(Sgd) Or A. Kone-Diabi
EB 10 1/1998/REC/2
WORLD HEALTH ORGANIZATION
EXECUTIVE BOARD 101 ST SESSION GENEVA, 19-27 JANUARY 1998
SUMMARY RECORDS
GENEVA 1998
EB 101 I 1998/REC/2
WORLD HEALTH ORGANIZATION
EXECUTIVE BOARD 101 ST SESSION GENEVA, 19-27 JANUARY 1998
SUMMARY RECORDS
GENEVA 1998
ABBREVIATIONS
Abbreviations used in WHO documentation include the following: ACC ACHR AGFUND
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ASEAN CIDA CIOMS
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DANIDA ECA ECE ECLAC ESCAP
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ESCWA FAO
FINNIDA IAEA IARC ICAO IFAD ILO IMO ITU
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Administrative Committee on Coordination Advisory Committee on Health Research Arab GulfProgramme for United Nations Development Organizations Association of South-East Asian Nations Canadian International Development Agency Council for International Organizations of Medical Sciences Danish International Development Agency Economic Commission for Africa Economic Commission for Europe Economic Commission for Latin America and the Caribbean Economic and Social Commission for Asia and the Pacific Economic and Social Commission for Western Asia Food and Agriculture Organization of the United Nations Finnish International Development Agency International Atomic Energy Agency International Agency for Research on Cancer International Civil Aviation Organization International Fund for Agricultural Development International Labour Organization (Office) International Maritime Organization International Telecommunication Union
NORAD OAU OECD PAHO SAREC
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SIDA UNAIDS UNCTAD UNDCP UNDP UNEP UNESCO
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UNFPA UNHCR
UNICEF UNIDO UNRWA
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UNSCEAR
USAID WFP WIPO WMO WTO
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Norwegian Agency for International Development Organization of African Unity Organisation for Economic Co-operation and Development Pan American Health Organization Swedish Agency for Research Cooperation with Developing Countries Swedish International Development Authority United Nations Joint Programme on HIV/AIDS United Nations Conference on Trade and Development United Nations International Drug Control Programme United Nations Development Programme United Nations Environment Programme United Nations Educational, Scientific and Cultural Organization United Nations Population Fund Office of the United Nations High Commissioner for Refugees United Nations Children's Fund United Nations Industrial Development Organization United Nations Relief and Works Agency for Palestine Refugees in the Near East United Nations Scientific Committee on the Effects of Atomic Radiation United States Agency for International Development World Food Programme World Intellectual Property Organization World Meteorological Organization World Trade Organization
The designations employed and the presentation of the material in this volume do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation "country or area" appears in the headings of tables, it covers countries, territories, cities or areas.
- ii-
PREFACE
The JOist session of the Executive Board was held at WHO headquarters, Geneva, from 19 to 27 January 1998. The proceedings are published in two volumes. The present volume contains the summary records ofthe Board's discussions, list of participants and officers elected, and details regarding membership of committees and working groups. The resolutions and decisions and relevant annexes are published in document EBIOI/1998/REC/1.
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CONTENTS
Page Preface Agenda ............................................................................ Ill
x1 xv
List of documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . List of members and other participants ................................................... . Committees and working groups ........................................................
15
SUMMARY RECORDS
First meeting 1. 2. 3. 4. 5. 6. Opening of the session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Adoption ofthe agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Programme ofwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Statement by the Director-General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Regional matters: reports by the Regional Directors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reports of advisory bodies and related issues International Agency for Research on Cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 19 19 20 23 31
Second meeting 1.
2. 3. 4.
Regional matters: reports by the Regional Directors (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . Reports of advisory bodies and related issues (continued) International Agency for Research on Cancer (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . Reports of the Programme Development Committee and the Administration, Budget and Finance Committee of the Executive Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHO reform Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34 37 38
39
Third meeting Director-General Nomination for the post . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
46
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Page Fourth meeting
1. 2.
Director-General (continued) Nomination for the post (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHO reform (continued) Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group (continued) . . . . . . . . . . . . . . . . . . . . . . . . . .
47
47
Fifth meeting
WHO reform (continued) Review of the Constitution and regional arrangements ofthe World Health Organization: report of the Executive Board special group (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . Sixth meeting
58
WHO reform (continued) Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . WHO country offices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Seventh meeting I.
68 73
2.
WHO reform (continued) Programme budget evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Health-for-all policy for the twenty-first century . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
79 81
Eighth meeting I.
2.
3.
Health-for-all policy for the twenty-first century (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 WHO reform (continued) Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . 93 Implementation of resolutions and decisions (reports by the Director-General) . . . . . . . . . . . . . . . 97 Task force on health in development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Section I. WHO collaborating centres . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Section 11. Section Ill. Improving technical cooperation among developing countries . . . . . . . . . . . I 0 I Section IV. Prevention ofviolence ........................................... lOI Section V. Health systems development ...................................... 101
Ninth meeting I.
Implementation of resolutions and decisions (reports by the Director-General) (continued) Section IV. Prevention of violence (continued) ................................. 105 Section VI. Fellowships programme and policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111 Section VII. Revised drug strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Tenth meeting
1.
Implementation of resolutions and decisions (reports by the Director-General) (continued) Section VIII. Cross-border advertising, promotion and sale of medical products using the Internet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1I8 Section IX. Ethical, scientific and social implications of cloning in human health . . . . . . 121
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Page Section X. Section XI. Health promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Infant and young child nutrition ................................... 127
Eleventh meeting I. Implementation of resolutions and decisions (reports by the Director-General) (continued) Section XI. Infant and young child nutrition (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . Section XII. Tuberculosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section XIII. Global elimination of blinding trachoma ............................ Disease prevention and control Control oftropical diseases Chagas disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Leprosy ............................................................ Lymphatic filariasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Revision oflntemational Health Regulations: progress report ....................... Reports of advisory bodies and related issues (continued) Report on the thirty-fifth session of the global Advisory Committee on Health Research (ACHR) ................................................................ Report on meetings of expert committees and study groups (including report on appointments to expert advisory panels and committees) .......................... WHO Expert Committee on Biological Standardization: Forty-sixth report ....... Programming for adolescent health: Report of a WHO/UNFPA/UNICEF Study Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHO Expert Committee on Leprosy: Seventh report ........................ Food safety issues associated with products from aquaculture: Joint WHO/NACAF (Network of Aquaculture Centres in Asia and the Pacific) Study Group .......................................................
131 133 136
2.
136 137 138 138
3.
140 143 144 144 145
145
Twelfth meeting I. WHO reform (continued) WHO country offices (continued) .............................................. Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . Health-for-all policy for the twenty-first century (continued) ............................. Implementation of resolutions and decisions (reports by the Director-General) (continued) Section IV. Prevention of violence (continued) ................................. Section X. Health promotion (continued) ..................................... Disease prevention and control (continued) Emerging and other communicable diseases: antimicrobial resistance ................. Noncommunicable disease prevention and control .................................
147 149 156 157 159 161 163
2. 3.
4.
Thirteenth meeting Director-General (continued) Nomination for the post (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Fourteenth meeting Director-General (continued) Nomination for the post (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168
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Page Fifteenth meeting Director-General (continued) Nomination for the post (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Draft contract (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169 Sixteenth meeting 1. Awards Dr A. T. Shousha Foundation Prize (report of the Dr A. T. Shousha Foundation Committee) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Jacques Parisot Foundation Fellowship (report of the Jacques Parisot Foundation Committee) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Sasakawa Health Prize (report of the Sasakawa Health Prize Committee) . . . . . . . . . . . . . . United Arab Emirates Health Foundation Prize (report of the United Arab Emirates Health Foundation Committee) .............................................. Disease prevention and control (continued) Noncommunicable disease prevention and control (continued) ....................... Collaboration within the United Nations system and with other intergovernmental organizations General matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHOIUNICEF/UNFPA Coordinating Committee on Health . . . . . . . . . . . . . . . . . . . . . . . . Environmental matters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . International Decade ofthe World's Indigenous People ............................ Reports of the Joint Inspection Unit ............................................ Matters related to the programme budget Efficiency plan for the financial period 1998-1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Programme budgeting and priority-setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Financial matters Status of collection of assessed contributions, including Members in arrears to an extent which would justify invoking Article 7 of the Constitution ................. Casual income . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Follow-up to the report of the External Auditor ................................... Amendments to the Financial Regulations and Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Real Estate Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Personnel matters Statement by the representative of the WHO staff associations on matters concerning personnel policy and conditions of service . . . . . . . . . . . . . . . . . . . . . . . . . . . . Employment and participation of women in the work of WHO . . . . . . . . . . . . . . . . . . . . . . . Report of the International Civil Service Commission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Confirmation of amendments to the Staff Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reports of the Programme Development Committee and the Administration, Budget and Finance Committee of the Executive Board (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Collaboration with nongovernmental organizations Applications of nongovernmental organizations for admission into official relations with WHO Review of nongovernmental organizations in official relations with WHO Review of overall policy on collaboration with nongovernmental organizations . . . . . . . . . Method of work of the Health Assembly ............................................. Health-for-all policy for the twenty-first century (continued) .............................
172 172 172 172 174
2. 3.
175 176 177 177 178
4.
178 181
5.
6. 7.
183 186 186 186 187
188 188 189 189 190
8. 9.
10. 11.
190 192 193
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Page 12. Implementation of resolutions and decisions (reports by the Director-General) (continued) Section IV. Prevention of violence (continued) ................................. Section VII. Revised drug strategy (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Section IX. Ethical, scientific and social implications of cloning in human health (continued) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Disease prevention and control (resumed) Emerging and other communicable diseases: antimicrobial resistance (continued) . . . . . . . Provisional agenda for and duration of the Fifty-first World Health Assembly ................ Date and place of the 102nd session of the Executive Board .............................. Closure of the session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
194 195 197 199 200 201 201
13. 14. 15. 16.
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AGENDA 1
Item No.
I. 2. 3. 4. 5.
Opening of the session Adoption of the agenda Statement by the Director-General Regional matters: reports by the Regional Directors Director-General 5.1 5.2 Nomination for the post Draft contract
6.
Reports of the Programme Development Committee and the Administration, Budget and Finance Committee of the Executive Board WHO reform 7 .I 7.2 7.3 WHO country offices2 Programme budget evaluation Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group
7.
8. 9.
Health-for-all policy for the twenty-first century3 Implementation of resolutions and decisions (reports by the Director-General) - Task force on health in development (resolution WHA50.23) - WHO collaborating centres (resolution WHA50.2) - Improving technical cooperation among developing countries (resolutions WHA43.9 and WHA50.27)
1 2
As adopted by the Board at its first meeting (19 January 1998). See summary record of the first meeting of the Executive Board at its lOOth session (document EB100/1997/REC/1, See summary record of the third meeting ofthe Executive Board at its 100th session (document EBI00/1997/REC/1,
p. 38). 3
p. 59).
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EXECUTIVE BOARD, 101st SESSION
- Prevention of violence (resolution WHA50.19) - Health systems development (resolutions WHA50.27 and EB 1OO.R1) - Fellowships programme and policy (resolution EB87.R23 and document EB99/1997/REC/2, p. 166) - Revised drug strategy (resolution WHA49 .14) - Cross-border advertising, promotion and sale of medical products through the Internet (resolution WHA50.4) - Ethical, scientific and social implications of cloning in human health (resolution WHA50.37) - Health promotion (resolution WHA42.44) - Infant and young child nutrition (resolutions WHA33.32 and EB97.R13) - Tuberculosis (resolution WHA46.36) - Global elimination of blinding trachoma (resolution WHA45.10) I 0. Disease prevention and control I 0.1 Control of tropical diseases - Chagas disease 1 - Leprosy 10.2 Revision of the International Health Regulations: progress report I 0.3 Emerging and other communicable diseases: antimicrobial resistance 10.4 Noncommunicable disease prevention and control 11. Reports of advisory bodies and related issues 11.1 Report on the thirty-fifth session of the global Advisory Committee on Health Research (ACHR) 11.2 Report on meetings of expert committees and study groups (including report on appointments to expert advisory panels and committees) 12. Collaboration within the United Nations system and with other intergovernmental organizations 12.1 General matters 12.2 WHO/UNICEF/UNFPA Coordinating Committee on Health
1 See summary record of the fourteenth meeting ofthe Executive Board at its ninety-ninth session (document EB99/1997/REC/2, p. 173).
- xii-
AGENDA
- UNICEF/WHO Joint Committee on Health Policy: report on thirty-first session - Progress report on establishment of Coordinating Committee on Health (resolution EB l OO.R2) 12.3 Environmental matters - Strategy on sanitation for high-risk communities - Climate change and human health - WHO participation in the "interagency climate agenda" 12.4 International Decade of the World's Indigenous People 12.5 Reports of the Joint Inspection Unit 13. Matters related to the programme budget 13 .I Efficiency plan for the financial period 1998-1999 13.2 Programme budgeting and priority-setting 13.3 [deleted] 14. Financial matters 14.1 Status of collection of assessed contributions, including Members in arrears to an extent which would justify invoking Article 7 ofthe Constitution 14.2 Casual income 14.3 [deleted] 14.4 Follow-up to the report of the External Auditor 14.5 Amendments to the Financial Regulations and Rules 15. 16. Real Estate Fund Personnel matters 16.1 Statement by the representative of the WHO staff associations on matters concerning personnel policy and conditions of service 16.2 Employment and participation of women in the work of WHO 16.3 Report of the International Civil Service Commission 16.4 Confirmation of amendments to the Staff Rules 17. Collaboration with nongovernmental organizations 17 .I Applications of nongovernmental organizations for admission into official relations with WHO
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EXECUTIVE BOARD, 101st SESSION
17.2 Review of nongovemmental organizations in official relations with WHO 17.3 Review of overall policy on collaboration with nongovemmental organizations 18. Awards 18.1 Dr A.T. Shousha Foundation Prize (report of the Dr A.T. Shousha Foundation Committee) 18.2 Jacques Parisot Foundation Fellowship (report of the Jacques Parisot Foundation Committee) 18.3 Sasakawa Health Prize (report of the Sasakawa Health Prize Committee) 18.4 United Arab Emirates Health Foundation Prize (report of the United Arab Emirates Health Foundation Committee) 19. 20. 21 . 22. Method of work of the Health Assembly Provisional agenda for and duration of the Fifty-first World Health Assembly Date and place of the I 02nd session of the Executive Board Closure of the session
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LIST OF DOCUMENTS
Executive Board documents1 EBIOI/I Rev.l EBIOI/2 EBIOI/3 Agenda2 Regional matters: reports by the Regional Directors Programme Development Committee of the Executive Board. Report of the fourth meeting Administration, Budget and Finance Committee of the Executive Board. Report on the eighth meeting WHO reform. WHO country offices. Report by the Director-General
EBIOl/4
EBIOl/5 and Corrs I and 23 EBIOI/64 EB I OI/7 and Corr.1 s
Programme budget evaluation. Report by the Director-General Review of the Constitution and regional arrangements of the World Health Organization. Report of the special group Health for All in the 2I st Century (Draft) Health-for-all policy for the twenty-first century Implementation of resolutions and decisions. Report by the Director-General Implementation of resolutions and decisions. Report by the Director-General
EBIOI/8 EBIOl/9 EBIOIIIO and Corr.l EBIOI/10 Add. I and Corr.l EB101/10 Add.2 EBI01/1I
Implementation of resolutions and decisions. Report by the Director-General Disease prevention and control. Control of tropical diseases: Chagas disease and leprosy. Report by the Director-General Revision of the International Health Regulations: progress report. Report by the Director-General
EBI01/I2
1
Issued in Arabic, Chinese, English, French, Russian and Spanish. See page xi. See document EBlOI/1998/REC/1, Annex I. See document EBIOJ/1998/REC/1, Annex 2. See document EBIOI/1998/REC/1, Annex 3. -XV-
2 3 4
5
EXECUTIVE BOARD, 101st SESSION
EB101/13
Emerging and other communicable diseases: antimicrobial resistance. Report by the Director-General Noncommunicable disease prevention and control. Report by the Director-General Report on the thirty-fifth session of the global Advisory Committee on Health Research (ACHR). Report by the Director-General Report on meetings of expert committees and study groups. Report by the DirectorGeneral Report on appointments to expert advisory panels and committees. Report by the Director-General Collaboration within the United Nations system and with other intergovernmental organizations. General matters. Report by the Director-General WHOIUNICEF/UNFPA Coordinating Committee on Health Environmental matters. Strategy on sanitation for high-risk communities. Report by the Director-General Environmental matters. Climate change and human health -WHO participation in the interagency climate agenda. Report by the Director-General Collaboration within the United Nations system and with other intergovernmental organizations. International Decade of the World's Indigenous People. Report by the Director-General Collaboration within the United Nations system and with other intergovernmental organizations. Reports of the Joint Inspection Unit. Report by the Director-General Matters related to the programme budget. Efficiency plan for the financial period 1998-1999. Report by the Director-General Programme budgeting and priority-setting. Analytical framework for setting WHO priorities. Report by the Director-General Status of collection of assessed contributions. Report by the Director-General Members in arrears in the payment of their contributions to an extent which would justify invoking Article 7 of the Constitution: Status as at I January 1998. Report by the Director-General Report on casual income Follow-up to the report of the External Auditor. Report by the Director-General
EB101/14 1 EB101/15 and Add.1
EB101116
EB101/16 Add.1
EB101117
EBlOl/18 EBIOI/19
EBIOI/20 and Corr.l
EB101/21
EB101122
EB101/23
EBIOI/24 2
EBIOl/25 EBIOl/26
EBIOl/27 EBIOl/28
1 2
See document EBIOl/1998/REC/1, Annex 4. See document EBIOl/1998/REC/1, Annex 5.
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LIST OF DOCUMENTS
EBlOI/29 EBlOI/30
Real Estate Fund. Report by the Director-General Personnel matters. Employment and participation of women in the work of WHO. Report by the Director-General Personnel matters: report of the International Civil Service Commission. Report by the Director-General Collaboration with nongovernmental organizations. Committee on Nongovernmental Organizations Report of the Standing
EBlOl/3 I
EBIOI/32
EBIOI/33
Collaboration with nongovemmental organizations. Review of overall policy on collaboration with nongovemmental organizations. Rt;port by the Director-General Method of work, of the Health Assembly. Report by the Director-General Provisional agenda for and duration of the Fifty-first World Health Assembly Amendments to Financial Regulations and Rules. Report by the Director-General Confirmation of amendments to the Staff Rules. Report by the Director-General Director-General. Draft Contract Report by the Director of the International Agency for Research on Cancer (IARC)
EBIOI/34 EBIOI/35 EBIOI/36 1 EBl 01/37 2 EB I OI/38 EBlOl/39
Information documents 3 EB 101/INF;DOC./1 EBI 0 I /.INF .DOC./2 and Corr.I EB I 0 I /INF .DOC./3 Preliminary daily timetable for the Fifty-first World Health Assembly Implementation of resolutions and decisions. Fellowships programme and policy
Implementation of resolutions and decisions. implications of cloning in human health
Ethical, scientific and social
EB I OI/INF.DOC./4 EBIOI/INF.DOC./5 EB I 0 1/INF.DOC./6 EB 10 1/INF .DOC./7
Implementation of resolutions and decisions. Infant and young child nutrition Statement by the representative of the WHO staff associations Implementation of resolutions and decisions. Prevention of violence Disease prevention and control. Control of tropical diseases. Elimination of lymphatic filariasis
1
See document EB101/1998/REC/1, Annex 6. See document EB101/1998/REC/1, Annex 7. Issued in Arabic, Chinese, English, French, Russian and Spanish.
