector reforms likewise endangered health, because the introduction of user fees excluded many poor patients. The trend towards managed health care was leading to the imposition of new health treatment procedures with the aim of enabling managers to obtain higher profits. However, the biggest risk to health was HIV infection: 20% of the population of Zimbabwe was infected. A variety of measures had been introduced to curb the spread of the disease, but the worst problem was the non-availability of expensive antiretroviral drugs, although it had been proved that it was more cost-effective to treat patients than not to treat them. Governments should make health a priority in their budgets. Poverty constituted a great danger to health, as it exacerbated vulnerability to disease, malnutrition, and risky sexual behaviour leading to sexually transmitted diseases and HIV. In order to address that issue, his country had decided to redistribute land, because many people were living in crowded conditions in small areas while one population group had huge farms. Zimbabwe was not prepared to reverse its policy in that respect, despite the sanctions that had been imposed. He appealed to delegates to persuade their governments to lift the sanctions they had placed on a country where abject poverty existed. Ms KING (New Zealand) said that noncommunicable diseases were the main risk to health in her country. Solutions suggested by earlier speakers had a pragmatic approach, honesty with the public, new paradigms and innovation and open-mindedness. The value of the round table was that it offered an opportunity to learn from one another, to gain strength from collective action, to give leadership and to find lasting solutions. One positive step forward would be to unite on tobacco control. It should be possible to develop a strong framework for that purpose, since the burden of disease from tobacco in the following 20 years in both developed and developing countries would be enormous. Such a framework would provide collective strength against the power of the tobacco companies and would give countries authority to take regulatory and legislative action. It would promote the implementation of tobacco control strategies and public health programmes, and would supply a basis for obtaining funding from ministers of finance and seeking higher taxes on tobacco with a view to curbing consumption. She agreed with the delegate of the Maldives that leadership meant setting an example, and she suggested that a resolution should be drafted to the effect that the building in which the Health Assembly was held should be smoke-free for its duration. Some success had been achieved over the past 12 years in her country through legislative reforms, tax increases and public health programmes, but responses were needed to counter arguments from human rights activists and smokers that low-income groups were being penalized. A strong framework convention would provide an important tool in that effort. Another important issue which had been neglected was obesity; always recognized as a major killer in the developed countries, it was currently affecting many developing countries. One thousand million people in the world were overweight, and obesity was a global pandemic affecting both younger and older people. It was caused by a poor diet, inactivity, fatty food, sugary drinks and alcohol. The Director-General had stated that two-thirds of diseases in later life could be traced to childhood or adolescent environment, and juvenile obesity was likely to lead to various

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noncommunicable diseases. A recent Australian study had shown that when co-morbidities arising from obesity were combined, the burden of disease amounted to 15% - higher than that of tobacco. Obesity was therefore a serious threat to life expectancy and a major drain on health resources. Strong and sustainable strategies were needed, including support for breastfeeding and guidance to families on appropriate foods for children. Honest food labelling was likewise essential. Given the importance for developed and developing countries alike, she would welcome some advice about a strategy to defuse what was a ticking time-bomb for most countries. Professor MOSKALENKO (Ukraine) said that a systematic attempt to reduce risk factors was the best way of improving the quality and length of life throughout the world. He was therefore glad that the matter had been raised in the address by the Director-General (document ASS/3) and at the round table. The significance and interrelation of risks differed from country to country, and it would be useful to establish models of those risks on the basis of the socioeconomic situation of each country. Global risks to health included alcohol and tobacco, and it might be possible to work out common strategies to combat them. To that end, he welcomed WHO's efforts to reach agreement on a framework convention on tobacco control. It was essential to set up a system to monitor information on risks, so as to evaluate the development of each country or group of countries and to see what results their strategies had achieved. It was also important to set up a special risk management system. A progress report should be made every year to the Health Assembly about the reduction of risks and improvements in the quality of life worldwide. Mrs ABDOUL WAHID (Niger) said that for her country the chief risk factors were currently drought, poverty, the acculturation ofyoung people and epidemics of meningitis and measles. Tobacco addiction among the 10 to 18 age group was also a problem, which was being countered by a ban on tobacco advertisements in the media and by restrictions on tobacco imports. HIV/AIDS infection was a major concern for Niger, owing to the massive seasonal exodus of its labour force to neighbouring countries. HIV and other infections were being imported by prostitutes flooding into the country in the wake of the introduction of the sharia code in other States in the region. The Government had decided that such persons should be turned back at the border to protect the population, especially young people who tended not to use contraceptives. The President himself was supporting the campaign against AIDS which was based on prevention, social mobilization and the engagement of local opinion leaders (marabouts). A further concern was that, while unofficial pharmacies made drugs accessible to the most disadvantaged sections of the general public, the products they sold were sometimes out of date, unlabelled and not accompanied by instructions regarding dosage. The purchaser might therefore be buying a product that was not fit for consumption. Malaria was the main cause of death in Niger. The Government had launched an initiative to decentralize health care by building health centres at peripheral level in an effort to bring health-care facilities closer to the population so that they would no longer have to travel huge distances to obtain treatment. Where HIVIAIDS was concerned, the biggest difficulty was paying for expensive antiretroviral drugs and training doctors and health personnel in specialized care. Dr MUGABO (Rwanda) said that, although health risks differed between countries, for developing countries, the main problem was poverty with its attendant effects, one of which was the low level of women's education which in turn had repercussions on the family and the community in general. In the sub-Saharan region, where the rate of literacy among women was low, the rate of maternal and infant mortality was excessively high. In her country, the maternal mortality rate was over 1000 per 100 000 live births, and the infant mortality rate was over 100 per 1000 live births. As her colleagues had stressed, that problem was related to the meagre budget allotted to ministries of health. In addition, Rwanda suffered from a shortage of health staff as a result of the events of 1994.

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All countries needed strong leadership and a common vision, without which it would be hard to bring about change. Her country had tried to adopt new policies, such as decentralization policy to bring health services closer to the population, but the lack of resources had hampered their effective implementation. Dr BALAKRISHNAN (Facilitator), summing up, said that the range of risk factors discussed at the meeting reflected the range of challenges faced by populations. The reduction of risk factors needed to be linked to the social, political, regulatory and development climate prevailing in particular countries and regions. For example, several delegates had referred to populations that were selfsustaining and which had little ability to modify or influence risk factors, for example by altering their lifestyles. Different interventions were clearly needed for such populations. There was a definite relationship between health risks, disease burden and the prevailing economic environment. Several ministers had pointed to the need to modify international business policies, which were not conducive to reducing risks at local level. The view was shared that risk communication improved ability to mobilize multisectoral support for implementing initiatives. While it had been recognized that transparency, accountability and availability of timely scientific information also improved that ability, several barriers still remained to effective risk communication in most settings. There had been wide recognition of the importance of meeting the concerns of vulnerable groups, either because of their particular position on the socioeconomic ladder or because of their greater exposure to risk. Education, especially targeting at the adolescents, could be extremely cost-effective. At the same time, resources should be augmented at national level to overcome the particular risks faced by certain population groups. Health budgets were not always sufficient to meet the requirements of effective risk reduction. Consensus had also emerged on strategies to reduce selected risk factors: nearly all participants had expressed the desire to impose measures to curb tobacco consumption. It had been acknowledged that poverty underlay the burden from risk factors for a large proportion of the world's population, and that the challenge was therefore to integrate mechanisms for decreasing those risk factors into mainstream policies aimed at poverty reduction. Unless concerted efforts were made to address risks to health within an integrated framework, there would be little hope of achieving a world offering equal opportunities for all its citizens to enjoy a healthy life and to leave a legacy for future generations to enjoy.

The meeting rose at 12:30.

Salle XVII, Tuesday, 14 May 2002, at 9:30 Chairman: Mr T. EL KHYARI (Morocco)

The CHAIRMAN opened the round table and introduced the Facilitator, Dr P. Vaughan, Emeritus Professor of Epidemiology and Public Health in the Health Policy Unit at the London School of Hygiene and Tropical Medicine (United Kingdom of Great Britain and Northern Ireland). Dr VAUGHAN (Facilitator) said that The world health report 2002 on risks to health, to be published later in the year, would be about trying to change the focus from diseases to their causes, by looking at major risks and risk factors. Hence, the emphasis was moving up the causal chain towards

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primary causes inherent in people's way of life and habits, especially leisure activities, diet, the environment, etc. The focus was on common risks, particularly those with the potential to spread throughout the world. Some risks were important in particular countries, but not necessarily globally. Most of the big risks fell disproportionately on the world's poorer countries and on the poorer sectors of their populations. The risks also tended to be concentrated, with several factors combining to cause an outcome. Many were distributed throughout the population, rather than located in a small sector, so that the whole population could be said to be at risk. Risk prevention entailed two main approaches. The first, the "high-risk approach", adopted by many health ministries and WHO, targeted those at high risk, but it was not necessarily the most costeffective in the long term. The "population approach", which was often less well understood, set out to reach the whole population and to move the distribution of risk downwards towards a lower level. In many cases, bigger health gains could be achieved in that way. Cost-effectiveness was the key to both choice of intervention and affordability. It was basically a matter of determining for a specific intervention the cost of gaining a specified number of years of life or avoiding a specified number of deaths. Experience in recent years had shown that tackling risks such as those related to diet, alcohol, road traffic accidents and environment was extremely difficult and required a great deal of public confidence in experts and in the policies of health ministries. That raised the important question of how to communicate with the public, as well as the scientific basis behind the risks. The challenge for all health ministries was how to use the information available in order to arrive at the right policies. Many common risks, often those associated for instance with the local environment and lifestyle, were spreading with globalization. At the same time, some other major risks were perceived by the public as high but were low in terms of actual numbers of recorded deaths. Bovine spongiform encephalopathy in the United Kingdom was a case in point: so far, 100 deaths had been recorded. Tackling major risks to health rested on identifying common risks, formulating policies on the basis of good evidence, and defining roles for government, community and individuals. Governments had many options besides imposing changes in people's lifestyle. The table in Annex 1 of document A55/DIV /5 on major selected causes of disease for 2000 set out some of the common risks identified by analysis. The three columns corresponded roughly to low-, middle- and high-income countries. Most of the world's disease burden fell in the first column, the low-income countries, where the highest risks were protein-energy malnutrition and unsafe sex. As a country's national income grew, alcohol consumption, high blood pressure, tobacco use and high body mass index were added to the high-risk category. It was striking that those risks were already present in many low-income developing countries and were becoming a major challenge in middle-income countries. The tabulation was based on measurement of the current burden, although that was clearly the result of factors and circumstances obtaining in previous decades. The challenge for ministries of health was to determine what should be changed to avoid the burden in the future. Some burdens were already known to be increasing. It was hoped that The world health report 2002 would provide at least some answers to the questions and challenges listed as suggested discussion points at the end of document A55/DIV /5. Mr LEHTO (Finland) said that reducing health risks to attain better health had been a consistent feature of Finnish health policy, and the national health-for-all programme, based on WHO principles, had provided the framework during the previous two decades. The results were encouraging and a good basis for further work. The risk factors for major diseases were prevalent among the whole population, so that risk reduction offered a good opportunity for prevention. Moreover, the risk factors for many major diseases, such as cardiovascular diseases, diabetes and cancer, were much the same, which helped to focus the work. Emphasizing the role of results in a successful prevention policy, he said that the continuity of results required sufficient institutional resources. Once resources were available, it was possible to build bridges between professionals, voluntary workers, enterprises and the media. The prevention of cardiovascular diseases in Finland had seen good results, as mentioned in document A55/DIV/5, and the observed increase in life expectancy was largely a consequence of the decrease in cardiovascular