2 3
- xvii-
EXECUTIVE BOARD, 101st SESSION
EB 101 /INF .DOC./8
Regional matters. Report on the situation in the WHO Regional Office for Africa, Brazzaville Health-for-all policy for the twenty-first century: "health telematics" Implementation of resolutions and decisions. Health systems development
EB 101 /INF .DOC./9 EB 10 1/INF .DOC./1 0
- xviii-
LIST OF MEMBERS AND OTHER PARTICIPANTS '
MEMBERS, ALTERNATES AND ADVISERS
Designated by Professeur A. ABERKANE, Conseiller special du Ministre de la Sante et de la Population, Chef du Service de Reanimation, Centre hospitalier universitaire de Constantine, Constantine (Chairman) Alternates M. M.-S. DEMBRI, Ambassadeur, Representant permanent, Geneve M. M. MESSAOUI, Ministre Conseiller, Mission permanente, Geneve Dr F. R. AL-MOUSAWI, Minister of Health, Manama Alternates Dr S. A. KHALFAN, Director of Public Heaith, Manama Mr I. I. AKBA PJ, Chief, international Health Relations, Ministry of Heaith, Manama Mr R. A. DHAIF, Director, Office of the Minister of Health, Manama Dr A. ALVIK, Director-General ofHealth, Norwegian Board ofHealth, Oslo Alternates Mr B. SKOGMO, Ambassador, Permanent Representative, Geneva Mr M. WETLAND, Ambassador, Ministry of Foreign Affairs, Oslo Ms H. C. SUNDREHAGEN, Director-General, Ministry of Health and Social Affairs, Oslo Mr J. G. STORE, Director-General, Office of the Prime Minister, Oslo Dr 0. T. CHRISTIANSEN, Counsellor, Permanent Mission, Geneva Dr P. WIUM, Adviser, Norwegian Board of Health, Oslo Advisers Mr K. LANGELAND, Head of Division, Ministry of Foreign Affairs, Oslo Mr V. C. RONNEBERG, Deputy Director-General, Ministry of Foreign Affairs, Oslo Dr N. BLEWETT, Australian High Commissioner, London Alternates Mr J. CAMPBELL, Ambassador, Permanent Representative, Geneva Professor J. WHITWORTH, Chief Medical Officer, Department of Health and Family Services, Canberra Ms S. INGRAM, Assistant Secretary, Industry Development and International Branch, Department of Health and Family Services, Canberra Mr A. ROBERTSON, Executive Officer, Department of Foreign Affairs and Trade, Canberra Advisers Mr C. LANGMAN, Counsellor, Permanent Mission, Geneva Algeria
Bahrain
Norway
Australia
- 1-
2
EXECUTIVE BOARD, 101st SESSION
Designated by Mr R. MOORE, Director, United Nations and International Program Section, AUSAID, Canberra Mr A. MACDONALD, Counsellor (Development Assistance), Permanent Mission, Geneva Mr E. VAN DER W AL, First Secretary, Permanent Mission, Geneva Ms A. KERN, Consultant to the Department of Health, and Family Services, Permanent Mission, Geneva Dr K. CALMAN, Chief Medical Officer, Department of Health, London Alternates Mr R. L YNE, Ambassador, Permanent Representative, Geneva Mr R. A. KINGHAM, International Branch, Department of Health, London Dr J. METTERS, Deputy Chief Medical Officer, Department of Health, London Advisers Mr J. RAMSDEN, DtpUt"j Pe~3nent Representative, Geneva Mr G. WARRliNGTON, First Secretary, Peiill:!~ent Mission, Geneva Dr W. THORNE,:Senior Medical Officer, Internationai Bi·~r:ch; 'Dc;;partment ofHealth, 'London Mrs A. MASLIN, Nursing Officer, lnternationaifBranch,.Department of Heatth, London Dr D. NABARRO, Health and Population Division, Department .for International Development, London Mrs M. MCCOWAN, Health.and Population Division, Department for International Development, London Ms H. FRARY, Third Secretary, Permanent Mission, Geneva Mr M. PROCTOR, Attache, Permanent Mission, Geneva Dr P. DOSSOU-TOGBE, Directeur adjoint de cabinet, Ministere de la Sante, de la Protection sociale et de la Condition feminine, Cotonou Dr G. M. VAN ETTEN, Head, International Affairs Division, Ministry of Health, Welfare and Sport, Rijswijk (Rapporteur) Alternates Mr P. P. VAN WULFFTEN PALTHE, Minister Plenipotentiary, Permanent Mission, Geneva Mr A. F. VAN DONGEN, Head of the United Nations Department, Ministry of Foreign Affairs, The Hague Ms M. A. C. M. MIDDELHOFF, Senior Adviser, International Affairs Division, Ministry of Health, Welfare and Sport, Rijswijk Mr J. W ASLANDER, First Secretary, Permanent Mission, Geneva Mr J.-P. G. MOUT, Senior Policy Adviser, Ministry of Foreign Affairs, The Hague Dr E. M.-R. FERDINAND, Chief Medical Officer, Ministry of Health and the Environment, Bridgetown Alternates Ms B. A. MILLER, Deputy Prime Minister and, Minister of Foreign Affairs, Bridgetown Ms E. THOMPSON, Minister of Health and the Environment, Bridgetown United Kingdom of Great Britain and Northern Ireland
Ben in
Netherlands
Barbados
MEMBERS AND OTHER PARTICIPANTS
3
Designated by Mr B. GODDARD, Permanent Secretary for Health, Ministry of Health and the Environment, Bridgetown Mr M. I. KING, Ambassador, Permanent Representative, Geneva Advisers Mr B. TAITT, Member of Parliament, Bridgetown Mr P. LAURIE, Permanent Secretary, Ministry of Foreign Affairs, Bridgetown Mr P. SIMMONS, High Commissioner of Barbados to the United Kingdom, London Miss S. PHILLIPS, First Secretary, Permanent Mission, Geneva Miss S. RUDDER, Foreign Service Officer, Ministry of Foreign Affairs, Bridgetown Dr M. FIKRI, Assistant Under-Secretary, Preventive Medicine Affairs, Ministry of Health, Abu Dhabi (Vice-Chairman) Alternates Mr N. S. ALBOODI, Ambassador, Permanent Representative, Geneva Mr A. ALSHAMSI, Counsellor, Permanent Mission, Geneva Dr A. HEMBE, Directrice nationale de la Sante publique, Ministere de la Sante, Luanda Alternate M. M. de AZEVEDO CONSTANTINO, Deuxieme Secretaire, Mission permanente, Geneve Mr J. HURLEY, Secretary, Public Service Management and Development, Department of Finance, Dublin Alternates Mrs A. ANDERSON, Ambassador, Permanent Representative, Geneva Dr J. KIELY, Chief Medical Officer, Department of Health, Dublin Mr J. CREGAN, Principal Officer, Department of Health, Dublin Mrs M. A YL WARD, Assistant Principal, Department of Health, Dublin Advisers Mr N. A. BURGESS, First Secretary, Permanent Mission, Geneva Ms S. KELLY, Assistant Principal, Department of Health, Dublin Mr S. MCCORMACK, Higher Executive Officer, Department of Health, Dublin Mr P. DRURY, Attache, Permanent Mission, Geneva Ms C. KINSELLA, Permanent Mission, Geneva M. A. JUNEAU, Sous-Ministre adjoint, Direction generale des Politiques et de la Consultation, Sante Canada, Ottawa Alternates Mr M. MO HER, Ambassador, Permanent Representative, Geneva Mr E. AISTON, Director General, International Affairs Directorate, Health Canada, Ottawa Or J. LARIVIERE, Senior Medical Advisor, International Affairs Directorate, Health Canada, Ottawa Ms J. PERLIN, Counsellor, Permanent Mission, Geneva Advisers Mr A. MCALISTER, Minister and Deputy Permanent Representative, Permanent Mission, Geneva United Arab Emirates
Angola
Ireland
Canada
4
EXECUTIVE BOARD, 101st SESSION
Designated by Ms A. LAMARRE, United Nations Division, Department of Foreign Affairs and International Trade, Ottawa Or J. M. KARIBURYO, Ministre de la Sante publique, Bujumbura Or C. KOMODIKIS, Chief Health Officer, Ministry of Health, Nicosia (alternate to Mr C. Solomis) Alternates Mr P. EFTYCHIOU, Ambassador, Permanent Representative, Geneva Mrs I. ATTESLI, Chief Administrative Officer, Ministry of Health, Nicosia Mr P. KESTORAS, Deputy Permanent Representative, Geneva Professor J. LEOWSKI, Director, School of Public Health and Social Medicine, Medical Centre for Postgraduate Education, Warsaw Alternates Mr K. JAKUBOWSKI, Ambassador, Permanent Representative, Geneva Ms J. WRONECKA, Deputy Director of the UN System Department, Ministry of Foreign Affairs, Warsaw Advisers Mrs B. BITNER, Deputy Director, Bureau of European Integrated and International Relations, Ministry of Health and Social Welfare, Warsaw Mr K. ROZEK, Counsellor, Permanent Mission, Geneva Or L. A. LOPEZ BENITEZ, Viceministro de Politica Sectorial y Desarrollo Institucional, Secretaria de Estado en el Despacho de Salud Publica, Tegucigalpa Alternates Sra. G. BU, Consejera, Encargada de Negocios, a.i., Misi6n Permanente, Ginebra Sra. M. T. DACOSTA GOMEZ, Agregada, Misi6n Permanente, Ginebra Or A. J. MAZZA, Ministro de Salud y Acci6n Social, Buenos Aires (Vice-Chairman) Alternates Sr. J. C. SANCHEZ ARNAU, Embajador, Representante Permanente, Ginebra Profesor A. L. PICO, Subsecretario de Politicas de Salud y Relaciones Internacionales, Ministerio de Salud y Acci6n Social, Buenos Aires Advisers Sr. M. BENITEZ, Ministro Plenipotenciario, Representante Permanente Adjunto, Ginebra Srta. C. TOSONOTTI, Primera Secretaria, Misi6n Permanente, Ginebra Ora. M. PICO, Asesora de la Subsecretaria de P61itica de Salud y Relaciones Internacionales, Ministerio de Salud y Acci6n Social, Buenos Aires Sra. C. GUEVARA DE MAZZA Burundi Cyprus
Poland
Honduras
Argentina
MEMBERS AND OTHER PARTICIPANTS
5
Designated by Dr A. MELON!, Director General, Oficina de Financiamiento, Inversiones y Cooperaci6n Externa, Ministerio de Salud, Lima Alternates Sr. J. VOTO-BERNALES, Embajador, Representante Permanente, Ginebra Sr. J. PAULINICH, Embajador, Representante Permanente Alterno, Ginebra Sr. G. GUILLEN, Primer Secretario, Misi6n Permanente, Ginebra Dr C. M. MOREL, Department of Biochemistry and Molecular Biology, Oswaldo Cruz Institute at FIOCRUZ, Ipanema Alternates Mr G. VERGNE SABOIA, Deputy Permanent Representative, Geneva Mr C. A. SIMAS MAGALHAES, Minister Counsellor, Permanent Mission, Geneva Mr L. COELHO DE SOUZA, Second Secretary, Permanent Mission, Geneva Dr J. K. M. MULWA, Permanent Secretary, Ministry ofHealth, Gaborone Dr E. NAKAMURA, Technical Adviser, Division of International Affairs, Ministry of Health and Welfare, Tokyo Alternates Mr N. AKAO, Ambassador, Permanent Representative, Geneva Dr M. ITO, Counsellor for Science and Technology, Minister's Secretariat, Ministry of Health and Welfare, Tokyo Mr K. AKASAKA, Deputy Director-General, Multilateral Cooperation Department, Ministry of Foreign Affairs, Tokyo MrS. KANEKO, Director, International Affairs Division, Minister's Secretariat, Ministry of Health and Welfare, Tokyo Mr S. SUMI, Counsellor, Permanent Mission, Geneva Dr M. MUGITANI, Director, Office of International Cooperation, International Affairs Division, Minister's Secretariat, Ministry of Health and Welfare, Tokyo Advisers Mr H. HA YASHI, First Secretary, Permanent Mission, Geneva Dr E. SEKI, Deputy Director, International Affairs Division, Minister's Secretariat, Ministry of Health and Welfare, Tokyo Mr M. TAKANO, Assistant Director, Specialized Agencies' Administration Division, Multilateral Cooperation Department, Foreign Policy Bureau, Ministry of Foreign Affairs, Tokyo Mr S. TSUDA, Deputy Director, International Affairs Division, Minister's Secretariat, Ministry of Health and Welfare, Tokyo Mr T. IKENAGA, First Secretary, Permanent Mission, Geneva Mr A. YOKOMAKU, Deputy Director, International Affairs Division, Minister's Secretariat, Ministry of Health and Welfare, Tokyo Dr T. MIYAMOTO, Technical Official, Office for Life-style Related Diseases Control, Community Health, Health Promotion and Nutrition Division, Health Service Bureau, Ministry of Health and Welfare, Tokyo Peru
Brazil
Botswana Japan
6
EXECUTIVE BOARD, 101 st SESSION
Designated by MrS. NGEDUP, Secretary, Health Services, Ministry of Health and Education, Thimphu Alternate Dr J. SINGAY, Director, Health Division, Ministry of Health and Education, Thimphu Professor Z. REINER, Deputy Minister of Health, Zagreb Adviser Ms S. BLAZEVIC, Permanent Mission, Geneva Professor I. SALLAM, Minister of Health and Population, Cairo Alternates Dr M. ZAHRAN, Ambassador, Permanent Representative, Geneva Dr A. BADRAN, Adviser to the Minister of Health and Population, Cairo Advisers Dr M. EL-SHAFEY, Under-Secretary for Population and Family Planning, Ministry of Health and Population, Cairo Professor W. ANWAR, Adviser to the Minister of Health and Population for Scientific Research and International Relations, Cairo Dr A. EL BINDARI-HAMMAD, Adviser to the Minister of Health and Population, Cairo Mr T. ADEL, First Secretary, Permanent Mission, Geneva Mr M. TA WFIK, Counsellor, Permanent Mission, Geneva Dr A. SANOU IRA, Directrice des Etudes et de la Planification, Ministere de la Sante, Ouagadougou (Rapporteur) Dr Y.-S. SHIN, President, Korea Institute of Health Services Management, Seoul Alternates Mr Y.-H. YANG, Counsellor, Permanent Mission, Geneva Mr G. L. KIM, Deputy Director, International Cooperation Division, Ministry of Health and Welfare, Seoul Mr N. S. DE SIL VA, Minister of Health and Indigenous Medicine, Suwasiripaya, Colombo Alternates Mr H. M. G. S. PALIHAKKARA, Ambassador, Permanent Representative, Geneva Dr M. A. L. R. Perera, Senior Assistant Secretary (Health Services), Ministry of Health and Indigenous Medicine, Colombo Adviser Mr A. S. U. MENDIS, Second Secretary, Permanent Mission, Geneva Dr T. J. STAMPS, Minister of Health and Child Welfare, Causeway, Harare Alternates Dr T. J. B. JOKONYA, Ambassador, Permanent Representative, Geneva Or P. L. N. SIKOSANA, Permanent Secretary, Ministry of Health and Child Welfare, Harare Bhutan
Croatia
Egypt
Burkina Faso
Republic of Korea
Sri Lanka
Zimbabwe
MEMBERS AND OTHER PARTICIPANTS
7
Designated by
Advisers Mr T. T. CHIF AMBA, Minister Counsellor, Permanent Mission, Geneva Mr C. L. ZA V AZA VA, Minister Counsellor, Permanent Mission, Geneva Mr N. KANYOWA, First Secretary, Permanent Mission, Geneva Dr A. J. M. SULAIMAN, Director-General of Health Affairs, Ministry of Health, Muscat Mr H. VOIGTLANDER, Director, International Relations and Cooperation with the European Union, Federal Ministry for Health, Bonn Alternates Dr W. HOYNCK, Ambassador, Permanent Representative, Geneva Mr H. EBERLE, Minister, Permanent Mission, Geneva Mr M. DEBRUS, Head of Division, International Cooperation in the Field of Health, Federal Ministry for Health, Bonn Mr U. KALBITZER, Counsellor, Permanent Mission, Geneva Mr P. SILBERBERG, Deputy Head of Division, Federal Ministry for Foreign Affairs, Bonn Dr E. ADERHOLD, First Secretary, Permanent Mission, Geneva Dr B. W ASISTO, Senior Adviser to the Minister of Health, Jakarta (Vice-Chairman) Alternates Dr SUYUDI, Minister of Health, Jakarta Dr N. K. RAI, Director General of Community Health, Department of Health, Jakarta Dr H. M. ABEDNEGO, Director General of Communicable Disease Control and Environmental Health, Department of Health, Jakarta Mr A. T ARMIDZI, Ambassador, Permanent Representative, Geneva Mrs S. B. A. SYAHRUDDIN, Ambassador, Deputy Permanent Representative, Geneva Advisers Mr E. PRATOMO, Counsellor, Permanent Mission, Geneva Ms D. H. MOEHARIO, First Secretary, Permanent Mission, Geneva Mrs A. LANTU-LUHULIMA, Third Secretary, Permanent Mission, Geneva Mr A. H. UGROSENO, Directorate for International Organizations, Department of Foreign Affairs, Jakarta Ms M. DJAMALUDDIN, Bureau of Planning, Department of Health, Jakarta Dr S. P. SOEDARMO, Senior Adviser to the Minister of Health, Department of Health, Jakarta Dr S. ROES MA, Department of Health, Jakarta Mr G. PRANOTO, Department of Health, Jakarta Mr T. POELOENGAN, Department of Health, Jakarta Dr J. WILLIAMS, Member of Parliament, Health Consultant, Ministry of Health, Rarotonga Alternate Dr R. DANIEL, Secretary of Health, Ministry of Health, Rarotonga Oman
Germany
Indonesia
Cook Islands
8
EXECUTIVE BOARD, 101st SESSION
GOVERNMENT REPRESENTATIVE ATTENDING BY VIRTUE OF RULE 3 OF THE RULES OF PROCEDURE
Agenda item 9: Implementation of resolutions and decisions M. M. COLLA, Ministre de la Sante
Country represented Belgium
REPRESENTATIVES OF THE UNITED NATIONS AND RELATED ORGANIZATIONS
United Nations Mr S. KHMELNITSKI, External Relations and Inter-Agency Affairs Officer, Geneva Mr F. MEZZALAMA, Chairman, Inspector, Joint Inspection Unit, Geneva Mr A. ABRASZEWSKI, Vice-Chairman, Inspector, Joint Inspection Unit, Geneva Mr F. BOUAYAD-AGHA, Inspector, Joint Inspection Unit, Geneva Mr H. HERNANDEZ, Inspector, Joint Inspection Unit, Geneva Mr W. MUNCH, Inspector, Joint Inspection Unit, Geneva Mr K. OTHMAN, Inspector, Joint Inspection Unit, Geneva Ms M. NINABER VAN EYBEN, Humanitarian Affairs Officer, Office of the Director and IASC, Secretariat, Department of Humanitarian Affairs, Geneva Ms K. TOLL, Humanitarian Affairs Officer, InterAgency Support Branch (IASB), Department of Humanitarian Affairs, Geneva
United Nations Development Programme Mr E. BONEV, Senior Adviser, UNDP European Office, Geneva Ms T. RIEDY, United Nations Volunteers, Humanitarian Relief Unit and Laision Office in Geneva
United Nations Population Fund Mr A. L. MACDONALD, Chief, UNFPA European Liaison Office, Geneva Mr S. BAVELAAR, Senior External Relations Officer, UNFPA European Liaison Office, Geneva Miss N. CONFALONE, Junior Professional Officer, UNFPA European Liaison Office, Geneva Dr D. PIEROTTI, Senior Officer, UNFPA Emergency Relief Operations, UNFP A European Liaison Office, Geneva Mr A. MARSHALL, Deputy Director, Information and External Relations Division, New York
United Nations Children's Fund World Food Programme Mr A. ROBERFROID, Director, UNICEF Office for Europe, Geneva Mr B. K. UDAS, Deputy Director, Geneva Office
United Nations Conference on Trade and Development Mr R. URANGA, Senior Adviser, United Nations and UNCTAD Focal Point on Tobacco or Health
United Nations Relief and Works Agency for Palestine Refugees in the Near East Dr M. ABDELMOUMENE, Deputy Commissioner-General
MEMBERS AND OTHER PARTICIPANTS
9
Office of the United Nations High Commissioner for Refugees Dr M. DUALEH, Senior Public Health Officer, Programme and Technical Support Service Dr S. MALE, Senior Epidemiologist, Programme and Technical Support Service Mr P. MA TEU, Senior Inter-Organization Officer, Inter-Organization Affairs and Secretariat Service Ms J. MENNING, Professional Assistant, InterOrganization Affairs and Secretariat Service
World Bank Dr R. G. A. FEACHEM, Director, Health, Nutrition and Population, Human Development Department
International Monetary Fund Mr A. A. TAIT, Regional Trade Representative and Director, IMF Office, Geneva
International Telecommunication Union International Labour Organization Mr V. PARATIAN, External Affairs Unit M. C. PERRIN, Bureau des relations interorganisations
World Meteorological Organization Food and Agriculture Organization of the United Nations Mr A. PURCELL, Senior Liaison Officer, FAO Liaison Office, Geneva Ms F. EGAL, Nutrition Officer, Nutrition Programmes Service, Food and Nutrition Division, Economic and Social Department Mr T. W. SUTHERLAND, Office of the Secretary-General
United Nations Industrial Development Organization Mr M. TOURE, Director, UNIDO Office, Geneva Ms F. SIDIBE, UNIDO Office, Geneva
United Nations Educational, Scientific and Cultural Organization Mme A. CASSAM, Directeur, Bureau de Liaison, Geneve
International Atomic Energy Agency Ms M. S. OPELZ, Head, IAEA Office, Geneva Ms A. WEBSTER, IAEA Office, Geneva
REPRESENTATIVES OF OTHER INTERGOVERNMENTAL ORGANIZATIONS
League of Arab States MrS. SEF ALYAZAL, Charge d'affaires a.i., Delegation permanente de la Ligue des Etats Arabes aupres de !'Office des Nations Unies a Geneve Dr 0. EL HAJJE, Attache, Delegation permanente de la Ligue des Etats Arabes aupres de !'Office des Nations Unies aGeneve
Mr M. CHATTI, Attache, Permanent Delegation, Geneva
Commonwealth Secretariat Professor S. MATLIN, Director, Human Resource Development Division Dr Q. Q. DLAMINI, Special Adviser, Head, Health Department
Organization of African Unity Mr V. W. NZOMWITA, Assistant Permanent Observer, Permanent Delegation, Geneva
European Commission Dr A. BERLIN, Adviser, Directorate General for Employment and Social Affairs
10
EXECUTIVE BOARD, 101st SESSION
Dr A. LACERDA, Principal Administrator, Directorate General for Employment and Social Affairs Mr C. DUFOUR, Permanent Delegation of the European Commission at Geneva Health Ministers' Council for Gulf Cooperation Council States Dr H. A. GADALLAH
International Organization for Migration Dr B. GUSHULAK, Director, Medical Services Mr P. SCHATZER, Director, External Relations and Information Organisation of the Islamic Conference Dr N. S. TARZI, Ambassadeur, Observateur permanent, Delegation permanente, Geneve M. J. OLIA, Observateur permanent adjoint, Delegation permanente, Geneve
REPRESENTATIVES OF NONGOVERNMENTAL ORGANIZATIONS IN OFFICIAL RELATIONS WITH WHO
CMC- Churches' Action for Health Dr D. MUKARJI Commonwealth Association for Mental Handicap and Developmental Disabilities Dr V. R. PANDURANGI Dr G. SUPRAMANIAM Council for International Organizations of Medical Sciences Dr Z. BANKOWSKI Professor J. H. BRYANT Dr J. GALLAGHER Professor J. C. SliM Inclusion International Dr A. KONIG Industry Council for Development DrD. JONAS
Inter-Parliamentary Union Mr S. Tchelnokov International Agency for the Prevention of Blindness DrM. CHOVET International Association for Maternal and Neonatal Health Professor A. CAMP ANA Mr H. WAGENER Professor A. FANDES International Association of Cancer Registries DrF. LEVI International Confederation of Midwives MsR.BRAUEN International Council for Control of Iodine Deficiency Disorders Dr F. DELANGE International Council of Nurses Dr J. A. OULTON Dr T. GHEBREHIWET Miss T. TEMINSKY
Inter-African Committee on Traditional Practices affecting the Health of Women and Children Mrs B. RAS-WORK Mrs R. BONNER Mrs J. JETT-ALI
MEMBERS AND OTHER PARTICIPANTS
11
International Council of Scientific Unions Professor Y. VERHASSELT
International Federation of Oto-rhinolaryngological Societies Dr P. W. ALBERTI
International Council of Women Mrs P. HERZOG
International Federation of Pharmaceutical Manufacturers Associations Dr H. E. BALE, Jr MsM.CONE Mr J.-F. GAULIS Dr 0. MORIN CARPENTIER Mrs S. CROWLEY Dr P. CARLEV ARO Mr G. H. A. SIEMONS MrK. SATO
International Council on Alcohol and Addictions DrS.FLACHE
International Council on Social Welfare Mr N. DAHLQVIST
International Cystic Fibrosis (Mucoviscidosis) Association MsL. HEIDET
International Federation of Surgical Colleges Dr S. W. A. GUNN
International Diabetes Federation International Lactation Consultant Association Professor K. G. M. M. ALBERTI Ms H. WILLIAMS Ms M. LEHMANN-BURI
International Epidemiological Association International Medical Informatics Association Dr R. SARACCI Dr R. P. BERNARD Dr V. GRIESSER
International Federation of Gynecology and Obstetrics Professor A. CAMPANA
International Occupational Hygiene Association Professor M. P. GUILLEMIN Mrl. OBADIA
International Federation of Hydrotherapy and Climatotherapy DrG. EBRARD M.C.OGAY
International Organization of Consumers Unions (Consumers International) Mrs M. MORSINK Mr B. VAN DER HEIDE Ms A. LINNECAR MsN. J. PECK MsA.ALLAIN MsE. SOKOL Ms S. THIAGARAJAG Ms P. RUNDALL
International Federation of Medical Students Associations Mr B. TORSTEINSDOTTIR MrK.MANI Mrs M. L. GANDER Ms S. DE RIBOUPIERRE MsF. PORTA
12
EXECUTIVE BOARD, 101 st SESSION
International Pharmaceutical Federation Mr A. GALLOPIN MrP.BLANC Mr J.-C. FILLIEZ Mrs R. FILLIEZ Dr H. IBRAHIM Mr A. W. DAVIDSON Miss A. SUTHERLAND Dr D. STEINBACH International Society and Federation of Cardiology Dr A. BAYES DE LUNA Ms M. B. DE FIGUEIREDO International Society for Preventive Oncology Professor H. E. NIEBURGS Professor L. SANTI
International Union against Cancer Mr A. J. TURNBULL Mrs I. MORTARA International Union against Sexually Transmitted Infections DrG.M.ANTAL International Union for Health Promotion and Education DrS. HAGARD International Union of Family Organizations Dr D. N. WEBER KUZSTRA Dr C. VALLADAO La Leche League International Ms G. LA VIOLLE
International Society of Chemotherapy Medical Women's International Association Professor J. C. PECHERE Dr V. JORGENSEN International Society of Surgery Dr S. W. A. GUNN Rotary International MrE.JUCKER Mr G. HERMANN Save the Children Fund (UK) Ms A. TAYLOR Soroptimist International Mrs I. S. NORDBACK World Association for Psychosocial Rehabilitation DrS. FLACHE World Association of Girl Guides and Girl Scouts Ms L. SCHURCH Ms J. CRETTAZ Ms N. FISCHER MsC.LOCHER Ms S. VIGANI
International Special Dietary Foods Industries Ms C. EMERLING Ms B. HALCHAK MsJ. KEITH Mr D. BARRETT MrS. TASHER Mr P. BORASIO Dr A. BRONNER MsC.REGAN MrG. FOOKES Mr VAN HINDES Mr N. CHRISTIANSEN MrK.DEJONG DrD. SEGAL Dr B. DE BUZONNIERE Ms H. MOUCHLY-WEISS Ms K. BOLOGNESE Mr M. DE SKOWRONSKI MsFRADE MrL. BICK
MEMBERS AND OTHER PARTICIPANTS
13
World Confederation for Physical Therapy Ms B. J. MYERS
World Medical Association Dr A. M. MILTON Dr D. H. HUMAN
World Federation for Medical Education World Psychiatric Association DrH.KARLE Professor N. SARTORIUS
World Federation for Mental Health World Self-Medication Industry Dr S. FLACHE Dr J. A. REINSTEIN Mr A. J. JAMISON
World Federation of United Nations Associations Dr R. MASIRONI Dr J. STEINBART MrM.WEYDERT Mr P. IGNA TIEFF Mme M. VIOLAKI-PARASKEVA
World Veterans Federation MrH.HOEGH
World Veterinary Association Dr A. MEISSER
World Hypertension League Dr T. STRASSER
World Vision International DrE.RAM
COMMITTEES AND WORKING GROUPS 1
A. COMMITTEES2 AND WORKING GROUPS OF THE BOARD
1.
Programme Development Committee Dr M. Fikri (Vice-Chairman of the Board, member ex officio), Mr J. Hurley, Mr A. Juneau, Dr J. K. M. Mulwa, Dr E. Nakamura, Mr N. S. de Silva, Dr A. J. M. Sulaiman
Fourth meeting, 14-16 January 1998: Mr J. Hurley (Chairman), Dr M. Fikri, Dr J. Larivil!re (alternate to Mr A. Juneau), Dr J. K. M. Mulwa, Dr E. Nakamura, Mr N. S. de Silva, Dr A. J. M. Sulaiman
2.
Administration, Budget and Finance Committee Dr A. J. Mazza (Vice-Chairman ofthe Board, ex officio), Dr C. M. More!, Professor I. Sallam, Dr A. Sanou Ira, Dr Y.-S. Shin, Mr H. VoigtUinder, Dr B. Wasisto
Eighth meeting, 15 January 1998: Dr B. Wasisto (Chairman), Dr A. Badran (alternate to Professor I. Sallam), Dr C. M. More!, Dr A. Sanou Ira, Dr Y.-S. Shin, Mr H. Voigtlander
3.
Standing Committee on Nongovernmental Organizations Dr N. Blewett, Dr P. Dossou-Togbe, Dr G. M. van Etten, Dr E. M.-R. Ferdinand, Mr C. Solomis
Meeting of20 January 1998: Dr E. M.-R. Ferdinand (Chairman), Dr N. Blewett, Dr P. Dossou-Togbe, Dr G. M. van Etten, Dr C. Komodikis (alternate to Mr C. Solomis)
B. OTHER COMMITTEES3
1.
Darling Foundation Committee Chairman of the WHO Expert Committee on Malaria and Chairman and Vice-Chairmen ofthe Board, ex officio
1 Showing their current membership and listing the names of those who attended meetings held since the previous session of the Board. 2
Committees established pursuant to the provisions of Rule 16 of the Rules of Procedure of the Executive Board. Committees established in accordance with the provisions of Article 38 of the Constitution.
3
-15-
16
EXECUTIVE BOARD, 101st SESSION
2.
Leon Bernard Foundation Committee Professor Z. Reiner, together with the Chairman and Vice-Chairmen of the Board, ex officio
3.
Jacques Parisot Foundation Committee Professor J. Leowski together with the Chairman and Vice-Chairmen of the Board, ex officio Meeting of21 January 1998: Dr A. J. Mazza (Chairman), Professor A. Aberkane, Dr M. Fikri, Professor J. Leowski, Dr B. Wasisto
4.
lhsan Dogramaci Family Health Foundation Committee The Chairman and Vice-Chairmen of the Board, ex officio, a representative of the International Pediatric Association, a representative of the International Children's Centre, Paris, and the President ofBilkent University, Turkey, or his representative
5.
United Arab Emirates Health Foundation Committee Dr F. R. Al-Mousawi, together with the Chairman and Vice-Chairmen of the Board, ex officio, and a representative designated by the Founder Meeting of21 January 1998: Dr B. Wasisto (Chairman), Professor A. Aberkane, Dr F. R. Al-Mousawi, Mr A. Alshamsi (representative of the Founder), Dr M. Fikri, Dr A. J. Mazza
6.
Sasakawa Health Prize Committee The Chairman and Vice-Chairmen of the Board, ex officio, and a representative designated by the Founder Meeting of26 January 1998: Professor A. Aberkane (Chairman), Dr M. Fikri, Professor K. Kiikuni (representative of the Founder), Dr A. J. Mazza, Dr B. Wasisto
7.
UNICEF/WHO Joint Committee on Health Policy, subsequently WHO/UNICEF/UNFPA Coordinating Committee on Health WHO members: Dr P. Dossou-Togbe, Professor J. Leowski, Dr A. Meloni, MrS. Ngedup, Professor I. Sallam, Dr J. Williams; Alternates: Dr G. M. van Etten, Dr A. J. Mazza, Dr E. Nakamura, Mr C. Solomis, Dr T. J. Stamps, Dr B. Wasisto Meeting of 19-20 May 1997: Dr R. Daniel (alternate to Dr J. Williams), Dr P. Dossou-Togbe, Professor J. Leowski, Dr A. Meloni, Dr B. Wasisto
COMMITTEES AND WORKING GROUPS
17
8.
Special group to review the Constitution of the World Health Organization Professor A. Aberkane (Chairman of the Board, ex officio), Dr F. R. Al-Mousawi, Dr N. Blewett, Dr L. A. L6pez Benftez, Professor Z. Reiner, Dr T. J. Stamps, Dr B. Wasisto Fifth meeting, 9-11 July 1997: Dr N. Blewett (Chairman), Professor A. Aberkane, Dr F. R. Al-Mousawi, Dr L. A. L6pez Benftez, Professor Z. Reiner, Dr T. J. Stamps, Dr B. Wasisto Sixth meeting, 5-7 November 1997: Dr N. Blewett (Chairman), Professor A. Aberkane, Dr F. R. Al-Mousawi, Dr L. A. L6pez Benftez, Professor Reiner, Dr T. J. Stamps, Dr B. Wasisto
z.
9.
Working group to evaluate the Programme Development Committee and the Administration, Budget and Finance Committee Dr K. Calman, Dr E. Nakamura and the Chairmen of the Programme Development Committee and the Administration, Budget and Finance Committee, ex officio
SUMMARY RECORDS
FIRST MEETING Monday, 19 January 1998, at 9:30 Chairman: Professor A. ABERKANE
1.
OPENING OF THE SESSION: Item 1 of the Provisional Agenda
The CHAIRMAN declared open the 101st session of the Executive Board and welcomed all participants. He expressed confidence that the Board would fulfil its collective responsibility by engaging in fruitful discussion and taking decisions that would be of benefit to WHO.
2.
ADOPTION OF THE AGENDA: Item 2 of the Provisional Agenda (Documents EB101/1 and EB101/DIV/3)
The CHAIRMAN indicated that items 13.3 and 14.3 should be deleted from the provisional agenda in document EB 10111. As item 16.4 would be considered, the words "if any" in that item should be deleted.
The agenda, as amended, was adopted. 1
3.
PROGRAMME OF WORK
The CHAIRMAN proposed that the Board should endeavour to complete its work by Tuesday, 27 January in order to allow several of its members to observe Id ai-Fitr; if necessary, a meeting might be held on Saturday afternoon to compensate for shortening the session by one day. It was so decided.
The CHAIRMAN, announcing the dates and times of meetings and calling for punctuality, said that the Board would meet in private to consider item 5; he urged members to show restraint with regard to the numbers of alternates and advisers accompanying them to the private meetings. Professor REINER said that, despite an overloaded agenda and the inevitably lengthy discussion that would take place regarding the nomination for the post of Director-General, adequate time should be allocated for consideration of item 7.3, Review of the Constitution and regional arrangements of the World Health Organization. Discussion of that topic should precede consideration of item 7.1, WHO country offices. Another subject that required discussion but was not included in the agenda for the current session of the Board, was
1
See page xi.
- 19-
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EXECUTIVE BOARD, 101 st SESSION
United Nations reform, particularly in regard to the implications for WHO. He proposed that that topic should be included in the agenda for the 102nd session. Mr AITKEN (Assistant Director-General) replied that, as it was not known how many speakers would take the floor on a topic, it was not possible to specify the duration of discussion on any particular item. The comment by Professor Reiner would, however, surely be taken into account. He thought that there was unlikely to be any objection to the proposed change in the order of discussion with regard to item 7. As to the question of United Nations reform, it would be advisable to defer the matter to the 102nd session, since certain issues were still to be examined by the United Nations General Assembly at its resumed session in the present year.
4.
STATEMENT BY THE DIRECTOR-GENERAL: Item 3 of the Agenda
The DIRECTOR-GENERAL said that WHO would be 50 years old in the current year. Celebrating its fiftieth anniversary, the Organization could look back with legitimate pride to its many achievements in health for the benefit of all the peoples of the world. At the same time, in full awareness of WHO's responsibilities for the present and future generations, emerging global health challenges had to be assessed in order to ensure that the Organization's policies and structures were well adapted and would enable it to meet the expectations of all whom it existed to serve. In May 1998, reasserting the principles and values set out 50 years previously in WHO's Constitution, a new declaration or charter on global health and a new health-for-all policy would be adopted as a framework for the Organization's activities in the twenty-first century when, in his view, international cooperation would increasingly have to focus on the developmental aspects of health. WHO's entire reform process, in fact, had been guided by a concern to meet the ever-changing needs of Member States more efficiently and secure the mutual reinforcement of health and socioeconomic development. Fifty years ago, WHO's main priorities had included immunization, infectious and parasitic diseases, malnutrition, hygiene and sanitation, basic health infrastructure, education and training for health workers, and the development or reconstruction of health services. To a large extent, those remained major areas of concern and activity. Yet the scope of the challenges currently faced by the Organization, and the approaches to dealing with them, had changed considerably. In the area of immunization against childhood diseases, global coverage rates for children under one year of age had been increased from an average of less than 5% in 1974 to about 80% in 1994. After having been able to declare the eradication of smallpox, in 1980, WHO had embarked on further ambitious yet feasible endeavours, including the eradication of poliomyelitis and the elimination of other preventable diseases such as measles and neonatal tetanus. By 1996, the global incidence of measles had been reduced by about 70%. The eradication of poliomyelitis had been achieved in the Region of the Americas and was near completion in the Western Pacific, while enormous progress was being made in Africa and South-East Asia. Effective tools and strategies were available, and national immunization days were being organized regularly in all countries and regions concerned. The task now was to ensure the sustainability of those efforts and promote the development of multipurpose vaccines that would be both easier to use and affordable to those who needed them most. Thus the highly successful Expanded Programme on Immunization had been supplemented by the Children's Vaccine Initiative, mobilizing the support of partners in both the public and the private sectors. With the extension of immunization coverage, ways must be found of reaching populations that remained excluded by poverty and other disadvantages. There again, the solutions had to be worked out with other sectors. With WHO's support, the development of global coalitions and intersectoral cooperation against a number of other diseases, such as leprosy, dracunculiasis, onchocerciasis and Chagas disease had produced impressive results. Between 1985 and 1996, the global prevalence of leprosy had been reduced by 82%. During roughly the same period, the global prevalence of dracunculiasis had fallen from 3.5 million to only 130 000 cases. Onchocerciasis had been eliminated from 11 countries of Western Africa and 1.5 million previously infected people had been freed from the risk of blindness. Launched in 1991, activities to eliminate the transmission of Chagas disease were making remarkable progress in Latin America. For many years, WHO had been warning the international community that neglecting health needs had disastrous consequences for human and economic development, and had argued that a healthy environment was
SUMMARY RECORDS: FIRST MEETING
21
required to attract domestic and foreign investment for socioeconomic development. The Organization had alerted public opinion and led the global mobilization against such scourges as HIVI AIDS, malaria and tuberculosis. An active cosponsor of UNAIDS, WHO also provided countries with specific support for epidemiological surveillance, research, control of sexually transmitted diseases, health education and information, blood safety, and access to antiretroviral drugs and other health products. The launching of an African initiative based on the revised global malaria strategy, and the successful development of the directlyobserved treatment, short course (DOTS) strategy against tuberculosis were other examples of WHO's continued leadership in the fight against communicable diseases. Fifty years ago, it had seemed self-evident that science and technology signified progress, and that progress was irreversible. Such assumptions had been called in question by the emergence of new infectious agents, new environmental health hazards, and drug resistance. Outbreaks had occurred of diseases such as plague, cholera, dysentery, E. coli 0157 infections, viral haemorrhagic fevers of the dengue, Ebola and Hantaan type, yellow fever, Rift Valley fever, bacterial and viral meningitis, transmissible spongiform encephalopathies and, more recently, avian influenza A(H5Nl) in humans. In response to those additional challenges, considerable efforts had gone into the development of networks to improve global preparedness for epidemics, and WHO's capacity to respond to countries' requests for emergency support had been successfully built up. The International Health Regulations were also being revised to maximize health protection while minimizing social and economic constraints. Mother and child health had always ranked high on WHO's agenda. Over the years, significant reductions had been achieved globally in infant and child mortality and morbidity rates. While implementing commitments made at the World Summit for Children, WHO had moved away from a focus on narrowly defined age groups and diseases to broader community and family health approaches. Those approaches had been based on the concern that all people should have ready access to a continuum of essential care and support at all stages of their lives, at home, at school, at work and in their communities. The integrated approach to issues such as childhood illness, adolescent and women's health, reproductive health, nutrition, substance abuse, noncommunicable diseases, health of older persons and disability, could be traced back to the inclusive definition of health provided by WHO's Constitution. It might also be seen as a direct extension of the WHO primary health care strategy, defined 20 years ago at Alma-Ata. Much current terminology might remain the same but he believed that there had been a fundamental change in perspective, the consequences of which had yet to be fully recognized. As he saw it, in the new approach to developing integrated primary health care, the focus was moving from structures and systems to people. In the future, an even greater effort would have to be made to understand users' needs, their expectations, and their potential to contribute to the definition and implementation of health priorities and interventions. That change in perspective reflected a growing awareness of the importance of developing an open and mutually respectful dialogue between health professionals and the public. Empowering people in all cultures and segments of society with the necessary information and opportunities for health development was both an ethical and a technical imperative. Noncommunicable diseases, such as cancer, cardiovascular diseases, diabetes and mental health disorders, were on the rise everywhere and a major cause of suffering and disability. They were influenced by a combination of factors which included lifestyles, environmental hazards, genetic predisposition and the global ageing of the world's population. A vast amount of epidemiological data on those diseases had been generated worldwide through research coordinated by WHO. Cost-effective interventions and strategies were available. WHO's next urgent task must be to help integrate them into national health policies, especially in developing countries, to put in place health promotion and education activities, case-finding, case-management, and rehabilitation and social support services. Success would depend increasingly on the Organization's ability to communicate with the public about the need to adopt health-conducive lifestyles. The link between health, lifestyles and the environment had already been made by the Constitution in the context of what had then been called "environmental hygiene". Traditionally, WHO had been particularly strong in areas such as nutrition, sanitation and vector control, and remained actively involved in initiatives such as Africa 2000, for the development of basic sanitation, including water supply and waste disposal systems. But, especially during the two final decades of the present century, environmental health had become an entirely new area of major concern worldwide, closely related to issues of sustainable development and justice. The WHO Commission on Health and Environment had played a decisive role in that regard at the Rio Conference. Currently, such matters as air and water pollution, urban and industrial development, occupational hazards,
22
EXECUTIVE BOARD, 101st SESSION
climate change, and chemical and food safety were being hotly debated both by the general public and by governments. As the nature and scope of environmental and man-made health hazards had changed, WHO had redefined its emergency relief capability. It had placed new emphasis on preparedness to mitigate the health consequences of both natural and man-made disasters, and on providing technical backup for the health aspects of humanitarian and rehabilitation work. Fifty years after its foundation, WHO's prime responsibility remained that offostering access to health for all through international cooperation. It did so by working with countries to formulate sound health policies and strategies, and to establish and manage effective and sustainable health services. Capacity-building, a prerequisite for sustainability, had to include not only human resource development but also the financial and institutional support measures that would render health services fully operational. At a time of wide-ranging social, political and economic change, practically all countries in the world were having to redefine their development strategy and reform their national health systems. WHO's new health-forall policy offered support to Member States as they strove to ensure the relevance, effectiveness and sustainability of their action for health development. The definition of essential public health functions provided a basis on which national health services could be organized and operated. The health services of the future would continue to carry out disease prevention and control activities using traditional approaches, but they would also include the public health applications of new knowledge and technology, in areas such as genetics, molecular biology, immunology and diagnostic imaging. It was particularly important in that context to strengthen collaborative research based on actual public health needs and ensure the dissemination of relevant findings to potential users. It was just as important that the development and implementation of research, technology and health services should be carefully assessed and guided by sound technical and ethical principles. Rapidly evolving areas of science and medical practice such as organ transplantation, cloning, genetic engineering and clinical research had major ethical and social implications for humanity. WHO provided a forum within which international consensus could be built with regard to the many crucial issues that arose in those domains. Ethical concerns were also at the core of the health-for-all policy. WHO's goal of promoting equitable and universal access to health services, including care and essential drugs, was based on the principle of justice and the recognition that all human beings should enjoy equal rights and opportunities. The new partnerships for health would stimulate innovation and encourage the participation at national and international level of all institutions and sectors concerned, including civil society and nongovernmental organizations. During 1997, reform in WHO had continued as an ongoing process of change, focusing on further improving accountability and efficiency. In the preparation of the Tenth General Programme of Work, particular care had been given to ensuring consistency with health policy reform and strategic budget orientations. The major elements of reform before the Board were related to the review of the Constitution and WHO's regional arrangements, as well as the revised proposals for WHO's representation and cooperation mechanisms at country level. Other important items on the agenda included the nomination of the next Director-Genetal and the review of the proposed new declaration on health and new health-for-all policy which the Health Assembly would adopt in May 1998. Over its 50 years of existence as a vital part of the United Nations system, WHO had done an impressive amount to promote health and peace worldwide. The Organization should celebrate its anniversary with feelings of pride, gratitude and humility. To have been able to take part in WHO's inspiring endeavour gave cause for pride, and gratitude was due to all who throughout the Organization's history had contributed to making its achievements possible. Lastly, it was important to recognize, in all humility, that the task ahead remained formidable. That must prompt renewed determination, and the mobilization of available resources and efforts to further advance the common goal of making health accessible to all. Fighting disease and alleviating human suffering would continue to require the dedication and cooperation of all.
SUMMARY RECORDS: FIRST MEETING
23
5.