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mortality. Several nationwide factors underlay the trend: primary health care reform, organization of health education, anti-smoking legislation launched in the early 1970s and, later, the systematic treatment of hypertension and high cholesterol, a health-targeted nutritional policy and mental health promotion. The latest government action plan aimed to promote physical exercise among all age groups. As a crucial part of prevention policy, a system for monitoring risk factors had been devised. Hypertension and high cholesterol had significantly decreased in both sexes. Largely as a result of regulation, the reduction in smoking had been significant among men, less so among women. According to interviews, people had increased their leisure-time physical activity, and there had been significant changes in dietary quality thanks to good cooperation with enterprises. The fact that people were becoming increasingly obese was related to the decrease in total physical activity. Health was being used as an important competitive factor in the Finnish food market; in the past health food had often been associated with asceticism. The media had a crucial role to play in backing up health promotion. A sound scientific basis was important in communication with the media and the public. Although a consistent policy to decrease significant regional differences in Finland in the health status of the population had produced some results, especially among children, there was, unfortunately, no sign of a change in the trends related to social groups. Major diseases and risk factors were still more prevalent in lower socioeconomic groups. Reducing socioeconomic differences in health remained a major challenge for the future. Encouraging results of smoking and nutritional policies indicated that, if supportive environments were created, the positive change in risk could be even higher in lower social groups. In 2001 the Finnish Government had adopted a new long-term public health action programme built on health-for-all principles, which set several crucial targets for 2015 and associated policy lines. As positive trends in health indicators were expected to continue during the same period, the goal was also to decrease inequity. Implementation of the programme was based on national intersectoral work and on local community activities. Much work had been done to include as many parties as possible. The Regional Office for Europe had been asked to organize an external evaluation of the policy. The results, available in late 2002, would provide an opportunity for Finland to share its experience with others. Professor WANECK (Austria), welcoming the choice of "Move for Health" as the theme for World Health Day 2002, said that surveys had found that only 36% of the population of Austria deliberately engaged in physical activity as a means of staying healthy. As far as nutrition was concerned, further efforts were needed to reduce nutrition-related diseases and their financial and social costs. The proportion of persons with a body mass index higher than 30 had risen from 8% to more than 10%, and the prevalence of obesity among adolescents was rising. An intersectoral policy on food was required. Alcohol was considered by many to be an integral part of social life and some 40% of the population drank more than was considered safe for health. He was grateful for the initiatives by WHO and the European Union, which were helping to support action at the national level to curb tobacco use. Based on WHO's programme to promote community safety, Austria had launched a project to reduce accident-related risks to health. The Government had passed a law on health promotion and set up a fund to support health promotion activities, including a nationwide lifestyle campaign to raise awareness and encourage personal responsibility, in which physical activity and nutrition featured prominently. The campaign would be enlarged to include tobacco control later in 2002. Dr AL-MAZROU (Saudi Arabia) said that the particular risks to health in his country included obesity, high cholesterol, tobacco use and road accidents. Marriages between close relatives were another risk factor to be considered. Strategies had been implemented to make people, particularly the young, more aware of the need to look after their health, and monitoring and surveillance activities were also under way. Efforts to encourage sport and physical activity had to overcome strong resistance in the population, however. Efforts were also being made to manage better the health risk inherent in the hajj, during which large numbers of pilgrims visited Saudi Arabia each year.

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Generally speaking, the country's ministries were trying to work together to manage health risks and implement healthier education campaigns using the mass media, with the Ministry of Education playing a particular role in targeting children. More coordination and cooperation were required, and more financial resources, especially from the private sector, so that Government and the private sector could work hand in hand. Cooperation was also needed with voluntary groups. The Ministry of Health was running training seminars for health personnel, and supervising the main activities of other government bodies, including the police, in order to obtain a more detailed picture of the risks and improve risk management. Four factors would help countries build a better system for dealing with and eradicating health risks: training of health personnel in the development of statistics-based programmes; promotion of scientific research to facilitate the evaluation of existing risks for the benefit of decision-makers; coordination between, and awareness raising among, government sectors involved in managing health risks; and international coordination based on an exchange of information and experience. Ms RAVNANGER (Norway) included tobacco use, mental stress and depression, and alcohol abuse among the main risks to health in her country. While there had been an overall decline in the number of smokers, smoking continued to rise among young people. Therefore the central component to tobacco prevention was a project being conducted in schools, aimed at youths aged 13-15 years. In the future more nonsmoking areas would be created and it was proposed to ban all smoking in restaurants and bars. The Government was strengthening the mental health service, creating district psychiatric centres to improve treatment. Although the Government had imposed a strict ban on alcohol advertising, the industry had tested the limits of the legislation, and the consumption of alcohol, as well as drugs, among young people was increasing. Further action to combat those trends was being planned. Norway would be chairing a task force on the control of communicable diseases in the Baltic region, in cooperation with the Baltic States and the European Union, whose programme had five areas of collaboration: surveillance, tuberculosis, HIVI AIDS, resistance to antibiotics, and primary health care. She underlined her Government's commitment to health promotion; a white paper on public health would be presented to Parliament later in the year. Professor PHAM MANH HUNG (Viet Nam) said that the three main risks to health in VietNam were malnutrition, tobacco use and injuries arising from accidents. Levels of malnutrition were among the highest in the region, especially in lower socioeconomic groups and in children under five years. The Government had promulgated a national strategy on nutrition for 2001-2010 which aimed to improve nutrition and food safety and increase health education. VietNam had one of the highest prevalences of smoking in the world, especially among adult men. The Prime Minister had announced a national policy for tobacco control for the period 2000-2010. Measures included health warnings on cigarette packs, the setting up of nonsmoking areas, controlling tobacco production, prices, and sales, and prohibiting tobacco imports. Owing to economic expansion and rapid urbanization, injuries from accidents had increased dramatically over the past 10 years, becoming one of the leading causes of morbidity and mortality in the country. A pilot project on injury prevention, carried out in six provinces, had been effective in reducing their number, leading to the promulgation of a national policy on injury and accident prevention for the period 2002-2010. Professor RA TSIMBAZAFIMAHEF A (Madagascar) said that consideration of the risks to health was an area that tended to be neglected by health policy-makers, who concentrated more on curative care and rehabilitation. Moreover, even when the quality of the risk, either for communicable or noncommunicable diseases, was recognized, their extent was little measured, making it more difficult to structure information and education programmes aimed at changing behaviour. Programmes were targeted at high-risk groups but monitoring and surveillance were limited. In addition, it was difficult to formulate and communicate messages in the face of high levels of illiteracy and for both rural and urban environments. Specialized services within the health service were needed

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to identify risks and the stakeholders involved in risk reduction. Such measures should be set out in a framework document on the protection of health, which should also identify resources for implementation. Professor ABENHAIM (France) remarked that the analysis of public health based on life expectancy rather than the incidence of disease was an interesting proposal, revealing unexpected parallels between countries of different socioeconomic levels. The analysis reflected accurately the reality of the situation in his country, where the capacity to act on the determinants of health was poor, and would enable policy-makers to orient public health programmes towards prevention rather than health care. WHO should also consider the question of the identification and evaluation of unknown risks, which were not easily quantifiable in terms of disease burden, such as those associated with environmental factors. While his country had set up agencies to monitor health safety, great differences had been revealed between levels of risk, as well as perceived levels of risk, and levels of morbidity. WHO could help in drawing up agreed definitions and methods and increasing understanding as well as communication of those problems, including uncertainties. Public health priorities would be discussed annually in the French Parliament and the proposed methodology would greatly assist the debate. Dr KEBER (Slovenia) said that cardiovascular disease was the leading cause of death in his country, but although alcohol abuse had a relatively low ranking in terms of disease burden, its economic and social consequences were greater. Monitoring had shown that the major risk factors were increasing in Slovenia, except for tobacco consumption which, apart from a rise among young people, had diminished substantially. A new monitoring system, with a health card, had been introduced, whereby data on risk factors for the entire adult population would be monitored every five years, in time building up an online data bank. To overcome the problem of a piecemeal approach to risk factors, a regional project had been launched in a rural part of his country where life expectancy was below that of the national average. It was hoped that an intersectoral approach based, among others, on better education and an alteration to dietary habits, would produce positive results. Mr KONDO (Japan) attributed mortality in his country mostly to cancer, cardiovascular and cerebrovascular diseases and diabetes, all of which were related to lifestyle factors such as smoking or lack of physical exercise. A national campaign, Health Japan 21, had been launched two years previously aimed at reducing risks to health, extending life expectancy and improving quality of life. Central and local government, private corporations, nonprofit-making organizations, schools, communities and families were all collaborating in changing the perceptions and behaviour of citizens. It was hoped that the initiative would reduce the cost of medical and nursing care in the future in an ageing society. Mr LEE (Republic of Korea) observed that, in his country, population ageing and rapid industrialization had changed morbidity and mortality patterns. Chronic degenerative diseases and accidents had become the main causes of death and the main risk factors were smoking, heavy drinking and lack of exercise. National surveys undertaken every three years by the Ministry of Health had shown a rise in risk factors. Emerging economies and developing countries were all suffering from the dual burdens of new and conventional problems, and were facing difficulties in mobilizing adequate financial resources for prevention and health promotion. He expressed his readiness to exchange information with similar countries. In his country, the National Health Promotion Act of 1995 had established a fund through taxation on cigarettes, a measure which in future might be extended to alcoholic drinks and petrol. Another scheme involved competition between health centres, whereby part of their budget depended on the result of their promotion activities. The private sector had been mobilized using part of the national health promotion fund, in order to finance research on management and cost-effectiveness.