REGIONAL MATTERS: REPORTS BY THE REGIONAL DIRECTORS: Item 4 of the Agenda (Documents EB101/2 and EB101/INF.DOC./8)
Dr SAMBA (Regional Director for Africa) called attention to the report in document EBIOI/INF.DOC./8, which summarized the salient events of the security crisis in Brazzaville, described its impact on the work of the Regional Office for Africa and outlined the current situation. Many people and organizations deserved the deepest gratitude for their support during the crisis. He praised the staff of the Regional Office who had remained calm in a dangerous and confused situation. The WHO office, the only United Nations office in Brazzaville to stay open throughout, had continued to operate with a minimum of disruption. Special tribute was due to the exemplary bravery and dedication to duty of Ms McAdam, the UNDP resident representative and security officer in Brazzaville. He thanked the Ambassador of France for his help in mediating with the French military for the evacuation of WHO personnel. It was undoubtably thanks to them that no one had been injured or killed. He was also very grateful for the numerous supportive telephone calls he had received from all parts of the globe. Collaboration with countries had continued uninterrupted despite the situation; he praised the devotion to duty of the core of local staff who had remained in Brazzaville to continue some of the work of the WHO office and assist other agencies in many ways. He expressed his warmest thanks to the Government of Zimbabwe for providing facilities for the temporary relocation of the Regional Office to Harare. · A small task force comprising staff from WHO headquarters and the Regional Office had visited Brazzaville in November 1997 to assess the situation. They had recommended that, in view of the extensive damage and lack of amenities, full operations should not be restored for at least two years and that the situation should meanwhile be kept under constant review. Dr ALLEYNE (Regional Director for the Americas) said that the thrust of his annual report for 1996, entitled "Healthy people, healthy spaces", which had been submitted to the forty-ninth session of the Regional Committee in September 1997, had been that WHO should discharge its responsibility to monitor the human condition and demonstrate where inequities existed, so that the Secretariat and Member States might determine where appropriate interventions to improve health status should be made and assess the extent to which they were effective. He had introduced the use of cartographic information to demonstrate health inequities and had coupled the concept of healthy spaces with the preservation or creation of "social capital", which had only recently been recognized as one of the most important prerequisites for progress and economic growth: investment in healthy environments, healthy spaces, contributed to the creation of vitally important social capital. Technical cooperation at the country level had been summarized. The Member States of the Region had welcomed the approach to defining local inequities, and that would be the focus of intensified cooperation. The stress on equity in the report had been associated with the renewal of the health-for-all policy, which the Board was to discuss. The session of the Regional Committee had been noteworthy for the presentation and unanimous acceptance of a zero nominal growth budget. The Organization had, however, experienced real budgetary reductions over the past six years, and it was to be hoped that that trend would be reversed. The Members of the Committee had received reports on the extent to which the expected results of technical cooperation had been achieved during the previous biennium. The budget also reflected the effort made to increase funding to areas designated as priorities by the Executive Board, with greater allocation to specific country activities and a smaller percentage earmarked for administration. There had been a 30% increase in funds for technical cooperation among countries, an important area of work for the Organization. The area of new and emerging diseases had also received special attention. In response to the El Nifio phenomenon, the Regional Office had been charged with assisting countries in preparing for possible disasters. The aspect of HIVIAIDS that had received the most attention in the Committee was the high cost of the newer therapies, which many countries could not afford. The discussion on environmental health had focused on the need for ministries of health to assume stronger leadership. In collaboration with the Government of Mexico, the Pan American Center for Human Ecology had been closed and its responsibilities transferred to a national institution. The conclusions of the Regional Committee with regard to the matters referred to it by the Executive Board special group for the review of the Constitution were outlined in document EB I 01/2. Recalling that WHO was a forum for debate at the ministerial level on important health issues, he said that the Regional Committee
24
EXECUTIVE BOARD, 101st SESSION
had held a stimulating, productive discussion on an aspect of health sector reform that was usually ignored: the regulatory role of ministries of health. The health-for-all policy had been reviewed, and the recommendations of the Committee had been transmitted to WHO headquarters and taken into account in the final draft that would be considered by the Board. The Member States of the Region of the Americas had stressed the need to involve other agencies and actors in the debate on health policy, and special emphasis had been laid on the importance of equity in general and between the sexes in particular. Mental health had been discussed in the Committee for the first time in 20 years, and enthusiasm had been expressed for effective action within the health services. Regional affairs during 1997 that had not specifically been brought to the attention of the Committee reflected active, productive participation by the governments of all of the Member countries in WHO's work. The level of assessed contributions received by the end of 1997 had been the highest of the decade and - beyond the strictly financial implications - constituted a political affirmation of Member States' appreciation of the worth of WHO and a palpable demonstration of the value they attached to technical cooperation with the Organization. The Regional Office had also been active in following up the various presidential summit meetings and in preparing for the summit in 1998. An initiative of the Regional Office for "health technology linking the Americas" would be considered when the presidents of the Americas met in Santiago, Chile. The Regional Office also actively supported the conferences of First Ladies of the Americas. At the latest conference in Panama, the wife of the President of the World Bank and he had launched a "healthy schools initiative", which had found funding. The year 1997 had seen an improvement in the ordering and structuring of the relationship with WHO collaborating centres. Resource mobilization had been pursued with the result that by the end of the year about 45% of the Region's funding had come from extrabudgetary sources, reflecting confidence in WHO on the part of governments and agencies. He would not detail the significant accomplishments achieved in all of the technical areas, and concluded by remarking that the greatest satisfaction lay in the knowledge that the Regional Office was of use and of service to the people and countries of the Americas. Dr UTON RAFEI (Regional Director for South-East Asia) described important actions taken jointly by the Member States and WHO to improve the delivery of WHO collaborative programmes in the Region. During 1996-1997, both the timeliness and the quality of the implementation ofthe programme budget had improved. By December 1997, all of the regular budget funds for the biennium had been fully committed, largely due to steps taken by the Regional Committee in 1995 to enhance intercountry collaboration in tackling common health priorities in a spirit of regional solidarity and cooperation. The achievements of that innovative move had been well received, and the Member States had recommended that such efforts be expanded during the 1998-1999 biennium. Within the same context, hi-regional cooperation had been fostered to address common problems, especially in border areas, with countries in the Western Pacific and Eastern Mediterranean Regions. Preliminary steps had been taken to ensure efficient and effective use of available WHO resources in responding to countries' priority needs during 1998-1999. An efficiency plan had been prepared and was being implemented for that purpose. In order to implement the Board's directive to pursue assessment and evaluation of WHO's work vigorously at all levels, he had launched a series of internal evaluation exercises in 1997. WHO collaborative programmes in three countries, Bhutan, Myanmar and Thailand, had been reviewed in depth, and four regional programmes of high priority had been evaluated in order to ascertain the extent of their contributions to health development in the countries. Similar exercises would be carried out in 1998, with an improved methodology. The views ofthe Regional Committee for South-East Asia on various aspects of the review of the WHO Constitution, including regional arrangements, were reflected in the report before the Board (document EB 10 I /2) and had been conveyed to the Director-General for further action. Advocacy to place health high on political and development agendas had continued. Institutionalization of the Health Ministers' Forum had enhanced technical cooperation among the Member States. The health secretaries at their annual meetings had agreed to promote new initiatives in health sector reform, and vigorously to pursue renewal of the health-for-all strategy at the country level. Response to concerns about women, health and development had been remarkable; the subject had been discussed extensively at a recent regional conference of parliamentarians; and as a further token of its importance, the Regional Committee had selected "Partnerships for health development with a focus on women's health and development" as the topic for the technical discussions at its fifty-first session in
SUMMARY RECORDS: FIRST MEETING
25
September I998. A separate unit designed to address specifically crucial concerns in the area had been established in the Regional Office, where recruitment of women at professional level had increased, the proportion of female professional staff members having risen from I 0% to 20% in three years. The first woman programme director had been appointed recently. All I 0 Member States had contributed to the third evaluation of progress in implementing the strategies for health for all by the year 2000. The I997 regional health report traced achievements and shortcomings in Member States in their health-for-all endeavours during the 20-year period I977-I997. Both the evaluation findings and the report clearly showed that a great deal of progress had been made. For example, the infant mortality rate had declined from very high levels ranging from 85 to 203 per 1000 live births in the I960s to much lower levels ranging from 15 to 78 at present. Remarkable progress had also been made in the prevention of vaccine-preventable childhood diseases. Most of the Member States were well on the way to reaching the goal of eliminating leprosy by the year 2000. There had been no reports of dracunculiasis, formerly highly endemic in the Region, since a case in India in July 1997. There had been an impressive advance towards the eradication of poliomyelitis, due primarily to improved control efforts, including the synchronization of national immunization days. In January I997, I27 million children in India alone had been immunized in a single day, representing the largest immunization coverage achieved in such a space of time. Moreover, in Bangladesh, Bhutan, Myanmar, Nepal and Thailand, together with neighbouring China and Pakistan, a total of more than 257 million children - nearly 40% of the world's children under five years of age - had been immunized in one round of national immunization days. The disease was expected to be eradicated from the South-East Asia Region by the turn of the century. While there had been success in controlling certain communicable diseases, others continued to pose a formidable challenge. South-East Asia was not only home to a quarter of the world's population, but it also bore a large proportion of the global burden of disease. HIVIAIDS was assuming epidemic proportions in some countries of the Region: the available data indicated that in I997, 3.75 million people were infected with HIV. Long-endemic diseases, like cholera and tuberculosis, still dominated the disease pattern, and others had reemerged, including malaria, with 3.4 million cases registered in I995, and plague and kala-azar, which had been on the verge of eradication. The appearance of drug-resistant strains of the causative agents of tuberculosis, gonorrhoea and malaria was an additional cause for concern. Meanwhile, acute respiratory infections and diarrhoea! diseases remained the leading causes of mortality among children under the age of five. The maternal mortality rate in a few countries of the Region was still unacceptably high. In addition, many chronic and noncommunicable diseases related to lifestyle were becoming major public health problems. Although there had been significant growth in private sector provision, medical care was often not accessible to the people most in need because of high costs. The same was true for drugs of good quality. Thus, while large numbers of the population in some countries did not have access to simple medical care, sophisticated medical techniques were available for a privileged few. As a response to such inequity, health sector reform had been the topic of technical discussions during the fiftieth session of the Regional Committee. In December I997, he had convened a meeting on "public-private mix" in relation to the growing role of private sector health care. The resultant recommendations should help WHO to advise Member States appropriately in developing the necessary policy framework for addressing privatization. It was clear that the health sector alone would not be able effectively to tackle present and future challenges. Partnerships would have to be forged with other players, including the private sector, industry, other government sectors and nongovernmental organizations. In that context, the Regional Office had issued a publication, Partnerships for health: a new vision, analysing successes and failures and demonstrating challenges and opportunities. In order to translate that effort into practical terms, a series of multidisciplinary consultations had been convened during I997 to study the many determinants of health and to formulate a strategy for health development in the Region in the twenty-first century. Those deliberations had resulted in a Regional Health Declaration, which, having been adopted by the ministers of health of the Region at their fifteenth meeting in August I997 and endorsed by the Regional Committee in September, should also be seen as a contribution of the South-East Asia Region to the global policy of health for all. Indeed, the Member States in the Region were intensifying their efforts with WHO to achieve health for all, and would effectively mobilize and use all available resources and mechanisms towards that end. They pledged themselves to ensure that the development momentum was truly enhanced and maintained in coming years.
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EXECUTIVE BOARD, 101st SESSION
Dr ASVALL (Regional Director for Europe) said that, fortunately, the conflicts formerly prevalent in the Region had now subsided. In Bosnia the peace had held, and WHO had continued to chair the multisectoral Health Development Task Force that brought together various agencies concerned with the health aspects of the reconstruction of the country. In Croatia, now that control of Eastern Slavonia was in the hands of the Croatian Government, WHO had been able to pull back from its humanitarian assistance work there. In Serbia, efforts had been concentrated in Kosovo, where, in particular, joint action with UNICEF had ensured proper poliomyelitis immunization coverage for the first time in many years. Both in Tajikistan and in Chechnya, where the armed conflicts had subsided, the Office had continued its programme of assistance in 1997. The major political development in the Region had been the Treaty of Amsterdam, under which it had been decided that a further six countries would become members of the European Union at the beginning of the twenty-first century. WHO had continued its cooperation with the European Commission, in particular in developing a new public health information network for eastern European countries. In regard to economic development, although the situation of some countries of the central and eastern parts of the Region was improving, others were experiencing a serious downturn, while in western Europe unemployment was continuing to increase, even in the more well-to-do countries. The impact of that trend on the health and social sectors gave cause for concern. The major diphtheria epidemic which had hit the former Soviet Union countries had now been substantially curtailed, with some 7000 cases in 1997 as compared to 50 000 in 1996. That had been due to the joint efforts of a consortium consisting of 15 countries and a number of organizations, notably WHO, UNICEF, the International Federation of Red Cross and Red Crescent Societies and the United States Centers for Disease Control and Prevention, which had enabled almost half a million people to escape the disease and prevented some 15 000 deaths - a h~ge success for preventive medicine. Poliomyelitis eradication in the Region was proceeding well. Following the setback in the Balkans in 1966, when 193 cases in eight countries had been reported, eradication efforts had been intensified in cooperation with countries of the Eastern Mediterranean Region under the MECACAR project. As a result, only seven cases had been reported in 1997, one in Tajikistan and six in Turkey. Measures had been taken to strengthen surveillance of acute flaccid paralysis, as well as to develop a work plan for the Regional Certification Commission, which was to begin operations in 1998. Unfortunately, tuberculosis was continuing to rise in a number of countries in the eastern part of the Region, with the result that various activities had been launched to deal with the problem in close cooperation with WHO headquarters. Likewise, malaria was still ravaging Azerbaijan, Tajikistan and Turkey, where in 1997 an intensified control programme had been carried out with support from Japan and Italy. However, by far the largest infectious disease threat in the Region was the increase in sexually transmitted diseases and HIV/AIDS. Although the incidence of AIDS continued to fall in western Europe, owing to the intensive prevention efforts of the past 10 years, there had been a sharp rise in drug abuse-related HIV infections in eastern countries. The danger that posed in the light of the explosive increase in sexually transmitted diseases in those countries had led the Office in 1997 to set up a task force, which included representatives of UNICEF, UNAIDS, UNFPA and a number of countries inside and outside the Region, to tackle the problem. In the field of lifestyles and health, the Regional Office had extended the external evaluation of health promotion at national level, initiated at the request of national parliaments, from Slovenia in 1996 to Hungary in 1997. That exercise might signal a new role for WHO in the future in evaluating the performance of its Member States in the health field. A significant event in the year had been the approval by the Regional Committee of a new five-year plan for a "smoke-free" Europe, followed by the establishment of a special centre in London to support the action of national medical associations to achieve that end. As part of that action, 23 of those associations had approached their national airlines to press for the introduction of a smoking ban on all flights. Efforts to combat alcohol and drug abuse, particularly in countries of the eastern part of the Region, had continued. Following the very successful WHO Environment and Health Conference in Helsinki in 1994, national environment and health plans had been launched in more than half the Member States of the Region, the first time that those two sectors had joined forces in planning combined long-term national strategies. He was confident that almost all countries of the Region would have completed the planning process in time for the next major conference of ministers ofhealth and ofthe environment in London in 1999. The role of the European Environment and Health Committee, which comprised representatives of the Regional Office, the European Commission, the World Bank, the Organisation for Economic Co-operation and Development, the Economic
SUMMARY RECORDS: FIRST MEETING
27
Commission for Europe, UNEP and other partners, had been crucial in helping to formulate a regional strategy on the subject. Work on health care reform had continued following the major conference on the subject held in Ljubljana in 1996. A recent publication by the Regional Office based on the findings of the conference, European health care reform: analysis of current strategies, was now recognized as a key document in the field. In order to enable such analyses to be provided on a continuous basis, the Regional Office had set up in 1997 an Observatory on Health Care Systems and Reform, with support from the World Bank, the European Investment Bank, the Government ofNorway, and two collaborating centres in the United Kingdom. Work on maternal and child health and family planning had also continued in close cooperation with UNICEF and UNFPA, with emphasis on countries in the eastern part of the Region. With respect to quality of care, a new system for data exchange had been established in cooperation with headquarters, which included the EPiinfo software package. By that means, data on such subjects as diabetes, stroke care, oral health care, perinatal care and mental health care in different countries could be compared. Seven countries of the Region had been assisted during the previous year in developing national healthfor-all policies, and the Regional Office had embarked on its second update of the regional health-for-all strategy, in close collaboration with headquarters, to ensure the compatibility of regional and global policies. An important part of that strategy was played by the collaborative networks. There were four types of network, the first subregional, comprising CARNET for central Asian countries, EASTNET for such countries as the Russian Federation, Belarus and the Ukraine, MIDNET for central and east European countries, and (a 1997 addition) SOUTHNET for countries in the south-eastern part of the Region. The second type of network was of health professionals, and included national medical, nursing and pharmaceutical associations. The third type covered communicable and noncommunicable diseases. The CINDI network covered 24 countries. Another 46 Member States were participants in the diabetes network, and a meeting of 600 programme managers in Lisbon in April had shown that very considerable progress had been made in reducing amputations, blindness and kidney failure among the 25 million diabetics in the Region. The fourth type was the "settings" network, under such headings as "healthy cities", "health-promoting schools", "health-promoting hospitals", and "health in prisons". With regard to reform, external evaluation of programmes had continued, focusing in 1997 on maternal and child health. In addition, a firm of professional management consultants had been appointed to carry out an evaluation of the Regional Office's Administrative and Finance Department and its Executive Management Department. While all those aspects of the work of the Regional Office were important, what was most important was how far it had succeeded in helping those countries of the Region most in need. Many of its activities in 1997 had been concentrated on the 26 countries in transition: thus, in 1997, a network of national programme officers had been strengthened in those countries, and the Regional Office had joined the United Nations Development Assistance Framework pilot effort in Romania. However, such work was becoming increasingly problematic owing to the steep rise in requests for the Regional Office's services and the decline in the resources available to meet them. While he had never before complained to the Board about the resources allocated to the Region, he believed that the situation had now changed to an extent that Board members did not perhaps realize. Since 1990, the composition of the Region had increased from 31 to 51 Member States. According to the most recent UNDP report, income poverty in the 26 countries in transition had increased sevenfold during that period. In 1994, 32% of the population of those countries had had an income below the poverty level, the same percentage as that for developing countries. Furthermore, average gross domestic product per capita there had declined by 9% from 1993 to 1994, whereas the average for all developing countries showed a growth of 4.5%. Life expectancy had been falling in the eastern part of the Region, and now stood at 66 years as compared to 62 years for developing countries. In the Russian Federation, for example, a male child would not now live long enough to draw his pension, since average life expectancy was less than 60 years. Despite those trends, the Regional Office during the 1990s had not received a single dollar more either from the Organization's regular budget or from the Director-General's Development Fund, but had instead suffered a budgetary cut of22%. The Regional Committee had discussed the problem extensively in September 1997, and had adopted a resolution requesting the Board to review the situation. He hoped that the figures he had given would help towards a better understanding of the huge changes that had taken place in the Region, and that that understanding would be reflected in the Board's decisions.
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Dr GEZAIRY (Regional Director for the Eastern Mediterranean) said that the Regional Office was continuing to pursue activities relating to the renewal of the health-for-all policy at all levels. In that connection, the possible impact of globalization, the increasing drive towards market economies, liberalization of trade, privatization and rapid scientific and technological developments in health and health services delivery warranted special attention. The regional task force on health for all for the twenty-first century had conducted broad consultations within the Region with a view to providing regional input to the global policy document and to preparing a regional policy paper. At its forty-fourth session, the Regional Committee had affirmed the continuing validity of the goal of health for all, the importance of national health policy as an integral part of national socioeconomic development policy and the need for national and regional policy to take account of social and cultural characteristics. Furthermore, the Regional Committee had requested the Regional Director to ensure that contributions from Member States were reflected in the global document on health for all for the twenty-first century and to take measures to have the spiritual dimensions of health incorporated in that document as well as the revised WHO Constitution. Many countries in the Region had embarked on health sector reform; however, greater efforts in the area of policy analysis and formulation were required. The Regional Office was focusing on policy analysis, strategic planning and health futures. A priority of health systems in the Region was the strengthening of planning capabilities. The introduction of strategic thinking into health planning management would play an important role, while scenario and predictive techniques would be powerful tools in planning. The concept of health futures had been introduced in the Region in 1997, with the result that some countries were now intending to launch strategic planning exercises. Another important aspect of reform was improving management at all levels and strengthening managerial capabilities. A number of countries had embarked on strengthening institutions and decentralization and many more were applying the district team problem-solving approach. It was now being evaluated by the Region as a means of strengthening the skills of middle managers. Member States were also encouraged to establish mechanisms for intersectoral cooperation, particularly in areas where the basic development needs and quality of life approach had been adopted. Quality of health care was also a concern gaining ground in the Region, with the institutionalization of quality assurance receiving special attention. Countries had been provided with technical support to develop awareness, build capacities and provide training on the principles and development of quality health care programmes. Guidelines on the subject had also been prepared by the Regional Office. With regard to the progress of reform at regional level and the recommendations of the Executive Board Working Group on the WHO Response to Global Change, it was worth noting that, as a result of the WHO/government joint programme review missions, the governments of the Region now regarded WHO as a partner in health rather than a donor. Such missions provided an opportunity for regular consultation on the collaborative programmes as well as for feedback on the effectiveness of WHO input and budgeting. Although the members of the group undertaking the recent independent survey of WHO support to country programmes (the Oslo phase 11 study) had not visited any of the countries of the Eastern Mediterranean, its comments and recommendations had been well received in the Region, in particular those on the need to widen partnership at country level - an initiative that would be facilitated by greater coordination through joint committees with partners at headquarters and regional level. Collaboration between WHO and other agencies and partners was a priority of the Regional Office and WHO Representatives had taken the lead in that area. Efforts were being made to ensure that health aspects were taken into consideration in development projects. The Regional Office had developed a practical approach for coordination with donors and provided technical support to ensure that reform was in accordance with national health policies. The regional health database was currently being upgraded. initial output in 1997 consisted of a pamphlet giving the demographic and health indicators for the Region, which would be updated annually. Most country offices in the Region were already connected electronically to the Regional Office and should soon be connected through the regional intranet. Staffing structure was under constant review to ensure appropriate selection and recruitment and efforts were being made to improve the proportion offemale professional staff, which currently stood at 22%. Work was under way to develop a system of technical consultation through better use of WHO collaborating centres. Rotation of WHO Representatives between country offices and the Regional Office was being actively pursued.
SUMMARY RECORDS: FIRST MEETING
29
In the area of disease control, those Member States with high immunization coverage rates had been able to sustain them in 1996. Most countries had reported an immunization coverage of 90% or more for DPT3/0PV3 and measles. The estimated regional immunization coverage rates for 1996 were 89% for BCG, and 82% for OPV3, DPT3 and measles. Hepatitis B immunization was incorporated in immunization programmes in 15 Member States and nine of them had reported coverage rates of 90% or more. Fifteen Member States had reported no cases of poliomyelitis in 1996 or 1997, with nine maintaining poliomyelitis-free status for the past three years. National immunization days had been held in all Member States except one, and many countries had set up national committees for certification of poliomyelitis eradication. Neonatal tetanus, leprosy and dracunculiasis were close to eradication in the Region. At its forty-fourth session the Regional Committee had adopted a resolution to achieve the elimination of measles by the year 2010. With regard to tuberculosis, the strategic plan of"directly-observed treatment, short course (DOTS) all over" by the year 2000 had been rapidly implemented in most countries and had produced some very positive results. The first tuberculosis elimination initiative at subregionallevel had been launched by the member countries of the Gulf Cooperation Council with the aim of achieving elimination by the year 2010. The Eastern Mediterranean had remained the Region least affected by the HIVIAIDS pandemic. However, aware of the need to avoid complacency, effective preventive programmes were being implemented throughout the Region to reinforce the contribution made by social and cultural traditions. Despite the progress achieved, much remained to be done in the area of disease control. Malaria remained a major public health problem in Djibouti, Somalia, Sudan and Yemen, while there was room for improvement in communicable disease surveillance and capability for epidemic management including preparedness and response. However, there was now a better understanding ofthe epidemiology of the major noncommunicable diseases and several countries in the Region had launched internationally accepted intervention programmes for the prevention and control of specific chronic diseases. Universal salt iodization had been achieved in the majority of countries affected by iodine deficiency diseases. Several member countries of the Gulf Cooperation Council now fortified all bread with iron, while progress was being made in vitamin A control. Work had continued on programmes relating to reproductive health and focused specifically on safe motherhood. The mother-baby package had been adopted by Member States as a route to safe motherhood while the Regional Office had assisted countries in identifying priority areas for research in reproductive health, including safe motherhood, in order to protect and promote the health of women and children. The health of women throughout their entire life span was now receiving proper attention. Through its contribution to the task force on health in development and the Global Commission on Women's Health, the Regional Office continued to play an active role in drawing attention to the specific health needs of women, with special attention to adolescents and the elderly. National commissions on women's health had been established in most countries and interaction with the Regional· Office had been stepped up. Female genital mutilation remained widespread in some countries of the Region, problems being encountered in any effort to prohibit the practice. The solution probably lay in making greater efforts in community health education and promotion. At an intercountry meeting in 1997 on women's health and the quality of life, the issue of domestic violence had been discussed. In the area of mental health, a multidisciplinary meeting on mental health legislation in different legal traditions, including that oflslamic law, had been held in 1997 in cooperation with the Islamic Organization for Medical Sciences. Its recommendations would give guidance to countries drafting mental health legislation. Furthermore, in cooperation with the headquarters Nations for Mental Health Programme, a special session on the promotion of mental health had been held at the Regional Committee resulting in a declaration signed by heads of delegations and ministers in support of mental health programmes in the Region. The Regional Office had followed up that commitment by providing countries with an optional I 0-point programme in different areas of mental health. Two demonstration programmes for the integration of mental health into primary health care had been launched in Egypt and Yemen In 1997 the Regional Office had endeavoured to assist countries in the Region confronting emergencies. Considerable help had been given to Iraq to ensure implementation of the Memorandum of Understanding concerning the sale of oil for food and medicines. The approach was cost-effective and had yielded good results in the distribution of drugs throughout the country.
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In health services development, the Regional Office had continued to cooperate closely with several countries in the Region in establishing and promoting the basic development needs approach. A number of countries had made a firm commitment to adopt the approach in their country, such as Pakistan, which had allocated considerable funds in its budget to extend the approach throughout the country in the coming three years. Resolution WHA48.8 on reorientation of medical education and medical practice for health for all had been actively followed up at regional level. In response to the resolution and the recommendations of a 1995 ministerial consultation, a meeting had been held in March 1997 to discuss effective mechanisms for initiating and strengthening the partnership between the community, health authorities, academia and professional associations, and to define their roles in supporting health for all. The role of the universities and the professional associations had subsequently been discussed by the Regional Committee. A regional plan of action on health and environment had been approved at a ministerial conference held in December 1997. Progress had also been made in the preparation of national health and environment plans in 16 countries, in some cases as part of the joint UNDP/Capacity 21 and WHO country-based initiative for incorporating health and environment considerations into planning for sustainable development. The next step would be to reflect those strategies and plans of action in the national planning process for sustainable development. Dr HAN (Regional Director for the Western Pacific) said that 1997 had been a period of intense reevaluation. Completion of the third evaluation of the health-for-all strategy had made it necessary to examine all programmes closely to determine what had worked and what had not. At the same time, the fiftieth anniversary of the Organization was an occasion encouraging further reflection as to the extent to which WHO had fulfilled the expectations of the International Health Conference held in New York in 1946. The preparation of a renewed health-for-all policy had forced WHO to question how well it was equipped to deal with the health needs of the next 50 years. By the year 2000 seven cities with populations of more than I 0 million and almost half the world's cities with populations of more than two million would be situated in the Western Pacific Region. Disease profiles would be characterized less by communicable diseases and more by chronic disabling conditions, often associated with unhealthy lifestyles. It would be better to prepare for that transition now, rather than to rely on crisis management in the next century. The proportion of diseases in the Region attributable to noncommunicable diseases had outstripped that attributable to communicable diseases in the early 1980s and by the twenty-first century, injuries would be responsible for a larger proportion of overall disease than communicable diseases. Although diseases of the elderly were increasing their share of the disease profile, so too was illness in middle age, in particular cardiovascular diseases, cancer and other lifestyle-related diseases. Thus, as progress was made in combating communicable diseases greater attention would have to be given to reducing the risk factors associated with noncommunicable diseases. Lifestyle-related diseases would be particularly significant for WHO's future work in the Region. Not only were those conditions increasing; in many cases they could be prevented and controlled by individuals and communities. The regional policy document New horizons in health, which emphasized the role of the individual, was thus an intrinsic part of the regional renewal of the health-for-all policy. The draft regional policy for the twenty-first century was based on the belief that some features of the health transition would be difficult or even impossible to control, while others could, to a certain extent, be influenced. For example, cardiovascular diseases and cancer were major public health issues. Cancer was one of the three leading causes of death in 26 of the 37 countries and areas in the Region. Much work was being done to prevent and achieve early detection of cancer as well as to provide training in cancer pain relief and palliative care. Although the incidence of cancer in the Region would increase in the twenty-first century, everything possible would be done to slow its rise and to ensure that cancer sufferers would be able to lead dignified and fulfilling lives. Similarly, through intensive health promotion campaigns, regional programmes aimed to slow the rate of increase of cardiovascular diseases and diabetes and, where possible, to reduce their incidence and mortality. One.ofWHO's original goals had been the eradication of malaria. However, it was now accepted that some countries would continue to suffer from the disease for many years to come. The Region's strategy had been, and would continue to be, the application of intensified control measures in selected countries. For example, measures to reduce breeding sites and a mass drug administration campaign in the capital city of Honiara had helped to achieve a significant reduction in malaria cases in the Solomon Islands, the country with
SUMMARY RECORDS: FIRST MEETING
31
the highest incidence in the Region. Ambitious targets for malaria reduction had been set: by 2020 the objective was to reduce the number of microscopically diagnosed cases to 15% of 1995 levels and reduce deaths due to malaria to 10% of 1995 levels. In recent years tuberculosis had re-emerged as a major public health problem all over the world. Consistent application of WHO's tuberculosis control strategy, DOTS, had however achieved some success in containing re-emergence in the Region. If the targets for future DOTS implementation were to be achieved, and tuberculosis was to be controlled and eventually eliminated in the Region it was crucially important that national governments as well as WHO should devote sufficient resources and supervision. In 1997, the number of HIV -infected individuals in the Region had been estimated to exceed 700 000. Although, comparatively speaking, the HIV epidemic in the Western Pacific had been moderate, it was projected to spread rapidly in some countries, such as Cambodia, VietNam and southern China. The hope was that before long, effective and affordable preventive and therapeutic measures would be developed to counter that continuing spread. There was a good chance that poliomyelitis would shortly be eradicated from the Region. By 25 November 1997, only nine cases of wild poliovirus with onset of illness, the last occurring on 19 March, had been reported for the year. WHO reform had been a major priority. The Region had adopted the 47 recommendations of the Executive Board Working Group on the WHO Response to Global Change. In addition, the structure and operations of the Regional Office had been streamlined to focus more closely on cross-programme activities. Dialogue had begun with all professional and general services staff, together with WHO Representatives and country liaison officers, leading to 260 recommendations of varying significance. Over 50% of the recommendations had subsequently been implemented. Maintaining staff morale at its current high level was considered crucial. Every effort was being made to recruit qualified women in order to improve the balance between the sexes at the Regional Office. In the 1996-1997 biennium, seven of the 16 long-term professional staff recruited were women, bringing the overall figure to 44%. Reform was also a major theme at country level. The document on renewing the health-for-all policy emphasized that health sectors faced three major challenges: ensuring equity of access, providing quality of care and containing costs. The role of the Regional Office was to support those reform initiatives and to ensure that the people ofthe Region received the best health services possible, bearing in mind that some countries faced a double burden of communicable and noncommunicable disease. The Region's capacity to respond to new challenges had been tested in recent months by the emergence ofthe new H5N1 influenza virus strain in Hong Kong, Special Administrative Region of China; the Regional Office had been able to initiate rapid collaboration with the authorities in Hong Kong and in the rest of China. However, despite all its efforts, the Regional Office remained conscious that there were still underserved communities whose health needs were no different from those prevailing at WHO's establishment 50 years previously. Over the coming half century, the aim should be to strike a balance between responding to changing circumstances and remaining true to the Organization's raison d'etre- a delicate balancing act which made the current period of its history such a challenging one. (For continuation, see summary record of the second meeting, section 1.)
6.
REPORTS OF ADVISORY BODIES AND RELATED ISSUES: Item 11 of the Agenda (Document EB101/39)
International Agency for Research on Cancer Dr KLEIHUES (Director, International Agency for Research on Cancer), noting that IARC was an integral part of WHO, said it was currently supported by 16 Member States. It was hoped that Argentina would join those participating States in the coming year. The current annual budget was some US$ 18 million and the Agency employed 240 staff members from 35 countries. The Agency's work focused on determination of the
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EXECUTIVE BOARD, 101st SESSION
causes of human cancer, elucidation of the mechanisms of cancer induction, and the scientific development of strategies aimed at cancer prevention. A highlight of 1997 had been the publication of Volume VII of Cancer incidence in jive continents, the flagship publication ofthe Agency's epidemiology division. The work covered 180 populations in 50 countries and was considered the most reliable review of cancer epidemiology worldwide. Knowledge of cancer incidence, mortality and the survival of cancer patients was a necessary prerequisite for any national cancer control strategy. The publication, for the first time, contained data from Argentina, Republic of Korea, VietNam, and Uruguay. In view of the bulkiness of the printed version, the fact that an electronic version was available meant that cancer incidence in different countries could be easily visualized and age-adjusted cancer incidence compared in different regions of the same country. With regard to analytical epidemiology, a major study had been completed on passive smoking, and was playing a vital role in the battle currently being waged against the tobacco industry, since protection of nonsmokers and minors was crucial to prevention of tobacco-related cancers. The results of the study clearly indicated that passive smoking in spouses or in the workplace unquestionably increased the incidence of lung cancer. Although the increase in relative risk was only 1.16%, the large number of passive smokers made the public health impact a major one. As regards nutrition and cancer, the most important project was a European multicentre study involving seven countries. It was a prospective study to gather not only epidemiological data on lifestyle and nutritional habits but also more than 400 000 blood and serum samples from all over Europe. A special building had been constructed to store the samples at a temperature of -180°C for more than 20 years. The study was a good example of how epidemiology and basic research could be combined. It had many problems to solve, since it was well known that the western diet was associated with breast, prostate, colon and testicular cancers, although it was unclear what the nutritional components or the biological basis of interaction were. Extensive work had been done in the area of organ-specific carcinogenesis. One major example was cancer of the oesophagus, which was frequent throughout the world, particularly in many developing countries. Although in the developed world, the main causes were alcohol abuse and smoking, elsewhere constant injury caused to the oesophagus by hot beverages, hyponutrition and hypovitaminosis were among the culprits. The Agency had considered the problem from the molecular point of view and had looked at the type of mutations found in oesophageal cancer in different regions. A very clear pattern had emerged; cancers associated with alcohol consumption combined with smoking showed a particular type of transversion mutation in the p53 tumour-suppressor gene, whereas those resulting from chronic inflammation, chronic injury and Barrett's oesophagus showed a particular type of transition mutation. The latter were considered to be endogenous and not produced by environmental carcinogens; oxidative stress might play a role. They were also found in cancers for which no etiological role currently existed, for example brain tumours and sarcomas as well as in all cases of chronic infection, such as ulcerative colitis, before any evidence of cancer was found. One of the most interesting aspects of current cancer research was gene-environment interaction. Two years previously, a unit had been set up to study population-based mutations in breast cancer-associated genes. Although it was known that in Western countries, which had a high incidence of sporadic breast cancer, 60-80% of women with a mutation in any of those genes would develop breast cancer in their lifetime, it was unknown whether that relationship held in a low-incidence country. Active investigation was under way into whether a given genetic susceptibility was the overriding principle, or whether lifestyle factors still played a role. The results so far obtained indicated that the latter were just as important, if not more so, even in women with a genetic predisposition. Factors such as parity were also significant, as early child-bearing conferred a protective effect against breast cancer, even in the presence of certain breast-cancer associated gene mutations. The unpredictability of medical research was demonstrated by another study which had proved unexpectedly that smoking might give women with mutations in cancer-associated genes some protection, probably because smoking had a depressive effect on oestrogen metabolism. Another example had been given by a gene-environment interaction study to elucidate the gene responsible for poly(ADP)ribosylation of nuclear proteins, which had been under investigation for 20 years. Most research workers believed it related to the maintenance of genomic stability and DNA repair. However, mice produced without the enzymes concerned had been shown to be resistant to cerebral ischaemia and the induction of diabetes type 1. A supposedly cancerrelated gene could therefore well give rise to a new treatment against stroke and diabetes. As regards cancer prevention, a first handbook on the subject had been produced, which concentrated on evaluating the effects of aspirin, sulindac and related non-steroidal, anti-inflammatory drugs. Although many
SUMMARY RECORDS: FIRST MEETING
33
studies had indicated that aspirin had a preventive effect on the development of colon cancer, the dose and duration of administration necessary were not yet clear and aspirin could not therefore be recommended for this purpose to the general population. Two programmes had not lived up to expectations. Firstly, it had been hoped that phase I studies could be initiated to produce vaccines against human papilloma viruses. However, that had not proved to be the case. Secondly, the search for the gene responsible for X-linked lymphoproliferative disease, which conferred a high susceptibility to Epstein-Barr virus, was continuing, since elucidation of that gene and its function, might show why the virus sometimes caused nasopharyngeal cancer, Hodgkin's lymphoma and non-Hodgkin's lymphoma associated with AIDS, Burkitt's lymphoma and other conditions. The smallest deletion found in any of the affected families, covering 120 000 base pairs, had been sequenced, but the gene had not as yet been found, although the study was still continuing. In the area of personnel policy, a system of five-year fixed-term contracts for young scientists had been introduced within the existing WHO rules and had led to no decline in the previous high standard of applicants. The Governing Council of IARC had advocated that a flexible approach should be adopted in all parts of the Agency's hierarchy. For example, the Director served a term of office of five years which was renewable once. In addition to his administrative duties, he had produced a book on Pathology and genetics of tumours of the nervous system. Although histological classification of diseases had for long been the basis for clinical diagnosis, it was now recognized to be insufficient for many cancers, where genetic typing was also necessary. If successful, the book could well be expanded into a series on the pathology and genetics of various tumour sites. Finally, the WHO programme on cancer control, which had been transferred to the Agency in Lyons, was currently headed by Professor Sitora who had assumed office on 1 October 1997. He had begun to develop cancer-control strategies in close cooperation with the Regional Offices and with WHO headquarters. The continuing support of the Director-General for all the activities conducted by the International Agency for Research on Cancer was greatly appreciated. (For continuation, see summary record of the second meeting, section 2.)
The meeting rose at 12:35.
SECOND MEETING Monday, 19 January 1998, at 14:30 Chairman: Professor A. ABERKANE
1.
REGIONAL MATTERS: REPORTS BY THE REGIONAL DIRECTORS: Item 4 of the Agenda (Documents EB101/2 and EB101/INF.DOC./8) (continued from the first meeting, section 5)
The CHAIRMAN invited comments on the reports of the Regional Directors presented at the previous meeting. Mr VOIGTLANDER welcomed the fact that the Regional Director for Europe had mentioned the distribution of resources: a growing problem owing to an increasingly obvious imbalance that could no longer be neglected. As part of priority-setting and the attribution of corresponding resources to priority areas, there had been an efficiency drive within the European Region that merited the Board's attention. He requested the Regional Director for Europe to outline that process. Dr NAKAMURA welcomed the significant improvements in the presentations by the Regional Directors that had resulted from the use of a common framework in their preparation. The Western Pacific regional policy document, New horizons in health, had been well received and had assisted Member States of the Region in developing their national health policies. The eradication of poliomyelitis from the Region would soon become a reality, thanks to the leading role played by the Regional Office and substantial contributions from some countries, including his own. Emerging and re-emerging communicable diseases were of special concern to health authorities throughout the world. The Western Pacific Region had placed those problems at the top of its agenda: he welcomed that commitment. A new strain of influenza that had been shown to affect human health had recently become a matter of great concern to Japan and neighbouring countries. The Western Pacific Region's prompt and timely attention to the matter, in collaboration with the Division of Emerging and other Communicable Diseases Surveillance and Control, was welcome, and it was to be hoped that the Region would continue to take a leading role. The health effects of the haze caused by large-scale forest fires had been a matter of great concern during the most recent meeting of the Regional Committee for the Western Pacific. The preparedness and ability to respond to such emergencies of regional and country offices should be further strengthened, in close collaboration with WHO headquarters. Mrs SUNDREHAGEN (alternate to Dr Alvik) welcomed the standardized format of the Regional Directors' reports, which made them more concise and easier to read. The decision by the Regional Director for South-East Asia to set up a separate unit within the Regional Office to focus on women's health and development was an excellent way to implement the strategy outlined by the Executive Board. All the Regional Directors had expressed their views on regular budget allocations to the regions; the African Region, in particular, had a strong argument for changing the present situation. The Standing Committee of the Regional Committee for Europe, in whose work Norway had participated for the past three years, was doing an excellent job, and its cooperation with the Regional Office was good. The Regional Committee for Europe had adopted a resolution requesting the Regional Director to formulate a new, short publication to supplement the existing document on the health-for-all policy for the twenty-first century. The new document should affirm global health-for-all values and principles, as decided by the Health Assembly, - 34-
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35
clarify the main priorities for action in the European perspective, and facilitate action in Member States, including the mobilization for health of a wide range of partners and sectors. Professor REINERjoined previous speakers in commending the Regional Directors' reports prepared on the basis of a common framework, as requested by the Board. The comprehensive efforts by the Regional Director for Africa to mobilize action to attain health for all were impressive. It was to be hoped that other regions would follow that example, which offered hope that health-for-all policies and strategies would be successful in the next century. Paragraph 8 of the report by the Regional Director for the Americas (document EB 101/2, section II) set out the Regional Committee's position on regional arrangements for the semipermanent representation on the WHO Executive Board of Permanent Members of the Security Council. The position was similar to the one adopted by the Regional Committee for Europe, namely, that Member States of each Region should be free to continue the practice of nominating the Region's representatives on the Board. He commended the establishment of a special unit for women's health in the South-East Asia Region. Paragraph 6 of the report by the Regional Director for Europe (document EB 101/2, section IV) referred to an important effort which was related to the recent Global Conference on Climate Change, held in Kyoto, Japan, and to the implementation of Agenda 21, adopted at the United Nations Conference on Environment and Development in Rio de Janeiro in 1992. At a conference of ministers of health and of the environment held in June 1994 in Helsinki, all European countries had accepted the task of preparing national environmental health action plans, and most were now doing so. In Croatia, that was considered to be one of the most important ways of preventing ecological catastrophe. Each country should do its share, not only for the sake of environmental health, but also to create the necessary preconditions for sustainable development: environmental damage and pollution had no national boundaries. The European example could be instructive for other regions, just as Europe was carefully following positive developments in other regions. Finally, the Regional Director for Europe deserved praise for his clear presentation of a difficult financial situation, which he hoped the Board would reverse by wise decisions concerning regional allocations, country presence and other matters. Or BLEWETT agreed that the structure of the Regional Directors' reports had been improved. The Regional Committees had the job of supervising work at the regional level, but the Board had to look at all regions taken together, and could only do so effectively through a comparative approach. Efforts to improve the format should continue in order to facilitate comparison still further. He welcomed the commitments to reform the Regional Committees. It was important for regional leadership to incorporate a global vision of the Organization's needs and requirements for change. He expressed admiration for the response made by the Regional Director for Africa and his staff following the regrettable events in Brazzaville. Crises often brought out the best in an organization, and other regions might find that the approaches used in Africa gave them inspiration for better ways of getting things done in general. After the Regional Office had found a permanent home, the benefits of the creative thinking used in the interim must not be lost; it might be useful to prepare a report on the measures adopted. Or SANOU IRA pointed out that most of the Regional Directors' reports reaffirmed one of the Organization's principles, namely that the gaps among countries in the health field, particularly in respect of communicable diseases, represented a threat to the entire world. That was something that had to be taken into account in the future. The reports reflected the contribution made by each region to the elaboration and revision of the strategy for health for all for the twenty-first century, and demonstrated the importance of the approaches used in solving health problems. Environmental protection should be integrated into all development projects. Finally, the reports revealed a need for revision of the standard tools for programme evaluation available to States. All of those elements should be taken into account in order to improve project management and to prepare the strategy for the twenty-first century. Or WASISTO welcomed the progress made in many regions, especially the improvements in health status in the South-East Asia Region, and looked forward to the eradication or elimination of communicable diseases such as poliomyelitis, leprosy, neonatal tetanus and measles in the near future. The reports of the Regional
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EXECUTIVE BOARD, 101 st SESSION
Directors showed that, in nearly all parts of the world, noncommunicable diseases were on the rise. Concerted efforts to control such diseases had therefore to be intensified. Finally, he hoped the serious problems faced by one of the regions could be resolved in the near future. Dr STAMPS, referring to the report of the Regional Director for Africa, said the evidence now clearly showed that Africa was able to cope with unpredictable situations. It was transforming itself from a passive recipient of donor aid and advice into a capable and mature continent. A well-framed and innovative meeting ofthe Regional Committee had been staged in September 1997, despite the Regional Office's total disruption in June 1997 and the difficulties created by evacuation of the staff. He thanked the Director-General for his assistance in making sure that the work of the Regional Office could continue. Contrary to the impression given by Dr Blewett, the Regional Office did have a home, in Zimbabwe, which would continue to provide support for as long as was appropriate. Reports on the situation would be regularly provided, but he hoped it would be noted that when help had been needed for the Regional Office, it had come from within Africa, and without external subsidy. Two notable achievements in Africa, both generated from within the Regional Committee, could be discerned from the report. Africa-wide days of immunization against poliomyelitis and measles had been held in 1997 and were to be extended in 1998. They had been made possible largely through the support of Rotary International, UNICEF, UNDP and other United Nations organizations, and held out the real prospect of elimination of poliomyelitis from the continent within a very short time. With the emergence of the Democratic Republic of the Congo, coverage could be extended to an area that had in the past been difficult to reach. Africa's second achievement was the declaration on malaria adopted by OAU in June 1997, which committed African countries to providing resources for the control and, ultimately, elimination of the diseasea major threat to development as well as to health - from the continent. Some 90% of deaths from malaria worldwide occurred in sub-Saharan Africa and 90% of children under five who died from malaria were in that Region. The disease took the lives of more than one and a quarter million children every year, yet it was one for which a prevention strategy was in place and an affordable treatment method existed. The OAU declaration gave grounds for hope, and he thanked the Director-General for the allocation of funds, alongside the commitment of African countries, to enable it to become a reality. Significant progress had been made on issues related to land, but difficulties were being encountered, particularly in southern Africa, in transmitting the message that the distortions artificially created in colonial times could not be allowed to continue. A situation where people were deprived of the means of producing the food they needed while vast tracts of land were under foreign ownership could not be tolerated. That was no less a public health issue than the problem of malaria, poliomyelitis or HIV. He agreed with previous speakers that the Regional Directors' reports were much more clearly presented and readable than in previous years. Dr CALMAN supported Dr Blewett' s comments, particularly on the African situation, from which other regions could learn an enormous amount. Although there was still much to do, WHO had come a long way over the past few years in making changes and improving its ability to respond to issues and enhance health in general. A strong WHO was needed, and it was to be hoped that the forthcoming Health Assembly and The world health report would be used to highlight the changes introduced and to present them in a positive light. A positive message had come through clearly from the reports of the Regional Directors. Dr DOS SOU-TOGBE joined previous speakers in welcoming the standard structure of the reports by the Regional Directors, which made for easier reading and comparison. Referring to the comprehensive descriptions the Board had heard of the situation in Africa, he emphasized the fact that many problems and crisis situations were the consequence of human behaviour. For example, emergency situations caused by severe flooding were often the result of misguided house-building in areas subject to flooding. It was essential, through education, to make people more aware of such problems and to encourage more responsible behaviour. Secondly, he highlighted the importance of improving recruitment of women in the Organization, especially at higher levels. Recruitment was only one part ofthe overall process related to the utilization of human resources, the first step of which was training: emphasis should be laid on basic education and in-service training for women, so as to avoid the call for recruitment of women becoming an empty slogan.
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37
Dr ASVALL (Regional Director for Europe), replying to Mr VoigtUinder, said that the 3% shift of resources from administrative services to priority technical programmes, requested by the Health Assembly in May 1997, had been achieved in the European Region by: cutting building maintenance expenditure; reducing the number of permanent translation staff and utilizing more ad hoc arrangements to cover peak work periods; introducing electronic-based library facilities; reducing the number of staff in document reproduction and information system development; and transforming one WHO Representative's office into a liaison office, an arrangement which had proved technically sufficient for the country concerned. The resulting funds (approximately 3.2% of the budget) had been used to create new posts in the areas of sexually transmitted diseases, HIV/AIDS and other communicable diseases, women and child health, pharmaceutical and research mobilization for countries, and the re-establishment of the mental health programme.
2.
REPORTS OF ADVISORY BODIES AND RELATED ISSUES: Item 11 of the Agenda (continued from the first meeting, section 6)
International Agency for Research on Cancer The CHAIRMAN invited members of the Board to comment on the report of the Director of the International Agency for Research on Cancer presented at the previous meeting. Mr VOIGTLANDER said that the recent reforms ofiARC, closely monitored by its Governing Council, might serve as a useful example in that they had been achieved within the limits of the approved budget, with a corresponding shift of resources to the priority areas identified by the Council. Noting that IARC had only 16 Member States and that more countries could make a scientific contribution to its work, he recalled that, for many years, one obstacle to membership had been that the full contribution had to be paid in the first year. He requested clarification concerning the Governing Council's recent decisions aimed at facilitating accession to the Agency. Dr STAMPS asked how IARC selected the questions to be pursued and how the Governing Council was guided in determining priorities. Dr KLEIHUES (Director, Internationai Agency for Research on Cancer) explained that all Member States of IARC contributed equally to 70% of the budget, and only the remaining 30% was assessed on the basis of economic strength. Currently, each Member State therefore paid between 5% and 9% of the total budget. That arrangement, although reasonable and effective, had meant that the assessment on new Member States was higher than in other organizations. The Governing Council had therefore decided two years previously that new Member States would contribute 25% of their assessed contribution in the first year of membership, 50% in the second year and 75% in the third year, and would only pay in full thereafter. Argentina had sent a letter of intent to the Director-General and was expected to become a Member during the current yt;ar, and two other States had indicated their intention to apply for membership. Priority was granted to projects that could be better implemented on an international than a national or regional level; to the investigation of cancers prevailing in developing countries; and specifically to research on prevention of cancer and on intervention studies, such as the study on hepatitis intervention in Gambia, which had proved highly successful.