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Dr VAUGHAN (Facilitator), summarizing the discussions so far, noted that many countries had reported the same problems, but success in dealing with them had varied. For example, reductions in alcohol and tobacco consumption had been achieved in certain countries, but obesity remained a problem in most countries. He also noted that, while the consequences of diet had been discussed, there had been few references to diet per se. Accidents, particularly road traffic accidents, had been identified as a major cause of death, but also accidents in the home or workplace. As regards actions to take, reference had been made to the role of different sectors of government, nongovernmental organizations, the private sector, and voluntary groups. Several countries were establishing national programmes, projects and policies to set future objectives relating to health risks. Better evidence was needed; that meant more research. While such evidence might not be a high priority for all countries, it could be argued that it was a high priority to develop such evidence and to share it around the world. Mr AZIZ (Brunei Darussalam) said that the sale and consumption of alcohol were banned by law in Brunei Darussalam. Violations were punished financially and accorded wide publicity in the media; that had proved to be an effective deterrent. Alcohol was not served at any official or private functions; it was also prohibited under religious law. Such measures had proved successful in overcoming the problem of alcohol dependence in the country. Mr KET Sein (Myanmar) suggested that countries should collaborate to develop strategies for dealing with common risk factors, with assistance from WHO. Each country should define its own risk factors, paying particular attention to the most vulnerable groups. Interventions should be directed to the promotion of healthy lifestyles and behaviours and the creation of suitable environments. Myanmar had established a health promotion programme in schools to minimize health risks at an early age. Many risks to health were beyond the scope of the health sector. To minimize them, strong intersectoral coordination was required at all levels. More emphasis should be given to risk assessment and to health impact assessments related to the projects carried out by government and the private sector. Mr BHANDARI (Nepal) stated that poverty was a major public health issue in Nepal. Over 50% of the population was at risk from premature death and disability due to communicable diseases, perinatal and maternal mortality and morbidity, deficiency disorders, an unhealthy diet, alcohol consumption and tobacco use. The Government's next five-year health plan focused on those diseases and conditions as priorities. In certain parts of the country, especially the poorest areas, social customs were such that the assessment of risks to health remained to be identified. Further research was needed to determine the burden of diseases in developing countries, which was quite different from that in developed countries. Developing countries were doing their best to tackle social problems, but had met with limited success. Nepal was in the process of introducing legislation to ban smoking in public places, but was unable to resolve the problem of alcohol abuse. More than 30% of the population suffered from alcohol dependence; alcohol consumption was widely accepted and often linked to social status. Diet was also a concern; people did not think of food in terms of dietary value, and malnutrition was widespread. He looked forward to having WHO's support and the tools necessary to carry out risk assessments. Mr DOSKALIEV (Kazakhstan) agreed that tobacco use was of critical importance in many countries. In Kazakhstan, which had a population of about 15 million people, over 20 000 deaths per year occurred as a result of tobacco-related conditions. He attributed the problem of smoking to widespread advertising and media representation. Legislation to prevent and restrict smoking was currently going through Parliament. In that context, Kazakhstan supported the preparation of the WHO framework convention on tobacco control. Another problem was the abuse of psychotropic substances (about 47 000 drug users were registered in the country) and alcohol, and the rehabilitation of former drug users. A law on the latter subject had been adopted. The Government had established a food supplementation programme to tackle deficiency of micronutrients, particularly iron and iodine, in

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food, especially in areas where nuclear testing had been carried out. However, legislation in that area too was needed. Dr PULA Y (Hungary) agreed with the Facilitator that the chain of causes underlying the health status of a population required a chain of interventions reaching individuals, local communities and society as a whole. Individual health was predominantly determined by environment and lifestyle; an individual's immediate environment, family, workplace and leisure activities influenced his or her lifestyle which in turn affected health. In Hungary, the principal factor causing differences in lifestyle was social inequality, mainly as a result of differences in education level, employment and income. Health problems were particularly common in disadvantaged social groups. Improving public health required concerted action by the whole of society. With assistance from the Regional Office for Europe, the Hungarian Government had therefore launched a 10-year public health programme setting five national targets and 17 programmes to reach those targets. Priorities included education for health, early detection of diseases of major public health importance, promoting physically active lifestyles, combating drug dependence and excessive consumption of alcohol and tobacco, and improving food safety. Such programmes required the cooperation of the whole of society for their success; the only real guarantee was for people to become aware of what needed to be done and to be ready to act for their own sake and for that of their children. Professor ASADOV (Uzbekistan) remarked on the particular attention that had been paid to tobacco use, which had become one of the most aggressive risk factors for individual health. In Uzbekistan, one-third of the population smoked and about 30 000 people died each year as a direct or indirect result of smoking. The quantity of tobacco imported into the country had doubled between 2000 and 2001. Since 1999, however, Uzbekistan had been actively collaborating in the preparation of the WHO framework convention on tobacco control. In addition, the Government had prepared a draft plan to control tobacco in the country, which had been submitted to WHO for consideration. Comprehensive efforts were needed to prevent young people from smoking. On World No Tobacco Day, the Uzbekh Ministry of Health had, in collaboration with WHO, organized a major event in Tashkent on prevention of smoking. Future similar events had also been planned, including the prohibition of smoking for one hour throughout the country on the occasion of the next World No Tobacco Day, an idea, it was hoped, that would be taken up throughout the world. Mrs PIERANTOZZI (Palau) commented that her country shared many of the risks to health cited by other speakers, such as the environment. Between 2000 and early 2002, an epidemic of dengue fever had occurred in Palau and she thanked Taiwan (China) and the United States of America for providing medical supplies and assistance. While smoking had been reduced to some extent, chewing of tobacco and betel nuts remained a problem. A study would be conducted towards the end of2002 to determine the impact of those practices during pregnancy, including the effects on the fetus. Unhealthy lifestyles were also a problem in Palau: the high incidence of sexually transmitted diseases, for instance, was attributable to the high numbers of people travelling to and from the country for business and tourism purposes; obesity was particularly related to the intake of convenience foods and lack of exercise; alcohol and substance abuse contributed to the high rates of fatal accidents and suicide among young people - a study was being conducted to determine the reasons for the latter. Palau had an acute shortage of trained medical and health support staff, which meant that people often had to be sent abroad for medical treatment. In addition, government policies and legislation had not always favoured health, such as the recent decision to lower taxes on imported tobacco and reduce the public health budget. She expressed interest in Slovenia's programme to monitor risk factors in all adults every five years and in the evaluation of the results of Finland's health programme, as well as in an external evaluation of her country's health policies in order to identifY where help was most required.

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Dr HAMUKWA YA (Angola) said that her country had experienced more than 25 years of armed conflict, which had resulted in the displacement of large numbers of persons to the major urban areas, where the water and sanitation infrastructure had consequently deteriorated. The health risks in Angola were those linked to factors such as poverty and illiteracy, and malnutrition, unhealthy diets and alcohol abuse. The main obstacles to intervention were linked to access because of the presence of land mines and the state of the roads. There was need to improve the health care infrastructure. A limited epidemiological system was in place to assess health risks, but risks had increased considerably in the past years. With the new measures for peace, it was expected that health risks would be reduced. Steps to improve immunization coverage had been taken, the Government had increased its budget for health and allocated resources for health education. Mr DE CORREIA PEREIRA (Portugal) said that the situation in Portugal was similar to that in the other Member States of the European Union, with hypertension and associated poor diet, tobacco use and alcohol abuse constituting the principal health risks. Drug abuse and road accidents, the incidence of which was particularly high in Portugal, were also causes for concern. For the latter, a public awareness campaign had been launched. In terms of the cost-effectiveness of public health measures, two routes were available: targeting the communities most at risk and general approaches to the whole population; against drug use, targeted campaigns were more effective. Finally, public information programmes were fundamental in gaining public confidence in public health policies. Dr AL-MOUSA WI (Bahrain) raised the problems posed by diabetes, high cholesterol levels, tobacco consumption and blood pressure in Bahrain. Diabetes and high blood pressure, in particular, had high prevalences and health education programmes were being undertaken in schools, through the mass media and in public meeting places to promote good health and reduce tobacco consumption. Sports organizations were being involved in the fight against obesity, informing the public of the benefits of physical exercise, and public information programmes were in place concerning the health risks of marriage between close relatives and to raise public awareness of health at the community level. The aim of such cooperation was to reinforce programmes to reduce risks to health. Another area of concern was nutrition, and interventions targeting young people and excessive consumption of convenience foods were needed. Mr MUHWEZI (Uganda) reported that poverty was a major health risk in Uganda, as elsewhere in Africa. Regular surveys revealed a clear distinction between health indices among the poorer members of society and those who were better off. Moreover, current annual health spending in Uganda was only US$ 9 per capita, far below that of many other countries. Support should be given to the global effort to reduce poverty, which would, in turn, make a major contribution to improving health. Another risk factor in Uganda was the level of health literacy. Cultural factors sometimes meant that a scientific interpretation of the causes of disease was rejected and health education was vital to enable people to lead healthy lives. Injuries of different kinds constituted health risks as did the climate itself, which encouraged the proliferation of disease vectors. Uganda also had a burden of mental illness as a result of the trauma the population had suffered in the past. A recent survey had shown that 70% of the total disease burden was accounted for by communicable diseases, superimposed on a background of malnutrition and anaemia, but also that, owing to noncommunicable diseases, that proportion was increasing. In an attempt to reverse the currently decreasing trend in life expectancy, Uganda was implementing a health policy and strategic plan focusing on a minimum health care package. In addition, there was a massive health education and promotion programme which, with the personal involvement of the President, had already succeeded in reducing the prevalence of HIVIAIDS from 18% to 6%. A health management information system had been installed to monitor disease and, finally, the health system was being reinforced, especially at community level, to improve access,