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EXECUTIVE BOARD, 101st SESSION
3.
REPORTS OF THE PROGRAMME DEVELOPMENT COMMITTEE AND THE ADMINISTRATION, BUDGET AND FINANCE COMMITTEE OF THE EXECUTIVE BOARD: Item 6 of the Agenda (Documents EB101/3 and EB101/4)
Mr HURLEY (Chairman, Programme Development Committee) highlighted some of the conclusions of the fourth meeting of the Committee (PDC), which were set out in document EB101/3, indicating that he would speak again on those points which were to be discussed in detail by the Board under the relevant agenda items. While supporting the draft document on health for all in the twenty-first century, the Committee had considered that it should be revised to incorporate a number of important changes. For example, it should underline the economic importance of investments in health and education as a basis for fostering development. Collaborative arrangements between other partners in the health area, both within and outside the United Nations system, should be given greater substance. Regarding the draft WHO charter/declaration based on the healthfor-all policy for the twenty-first century, some members of the Committee had expressed a preference for calling the document a declaration since the term "charter" might raise certain legal difficulties. In general the draft text had been regarded as a satisfactory basis for further discussion. It had also been suggested that a summary document on health for all should be prepared for ministers of health. Evaluation of PDC and the Administration, Budget and Finance Committee (ABFC) had not yet been completed and response to the relevant questionnaire had been low. Outside evaluation assistance might be required for completion of the exercise. Regarding programme management matters, a comprehensive document entitled "Planning and managing WHO's programmes", reflecting present changes and the interlocking nature of programme matters, would be made available to all Board members. Further items discussed under the general heading of programme management had included: the development of the WHO evaluation system, in which the complexity of the management tools must be balanced against their benefit to the Organization; draft guidelines for PDC which, it was felt, should recommend that interim financial information should be available in January 1999, prior to adoption of the programme budget for 2000-2001; the analytical framework for setting WHO priorities; plans of action, in which significant progress had been made, notably in the activity management system scheduled for use by January 1999, thus facilitating the preparation of a standard plan of action; and the proposed out! ine for the Tenth General Programme of Work, which would be further developed and subsequently reviewed by PDC. Regarding the review of Health Assembly resolutions, further attention should be given to the reporting dates, which were frequently periodic or unspecified, and to future reporting requirements in general, in line with resolution WHA47.14. He drew attention to the closing remarks in the Committee's report (document EBI01/3, paragraphs 37 and 38), which acknowledged the overall progress that had been made in the management process and proposed four areas for further review. Finally, with regard to the joint meeting of PDC and ABFC, two items had been emphasized: the efficiency plan for the financial period 1998-1999 and the evaluation of the two Committees an area in which ABFC supported PDC, particularly in relation to outside evaluation assistance. Dr WASISTO (Chairman, Administration, Budget and Finance Committee), introducing the Committee's report (document EB101/4), said that the recent ABFC meeting had been positive and open. All its agenda items would be taken up by the Board during the session and he would contribute further to the relevant discussions as appropriate. Highlighting certain points in the report, he stated that in debating the matter of efficiency savings in the programme budget, which would be taken up by the Board under item 13.1 of its Agenda, some members of the Committee had felt that the plan presented should have responded more closely to the Health Assembly's concerns while others had considered that the efficiencies should be monitored carefully during implementation. The Committee's conclusions in that regard were contained in paragraph 5 of the report. The suggestion of the External Auditor that the Committee's terms of reference should be expanded - or a new committee should be established- to include consideration of technical audit matters had been debated at some length; the Secretariat would pursue the matter in discussion with the External Auditor. If the Board so agreed, the Committee would report further during its consideration of the subject under item 14.4 of its Agenda. ABFC would consider the matter further and report to the Board at its I 02nd session.
SUMMARY RECORDS: SECOND MEETING
39
The situation of arrears of contribution and of casual income had also been examined; around US$ 11.5 million was available from casual income to help finance the 1999 budget. A number of issues relating to personnel, including the participation of women in the work of WHO, had also been reviewed. The CHAIRMAN invited comments on the reports of PDC and AFBC. Mr JUNEAU indicated that a number of Board members were preparing a draft resolution for consideration under item 7.2 of the agenda in relation to paragraph 25 ofPDC's report. Decision: The Executive Board noted the reports of its Programme Development Committee (PDC)l and Administration, Budget and Finance Committee (ABFCY and endorsed their conclusions concerning continuing evaluation of the two Committees, including the use of outside expertise, pursuance of the development of the evaluation system in WHO, progress made on plans of action, proposed outline of the Tenth General Programme of Work, and the recommendations: (a) that more attention be given to reporting requirements in Health Assembly resolutions; and (b) that the Director-General should study the matter further and report to the fifth meeting of PDC. It agreed to consider other matters raised in the reports ofPDC and ABFC under the related agenda items. 3 (For continuation, see summary record of the sixteenth meeting, section 8.)
4.
WHO REFORM: Item 7 of the Agenda
Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group: Item 7.3 of the Agenda (Resolution EB99.R24; Decision EB99(5); Document EB101/7) Dr BLEWETT, speaking as Chairman of the Executive Board special group for the review of the Constitution of WHO, recalled the original and extended mandate of the special group, which had been established by the Board in response to resolution WHA48.14. The group had met six times since its inception and had presented an interim report to the Board in January 1997. After thanking all those who had participated and assisted in the special group's work, he expressed the hope that Board members would judge the group's recommendations in the light of the contribution they made to the global needs of the Organization. The CHAIRMAN invited the Board to consider the recommendations made in the report section by section.
Review of provisions of the Constitution Professor REINER and Professor PICO (alternate to Dr Mazza) asked what procedure would be followed in regard to the proposals made by the special group. Dr BLEWETT, speaking as Chairman of the special group, explained that the intention was for the Executive Board to take a decision to reject or refer to the Health Assembly each of the recommendations for action, with the exception of matters pertaining to Article 2, which, in view of its fundamental importance, should be reviewed before receiving consideration by the Board and the Health Assembly in 1999.
1
Document EB!Ol/3. Document EBlOl/4. Decision EB!Ol(l).
2 3
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EXECUTIVE BOARD, 101st SESSION
The CHAIRMAN added that the intention was not to approve a text for Article 2 at the present stage but to promote a discussion within the various parts of WHO and to consider the matter again at the Board's 103rd session, if that approach was acceptable to the Board.
Definition of health (Preamble) Or VAN ETTEN said that the group had given no rationale for its proposal to include spiritual well-being in the definition of health given in the preamble. He requested further information on the type of government intervention that could be envisaged in that connection, which he felt was an individual matter, and on how spiritual well-being might be measured. Or SANOU IRA thought that the view of governments should be sought in order to arrive at a definition of health that assisted planners in their work. The word "spiritual" would pose problems in that regard. Or BADRAN (alternate to Professor Sallam) saw no objection to including spiritual well-being in the definition. It was now acknowledged that there was a strong link between spiritual and other aspects of health. He therefore supported the recommendation. Professor PICO (alternate to Or Mazza) endorsed the view of the previous speaker. The spiritual aspect of health was very important in connection with the defence of human dignity and with ethical considerations. Mr DE SIL VA also supported the inclusion of spiritual well-being, which was of great importance and well-proven value in certain systems of medicine and would provide a broader definition of health. Or LOPEZ BENITEZ stressed that there should be no confusion between spirituality and religion, since internal spiritual attitude was not dependent on being of any particular religious persuasion. Spirituality was connected with certain human aspirations which could be observed during illness. "Spiritual" had been included to emphasize the individual side of human nature in contrast to the part played in society, expressed by the word "social" in the definition. Furthermore, by including the word "dynamic", the group had reflected the fact that health and sickness were part of a continuum in which both states existed. He did not think that either the old or the new definition should cause difficulties for planners, whose work was based on having the necessary information on a particular health issue. Or STAMPS said that there was much evidence in recent times in many parts of the world that State interference in the spiritual freedoms of peoples created health problems. The state of spiritual well-being should be the responsibility of every individual and every community as an essential ingredient of the complete state of health. It was not a religious experience or particular form of religion or non-religion that was at issue. Spiritual well-being was necessary, especially in traditional medicine, for the effects of the medicine to be optimal. It was important to remember that the concept had been deleted from the original formulation of the definition in 1948 because of the objection of the Marxist group. The concept did not interfere with planning, except to the extent that no State, organization or community had any right to impose or impinge on personal spiritual beliefs and convictions; in fact, the State should facilitate personal spiritual ambitions and satisfaction. The group had felt that it was as intrinsic to health as were social, physical and mental well-being. Or SHIN said that he had followed the debate in the special group and understood the concept of spiritual well-being, which was in line with the fundamental goals ofthe Organization and of all public health action. However, he considered that there was room for further reflection before the definition was discussed at the 103rd session ofthe Board in January 1999. The impact ofthe revised definition on WHO, health policy, the academic world and industry must be taken into account. It might be valuable to create a forum for wide-ranging discussion of the matter. Or FERDINAND agreed that further discussion might be needed before a decision was taken. She supported the inclusion of a spiritual dimension in the definition of health; spiritual well-being was already included in the health promotion charter in her own subregion.
SUMMARY RECORDS: SECOND MEETING
41
Dr WILLIAMS said that the spiritual dimension had a tremendous bearing on the moral, emotional and social fabric of society, and therefore on health; he thus supported its inclusion. Dr CALMAN supported the inclusion of spiritual well-being in the definition of health, since it was very difficult to consider issues of quality of life or well-being without taking the spiritual dimension into account. Nevertheless, he recognized that further discussion on the subject was needed. The CHAIRMAN reminded members of the time-scale involved in having any resolution on the matter adopted by the Health Assembly - the earliest date being 1999 - and suggested that members should give their opinions on each amendment proposed by the special group so that they could proceed to adopt a resolution that included those points on which they were in agreement. Mr HURLEY said the inclusion of the spiritual dimension reflected its importance without in any way interfering in the way individuals conducted their lives. Dr SULAIMAN said there would be further opportunities to discuss the definition of health before the Health Assembly needed to make a final decision, but wondered if any definition accepted at the moment could be revised at a later date. He agreed with the inclusion of a spiritual dimension in the definition, but was concerned that that had not been adequately reflected in the Arabic text. Dr NAKAMURA was of the opinion that Member States would need more time to study the amendments to such a fundamental change. Dr BADRAN (alternate to Professor Sallam) was concerned that the inclusion of a word on which there was almost unanimous agreement should have provoked such a lengthy discussion. He suggested an appropriate Arabic translation for "spiritual". Professor LEOWSKI agreed with Dr Nakamura that more time was needed to study the matter, since the introduction of "spiritual" in the definition of health was not reflected in subsequent articles on the functions of the Organization. Mr NGEDUP joined the consensus supporting the inclusion of the word "spiritual", which had a broad and all-encompassing meaning, and was not in need of further definition. Dr MUL W A agreed with previous speakers that the spiritual aspect of human beings needed to be addressed in the definition of health. Traditional healers, for example, had an important role to play in the delivery of health services in some parts of the world. Mr DE SILVA said that the matter had already been considered at length by the special group, and that, in the interests of projecting a dynamic image of the Organization, the Board should take a decision promptly. Dr STAMPS, responding to Professor Leowski's concern that the functions of the Organization outlined in Article 2 did not specify what the Organization would do about spiritual well-being, pointed out that the same could be said of social well-being, but that the absence of the actual words did not mean that those aspects were not included in the list of functions. For example, a spiritual dimension was implicit in the proposed wording of Article 2, paragraph 2(h) on desirable and appropriate methods of teaching, and in paragraph 3(d) of the same Article, on promoting ethical standards. Moreover, spiritual well-being was a matter of personal choice, not something to be imposed by a community, and spiritual peace and comfort were a vital aspect of health. He agreed that the Board should move quickly to make what were, after all, only recommendations to the Health Assembly. Dr SANOU IRA said that, while she was not against the inclusion of the word "spiritual", further discussion was necessary to ensure that the word had the same meaning throughout the Organization.
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EXECUTIVE BOARD, 101st SESSION
Dr FIKRI, recalling that the original request to include the spiritual dimension had been made by the Regional Director for the Eastern Mediterranean, agreed with the majority of members that the definition of health should include spiritual well-being. Dr AL-MOUSA WI favoured the inclusion of the word "spiritual" but said its definition should be clear because it referred to spiritual well-being rather than to such practices as homeopathy, herbal medicine and traditional healing. Dr WILLIAMS recalled that the final decision on amendments to the Organization's Constitution could only be made by the Health Assembly, with a two-thirds majority, and with the decision then having to be ratified by two-thirds of the Member States. The CHAIRMAN said that most members of the Board seemed to be in favour of the recommendation of the special group, and those wishing to postpone consideration of the issue could abstain in the vote. Dr SHIN said that although he was not objecting to the inclusion of the word, the definition was so important that it had to be agreed by consensus following further wide-ranging discussion after a vote was taken. Dr STAMPS proposed that the Board should proceed with the vote. Dr V AN ETTEN proposed the insertion of an asterisk with a footnote providing a definition of the word "spiritual". Dr SULAIMAN said that the word should be accepted without any attempt being made to explain it. It was an all-encompassing term that embraced a large number of different kinds of traditional medicine practised in many different countries, as well as individuals ranging from men of religion to charlatans. Dr CALMAN said he had qualified his strong support for the word's inclusion, recognizing that it represented an important shift which required more discussion and acceptance by consensus. Voting during the present meeting would polarize views in ways that might be unhelpful. Board members who felt they needed more time would, if there was a vote, be forced to abstain. It should be noted that there was a consensus in favour of the shift but that the matter should be discussed further in the Health Assembly. For his part, he did not agree with some of the definitions that had been used: for example, tribal medicine and homeopathy were not what he understood by "spiritual". Dr BLEWETT, speaking as Chairman of the special group, observed that, because of the notice requirement, the subject would not be discussed by the Health Assembly before 1999. If progress was not made at the present session of the Board there was a danger that it would not be dealt with until the year 2000. Mr DE SIL VA said it would be a waste of time to postpone consideration of the recommendation because there would be other opportunities for views to be expressed before a final decision was taken by the Health Assembly. In his view it would not be helpful to include a definition of the word "spiritual": there were many words in the Constitution, and it would be pointless to try to define them all. Dr STAMPS said that spiritual healing was an intrinsic part of traditional medicine and central to health. The word "spiritual" was a very important one; there would be several opportunities for reservations to be expressed, but a decision should not be postponed. Professor REINER pointed out that the Board had been discussing the review of the Constitution for two years and it was time to reach certain conclusions. Whatever was decided was a recommendation to the Health Assembly for its consideration in 18 months' time, so a final decision was a long way off.
SUMMARY RECORDS: SECOND MEETING
43
Dr MELONI acknowledged the profound significance of the word "spiritual" but requested further clarification as to the implications of the effect which the inclusion of the word would have on the work of the Organization. Mr JUNEAU and Dr MAZZA said there would be plenty of time for views to be expressed but a decision should be taken by the Board at the present meeting.
The recommendation was approved by 22 votes to none, with 8 abstentions. Functions of WHO (Article 2) The CHAIRMAN explained that the special group's recommendation was that the revised text of Article 2 should be submitted to the governing bodies of WHO but that the details should be reviewed at all levels of the Organization during 1998 with a final text reflecting that consultative process being submitted to the Board at its 103rd session in January 1999. No decision was required of the Board at the present session. Dr BLEWETT, speaking as Chairman of the special group, said it had taken that view because of the extent of the revisions, which should remain on the table for a substantial period of time. Mr HURLEY, supported by Professor REINER, said that the function of the Organization as the coordinating authority on international health was so crucial that a mechanism should be developed to give effect to partnerships in health, and he wondered if it would be appropriate for such a mechanism to be considered alongside the content of Article 2. Dr MAZZA said that the drafting would be improved if some of the functions were grouped together. Dr SANOU IRA said it might be necessary to define the Organization's functions in terms of general and preferred principles. Mr AITKEN (Assistant Director-General) confirmed that the mechanism mentioned by Mr Hurley would be considered throughout the consultation process.
The Board took note of the recommendations. Consequences for Members failing to meet financial obligations (Article 7) Dr BLEWETT, speaking as Chairman of the special group, said that under the present Constitution a Member failing to meet its financial obligations could have services denied to it. The group believed that that penalty was both inappropriate and unfair and should be amended. Further, it proposed a tightening up of the particular financial and participatory penalties for failing to meet financial obligations. Dr VAN ETTEN said that in some exceptional cases the Organization might need to buy services from a Member State even if it had failed to meet its financial obligations. He therefore proposed that the words "if alternatives are available" be inserted after "any Member State" in proposed Article 7(a)(2), a wording that was in line with the phrase employed in the Fifth Committee of the United Nations General Assembly. Dr STAMPS said that the amendment to Article 7 did not go far enough, since a distinction should be drawn between Member States that were unable to meet their financial obligations because of their economic circumstances and those that were unwilling to pay. It should be possible, though not mandatory, for the Organization to refuse to pay for services from a State that defaulted on its obligations "without due cause", the latter phrase being a sufficient criterion. Major contributors had recently put the viability of the Organization at risk simply because they felt that some of its activities did not comply with their wishes. Reservations about the extent of the Organization's assistance to one or other State was no excuse for failing to pay assessed contributions. Any further dilution of Article 7(a)(2) would be inimical to the sanctioning of recalcitrant
44
EXECUTIVE BOARD, 101st SESSION
Member States, especially those which duly paid their assessed contributions to other similar organizations. In any event, the provision was not a prohibition ab initio, but a possibility to be decided on by the Health Assembly on the merits of the case. Dr BADRAN (alternate to Professor Sallam), referring to Article 7(b), raised the question of the proposed suspension of nonessential services and the distinction between those and essential services. Should a particular country, whose assets were frozen and was consequently unable, against its wishes, to pay its contribution be deprived of the WHO services to which it was entitled? The question was particularly critical in the country he had in mind, where health conditions were deteriorating; the Director-General himself had reported on the need for health services there to be supplemented and supported by WHO. Dr MAZZA said the paragraph was well drafted; it did not imply mandatory or automatic suspension of nonessential services, but left it to the Health Assembly to decide on the action to be taken bearing in mind any special circumstances, as in a recent case. Dr LOPEZ BENiTEZ agreed that the spirit that had prevailed when the Article had been revised had been to open up a range of possibilities for the Health Assembly when difficulties were encountered. The Health Assembly could decide to maintain certain services, but was given the possibility of applying sanctions if it so decided. That being said, Dr Badran' s comments were well taken and showed that even the best intentions could be interpreted differently. Dr SANOU IRA asked whether there was any formal definition of "nonessential" services in WHO documents. The CHAIRMAN, speaking in a personal capacity as a member of the special group, said that the proposal, which was fair and well balanced, was intended to enable the Organization to respond to difficult circumstances and show its determination to take firm measures to prevent a Member State or group of Member States from hampering the work of the Organization by failing to meet financial obligations. Dr MELONI said that further clarification was needed regarding two separate aspects of the proposals as they were presented, one being the restrictions to be applied to Member States which failed to meet their financial obligations - an issue which strictly concerned Article 7 - and the other being the functions of the Health Assembly, which might more appropriately be considered in connection with Article 18. Dr BLEWETT, speaking as Chairman of the special group, explained that the special group had made a point of separating the two issues covered by Article 7. The circumstances referred to in Article 7(b) related not to financial obligations but to other exceptional circumstances that would lead the Health Assembly to take very firm action. On the question of essential and nonessential services, the Constitution's present wording referred only to "services", and the intention of the special group had been to soften the conditions and make it clear that the services that would be denied such countries would be nonessential ones, and also to give the Health Assembly some guidance for the decision it would be making. In general, the proposed amendments were an attempt to spell out more clearly the kinds of steps available to the Health Assembly in determining the treatment of the Member States that had not met their financial obligations. Dr NAKAMURA said that it was becoming increasingly difficult for some countries to pay their assessed contributions. The intention of WHO reform was to make the Organization more effective and more efficient and thus more accountable to the taxpayers of Members States. Strict sanctions would not necessarily improve the situation regarding arrears, and he therefore had reservations about the proposal. Dr VAN ETTEN withdrew his amendment.
The recommendation was approved by 28 votes to none, with 2 abstentions.
SUMMARY RECORDS: SECOND MEETING
45
Representation of Members at the Health Assembly (Article 11) Dr BLEWETT, speaking as Chairman of the special group, explained that the special group had merely removed the requirement that delegates should be persons most qualified by their technical competence, since that requirement was self-evident. In reply to a question by Dr SULAIMAN, he said that the stipulated number of delegates for each Member State - three - was the number already provided for in the Constitution, and had not been questioned. Dr MAZZA said that it would be preferable for the word "Member" to read "Member State". Dr BADRAN (alternate to Professor Sallam) asked whether the delegates referred to included alternates and advisers. Mr TOPPING (Legal Counsel) said that, while Article 11 of the Constitution referred specifically to delegates, of whom there should be three, Article 12 referred to alternates and advisers, who were not limited in number. Dr MELONI said that it was not clear whether the emphasis in the original Article 11 was the representation of Member States or the technical competence of delegates, in which case the proposed amendment might be missing the point. Dr LOPEZ BENITEZ agreed with Dr Mazza that the word "Member" should be changed to "Member State" to avoid confusion with members of the Executive Board. The CHAIRMAN, in reply to a question by Dr FIKRI, specified that three was the maximum number of delegates; there was no lower limit.
The recommendation was approved unanimously. (For continuation, see summary record of the fourth meeting, section 2.)
The meeting rose at 17:35.
THIRD MEETING Tuesday, 20 January 1998, at 9:30 Chairman: Professor A. ABERKANE
DIRECTOR-GENERAL: Item 5 of the Agenda Nomination for the post: Item 5.1 of the Agenda
The meeting was held in private.
(For continuation, see summary record of the thirteenth meeting.)
The meeting rose at 12:40.
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FOURTH MEETING Tuesday, 20 January 1998, at 14:30 Chairman: Professor A. ABERKANE
1.
DIRECTOR-GENERAL: Item 5 of the Agenda (continued)
Nomination for the post: Item 5.1 of the Agenda (Decision EB1 00(7)) (continued) The CHAIRMAN said that at the private meeting held the previous day to discuss nominations for the post of Director-General, the Board had drawn up a short list of five candidates in accordance with Rule 52 of the Rules ofProcedure ofthe Executive Board and Executive Board decision EB100(7). In making their selection, Board members had been particularly impressed by the quality of all the candidates. It was a tribute to the Organization that the post to be filled had attracted so many highly competent and distinguished persons, although it had made the Board's task of drawing up a short list particularly difficult. He read out the short list established by the Board, in alphabetical order, as follows: Sir George Alleyne Dr Gro Harlem Brundtland Dr Nafis Sadik Dr Ebrahim Malick Samba Dr Uton Muchtar Rafei.
2.
WHO REFORM: Item 7 of the Agenda (continued)
Review of the Constitution and regional arrangements of the World Health Organization: report ofthe Executive Board special group: Item 7.3 of the Agenda (Resolution EB99.R24; Decision EB99(5); Document EB101/7) (continued) Review of the provisions of the Constitution (continued from the second meeting, section 4) Annual session of the Health Assembly (Article 13) Dr BLEWETT, speaking as Chairman of the Executive Board special group for the review of the Constitution, said that, after extensive discussion, the group had decided to recommend that no change should be made to Article 13 of the Constitution.
The recommendation was approved. Health Assembly authority to adopt conventions and agreements (Article 19) Dr BLEWETT, speaking as Chairman of the special group, said that the group had recommended that the authority to adopt international conventions, although never hitherto exercised, should not be deleted from the Constitution.