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increase awareness and encourage ownership. He expressed the hope that, as the economic situation improved, more money would become available for health care. Mr DANTAS DOS REIS (Cape Verde) said that poverty was a determining factor in relation to health risks in Cape Verde and was especially relevant for infants and children up to the age of 10, for whom environmental factors, such as clean drinking-water, played a significant role. Action to clean up the environment and to provide iron supplements for children was already being taken. For adolescents and adults up to the age of 40, legislation and public education aimed at fighting alcohol abuse and drug dependence existed but, as yet, had achieved only marginal success. Violence, road traffic accidents, sexually transmitted diseases and tuberculosis added to the burden of illness in this group. In the over-40 age group, hypertension, traffic accidents, alcohol abuse and diabetes were the significant factors. Interventions to reduce road traffic accidents, mainly related to alcohol abuse, and to promote health had not yet been successful. The ability to purchase appropriate drugs posed enormous problems for Cape Verde. The ultimate aim was to eliminate current health risks and attempt to avoid those suffered by the industrialized countries. Professor DIALLO (Guinea) said that like other developing countries Guinea faced three main types of risk factors which were all associated with underdevelopment. First, lifestyle and behavioural factors affected levels of sexually transmitted disease and unwanted pregnancy, and noncommunicable diseases, in particular diabetes, high blood pressure, cardiovascular disease and tobacco and alcohol abuse. Young people especially were increasingly associated with tobacco and alcohol abuse. The second type of risk factor was associated with nutrition, with high prevalences of malnutrition and anaemia. Vitamin A deficiency was increasingly being successfully combated, but iodine deficiency was still endemic. Finally environmental factors, such as sanitation, also constituted risk factors for health. As a means of reducing health risks, Guinea had established a national health development plan with 17 programmes to be implemented starting in 2003. Dr KAMIL (Djibouti) agreed that the biggest challenge developing countries faced was poverty in the widest sense of the term. In his view, insufficient attention had been paid to that subject in document A55/DIV/5. If poverty could be alleviated, then problems such as malnutrition, and the lack of access to drinking-water, and health education could be overcome. Djibouti had a health development plan, but the reduction of poverty remained the principal thrust in the fight against risks to health. Mr WABAIAT (Vanuatu) said that many of the health risks mentioned during the discussion were common to all. While much emphasis was placed on an intersectoral approach, programmes were still often implemented in isolation. The Director-General had stated that a more practical approach was needed. Vanuatu believed that better monitoring and evaluation of programmes were needed, in particular, of information and education awareness programmes, in order to ensure that they were effectively addressing health risks. The development of appropriate legislation would also be useful, but there must be adequate means of enforcing it. Referring to the risks associated with tobacco and alcohol, he pointed out that the private sector in those areas had strong bargaining powers, which it was difficult for less developed countries such as Vanuatu to counteract, and which should be renegotiated. Counselling and information and awareness campaigns could be useful in promoting exercise to counter some risks. Finally, it would be useful if different agencies could be encouraged to collaborate to ensure that programmes were developed in partnership to maximize the use of scarce resources. With regard to the Global Fund to Fight AIDS, Tuberculosis and Malaria, he asked whether his understanding was correct that WHO had little or no say in determining how the resources were distributed. The CHAIRMAN thanked the participants for sharing their experiences. His initial impression of a difference between the approach of developing countries and that of developed countries had been

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dispelled as the meeting had progressed. Consideration of the economic elements in the field of health was raising questions for Member States. Evidently, approaches needed to be refined and health risks prioritized, for which appropriate tools were required. Cost-efficiency was an essential element, but one that posed ethical problems that had to be taken into account. It was an unfortunate reality that the value of a human life varied from one continent to another, and from one country to another. It was a fact that differences existed and no single analysis could be applied to all countries. Dr VAUGHAN (Facilitator) said that, although it had been assumed that countries with low, middle and high incomes encountered different health problems, it had become apparent that risks that were present in the wealthier countries were also present in other countries, even if not to the same extent. It was gratifying to see that ministries of health were aware of and were tackling these problems. Poverty was indeed a major factor; however, it was difficult to determine how it could be prioritized as a risk. Clearly there were considerable inequities between countries. He agreed that development of appropriate methodologies was important and welcomed the interest expressed in collaboration between countries and with organizations such as WHO in that area. Finally he noted the importance given to the strengthening of human resources and the capacity to implement actions to tackle health risks.

The meeting rose at 12:10.

Salle XVIII, Tuesday, 14 May 2002, at 9:30 Chairman: Dr J. FRENK (Mexico)

The CHAIRMAN introduced the round table by commenting that consideration of risks to health, would extend understanding of health phenomena from damage to the risks that determined the probability of such damage. He invited participants to exchange views, answer comments from other participants and ask questions, without relying on prepared speeches. The facilitator of the meeting would be Dr S. Robles, Head of the Non-communicable Diseases Programme of PAHO, who had worked on evaluating the control of tobacco use in developing countries, helped to set up a risk factor monitoring system in the Americas and established standards to evaluate the quality of data. Dr ROBLES (Facilitator) said that, if due priority was to be given to preventive health activities, it was essential to know the magnitude and distribution of existing health risks, so that a populationwide approach could be adopted. The North Karelia project on coronary heart disease in Finland and similar projects had shown that such an approach could be successful in reducing risk factors associated with disease. Existing population-based programmes operated on three levels: the macro level, covering public policy, legislation and regulations; the community level, with action and participation by individuals and the community as a whole; and the inclusion of preventive measures in the activities of health services. It was important to ensure that the actions taken had the maximum possible effect. Cost-effectiveness analysis was a valuable tool in decision-making. One important objective was to establish indicators for comparing the disease burden created by exposure to various risk factors and the possible interventions that could be made. The table in paragraph 7 of document

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A55/DIV/5 listed the leading causes of disease in low-income, middle-income and high-income countries in the year 2000, and Annex I of that document showed the disease burden in disabilityadjusted life years lost. Those consequences resulted from people's exposure to risk factors- i.e. their behaviour- in the past. The question was how to reduce their exposure to risk factors in the present, in order to reduce future health problems. The round table should therefore discuss the form that risk management should take in each country, which programmes should be developed or further supported, which institutions should be strengthened, and how prevention could be put on to the political agenda. The CHAIRMAN said that a risk-based approach revealed not only a picture of disease and its consequences in terms of disability but also the factors that determined the probability of adverse health effects. One issue that the round table should discuss was the role of the State in the control of risk factors. To what extent should the State intervene to change the behaviour of people who were actively exposing themselves to risk, as in the case of tobacco smoking? To what extent should the State provide protection against risks to which people were exposed passively, such as air or water pollution? What were the limits of State control? Clearly, in order to control risk factors, a government must be familiar with the risk profile of its population. As the Director-General had said in her speech to plenary, risks fell into two main groups: those due to lacks of, for example, food, good diet or information on safer sex and those due to consumption, such as obesity or tobacco and alcohol misuse. Although the latter risk factors were most often observed in industrialized countries, they were becoming increasingly common in low- and middle-income countries, where they combined with the risk factors associated with deprivation to create a double burden. In one case, people had few other choices, and in the other they made the wrong choices. Health authorities in all countries needed to determine the incidence, extent and consequences of each risk factor and the priority to be given to it. Cost-effectiveness analysis should help them to decide which interventions would be most useful when resources were always limited, and for example, whether an intervention should be aimed at high-risk individuals, or at education and health promotion in the community as a whole. A major area of deficiency in many countries was that of communication about health risks. People's perceptions of risk were subject to a great many factors and were not always objective. Countries should develop effective strategies for risk communication, especially between the scientific community, public-sector decision-makers and the general public. A climate of mutual trust must be established. The round table should discuss how a clear understanding of the health situation based on sound evidence could be obtained, how to develop a method for choosing strategic priorities and how to create a strategy for communication with the general public. He called attention to the list of seven suggested discussion points contained in document A55/DIV/5. Dr ZHANG Wenkang (China) said that neither decision-makers nor the general public knew enough about health risks, whose better evaluation would help decision-makers to prioritize. He expressed the hope that the round table would increase public awareness in order to promote public health aims. China, in common with other developing countries, had many health risks. It had a wide variety of ethnic groups, lifestyles and customs and was undergoing a rapid economic transition, which had led to disparities in economic and social development between regions. The country experienced both the problems of underdevelopment, such as protein-energy malnutrition, micronutrient deficiencies, unsafe drinking-water and poor sanitation, and those of more developed countries, such as effects of lifestyle and behaviour, pollution, ageing and industrialization. It had developed a reliable surveillance system which had provided sound evidence for decision-making and cost-effective interventions in areas such as water supply and sanitation. Programmes of water fluoridation and immunization, especially against hepatitis B, and programmes against tuberculosis and AIDS had produced notable social and economic benefits. However, the Government had realized that surveillance of existing

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disease was not enough: it was also important to monitor health risks. Changes in policy and individual behaviour were important, particularly for the control of chronic and noncommunicable diseases. China had set up behavioural risk surveillance and environmental surveillance systems in some cities, which had provided important evidence for Government interventions and helped to evaluate their effectiveness. A health awareness programme had been established for the 900 million-strong rural population, including anti-smoking measures. Salt iodinization and initiatives for healthy eating and community sports had been introduced, and a code for occupational health had been drawn up. The importance of health risk factors was often underestimated, because a single one could give rise to several conditions, often with a long delay between exposure to risk and the emergence of symptoms. Public health officials should increase awareness of that important issue among policymakers and the public. Although interventions should be based on scientific evidence, that was an area in which many developing countries had little experience. He called upon WHO to support capacitybuilding in developing countries and promote exchanges of experience among Member States. Dr MO RENO PALANQUES (Spain), summarizing the major causes of morbidity and mortality in Spain, said that the health status of the population was similar to that of other developed countries in the region. Spain had established systems for the monitoring and surveillance of diseases including influenza, HIV/AIDS, spongiform encephalopathies and cancer. Information about the major risk factors was derived from morbidity data obtained from the biennial national health survey. However, better information was needed, particularly in relation to chronic diseases, their risk factors and the resulting disability, accidents on the road and in the workplace (rates of both of which were high in Spain), and the effects of exposure to chemical and physical agents at work. The new public health strategy of the European Union stressed prevention of disease by including measures against causative factors in all the policies and activities of the Commission. Those factors included lifestyle elements, such as diet and use of tobacco, alcohol and drugs, and mental health. The situation should be analysed and strategies drawn up on the basis of socioeconomic determinants of health and environmental factors. It would be important to exchange information on genetic determinants. Methods should be established to evaluate the quality and efficiency of strategies for health promotion. Spain had a decentralized political and administrative structure, and risk management was thus a matter for regional governments and autonomous communities. The central Government supported them, coordinated their activities and intervened in situations that went beyond a single region or community. The management of "uncertain" risks was particularly difficult. Well-designed early warning systems would be important in that regard, and the Spanish Government was working with the regional governments to improve three of its surveillance systems, on pharmaceutical vigilance, health products and epidemiology. Such systems must be rapid, selective, confidential and capable of operating efficiently. The mass media in Spain had only recently begun to devote attention to health issues, principally because of the so-called toxic oil syndrome. Coverage of health issues was variable and designed to appeal to the public, which meant that it was not always objective. Journalists were not trained to report on health issues, and contacts between communications professionals and health professionals were poor. A strategy for communication about prevention to the general public was required, based on television, which was the most popular medium. Professor NYMADA W A (Mongolia) said that his country had recently undergone an economic transition, which had completely changed its epidemiological profile. The changes in employment patterns resulting from the introduction of a market economy had led to unemployment, urbanization, migration and increasing poverty. Cardiovascular disease was the leading cause of death, and malnutrition, alcohol abuse, tobacco use and physical inactivity were major health risk factors. Existing monitoring and surveillance systems were inadequate. The health information system did not record all the causes of ill-health and could not be used to monitor exposure to health risks.