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The recommendation was approved. Health Assembly authority to adopt regulations in five specific areas (Article 21) Dr BLEWETT, speaking as Chairman of the special group, said that the group had recommended the revision of Article 21, which concerned the Health Assembly's authority to adopt regulations that became binding upon countries unless they specifically indicated their reservations. It had proposed the addition of a sixth specific area ("standards with respect to transplantation of tissues and genetic engineering, including cloning") in which the Health Assembly should have that authority, and the inclusion of a more general covering clause (subparagraph (b)) to give the Health Assembly authority to adopt regulations concerning any other health-related matter falling within the functions of the Organization as set forth in Article 2. Mr VOIGTLANDER, observing that one of the fundamental principles of constitutional law was that the delegation of powers must be concrete and precise, considered that the wording of proposed subparagraph (b) lacked precision, firstly because the long list of functions of the Organization as set out in Article 2, to which the subparagraph referred, was not intended to be exhaustive nor to limit the scope of the Organization's activities. Furthermore, it did not seem logical to list specific areas for standard-setting in the first part of the article and then to add a subparagraph indicating that regulations could be adopted concerning any other healthrelated matters, thus giving almost unlimited power to the Health Assembly. It was questionable whether WHO should set legally binding standards in fields such as health promotion, for example. He therefore proposed the deletion of the new subparagraph (b). Professor LEOWSKI supported the views of the previous speaker, especially as it was not clear whether the reference to Article 2 in subparagraph (b) referred to the existing formulation of Article 2 or to the proposed new version. Professor REINER said that, in his understanding, the special group had intended that the reference should be to the proposed new Article 2. However, he shared Mr Voigtllinder' s doubts concerning the advisability of the Health Assembly having legally binding authority in fields such as health promotion. He recalled that the inclusion of subparagraph (b) reflected a certain frustration in the special group that many of the substantial achievements of the past 50 years had failed, for legal reasons, to be enshrined in any binding text. The tobacco issue, for instance, had been discussed repeatedly at great length, yet no binding international text existed to oblige Member States to coordinate their action. Many countries which, for example, placed legal restrictions on advertising for tobacco often harmed their own tobacco industries and were at the mercy of imported advertising in the foreign press and media programmes. Dr LOPEZ BENiTEZ noted that under international law no substantive amendment to the existing text of the Constitution could come into force unless and until the full procedure of ratification by Member States had been completed. He recalled that although the Health Assembly had considered that there was no need for major reform of a text that had served the Organization well for 50 years, a decision had been made to initiate a process to consider where some change might be useful to elucidate points not clear in the original text or to cover new developments, such as cloning. In the particular case of Article 21, the proposed subparagraph (b) was necessary to ensure that possible future areas of concern to the Organization were covered as well as present ones.
The recommendation, with the inclusion ofthe new subparagraph (b), was approved by 22 votes to 5, with 1 abstention. Executive Board membership (Article 24) Dr BLEWETT, speaking as Chairman of the special group, said that the group had recommended by a clear majority that Article 24 should remain unchanged. The reservations expressed by one member of the group were reflected in paragraphs 14 and 16.
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Dr BADRAN (alternate to Professor Sallam) said that the provision whereby Executive Board members were designated in their personal capacity and not as representatives of their governments did not reflect actual practice and should be discontinued. The real choice in election to Board membership lay among Member States, following which the relevant State authorities designated a member and had the power to change that member during the term of office if he or she expressed views which did not coincide with State policy. Dr VAN ETTEN said that he would prefer to keep the provision that Executive Board members should be designated in their personal capacity. Dr STAMPS said that the reason for wording implying that Board members were to serve in their personal capacity, despite their designation by Member States, was to enable deliberations to be conducted without the constant need to refer points at issue back to governments. In any event, the Board was a recommending body without executive power; the ultimate decisions were taken by the Member States themselves when matters were brought before the Health Assembly. Dr SULAIMAN asked whether a Member State had ever revoked the mandate of a Board member it had designated. In his view the present formulation should be retained. Mr TOPPING (Legal Counsel) reminded the Board that its members were designated by Member States elected for the purpose by the Health Assembly and served in an individual capacity. Nevertheless, there were many instances where States had changed their designation of a Board member. Dr FIKRI pointed out that the procedure began by the regions proposing names of countries to designate Board members, the choice was then endorsed by the Health Assembly and finally, the members designated by those countries served in their personal capacity, although reflecting the views of their countries and their regions. His view was that the current provisions should be maintained. Dr AL-MOUSA WI also advocated maintaining the present wording of the provision; the Board's work would be hindered if members represented their countries and had to refer to them constantly for instructions. Mr JUNEAU expressed support for the special group's proposal in the interests of flexibility and the smooth running of the Board. The present provision allowed decisions to be made very rapidly and members could seek instructions from their countries if they felt the need to do so. Mr HURLEY also endorsed retention of the current provision. He shared the view referred to in paragraph 16 of the report that strict application of the term "technically qualified" would be unduly restrictive but wondered what the distinction was between "technically qualified" and "with experience" in that context. Dr MOREL found it confusing that at WHO he sometimes represented his country and at others acted in his personal capacity: it would be clearer if it was acknowledged that Board members represented their countries. He did not think that deliberations in the Health Assembly were slowed down by the fact that participants represented their countries. Dr SANOU IRA supported Article 24 as worded at present. As already stated, the Board made recommendations and the final decision was taken by the Health Assembly. Members brought their experience and their own sensitivities to the Board. Dr MAZZA expressed full agreement with the previous speaker. The countries entitled to designate Board members were selected by Member States at the Health Assembly and members were designated to enable the Board to act as an executive arm on behalf of the Assembly. With reference to the wording "technically qualified", he considered that the decision taken by the group to retain the present wording was absolutely appropriate in view of the types of subject discussed by the Board.
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Dr STAMPS pointed out that members of the Board were not appointed by the Health Assembly but designated by States approved by the Assembly to do so. Dr BADRAN (alternate to Professor Sallam) asked whether the term "personal capacity" meant that members of the Board were free to express their own views even if they were contrary to those of the countries to which they belonged. He did not think that the proceedings of the Board would be slowed down by amending the provision, since States sent delegates to meetings in full confidence that their views would be represented. Even if consultation were needed, modem communications were extremely swift. Although there had not been an instance of a member expressing views contrary to those of his State, that situation might arise and could create great difficulties. Mr TOPPING (Legal Counsel) confirmed that persons serving in their personal capacity were entitled under the Constitution to express their personal views; they had no obligation to express the view of the State by which they had been designated. In response to Mr HURLEY, he said that in practice the term "technically qualified" had not been the subject of close scrutiny by the Board recently. Some time ago the question had been raised but not pursued by the Board. He believed that the term was subject to a broad range of interpretation. The CHAIRMAN observed that if the wording "with experience" was adopted, the scope would be even broader.
The recommendation was approved by 24 votes to 4, with 3 abstentions. Election and term of office of members of the Executive Board (Article 25) Dr BLEWETT, speaking as Chairman of the special group, said that in view of the concern expressed in the group about the custom which had been established of Members of the United Nations Security Council having a semi-permanent membership of the Board, it had proposed the addition of wording to the effect that no Member should have a greater right than any other to designate a person to serve on the Board.
The recommendation was approved. Functions of regional committees (Article 50) Dr BLEWETT, speaking as Chairman of the special group, said that the group had suggested an addition to make clear the functions of the regional committees.
The recommendation was approved. Budget estimates (Article 55) Dr BLEWETT, speaking as Chairman of the special group, said that three small changes to the second sentence ofthe existing text had been proposed: the addition of"and review" after "consider" was designed to give the Board a rather stronger role in regard to the budget; "such" had been replaced by "those" and "them" had been added after "submit" to improve the drafting.
The recommendation was approved. Amendment of the Constitution (Article 73) Dr BLEWETT, speaking as Chairman of the special group, explained that many members of the group had expressed concern that the process of changing the Constitution was extraordinarily slow as a consequence of the requirement for adoption by a two-thirds majority of the Health Assembly and acceptance thereafter by a two-thirds majority of Member States in accordance with their respective constitutional procedures. Indeed
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some amendments had been waiting for many years to receive ratification after they had been adopted by the Assembly. The proposal was an effort to institute a speedier process, primarily by making the approval by States subject to a time limit of 18 months for notification of non-acceptance. Mrs SUNDREHAGEN (alternate to Dr Alvik) said that amendment of Article 73 could have wide implications and asked what procedures were followed in other United Nations organizations. Dr WILLIAMS said that Article 73 was the article most in need of amendment. Under the current procedure, even the simplest amendment took years to come into force. For example, it had taken 11 years to increase the representation of one region on the Executive Board by a single member. The special group's proposal did not go far enough: he favoured reducing the advance notice of proposed amendments to be given by the Director-General to Member States from the proposed 12 to six months and reducing the time-limit for formal notification of rejection from 18 to 12 months. Dr ITO (alternate to Dr Nakamura) preferred to retain the current provision in order to respect the sovereignty of Member States. A better way to expedite the process of amending the Constitution might be to delete any unnecessary provisions and to establish a general clause, along the lines of that proposed for Article 21, giving the Health Assembly the authority to define the meaning of articles of the Constitution in its resolutions. Mr JUNEAU had serious reservations about the proposed amendment, which would require a Member State to seek the support of one-third of Member States if it disagreed with an amendment, and which allowed obligations, including financial obligations, to be imposed on a Member without its consent, a power hitherto confined to the Security Council of the United Nations as far as he knew. He sought clarification from the Legal Counsel on that point. Dr STAMPS said that change was clearly needed when an amendment to Article 7 had been on the table for 32 years, and the Constitution was still not available in Arabic because, after 19 years, an amendment to Article 74 had not yet been ratified by enough countries to come into force. He saw the Constitution as an enabling instrument, not one that imposed liabilities on Members: that was reserved for resolutions of the Health Assembly. Moreover, the proposed amendment ensured that the power to make amendments remained with Members, who had sufficient time to study their full implications. Finally, the amendment to Article 73, and the other amendments currently being proposed, would have to go through the old process of adoption and ratification; it was possible that they too might remain on the table for many years. Mr DE SILVA agreed that change was necessary and that a time-limit should be stipulated. The years between the adoption and ratification of amendments were a waste oftime, money and energy. Professor LEOWSKI considered the proposed amendment to be revolutionary, in so far as it appeared to be an attempt to change internationally accepted ratification procedures, and international law itself. Was the Organization legally entitled to do that? Mr VOIGTLANDER recalled that the purpose of the amendment was to speed up procedures, but it was important to balance any benefits against possible negative effects. For example, he could envisage a situation under the proposed system in which as many as 30% of Members registered dissent with a proposed amendment (adopted by a two-thirds majority), not a single Member ratified it, and the amendment still entered into force. A constitutional change should not depend on ephemeral majorities; the Constitution was, after all, the basis for the work of the Organization. Moreover, domestic constitutional procedures could be lengthy. In Germany, for instance, if an amendment was made to the constitution of an organization of which it was a member, that amendment had to be adopted by the two chambers of Parliament, and if that procedure was not completed before the amendment came into force, Germany would be obliged to leave the organization, even if it supported the amendment. In most cases, the constitutions of international organizations made full provision for domestic
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ratification procedures. It would not be wise to lower the barrier to constitutional change too much; the current proposal went too far in that direction. Mr TOPPING (Legal Counsel), in reply to various points raised, said that the current text of Article 73 reflected the normal practice of most international organizations, including the United Nations itself. A basic principle of international law was that no State could be bound without its consent. Having said that, it was nevertheless true that, in the case of the entry into force of amendments to the WHO Constitution, and similar constitutions, such amendments would bind all Members of the Organization, whether or not all such Members had individually accepted them. That resulted from the wording of the Constitution, which provided for entry into force of amendments on the basis of their acceptance by a portion of the membership, and which had been accepted by each State when becoming a Member. One exception to the general practice for amending constitutions within the United Nations system was the Constitution ofFAO. It differentiated between "new obligations" and other obligations: if no new obligation was involved, an amendment could be adopted by a two-thirds majority vote and would enter into force with immediate effect, as when the Constitution had been amended to permit the European Union to be admitted as a Member. If new obligations were involved, amendments only entered into force if they had been adopted by a two-thirds majority, and they only entered into force with respect to those Member States that had ratified them. The proposed amendment to Article 73 was unprecedented in international law, although, on the basis of a preliminary review, he could find nothing in the Vienna Convention on the Law of Treaties to suggest it could not be implemented. He recalled that the special group had discussed a system whereby the Health Assembly would first consider an amendment and then consider its adoption at its next session a year later. He was concerned that the phrasing of the amendment, according to which texts of proposed amendments would be communicated to Members "at least 12 months in advance", did not adequately represent the group's intentions. Dr LOPEZ BENiTEZ said that the key to overcoming the problem of non-ratification by Members lay in the 12-month advance notice provided for in the proposed amendment. Such notice would allow those Members that so wished to ratify an amendment before its final adoption by the Health Assembly. Members who were opposed to the amendment would not proceed to ratification, and if the amendment did not receive the required two-thirds majority, it would simply not be adopted. Although that suggestion might appear to be a contradiction in legal terms, it did offer a solution to the delays in the entry into force of decisions that needed to be ratified at the national level. Dr CALMAN said it was important to consider ways of improving the procedure for amending the Constitution. However, like other Board members, he was not happy about the change as proposed. He had been impressed by the information provided about the Constitution ofF AO, and wondered whether that model had been considered by the special group. Dr BLEWETT, speaking as Chairman of the special group, said that the FAO Constitution had been drawn to its attention but, because of the difficulties involved in understanding the two levels of obligations concerned, it had not been given detailed consideration. Dr SANOU IRA said she was in favour of setting a realistic time limit for ratification because it expressed the Organization's will to assist countries in following up on the implementation of resolutions adopted by the Health Assembly. Without a time limit, ratification could take many years. It was, of course, necessary to take account of the realities on the ground, including the ratification processes of various countries, and to fix timelimits accordingly. Dr STAMPS said the reason why the special group had not adopted the FAO approach was that no obligations were imposed on Member States by virtue of the WHO Constitution. It merely enabled the Health Assembly to do certain things; it was the Assembly which imposed obligations on Member States. The Constitution clearly stated in various articles that processes that involved commitments by Member States had to be advanced in accordance with their own constitutional requirements; the WHO Constitution placed no imposition on any Member States' constitutional or sovereign freedom. He could not envisage the situation
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suggested by Mr Voigtllinder. It would not be credible for two-thirds of those attending the Health Assembly, who had devoted 12 months to considering a proposed amendment, to change their minds so dramatically and in such a short time. Moreover, the proposal was not in any sense revolutionary: all it did was to terminate the interminable debates for which the United Nations system had become famous. It was time for WHO to do what it was supposed to be doing, namely provide vanguard leadership in health for the world as a whole. The amendment should be seen as a proposition which would be debated at length over the coming months. Dr ITO (alternate to Dr Nakamura) proposed that any decision on the matter should be postponed. As the Legal Counsel had said, the proposal was unprecedented, and it was necessary to be very careful when making such important changes. The matter should receive further detailed legal consideration in order to determine whether it was at variance with commonly understood international legal procedures or went too far given the legal systems prevailing in Member States. Dr SHIN and Mr NGEDUP agreed that more time was needed to deal with such an important issue. Clearly the Organization must find a way of speeding up its decision-making, but the amendment proposed might not be the best option. Mr HURLEY submitted that the diversity of the views expressed would make it very difficult to reach agreement during the present meeting. There appeared to be some agreement in principle that the mechanism for handling amendments to the Constitution should be improved, but progress on the issue seemed unlikely without further work to resolve technical difficulties. Dr BADRAN (alternate to Professor Sallam) agreed, adding that the legal aspects required further study, with special reference to regulations and constitutions in force elsewhere in the United Nations system and to ratification procedures in different Member States. Dr BLEWETT, speaking as Chairman of the special group, agreed that it would be difficult to proceed with the proposal at the present time, but noted the desire within the Board to see the review continue; perhaps Dr lto's motion that the matter be postponed might make mention of the Board's recognition of the need for speeding up the process for the passage of amendments? Mr DE SILVA agreed on the need for postponement, but believed that a decision should be taken at the next session of the Board. Dr BADRAN (alternate to Professor Sallam) and Mr JUNEAU voiced agreement with Dr Blewett's suggestion. Mr VOIGTLANDERjoined in noting the basic desire to accelerate procedures but said that the existing proposal went too far. The Director-General should provide additional information on practices in other international organizations, for purposes of comparison. Dr STAMPS said he agreed with the thrust ofDr Blewett's suggestion, but was not clear whether it was intended that the special group should reconvene in order to study the information the Diector-General would be presenting. Or CALMAN said it was his understanding that the special group had completed its work, and that the Secretariat would, as requested, report to the Board at its next session in May 1998. The CHAIRMAN said he took it that, bearing in mind the proposals by Dr Ito and Or Blewett and statements by other members, the consensus was that the issue required further examination, but with the help of a mechanism to expedite its consideration, and that the Director-General might provide guidance in that regard.
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In response to a suggestion by Dr CALMAN, Mr AITKEN (Assistant Director-General) said that the Secretariat would draft a decision incorporating the proposal by Dr lto, as amended by Dr Blewett, for the Board's consideration at a later stage in the proceedings. It was so agreed. (For adoption of decision, see summary record of the eighth meeting, section 2.)
The CHAIRMAN said, with regard to the special group's review of provisions of the Constitution, that a resolution would be drafted to transmit to the Health Assembly the recommendations approved by the Board. Concerning Article 2, the Board had agreed to wait until the following year before deciding whether or not to recommend the framework proposed by the group for adoption by the Health Assembly. It remained for the Board to decide whether it wished to adopt a resolution on the recommendations it had already approved at the curent session or wait until the following year in order to incorporate a recommendation on Article 2. The Constitution required that amendments must be communicated by the Director-General to members at least six months in advance of their consideration by the Health Assembly, which meant that amendments proposed at the current session would not be considered until the Fifty-second Health Assembly in 1999. Any amendments proposed in 1999 would not be considered until the year 2000. (For adoption of resolution, see summary record of the eighth meeting, section 2.)
Implementation of resolutions WHA18.48 and WHA31.18 Mr TOPPING (Legal Counsel) informed the Board that the special group had noted that there were still two pending amendments to the Constitution, one concerning Article 7 and the other Article 74, which had still not been ratified by the required number of Member States. The ratification of the amendment to Article 74, relating to the authentic Arabic text of the Constitution, posed no particular problem, but a technical issue did arise in connection with the 1965 amendment to Article 7, as a result of the Board's decision at its current session to recommend a new amendment to that Article. If the new text were adopted by the Health Assembly, it would then be open for ratification and acceptance by Member States. That would mean that there would be two amended texts of Article 7 pending ratification, and whichever of the two first entered into force would then be replaced by the other when it subsequently came into force. In the circumstances, notwithstanding the value of the 1965 amendment, there was some doubt about the merits of continuing to urge all Member States to ratify it. Dr STAMPS pointed out that the proposed new version of Article 7 could not be discussed until 1999 at the earliest. At that time, if the 1965 amendment had not been ratified, Member States should be notified accordingly, clearly indicating that ratification would no longer be appropriate since an entirely new article was being presented. The issue again raised the problem of the shortcoming inherent in Article 73, namely its failure to set any time-limit for ratification. As a matter of principle, Member States' attention should be drawn to outstanding matters of that kind, of which they might not be aware. He hoped that the amendment to Article 74 could be dealt with as soon as possible. The recommendation was adopted.
Coordination of mandates in the United Nations system The Board took note of the special group's comments.
WHO regional arrangements Point (1) - Status and progress of reform in regional offices and at headquarters with reference to the 47 recommendations made by the Executive Board Working Group on the WHO Response to Global Change The Board took note of the special group's comments.
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Point (2) - Current practice at headquarters and in regional offices for: budget drafting; priority-setting and implementation; personnel appointments; programme implementation; and impact of extrabudgetary funds on regional budgets and priorities.
The Board took note of the special group's comments. Point (3) - Regular budget allocations to regions Mr AITKEN (Assistant Director-General), after drawing attention to an error in the tables in Annex I of document EBIOI/7, which would be the subject of a corrigendum, said that the special group had spent most of its time on point (3). Detailed data had been presented to it by a Secretariat working group, which had specified three or four characteristics of a possible system, as outlined in paragraph 32. The special group's task had been to use certain health criteria and other specific indicators for calculating a basis for distributing regional allocations, to consider how to address the population issue, and to present the outcome in terms of a model for individual countries, from which regional allocations had then been extrapolated. Detailed statistics and complex calculations lay behind the somewhat brief report. The models developed had been based on either the Human Development Index of UNDP and immunization coverage - designated as scenario A - or on four specific indicators referred to in paragraph 32 (scenario B). As would be seen, the use of one or other of those indicators did not make a substantial difference to the outcome. Paragraph 36 contained some of the special group's other key recommendations, notably on the need for gradual transition from the present arrangements and for the model adopted to be applied in a sensitive, not a mechanical manner. Professor REINER commended the analytical study prepared by the Secretariat working group. He felt he was reflecting the consensus in the special group by saying that the setting of objective criteria for regional allocations, which currently had no basis other than history and precedent, was badly needed. Moreover, if and when objective criteria were finally implemented, less time might be spent on lengthy and tiresome discussions about the allocation of resources at the global and regional levels alike. He was somewhat perplexed, however, to see that both scenario A and scenario B were presented as options, when virtually all the members of the special group and the majority of Member States taking part in the deliberations on the issue had been in favour of the former. Presenting both once again would inevitably lead to further lengthy debate. Another important psychological factor and one of the major reasons for the group's preference for scenario A should be mentioned, namely that WHO would sooner or later have to accept some of the key components of reform in the United Nations system, one of those being the proposed presence of a common United Nations house at country level under a single United Nations flag and with the UNDP country coordinator as the United Nations country resident representative. A major advantage of scenario A was that it was based on the universal index of the United Nations system, the now widely used Human Development Index, with its four components but with a weighted population factor enriched with data on immunization coverage. Scenario B, on the other hand, resulted in serious imbalances in allocations, an example being a reduction in allocations for the Africa Region. Remarking that the European Region fully supported those views and the proposed scenario A, he requested that the item be kept open at least until the following day, since a resolution was being drafted and consultations were under way. Dr ITO (alternate to Dr Nakamura) endorsed the direction of the suggested reform, designed to ensure equitable allocation of the budget in response to changing regional requirements. The budget for any given region must not be so drastically decreased that necessary services could not be provided by the Organization. Objective analysis of the weighting of each indicator, realistic simulations for each region and provisional measures to mitigate drastic changes in programme activities were all important. Dr BADRAN (alternate to Professor Sallam) expressed the hope that the consequence of serious efforts by a country to raise its gross national product per capita, reduce maternal and under-five mortality and increase immunization coverage would not be reduced budgetary allocations. Yet that might be construed to be the intention of the proposed measures, particularly of scenario B.