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Regular nutrition surveys and a growth monitoring system did not give a complete picture of the nutritional status of the population. The major obstacles to implementing population-wide strategies were a lack of institutionalized technical knowledge, financial resources, political commitment, awareness of health risks among policy-makers and the population, and sustainability of earlier achievements, and high turnover of staff in Government health institutions. Recent amendments to the country's health insurance law had paved the way for the allocation of more resources to the family doctor service. In 2001, the Government had approved a decree to promote healthy lifestyles and health-promoting behaviour through information, education and communication strategies. Additional institutional support would be required to implement the strategy fully. The Ministry of Health had set up a public relations department, which would work closely with the media and the general public. Dr HOSSAIN (Bangladesh) said that adverse effects on public health hindered sustainable economic development. The round table should provide a comprehensive assessment of the major health risks and concrete recommendations for means to deal with them. Although his country had been successful over the past few decades in controlling communicable diseases, noncommunicable diseases continued to pose a problem. In many developing countries ill health and low productivity of the "absolute poor" and marginalized populations were still a major challenge. Basic health services should be ensured for every citizen, at affordable prices. A major public health problem in his country was contamination of groundwater with arsenic, affecting 3 0 million people and resulting in over 10 000 cases of arsenic poisoning. A major effort had been undertaken to identify contaminated wells, to raise awareness about the problem, and to find alternative sources of safe drinking-water. Bangladesh had also taken several measures to reduce environmental pollution. Surveillance of risk factors for noncommunicable diseases was inadequate in many developing countries. Although ageing and urbanization were important, strong evidence pointed to the causative role of preventable lifestyle-related factors, such as consumption of tobacco, alcohol and high-energy diets and inadequate physical exercise. Reliable surveillance systems should be established, in order to monitor the pattern and trends and to measure the effectiveness of preventive interventions. In view of the changing health needs, countries should update their policies and strategies and create synergy with respect to global priorities. Mr AZEVEDO MERCADANTE (Brazil) said that Brazil, like many recently industrialized nations, was in epidemiological transition, with the double burden of communicable and noncommunicable diseases affecting mainly the poor. Owing to social inequality, risks differed among subpopulations in the country. Health information systems provided data at both national and regional levels, and that information was used to target health-promotion policy. WHO initiatives would help Member States to develop methods for evaluating health trends and risks. The Brazilian Ministry of Health had adopted several measures to reduce risks to health, including strict laws against tobacco advertising and promotion of healthy diets and safe water. The manufacture and marketing of food, drugs, cosmetics and related products were regulated, as was blood quality. Early-warning systems for disease outbreaks and contingency plans for chemical, biological or radioactive accidents were in place. Risk communication was being improved by enhancing cooperation with the media and civil society, with strategies designed for specific target groups, such as children and the elderly. Professor SHEVCHENKO (Russian Federation) pointed out that, although modem clinical medicine allowed early detection and treatment of disease, the evaluation of risks and implementation of prophylactic measures were the most effective means to reduce mortality rates. Agreement should be reached among various sectors of society on policies for prevention and priorities and strategies for joint action. Efforts had been made in his country to encourage the public to improve their general

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health, which had deteriorated seriously in the past decade. Only 12% of all Russians exercised, more than 35 million abused alcohol, 2 million regularly used drugs and more than 45% smoked. In view of the poor economic situation in the country, effective preventive measures were essential. Any policy to improve the health status of the population should be based on seven main principles: an integrated approach to improving lifestyle and the environment; intersectoral collaboration at governmental level; reducing the gap between medical advances and their application; an improved infrastructure for disease prevention, including provision of the necessary information in medical schools and to the general public; disseminating information about healthy lifestyles, with targeting to specific risk groups, and ensuring that legislative and economic measures did not adversely affect public health; community mobilization; and monitoring and evaluating the efficacy of prevention programmes. A database was being created in cooperation with WHO and with primary health care centres throughout the world, to monitor the effectiveness of preventive measures. Particular attention was being concentrated on the health of children, and centres had been established in which care was provided for young people under the age of 18. Ms BLACKWOOD (United States of America) observed that many risk factors for disease were known, but challenges remained in reducing those risks, treating the consequences and improving the quality of life. Her country had an extensive programme for health promotion and disease prevention, as preventable diseases were the leading causes of death, disability and morbidity. Prevention was cost-effective and improved the quality of life. It had been shown that diet and exercise resulting in a 5% to 7% weight loss had more than halved the incidence of type-2 diabetes. It was difficult to encourage behaviour that prevented disease. Successful programmes should cover many aspects, from education to changing individual behaviour, improving preventive health services and making the environment safe. In her country, the secretaries of education and of health had launched a campaign to induce families, communities and businesses to create innovative ways to increase physical activity among children. The disparities in health in the population were a major concern. The infrastructure of local and state public health organizations required strengthening, with improved surveillance of health risks and better coordination throughout government structures. Better understanding was needed of the interactions between behaviour, the environment and genetics in disease causation, and the research budget in her country had been increased to that end. Furthermore, resources were being sought from the private sector, on the basis that a healthy workforce was a more productive one. The core of a risk reduction programme was sound prevention policies and concerted research, including cooperative research between countries. Mr PAVIC (Bosnia and Herzegovina) stated that post-war Bosnia and Herzegovina was a lowincome country but was subject to the same health risks as high-income countries. Additional concern arose from the large numbers of disabled persons, displaced persons and refugees, persons from posttraumatic stress disorder and those at immediate risk of injury from landmines and chemical, biological, radioactive and other materials. The fact that 38% of the population was unemployed and 50% had no medical insurance gave rise to multiplicative risk factors. Reform of primary health care services had been slow, and, because of the precarious economic situation, emphasis had been placed on lifestyle changes and political commitment to reduce major health hazards. The main priorities were prevention of arteriosclerosis and cardiovascular diseases, early detection of cancer, accident prevention and rehabilitation, prevention of diabetes and reproductive health programmes. Health system reform depended on evidence-based solutions to the reduction of health hazards. Bosnia and Herzegovina required a State mechanism to replace international and domestic institutions. Improved risk measurement, cost-effective interventions, national disease prevention and health promotion programmes, continuous analysis of health decisions and policy-making risk management strategies, closer regional and subregional cooperation and continuous monitoring of health care reform should constitute the new orientation of world health policy. Health was closely linked to macroeconomics, and policies should be tailored to permit implementation at global, national, regional and subregional levels.

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Dr TSHABALALA-MSIMANG (South Africa) commended document A55/DIV/5, which was a well-thought out resume of complex issues that confronted policy-makers. In her country, the major health risks fell into three categories: those related to poverty, such as tuberculosis, cholera and sexually transmitted infections, including HIV; those of a society in transition, including road traffic accidents; and those of a society in epidemiological transition, including cardiovascular diseases and diabetes. Malnutrition was a major health risk factor in her country, resulting in low birth weight and birth defects, which themselves led to health problems in later life. To overcome widespread vitamin A deficiency, supplementation had been initiated among children. Collaborating with the grain industry in South Africa, the Government was fortifying basic foods as a means of reducing micronutrient deficiencies. A policy had been instituted for identifying and managing children with genetic and other birth defects. Obesity was becoming a serious threat, in both children and adults, putting them at risk for metabolic diseases such as diabetes and coronary heart disease. Part of the problem was due to the wide availability of cheap, unhealthy food. Health promotion guidelines had been formulated for the management of overweight and obese persons. Unsafe sex was also a major challenge, as evidenced by the high rates of sexually transmitted infections, including HIV. The Government had initiated a major public campaign with the media, faith-based organizations and others to disseminate appropriate reproductive health information. It also offered services for adolescents, with the direct involvement of young people. The importance of families and communities in that regard was primordial. Unplanned pregnancies posed a high risk of severe complications and death to women, contributing to the high maternal mortality ratios in her country. Free health care was offered to pregnant and lactating women and to children under the age of six. A system of notification of maternal deaths had been implemented with a confidential inquiry into each death to determine the cause. A Choice on Termination of Pregnancy Act had been passed and contraceptive and family planning programmes had been strengthened. Prevention of maternal deaths required that all sectors, including communities, be aware of the need for care. The country's expanded programme on immunization was a priority, although there were gaps in poorer and more rural provinces. Noncommunicable diseases, including mental disorders, were responsible for a high proportion of morbidity, disability and mortality. The major risk factors were tobacco smoking, high blood pressure and obesity. Substance abuse among the young was a growing problem, as were depression, violence and physical and sexual abuse. South Africa had implemented guidelines on the prevention and management of chronic diseases and started projects on substance abuse. A mental health bill was being finalized, and there were plans to launch a survey to determine risk behaviours among youth aged 13 to 15. With the causative risks for most diseases known, prevention strategies usually consisted of behavioural changes, which were difficult to implement. The media could play a vital role in promoting such changes. The Government needed to cooperate more and better with the media, particularly regarding youth. The community should be at the centre of preventive efforts. Health promotion and education were culturally and economically adapted for making those efforts sustainable. During April 2002, which had been designated as Health in Action month, Government officials had participated in community initiatives to promote volunteerism for environmental preservation and sanitation in health institutions and sustainable food production in vegetable gardens. South Africa needed to strengthen public health training and the content of curricula for health professionals to cover epidemiology, surveillance and monitoring. Research institutions also needed to be strengthened to provide the information necessary for planning and provision of health services. The next challenge was to increase resources for prevention, while ensuring that those resources reached the implementation stage. Other sectors were being lobbied to play their part in community and infrastructural development, such as the provision of piped safe water, roads, social security and sustainable food security through agricultural interventions and food storage.

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Dr ROBLES (Facilitator), summarizing the discussion at the request of the CHAIRMAN, noted that there were common threads in all the presentations. Countries with similar risks nevertheless showed complex changes in epidemiological profiles, which made risk management, particularly for noncommunicable diseases and environmental risks, difficult. Another commonality was a divergence between the population's perception of the magnitude and distribution of risks and the reality. The problem was how to communicate that reality to the population and how to establish channels for communication with the public and with other sectors, including private and nongovernmental, in order to formulate public policies to reduce those risks. Recalling the question raised by the Chairman with regard to the role of the State in risk management, the delegate of the United States had reported, for instance, that relatively modest changes in risk factors had significantly reduced the incidence of diabetes. Risk management should be approached by drawing up a preventive agenda in the public sector and in governmental policy. The CHAIRMAN invited delegates to consider the array of instruments for public policies that were available: information to the population; incentives, such as taxes to discourage tobacco consumption; instruction, such as State rules and regulations on emission levels and safety measures, and the internalization of values, to effect changes in long-term behaviour. The optimal mix of those instruments needed to be defined for different risks. Certain environmental risks involving passive exposure of the population required State intervention; other risks might best be addressed by incentives, such as a health taxation policy to raise tobacco and alcohol taxes. Still other interventions might be based on information and communication to the public. Finally, long-term changes could be brought about only through the internalization of values. It would be interesting to hear about national experiences with those instruments for management of health systems and how they could be used to change risk profiles. Dr AL-BABILI (Yemen) reported that his country had weak health and economic structures, with three categories of health risk: those associated with economic capacity, those related to the level of social services available; and those linked to social customs and traditions. Social services, comprising those for education, water, sewerage and health, were particularly poor, and, for lack of human resources, could not be provided on a sustainable basis. He emphasized the importance of agreed-upon definitions in order to establish a list of health risks. In Yemen, children, the young and women were at greatest risk, and he concurred with other delegates that health education and prevention as well as compulsory primary education, particularly for girls, were essential. Increased resources were needed for education and health services. That would require international cooperation, including increased contributions from donor countries for health priorities. Legislation that restricted contributions to health, particularly primary health care and reproductive health services, should be discouraged. Countries should maintain health statistics and train health personnel to use those systems to provide the data necessary to establish policies to avoid health risks. Mr SIRCHIA (Italy) said that the risk factors in his country were the same as those in other developed countries described in Annex 1 in document ASS/DIV/5. Certain risk factors, such as poor eating habits, were becoming common to both developed and developing countries, where negative effects were already evident. Regarding the role of the State in developing policies to manage risks, he considered education and communication as the most important means of changing habits. Television was not the only medium for transmitting health messages, and greater involvement of schools was vital. Role models had to be changed by effective educational programmes. More resources were needed for communication in order to counteract the commercial investments that advance negative role models. To that end, his Government was collaborating with leading brand names in "causerelated marketing" to raise awareness about healthy lifestyles. The messages should concentrate on unhealthy habits, such as tobacco use, lack of physical exercise and bad driving. In that context, his country would welcome collaboration with other countries to develop strategies for problem solving and communication.

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Dr VONGSACK (Lao People's Democratic Republic) observed that health risks were not limited to disease and infections but also included a large constellation of social, economic, educational and living conditions. A strong, coordinated social, economic, educational and political commitment was required from all sectors of society, with laws to facilitate implementation of risk management. In her country, reproductive health was a major concern. In particular, home deliveries without proper medical assistance had resulted in high rates of infant and maternal morbidity. To face that problem, her country was examining ways to establish homes for pregnant women that were located near health facilities, with staff trained in prenatal care. Also too many pregnancies were unwanted, too early, too late or too frequent. While it faced considerable difficulties her country was committed to improving the health status and living conditions of its population. It would, however, require technical guidance from WHO and financial assistance from international donor agencies to emerge from the vicious circle of poverty, disease and premature death. Dr MUNOZ (Chile) noted that both absolute and relative poverty were major health risks for the population of Chile. Much had been written about inequality as a risk factor per se, which, he considered, should be included in the round table discussions. It was important to link risk factors to the changes that countries had experienced. Successful health reform needed harmonization of the available instruments for education, work in communities and the organization and financing of health systems. Chile had defined its national long-term health objectives and established specific deadlines for reducing risk factors., National prevalence studies had been initiated to monitor individual factors such as high cholesterol and high blood pressure levels. Like many other countries, Chile faced a conflict between the importance of some of its export products, wine in particular, which necessitated keeping its domestic price low, while promulgating alcohol as a health risk. His country also had to deal with the pressures of multinational food-producing companies, including the fast-food industry, which had influence at high levels, and he called for an international effort to monitor those lobbies and the influence they had in shaping the food habits of populations. The Government had formed an intersectoral council of all those responsible for public policies that influenced the control of the most important risks to the health of the population. He reiterated the need for information on uncertain risks and for educating communicators about the probability of disease. Countries should choose those uncertain risks on which cooperative research and information were needed. He would welcome, for instance, a rapid evaluation of the risk of electromagnetic fields, on the basis of the extensive available information, so that communicators could give a balanced view to the general population in relation to more serious risks. It was important to emphasize the efficacy of interventions in other situations, such as the success stories in Europe in dealing with the most risky behaviours, particularly among young people. There was no guarantee that the models would be effective in different cultures, and the actual situation in each country should be assessed. Chile was undertaking health systems reform to improve financing and organization of services through explicit guarantees of the rights of the population, regardless of socioeconomic status, sex and age, to educational interventions, individual health monitoring and therapeutic interventions, among others. They were designed to ensure greater equity in respect of access to knowledge about dealing with individual risks and to the services that provided the necessary education and protection. WHO, like transnational corporations, should promote its services and products with similar media penetration and credibility. Mr COMENDEIRO (Cuba) said that risks to health in Cuba had been considerably alleviated in recent years, thanks to the strategies and programmes carried out by the Ministry of Public Health. Its mother and child intervention programme, which provided systematic care to all women during pregnancy and delivery and included micronutrient supplementation of diets and the promotion of breastfeeding, had considerably reduced the formerly high infant mortality rate in his country, which currently ranked among the countries with the lowest such rates. Cuba had also created an intersectoral commission for health and quality of life, under the chairmanship of a vice-president, which was

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responsible for coordinating and monitoring the programmes of all governmental and nongovernmental organizations involved in the health sector and in reducing health risks. Programmes had been instituted to reduce alcohol and tobacco consumption. His country's extensive primary health care system enabled risks to health to be properly identified and effectively addressed. In cooperation with PAHO, Cuba was conducting a health promotion programme, including the training of community health workers, in which priority was given to communication. An ageing programme designed to cope with the increasing proportion of people over the age of 60 included continuous monitoring of health indicators and education, for instance on the need for exercise. The extensive immunization programme conducted by Cuba against 13 diseases covered the entire population. While his country had established some indicators regarding people infected with HIV, it planned to devote further effort to that complex health issue, and particularly to the prevention of homosexual transmission. Cuba had set up an epidemiological network covering the entire country, which supplied information to guide action in specific areas. As a result of those efforts, communicable diseases had been almost entirely eradicated, and it was expected that a similar picture would emerge for noncommunicable diseases. He emphasized the need to work towards the eradication of poverty, unemployment, illiteracy and inequalities in countries experiencing grave economic difficulties. International assistance should be given to countries whose health pictures were very different from those of others. Professor PAKDEE POTHISIRI (Thailand) welcomed the initiative taken by WHO to discuss the issue of risks to health, which introduced the new concept of dealing more systematically with the burden of diseases, through identification, quantification and characterization of multiple risk factors, followed by cost-effective risk management and adequate risk communication. However, most developing countries were unlikely to be familiar with that approach, particularly regarding the need for a strong epidemiological surveillance system and determination of exposure in order to support risk assessment scientifically. WHO should therefore make increased efforts to support developing countries embarking in that new direction. While he agreed in principle with most of the concepts outlined in the background document (ASS/DIV/5), it appeared to be limited to one dimension- risks to physical health, whereas the WHO definition of health also included mental, spiritual and socioeconomic aspects. WHO should therefore also address the question of why the prevalence of risk factors was so varied among countries at different stages of socioeconomic growth. Thailand had experienced a rapid epidemiological transition from communicable to noncommunicable and lifestyle-related diseases. Its policies to reduce the risks to health were based on several important considerations. First, the social mobilization and empowerment of individuals and communities were crucial tools for increased societal awareness of a healthy lifestyle, physical fitness and mental well-being. No-drink driving was advocated through public media, and adolescents were trained in life skills and safer sex to reduce the risk for HIV infection. Secondly, legislation and law enforcement provided a conducive environment for health. The enactment of bills on tobacco products and a total ban of advertising had served gradually to reduce cigarette consumption. A smoke-free policy had successfully been enforced in all public buildings and transport. Public education and enforcement of the wearing of seat belts and helmets had minimized the severity of traffic injuries. Thirdly, through its effective financing mechanisms, Thailand was among the few countries in the world to have introduced an earmarked tax, of 2% on tobacco and alcohol, which was used to fund health promotion activities through community-based programmes. The policy of the Thai Government to increase the tax on tobacco products not only generated more revenue for the health promotion fund; it also curbed tobacco consumption, especially among adolescents. Fourthly, his country's public health policy, which included health impact assessment, resulted in an environment conducive to a healthy population. Research into exposure to risks and the burden of disease among the poor guided the Government's social and health policy to improve the health status of that group. The central theme of the national health system was that health was both the right and the responsibility of all Thais. The policy of universal coverage included special attention to personal and community-based health promotion and preventive programmes, with the provision of adequate

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funding. His Government would continue to work to improve the health ofthe nation, especially of the poor, through the primary reduction of risk, early detection and screening and social mobilization for health, with adequate funding and cost-effective interventions. Dr CARBONE CAMPOVERDE (Peru) said that he shared the concerns expressed by previous speakers on the double burden of communicable and noncommunicable diseases and that more precise indicators were required to assist in evaluating strategies to alleviate that burden. Certain strategies were vital for the promotion of health. First was the communication of health issues to the general population through the media, which exerted a strong influence on the behavioural patterns on the population at large and particularly on young people. It was therefore essential to establish a strategic alliance with the media, involving them in responsible decision-making about the content of the messages that they transmitted and in campaigns on particular health issues, both in the short- and the long-term, in order to create a health culture. Recent examples of fruitful collaboration with the communications media were the sensitive reporting of the tragic event of 29 December 2001, when 300 people died in a fire sparked by fireworks, and the campaign against dengue fever. The mass media were attracted by rapid successes. Unfortunately, his country had so many health problems that campaigns yielding rapid results could be launched every month, the lessons learned slowly being extended to campaigns for longer-term problems, such as diabetes, hypertension and changes in dietary habits. The second strategy was to concentrate efforts to promote a health culture within the family by encouraging discussions on health topics, so that individuals gained new knowledge which they would pass on to future generations. The concept of intersectoral activity was also of paramount importance in guiding his Government's health strategies, and its five-year development plan had been implemented in close collaboration with other Government sectors. The third strategy was based on a political commitment to give priority to the issues of health, education and nutrition issues in order to improve the health status of future generations. That could only be achieved by a combined effort of all relevant Government ministers and civil society. Mrs PHUMAPHI (Botswana) said that Botswana's health indicators, which had been the envy of many countries in Africa, had significantly regressed during the past 10 years. As a result, the Government was currently restructuring its entire health system and redefining its priorities in order not only to analyse health risks properly, but to manage those risks in an appropriate manner. In her country's experience, the problems of poverty, poor health education and poor resource availability and allocation increased the vulnerability of the population to risk. The risks associated with unhealthy lifestyles, such as high blood pressure and high cholesterol levels that had characterized her country's risks to health 10 years previously, had been outranked by the high priority risks of unsafe sex, alcohol consumption, the use of parallel traditional health systems, unsafe driving practices, tobacco and dagga abuse, unsafe sanitation and hygiene, non-breastfeeding, sexual abuse and violence. The results had been a high prevalence of HIVI AIDS, large numbers of orphans, overburdened health services, child and adult mortality rates that were arguably among the highest in Africa, and increased incidences of mental illness, disability and delinquency among her country's youth. In addition to restructuring its health system and services, Botswana was strengthening its epidemiological services, data capture, statistics, research, monitoring and surveillance systems, as well as its preventive services, with emphasis on public health education, family welfare education, integrated management of childhood illnesses and expanded immunization programmes. Her country was grateful to WHO for its assistance in establishing a programme for the aged, on whom it relied to care for its orphans. In addition, Botswana was establishing a medical school and a nurse aid programme, both of which were structured to meet her country's particular health needs, amending laws to deal with alcohol and tobacco abuse and road traffic and introducing a new law applying to traditional health practitioners. Priority had been given to sanitation, education and health in the national development plan. Relations with the media were being improved to achieve more effective public dissemination of health programmes. There was a new agricultural policy that emphasized food

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and nutrition to ensure a sustainably healthy population, and partnerships were being formed with local communities, such as women's and youth groups. Botswana was fostering its relations and forging new partnerships with nongovernmental organizations, which were critical in promoting reproductive health and safe motherhood, and enhancing its cooperation with United Nations agencies and bilateral partners. She considered it essential in the health sector to plan for the unexpected and the inconceivable. The health community was faced with the threatened use of biological weapons, and was facing the consequences of its lack of preparedness for the HIV IAIDS epidemic. Mr AL-MADFAA (United Arab Emirates) said that the political decision in his country to give high priority to health services and the health of the individual had led to tangible improvements in the health status of the population. The preceding debate had shown the enormous variation in health risks faced by different countries, regions and continents. Health patterns also changed over time, as they had in his country, since the communicable, childhood and perinatal diseases that it had faced some 20 years earlier had been all but conquered through the application of appropriate strategies, such as immunization programmes, with the assistance of the Regional Office for the Eastern Mediterranean and in cooperation with local communities. With societal changes, new, noncommunicable diseases had emerged, however, in his country, mainly cancer, cardiovascular disease, psychological disorders and traffic injuries, which affected the productive groups of society in particular. The concept of health as a shared responsibility, among both the various sectors of Government and individuals through increased awareness of lifestyle risks to health, had resulted in increased cooperation among various groups. He agreed with previous speakers that the time was ripe to focus on prevention rather than treatment. It was essential to continue immunization programmes for all groups, and especially children, to ensure that communicable diseases did not re-emerge, and to identify the main risks to health. Lifestyle was important as it was the source of many diseases, such as sexually transmissible diseases, which burdened health systems. It was also important to enlist the aid of the media and schools to spread awareness of lifestyle-related health issues. The CHAIRMAN, speaking as the delegate of Mexico, said that his Government had divided health risks into those to which the population was exposed passively, for example, environmental pollutants and food, from which the population needed to be protected, and those risks to which it was exposed actively, characterized by patterns of behaviour. Its public policy differed according to the two forms of risk. It had established an independent body to monitor passive exposure to risks. It would be important to review the regulatory role of health ministries in health promotion in developing countries, particularly in the light of growing trade liberalization; the topic should receive detailed consideration within WHO. That regulatory function was reflected in his country in a recent increase in taxes on tobacco. In the field of risk control, Mexico was investing in genetic research, which offered the possibility of establishing genetic predispositions in different populations and of identifying the risks for common diseases, such as diabetes and various cancers, and therefore of achieving more focused, effective health protection and promotion activities. Such research would also resolve the dichotomy between genetic and environmental determinants of disease. Speaking in his capacity as Chairman of the round table, he observed that examination of the risks to health resulted in a better focus on the anticipatory, rather than the purely reactive, role of the public health system. First, all were agreed that the epidemiological picture of the world had become more complex: there was no longer a simple division either between communicable and noncommunicable diseases, as most countries were experiencing both forms, or between the North and the South, since the developing countries experienced similar risks to developed countries. The consequent need for greater international cooperation in the design of comparable indicators and in standardizing the measurement and assessment of risk factors had been emphasized by all participants. They had also stressed the need to promote research not only into former risks but also into new risks, including uncertain risks, such as electromagnetic radiation and the deliberate use of biological,

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chemical and radionuclear toxic agents. Increased international cooperation was needed to establish better health practices. Round-table discussions were an important forum for sharing experiences and promoting best practices, and the Organization could use that means to support the regulatory role of health ministries and to promote best practices in the communication of risks to populations.

The meeting rose at 12:40.

PART Ill REPORTS OF COMMITTEES

The text of resolutions and decisions recommended in committee reports and subsequently adopted without change by the Health Assembly have been replaced by the serial number (in square brackets) under which they appear in document WHASS/2002/REC/1. The verbatim records of plenary meetings at which these reports were approved are reproduced in document WHAS 5/2002/REC/2.

COMMITTEE ON CREDENTIALS First report 1 [A55/42- 14 May 2002]

The Committee on Credentials met on 14 May 2002. Delegates of the following Member States were present: Cyprus, Estonia, Ethiopia, Fiji, Iceland, Panama, Qatar, Thailand, Togo, Turkey, Uruguay. The Committee elected the following officers: Dr F. Gracia (Panama) Dr K. Al-Jaber (Qatar)- Vice-Chairman; Mr I. Einarsson (Iceland)- Rapporteur. Chairman;

The Committee examined the credentials delivered to the Director-General in accordance with Rule 22 of the Rules of Procedure of the World Health Assembly. The credentials of the delegates of the Member States listed at the end of this report were found to be in conformity with the Rules of Procedure as constituting formal credentials; and the Committee therefore proposes that the World Health Assembly should recognize their validity. The Committee examined notifications from the Member States listed below, which, while indicating the names of the delegates concerned, could not be considered as constituting formal credentials in accordance with the provisions of the Rules of Procedure. The Committee therefore recommends to the Health Assembly that the delegates of these Member States be provisionally seated with all rights in the Health Assembly pending the arrival of their formal credentials: Azerbaijan, Djibouti, Ethiopia, Greece, Honduras, Italy, Libyan Arab Jamahiriya, Micronesia (Federated States of), Nicaragua, Portugal, Rwanda, Slovenia, Yugoslavia. States whose credentials it was recommended should be recognized as valid (see fourth paragraph above) Afghanistan; Albania; Algeria; Andorra; Angola; Antigua and Barbuda; Argentina; Armenia; Australia; Austria; Bahamas; Bahrain; Bangladesh; Barbados; Belarus; Belgium; Belize; Benin; Bhutan; Bolivia; Bosnia and Herzegovina; Botswana; Brazil; Brunei Darussalam; Bulgaria; Burkina Faso; Burundi; Cambodia; Cameroon; Canada; Cape Verde; Central African Republic; Chad; Chile; China; Colombia; Comoros; Congo; Cook Islands; Costa Rica; Cote d'Ivoire; Croatia; Cuba; Cyprus; Czech Republic; Democratic People's Republic of Korea; Democratic Republic of the Congo; Denmark; Dominica; Dominican Republic; Ecuador; Egypt; El Salvador; Eritrea; Estonia; Fiji; Finland; France; Gabon, Gambia; Georgia; Germany; Ghana; Grenada; Guatemala; Guinea; Guinea1

Approved by the Health Assembly at its fourth plenary meeting.

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Bissau; Guyana; Haiti; Hungary; Iceland; India; Indonesia; Iran (Islamic Republic of); Iraq; Ireland; Israel; Jamaica; Japan; Jordan; Kazakhstan; Kenya; Kiribati; Kuwait; Lao People's Democratic Republic; Latvia; Lebanon; Lesotho; Liberia; Lithuania; Luxembourg; Madagascar; Malawi; Malaysia; Maldives; Mali; Malta; Marshall Islands; Mauritania; Mauritius; Mexico; Monaco; Mongolia; Morocco; Mozambique; Myanmar; Namibia; Nepal; Netherlands; New Zealand; Niger; Nigeria; Norway; Oman; Pakistan; Palau; Panama; Papua New Guinea; Paraguay; Peru; Philippines; Poland; Qatar; Republic of Korea; Republic of Moldova; Romania; Russian Federation; Saint Kitts and Nevis; Saint Lucia; Saint Vincent and the Grenadines; Samoa; San Marino; Sao Tome and Principe; Saudi Arabia; Senegal; Seychelles; Sierra Leone; Singapore; Slovakia; Solomon Islands; Somalia; South Africa; Spain; Sri Lanka; Sudan; Swaziland; Sweden; Switzerland; Syrian Arab Republic; Tajikistan; Thailand; The former Yugoslav Republic of Macedonia; Togo; Tonga; Trinidad and Tobago; Tunisia; Turkey; Tuvalu; Uganda; Ukraine; United Arab Emirates; United Kingdom of Great Britain and Northern Ireland; United Republic of Tanzania; United States of America; Uruguay; Uzbekistan; Vanuatu; Venezuela; VietNam; Yemen; Zambia; Zimbabwe. Second report1

[A55/46- 16 May 2002]

On 16 May 2002, the Bureau of the Committee on Credentials examined the formal credentials of the delegations of the following Member States, who had been seated provisionally in the World Health Assembly pending the arrival of their formal credentials: Ethiopia, Greece, Honduras, Italy, Libyan Arab Jamahiriya, Portugal, Rwanda, Slovenia, Yugoslavia. These credentials were found to be in conformity with the Rules of Procedure of the World Health Assembly, and the Bureau therefore proposes that the World Health Assembly recognize their validity.

COMMITTEE ON NOMINATIONS First report2

[A55/39- 13 May 2002]

The Committee on Nominations, cons1stmg of delegates of the following Member States: Angola, Canada, Central African Republic, Chile, China, Ecuador, France, Greece, Guatemala, Indonesia, Iran (Islamic Republic of), Jamaica, Kuwait, Lebanon, Malawi, Maldives, Mauritania, Russian Federation, Samoa, Seychelles, Slovakia, United Kingdom of Great Britain and Northern Ireland, Uzbekistan, Zimbabwe; and Dr Hong Sun Huot (Cambodia) (ex officio), met on 13 May 2002. In accordance with Rule 25 of the Rules of Procedure of the World Health Assembly and respecting the practice of regional rotation that the Health Assembly has followed for many years in 1 2

Approved by the Health Assembly at its eighth plenary meeting. Approved by the Health Assembly at its first plenary meeting.

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271

this regard, the Committee decided to propose to the Health Assembly the nomination of Dr J.F. L6pez Beltnin (El Salvador) for the Office of President of the Fifty-fifth World Health Assembly. Second report 1

[A55/40- 13 May 2002]

At its first meeting held on 13 May 2002, the Committee on Nominations decided to propose to the Health Assembly, in accordance with Rule 25 of the Rules of Procedure of the World Health Assembly, the following nominations: Vice-Presidents of the Assembly: Mrs J. Phumaphi (Botswana), Professor V.F. Moskalenko (Ukraine), Mr S.S. Bhandari (Nepal), Mr B.R. Mooa (Kiribati), Dr A.J.M. Suleiman (Oman); Committee A: Committee B: Chairman- Dr J. Kiely (Ireland); Chairman - Professor A.M. Coli Seck (Senegal).

Concerning the members of the General Committee to be elected under Rule 31 of the Rules of Procedure of the World Health Assembly, the Committee decided to nominate the delegates of the following 17 countries: Barbados, China, Cote d'lvoire, Cuba, Democratic People's Republic of Korea, France, Japan, Mexico, Morocco, Russian Federation, Rwanda, Sao Tome and Principe, Sierra Leone, Spain, United Arab Emirates, United Kingdom of Great Britain and Northern Ireland, and United States of America. Third report2

[A55/41- 13 May 2002]

At its first meeting held on 13 May 2002, the Committee on Nominations decided to propose to each of the main Committees, in accordance with Rule 25 of the Rules of Procedure of the World Health Assembly, the following nominations for the Offices of Vice-Chairmen and Rapporteur: Committee A: Vice-Chairmen: Ms D. Costa Coitinho (Brazil) and Dr S.P. Agarwal (India); Rapporteur: Dr A. Msa Mliva (Comoros); Committee B: Vice-Chairmen: Mr H. M'barek (Tunisia) and Professor Pham Manh Hung (VietNam); Rapporteur: Dr S. Soeparan (Indonesia).

Approved by the Health Assembly at its first plenary meeting. See summary records of the first meetings of Committees A and B (pp. 15 and 137, respectively).

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GENERAL COMMITTEE Report1 [A55/44- 16 May 2002]

Election of Members entitled to designate a person to serve on the Executive Board At its meeting on 15 May 2002, the General Committee, in accordance with Rule 102 of the Rules of Procedure of the World Health Assembly, drew up the following list of 10 Members, in the English alphabetical order, to be transmitted to the Health Assembly for the purpose of the election of 10 Members to be entitled to designate a person to serve on the Executive Board: China, Gabon, Gambia, Ghana, Guinea, Kuwait, Maldives, Russian Federation, Spain, United States of America. In the General Committee's opinion these 10 Members would provide, if elected, a balanced distribution on the Board as a whole.

COMMITTEE A First report2 [A55/47- 16 May 2002]

On the proposal of the Committee on Nominations/ Ms D. Costa Coitinho (Brazil) and Dr S.P. Agarwal (India) were elected Vice-Chairmen, and Dr A. Msa Mliva (Comoros), Rapporteur. Committee A held its first five meetings on 14, 15 and 16 May 2002 under the chairmanship of Dr J. Kiely (Ireland), Ms D. Costa Coitinho (Brazil) and Dr S.P. Agarwal (India). It was decided to recommend to the Fifty-fifth World Health Assembly the adoption of the resolution, entitled "Mental health: responding to the call for action" relating to the following agenda item: 13. Technical and health matters 13.13 Mental health: responding to the call for change [WHA55.10].

1 2

See document WHA55/2002/REC/2, verbatim record of the eighth plenary meeting, section 3. Approved by the Health Assembly at its ninth plenary meeting. See the third report of the Committee on Nominations, above.

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273

Second report1

[A55/49- 17 May 2002]

Committee A held its sixth and seventh meetings on 17 May under the chairmanship of Dr J. Kiely (Ireland). During the sixth meeting Dr S.P. Agarwal (India) later took the chair ad interim. It was decided to recommend to the Fifty-fifth World Health Assembly the adoption of the resolutions relating to the following agenda items:

13.

Technical and health matters 13.3 World Summit on Sustainable Development Health and sustainable development [WHA55.11] 13.5 HIV/AIDS Contribution of WHO to the follow-up of the United Nations General Assembly special session on HIV/AIDS [WHA55.12] 13.2 WHO's contribution to achievement of the development goals of the United Nations Millennium Declaration -Protection of medical missions during armed conflict [WHA55.13] 13.8 WHO medicines strategy Ensuring accessibility of essential medicines [WHA55.14] 13.16 Smallpox eradication: destruction of Variola virus stocks [WHA5 5.15] 13.15 Natural and accidental release of biological, chemical or radionuclear agents affecting health or their deliberate use to cause harm Global public health response to natural occurrence, accidental release or deliberate use of biological and chemical agents or radionuclear material that affect health [WHA5 5.16] Third report 1

[A55/52- 18 May 2002]

Committee A held its eighth meeting on 18 May under the chairmanship of Dr J. Kiely (Ireland). It was decided to recommend to the Fifty-fifth World Health Assembly the adoption of three resolutions relating to the following agenda items:

13.

Technical and health matters 13.9 Quality of care: patient safety [WHA5 5.18] 13.14 Dengue prevention and control Dengue fever and dengue haemorrhagic fever prevention and control [WHA55.17] 13.2 WHO's contribution to achievement of the development goals of the United Nations Millennium Declaration [WHA55.19]

Approved by the Health Assembly at its ninth plenary meeting.

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COMMITTEEB First report 1

[A55/43- 16 May 2002]

On the proposal of the Committee on Nominations/ Mr H. M'barek (Tunisia) and Professor Pham Manh Hung (VietNam) were elected Vice-Chairmen, and Dr S. Soeparan (Indonesia), Rapporteur. Committee B held its first meeting on 15 May under the chairmanship of Professor A. Coli Seck (Senegal). It was decided to recommend to the Fifty-fifth World Health Assembly the adoption of the resolution relating to the following agenda item:

18.

Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine [WHA55.2]. Second report3

[A55/45- 17 May 2002]

Committee B held its second and third meetings on 16 May under the chairmanship of Professor A.M. Coli Seck (Senegal). It was decided to recommend to the Fifty-fifth World Health Assembly the adoption of one decision and seven resolutions relating to the following agenda items: 15. Financial matters 15.1 Financial report on the accounts of WHO for 2000-2001, report of the External Auditor, and comments thereon made on behalf of the Executive Board; report of the Internal Auditor [WHA55.3] 15.2 Status of collection of assessed contributions, including Members in arrears in the payment of their contributions to an extent that would justify invoking Article 7 of the Constitution Members in arrears to an extent which would justify invoking Article 7 of the Constitution [WHA55.4] Arrears in payment of contributions: Azerbaijan [WHA55.5] Arrears in payment of contributions: the Dominican Republic [WHA55.6] 15.3 Miscellaneous income [WHA55.7] 15.4 Revolving and other long-term funds Real Estate Fund [WHA55.8] Revolving Sales Fund [WHA55.9]

Approved by the Health Assembly at its eighth plenary meeting. See third report of the Committee on Nominations above. Approved by the Health Assembly at its eighth plenary meeting.

2 3

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15 .6 Assessments for 2003 Scale of assessments 2004-2005 [WHA55(9)] Third report 1

[ASS/48- 18 May 2002]

Committee B held its fourth meeting on 17 May under the chairmanship of Professor A.M. Coli Seck (Senegal). It was decided to recommend to the Fifty-fifth World Health Assembly the adoption of one decision and three resolutions relating to the following agenda items:

16.

17.

Staffing matters 16.2 Amendments to the Staff Regulations and Staff Rules Salaries of staff in ungraded posts and of the Director-General [WHAS 5.20] Amendments to the Staff Regulations [WHA55.21] 16.3 Appointment of representatives to the WHO Staff Pension Committee [WHA55(10)] Review of working methods of the Executive Board Reimbursement of travel expenses for members of the Executive Board [WHA55.22] Fourth report2

(ASS/50- 18 May 2002]

Committee B held its fifth meeting on 17 May under the chairmanship of Professor Pham Manh Hung (VietNam) and later Professor A.M. Coli Seck (Senegal). It was decided to recommend to the Fifty-fifth World Health Assembly the adoption of the resolution relating to the following agenda item:

13.

Technical and health matters 13 .11 Diet, physical activity and health [WHAS 5.23]. Fifth report 1

(ASS/51 -18 May 2002]

Committee B held its sixth meeting on 18 May under the chairmanship of Professor A.M. Coli Seck (Senegal). 1 2

Approved by the Health Assembly at its ninth plenary meeting. Approved by the Health Assembly at its ninth plenary meeting.

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It was decided to recommend to the Fifty-fifth World Health Assembly the adoption of two resolutions relating to the following agenda items: 16.1 Human resources: annual report The need for increased representation of developing countries in the Secretariat and in Expert Advisory Panels and Committees [WHA55.24] 13.10 Infant and young child nutrition [WHA55.25].

Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Governing Bodies documents

Date d'adoption 31 décembre 2002

Source Organisation mondiale de la santé