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Mr HURLEY welcomed the rational and sensible approach that the special group had taken. As the Regional Director for Europe had pointed out, WHO needed to respond in a dynamic way to the changes and challenges confronting all countries. It had long been recognized that regular budget allocations were based on outdated criteria. Mention was constantly made in the Organization's policy documents of the countries in greatest need. He strongly favoured scenario A because the major beneficiaries would be precisely those countries, particularly those on the African continent and in eastern Europe. Early decisions on the matter were imperative, and gradual introduction of the new allocation mechanism must be agreed upon to ensure a smooth transition. Dr WASISTO noted that many Board members agreed on the need for more equitable budget allocations among the regions. A new and more rational formula was required, but it might not be easy to create one that would satisfy all countries. Care should be taken in applying the new model, as mentioned in paragraph 36 of the document. He understood that some regional offices had carried out exercises using the new formula, and requested information on the results. Mr VOIGTLANDER said everyone seemed to agree that the present system was based on outdated historical precedents, that it had no logical basis, and that objective criteria had to be found. The indicators to be used must reflect current realities. The Regional Director for Europe had referred to the deterioration of that Region's situation, and the figures he had cited must be heeded. One of the countries in greatest need in the Region was to receive just over US$ 100 000 from WHO, yet if it was located in a different region, that amount would be multiplied many times over. The effect was to punish countries for being in a given geographical region - was that really the intent? The present system caused an even more fundamental problem: it undermined the political will of countries to cooperate with the Organization. For example, a country might contribute a considerable sum to WHO with the intention of helping countries in eastern Europe, only to find that those countries received only a very small portion of the amount. Parliamentarians might question the use of multilateral methods and wonder why preference was not given to direct bilateral aid, which guaranteed that sums really reached the designated countries. The system had a similar effect in the African Region: it did not reflect the true situation. The specific needs of that Region had often been acknowledged, but the necessary budgetary conclusions had never been drawn. The time had now come to change that. He therefore supported the idea of using the Human Development Index in combination with immunization coverage as a basis for the new system, but thought it must be introduced gradually, to cushion the effects. Dr SULAIMAN welcomed the detailed attention given to the subject by the special group and its proposal of scenarios for optimum distribution of resources among the regions. The system had remained unchanged for 50 years, and finding a replacement acceptable to all countries would not be easy. Attention should be given to the possible adverse effects on certain regions of major changes in regional budgeting. He understood that WH 0' s financial allocations to countries, both regular budget and extrabudgetary, amounted to less than I% of the total funds given by countries for disease control. A system should be developed for allocating funds in an appropriate manner, but time should be spent in reflecting on the possible consequences, and countries should be involved in that reflection. He hoped the members of the special group had visited the regional and country offices in the course of preparing the report to find out what was happening at national level. Because the country offices reflected the real situation in various regions, they could usefully play the role of focal or contact point. As had been said, development in the health field could not be measured solely by certain indicators. A reduction in financial assistance simply because a country had succeeded in lowering maternal or infant mortality could hardly be justified. On the contrary, such a country should be encouraged to take on further health challenges. The Human Development Index should be further scrutinized and the criterion of human resource development incorporated. Despite apparent success, according to existing development indicators, some countries had not really optimized the use of human resources, and complex problems remained. In his own country, for example, fine results had been achieved in the health sphere, particularly in the immunization campaigns, but with a heavy reliance on foreign health staff; 80% of health personnel came from abroad. Could it therefore be said that his country had succeeded in the health sphere? The Human Development Index should"
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therefore be analysed in greater depth, and care should therefore be taken in interpreting what it said about countries and regions. Dr AL-MOUSA WI said he agreed on the need for criteria for budget allocations that corresponded to the health needs of regions. As Dr Badran had implied, under both scenarios before the Board, improvements in general health in a region would translate into reductions in budgetary allocations, with a consequent inducement to countries to make minimal expenditure on health, so as to maintain WHO's contributions. He agreed with Dr Wasisto that care should be taken in selecting the criteria; the exercise should be rigorously examined to see what the allocations would be for each region, before any scenario was adopted and extrabudgetary funding should be taken into account. Mrs SUNDREHAGEN (alternate to Dr Alvik) agreed that current practice was outdated, and supported the special group's conclusion that new criteria for regional allocations based on national needs, rather than on historical precedents were called for. Under the current system, countries in greatest need were not given sufficient priority, a problem that seemed most evident in the African Region. The same assessment of needs could also guide country allocations, which was why the topic could usefully have been considered in conjunction with agenda item 7.1 - WHO country offices. Under that item, a set of criteria for grouping countries according to economic and health status was to be introduced. Though the special group had done a thorough job, that did not preclude improvement of the criteria proposed in scenarios A and B. For example, the criteria for country resource allocation and for assessing a country's need for WHO representation might need to be harmonized. The Board should therefore agree for the time being merely to develop criteria for resource allocation based on a combination of health indicators and social and economic status. Dr SHIN said that although no method for allocating resources could be ideal, an approach such as that offered in scenario A might provide the best solution at present, despite the problems inherent in some of the bases for calculation. He agreed that any new model should be applied through a gradual transition, to minimize disruptions, and in a sensitive, not mechanical, manner. A phasing-in period of two or three fiscal years should be envisaged for its application. After all, the budget in some regions would be reduced by more than 60% for a given fiscal year, and that could be expected to create tremendous problems, in relation, inter alia, to staffing levels, salaried positions and ongoing programme implementation. The Human Development Index, which encompassed gross national product statistics, birth and death rates, immunization coverage, and so on, was changeable. The allocation method should therefore be regularly updated, perhaps every four years. Professor LEOWSKI said that, having attended many Health Assemblies over the past 20 years, he knew that every two years, the budget discussion sparked heated arguments about increasing allocations to developing countries, especially the least developed countries. Every year, the Director-General presented a report on the global health situation indicating dynamic changes and widening gaps between countries. The world was quite clearly living under conditions of increasing economic constraint, and WHO's regular budget had to be adapted accordingly. He commended the special group on its most timely efforts to introduce logical changes in regional budget allocations. He agreed strongly with the points made by Dr Shin, but pointed out that the proposals addressed only country allocation budgeting, and not the overall issue; it was certainly true that the transition from present arrangements must be gradual, and that the model must be applied in a sensitive way. One could argue about the merits of the Human Development Index, but no better indicator seemed to exist. WHO, as part of the United Nations family, should move in the same direction as the whole. No time should be lost in coming to a decision on the issue, which was more urgent still than that of amendment of the Constitution. The Organization had lived for many years without changing the latter, but if it failed to modify the arrangements that were under discussion, it might just not survive.
The meeting rose at 17:35.
FIFTH MEETING Wednesday, 21 January 1998, at 9:30 Chairman: Professor A. ABERKANE
WHO REFORM: Item 7 of the Agenda (continued) Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group: Item 7.3 of the Agenda (Resolution EB99.R24; Decision EB99(5); Documents EB101/7 and Corr.1) (continued) WHO regional arrangements (continued) Point (3) - Regular budget allocations to regions (continued) In reply to a question by Dr CALMAN, the CHAIRMAN said that a draft resolution on regular budget allocations to regions, proposed by Dr Hembe, Dr Kariburyo, Professor Reiner and Dr Stamps, would be taken up when the round of general remarks on the subject had been completed. The text of the draft resolution read: The Executive Board, Having considered the report of the Executive Board special group for the review of the Constitution on regional allocations, RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution: The Fifty-first World Health Assembly, Recalling resolution EB99.R24 on regional arrangements within the context of WHO reform; Noting that allocations from the regular budget to regions have not been based on objective criteria but rather on the basis of history and previous practice; Concerned that, as a result, each region's share of such allocations has remained largely unchanged since the Organization's inception; Recalling that two basic principles governing the work of WHO are those of equity and support to countries in greatest need; and stressing the need for the Organization to apply principles which Member States have adopted collectively; Noting the very uneven economic development in different regions of WHO, in particular over the last decade, and concerned at the dramatic deterioration in socioeconomic conditions in Africa and in many of the countries in the eastern part of the European Region; Noting that other organizations of the United Nations system, particularly UNICEF, have already adopted models based on objective criteria to ensure a more equitable distribution of programme resources to countries, 1. THANKS the Executive Board and its special group for the review of the Constitution for the comprehensive study of allocations from the regular budget to regions; 2. DECIDES that the global country allocation in future programme budgets approved by the Health Assembly should be guided by a model that,
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(a) is based on UNDP's Human Development Index, adjusted for immunization coverage; (b) incorporates population statistics of countries calculated according to commonly accepted methods, such as "logarithmic smoothing"; (c) can be implemented gradually over two bienniums, as from the financial period 20002001; 3. DECIDES FURTHER that the model should be applied in a flexible, rather than a mechanical manner so as to minimize, to the extent possible, any adverse effects on countries whose budgetary allocations will be reduced; 4. REQUESTS the Director-General to report to the 103rd Executive Board and to the Fiftysecond World Health Assembly on the details of the model and the country allocations to be applied to the 2000-2001 biennium. Mr NGEDUP, calling attention to paragraph 36 of document EB101/7, asked whether a method of budget allocation based on the Human Development Index and immunization coverage would include a mechanism for adaptation to changes in either of those factors. Decisions should be based not on a single parameter but on several variables, an essential objective being support for countries in greatest need. A more detailed analysis should be made of the implications and of the positive and negative impacts of the proposals by the special group, to ensure that they were practical. Change was indeed called for, but it should have a rational basis. Dr MOREL noted the difficulties involved in the necessary move from budget allocations based on historical precedent to allocations based on objectives, goals and other indices. He requested further explanation with regard to paragraph 35 of the document, concerning the group's views on the population factor. The tables annexed to the special group's report showed that, in scenario A, allocations would differ considerably depending on whether raw or statistically adjusted population figures were used; which of the two was deemed preferable? Dr MELON! said that the very important topic of budget allocation required a broader analysis. Although some further aspects of the issue had most probably been addressed by the special group, he would like to have them spelled out more clearly. The overall amount of resources available should be taken into consideration for purposes of budget reallocation and the setting of priorities for less developed countries with indicators of poor health and socioeconomic status. Not only the regular budget but also extrabudgetary resources, headquarters resources and resources intended for regional, intercountry and country allocation should be included in the analysis. Furthermore, it was a question not only of how much was available, but also of how the resources were to be used. If the objective was indeed health for all and a reduction in gaps and disparities between indicators and health needs, changes would have to be introduced to render the Organization more effective and more efficacious, and they, too, should be analysed. Whatever the new methods of allocation adopted, they should not be a disincentive to countries with unfavourable health indicators that were making efforts to improve their situation, by making fewer resources from the Organization available to them just when they were attaining the agreed objectives. Reiterating Dr Morel's request for more information about the population index used in the analysis, he remarked that the population of a country or continent was only one factor to be considered. Large intraregional and intranational disparities existed in that domain; additional criteria, such as the Human Development Index ofUNDP, should be applied, otherwise the analyses would lack specificity and sensitivity. When such differences were added to strictly regional criteria, it became apparent that some countries on the same continent resembled one another but differed with regard to health and socioeconomic conditions, a state of affairs which could have inequitable consequences. The criteria could not, therefore, be applied mechanically. Account should be taken of the different functions, responsibilities and tasks of the Organization, at headquarters, in the regional offices and in the countries. In short, he commended the work done so far, but considered that further information was called for before a decision was taken. Dr SANOU IRA commented that the fact that the models advanced by the special group were not exclusively based on health criteria made them more credible and perhaps more acceptable. There should be
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periodic reassessment to take account of evolving situations. For certain indicators such as immunization coverage, which figured in both models, account should be taken of the law of diminishing returns, whereby more effort had to be expended after a certain threshold had been achieved in order to improve or at least maintain the results. Agreeing that the models should serve as a reference for the reallocation of resources at the regional level and to improve current practices, she endorsed a number of the special group's remarks concerning their application. Dr WILLIAMS noted that the group's proposals addressed only the reallocation of funds from the regular budget and not headquarters or interregional allocations. No single formula could satisfy everyone, and any formula that was developed must take account of population size, health indicators, "absorption capacity" and national resources. The Western Pacific Region offered good examples of the difficulties involved. It had the largest population of all the regions and included the world's most populous country; therefore, use in calculations of raw population data alone would double the allocation of the Region, which would be unrealistic. The Region also included some of the world's smallest countries, with populations of 10 000 or less; strict per-caput allocation of resources would mean that those countries received very little, although their health problems and concerns were real and could not be fully met without outside support. WHO had an important role to play in developing sustainable systems in such countries. Thus, fluctuations above and below the average should be considered carefully. Although the Human Development Index and gross national product were fairly indicative of the level of development of a population, they were not direct indicators of health needs and should be used in conjunction with others. A formula should be found such that countries that had worked hard in the past were not penalized, but rather encouraged; increased allocations should be found for less developed countries, especially from extrabudgetary funds. Any new policy should be introduced gradually, so that countries had enough latitude to deal with situations like the economic slump that had occurred recently in South-East Asia. The policy should not be introduced before 2000, since programme budgeting for 2000-2001 had already begun, and countries would need time to make the adjustment, for instance in finding partners, mobilizing resources and improving efficiency. Equity was essential but must have a sound, rational basis. Dr FIKRI submitted that use of the proposed indicators and criteria required further study, particularly since a number of major health concerns had not been taken into account. Although a new health policy would be called for in the coming century, some countries had health priorities that were not reflected in the proposed indicators; they included chronic diseases, accidents and new and re-emerging diseases, which affected large sectors of the population. Mother and infant health and immunization coverage were by no means the only major issues: cancer, AIDS and prevention-related matters such as the control of tobacco-smoking were also important. In a word, other health indicators must be used in developing a health policy for the twenty-first century; they should be studied carefully and matched against each other in order to arrive at a wider choice and avoid negative phenomena at the implementation stage. The alternatives currently proposed were sound but needed further elaboration to provide a basis for realistic decisions that could be accepted by all. Dr VAN ETTEN noted two events that were important for the Organization: its fiftieth anniversary and the new strategy for health for all for the twenty-first century. One of the key values on which the new strategy was to be based was equity. The document under discussion highlighted inequities in regional budget allocations and indicated that a majority of the special group favoured scenario A, which was based on a United Nations index, and provided a rational basis for a decision. The present system of regional allocation of the regular budget was based not on logic but on historical precedent. Urging that the decision not be postponed, he said that the Organization must show the world that it took its own principles, including equity, seriously. Dr MUL WA agreed that there was a need to define new criteria for adjusting regional budget allocations to take into account the deterioration of some economies and unequal rates of socioeconomic development. However, consideration should also be given to the special requirements of regions such as Africa, where, for instance, there was currently acute need for help in meeting the cost of antiretroviral drugs to combat mother-tobaby transmission of HIV. He therefore proposed that the special group should continue to refine the criteria proposed, in the quest for more equitable arrangements.
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Dr KOMODIKIS said that if changes simply resulted in the creation of new problems and new inequalities, they should not be made. She recalled that the Regional Committee for the Eastern Mediterranean, at its meeting in October 1997, had emphasized that the formula chosen should be based on authoritative data and be responsive to change, that it should take extrabudgetary resources into account and should be equitable in terms of the needs of countries and regions, and that overall allocations should not be reduced as a result of success in implementing health programmes. Professor PICO (alternate to Dr Mazza) said he fully appreciated that there was need to change the pattern of allocation in the interests of greater equity, but believed that any new model should be based on rational premises. As had been pointed out by earlier speakers, it would not be right to punish certain countries or regions for the health improvements they had achieved. A broader analysis of the subject, based on other indicators, was called for. While a way should be found of enhancing support to regions or countries whose current health situation required it, that should not be to the detriment of other regions or countries which had introduced far-reaching changes and were working to consolidate them. His proposal would be that consideration of the question be deferred, the special group being allowed time for further deliberations. Dr AL-MOUSA WI acknowledged the need to reconsider the formula for making budget allocations, but submitted that the options proposed should be further refined by giving less weight to the population indicator and more to that of gross national product per capita. Extrabudgetary resources should be taken into account when determining country allocation, and the headquarters allocation should be taken into consideration when considering the diversion of resources from one region to another. Any changes should be phased in gradually, over a period of five to 10 years. Dr FERDINAND agreed that a more rational and equitable, needs-related budget allocation was called for, but said that she found neither of the two scenarios proposed fully satisfactory. Querying the wisdom of selecting immunization coverage - generally successful, traditionally a measure of success and a source of encouragement to hard-working staff- as an indicator, she suggested that more work was called for, with the investigation of other indicators to be used in conjunction with the Human Development Index. Dr RAI (alternate to Dr Wasisto) suggested that the concerns voiced by previous speakers, might be met by incorporating in scenario A the "human poverty index" recently elaborated by UNDP. While evidence had shown that the Human Development Index was not always a good measure of advancement or equity in the field of health, the new index revealed the actual proportion of the population denied access to nutrition, drinkingwater and environmental sanitation programmes and thus demonstrated real needs. Dr BADRAN (alternate to Professor Sallam) remarked that it was very difficult to find an infallible indicator on which to base budget allocations, adding that in his view neither of the scenarios proposed by the special group offered an equitable solution. Many regions contained both high- and low-income countries, which meant that any region-based allocation would result in unfair treatment for some of them. It was also difficult to ensure that data collected were accurate because reporting methods varied from one country to another. In addition, indices might change from one year to another and it would be difficult to keep changing budget allocations accordingly. Weighting in favour of population could also be of disservice to the many countries that were tackling the problem of over-population. In short, the whole question needed further study. Mr JUNEAU said there was no doubt that the current system of budget allocation caused problems, particularly where Africa was concerned. However, great care must be observed in choosing a new model, and he shared the view that further study was called for. The models proposed could be useful for classifying countries, but had significant weaknesses as criteria for the allocation of funds. Professor REINER noted what seemed to be general agreement that objective criteria for determining regional budget allocations were essential. However, the Board should be clear that if changes were to be made to the current system on the basis of what was proposed, some would inevitably receive more, and others less, than in the past. The report by the special group might be succinct, but the group had spent a great deal of time discussing different scenarios and indices, and had carried out many simulations of how particular regions and
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countries would be affected by the changes. Of course, it would always be possible to spend a further two, five or 10 years refining the proposals, but no one should be in any doubt as to the urgency of the situation: at present the Organization had no parameters whatever for determining regional budget allocations or making adjustments to take account of changing situations, whether for the better or the worse. It should be specially borne in mind that many donor countries were concerned that the money they gave to WHO was not being distributed on the basis of greatest needs. Pointing out that the changes proposed were in line with reform measures being introduced in other United Nations organizations, he warned that if the Board did not grasp the nettle now, WHO might find itself in a far more inextricable situation in a few years' time. Dr SULAIMAN agreed that extrabudgetary resources should be a factor when defining any new formula. Population and gross national product should also be taken into account, with due weight given to the variation between countries and regions. It should also be borne in mind that many of the countries in transition were suffering not only from the problems of Third World countries but also from those of advanced countries, and were therefore in a special category. Any new method should therefore be applied with caution, and special measures should be taken to reduce its impact on needy countries and regions. Mr DE SILVA said that countries which had been successful in implementing their health programmes should not be penalized. He could not therefore accept that the Health Development Index and immunization coverage should be adopted as criteria. Donors should be made aware that countries of eastern Europe, which had originally had very good health systems, had seen those systems collapse through no fault of their own, and that they should therefore be treated as a special case. He agreed that population should be a criterion when deciding regional allocations. Dr CALMAN said that he was in favour of the proposed model based on scenario A, although some refinement was required and it should be applied in a gradual and sensitive manner. The Board had already discussed the role of its members as individuals and national representatives; however, they also had a responsibility towards the Organization as a whole, which included ensuring equity among the regions. He therefore hoped that the Board would adopt the draft resolution so that action could be taken without further delay, for the African Region in particular was in need of support and resources. Dr STAMPS said that the special group had been entrusted with the task of finding a health index that could be applied objectively to the allocation of the regular budget, which was, incidentally, intended to support national health systems and not to provide for emergencies. The Human Development Index had been chosen since it was the most accurate means of assessing the capabilities of national health systems. Furthermore, since the Index already covered factors such as literacy, water and sanitation and the status of women, there was no need to add any further indices, as some members had suggested. The adjustment for immunization coverage was a very simple indicator of an easily determined activity that was essential to health. Arguments about penalties and rewards were pointless; there was no room for competition, the aim was to work for the global good and rectify the wrong done to Africa in particular, which had been treated unfairly for the past 50 years. He expressed disappointment at comments on the need for refinement of the model or more in-depth study. In his view, the special group had devoted much time and attention to the matter and the proposed model was the best and most objective solution. Professor LEOWSKI said that the reforms of the Organization and the renewal of the health-for-all strategy on the basis of established criteria had already been discussed many times. However, members seemed to be concerned that any reform without consideration of the financial basis of implementation might be viewed as lip-service only. The special group had completed the task entrusted to it; now it was for the Board to take concrete action. In his view the draft resolution met most of the concerns raised during the discussion, although some amendments might be necessary under paragraph 2(c) regarding the proposed time-frame for implementation of the model, and paragraph 2(a) might perhaps be expanded to make mention of other indices considered appropriate for the task. On the basis of such a draft resolution, a new model for the regular budget allocations for consideration at the next Health Assembly and session of the Board could be prepared.
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Dr SHIN said that following the special group's last meeting he had set up an ad hoc group of experts in his home country to conduct a detailed examination of the equations and indicators used in developing the proposed model. The ad hoc group had reached the conclusion that the special group had done an excellent job and that the proposed model, although not ideal, was the best possible solution under the circumstances. Its only remaining concern was the rationale behind the adoption of logarithmic calculations for determining population statistics. While action was indeed necessary, the Organization must proceed cautiously. The model should therefore be phased in during a period of four to six years (two to three bienniums), with the submission of periodic progress reports to the Board. Dr KARIBURYO said that progress made in the attainment of WHO health objectives launched in a spirit of solidarity had been thwarted by natural and man-made disasters, resulting in a public health crisis, above all in Africa, which called for emergency measures. At a time when action by the international community was so politicized, perhaps WHO ought to reaffirm the principle of solidarity. If it failed to do so, not only countries, but entire subregions would be doomed by the resurgence of epidemics. From the discussions so far it was clear that the current system of budget allocations had limitations and needed to be reviewed. Any model adopted must meet the real needs of the world's sick populations. It was not a matter of how much was allocated to one country or another- the time had come to show solidarity. Dr MOREL observed that the establishment of democratic regimes did not always result in more funds being allocated to the health sector. While he supported the type of change proposed by the special group, he asked why indices other than immunization coverage should not be taken into account. It seemed that the problem in some countries was not lack of funds but rather how they were spent. Why not penalize countries with high military expenditure rather than those with good immunization coverage? Dr DOSSOU-TOGBE said that it was important to direct the great interest aroused by the work of the special group towards positive action. As in any family or community, everyone had a role to play and must take their share of responsibilities, especially in relation to values such as interdependence and solidarity. Everyone must undertake self-examination and be prepared to make concessions with a view to achieving results as soon as possible. It was not a matter of negotiating but of seeking consensus, together with greater solidarity. In the future, the factors exerting a positive influence on the criteria and indicators on which the different proposals were based should be improved. In any system, 80% of the results came from only 20% of the resources, and those who made the greatest contributions did not derive the greatest benefits from their efforts. Such a viewpoint would, he hoped, help the Board to move towards the adoption of the draft resolution proposed. Mr VOIGTLANDER said that everyone was agreed on the need to develop a system based on objective criteria, and several alternatives had been proposed. The discussion of regional allocations was a long-standing tradition, and it was time to undertake reform from within the Organization rather than waiting until external assessors drew the conclusions that were already obvious. Work should begin immediately, on a gradual and smooth basis. He therefore supported the draft resolution. Dr LOPEZ BENiTEZ emphasized that all those who had spoken had expressed their lack of satisfaction at the way in which the Organization's financial resources were currently allocated to regions and countries, and that something must be done. Dr Shin's group had discussed the matter in detail and had concluded that the task in hand was not an easy one, and that there were no further options. The Board should therefore seek a solution on the basis of the draft resolution. The CHAIRMAN, speaking in a personal capacity, said that the item under discussion provided a clear indication of the Organization's willingness to improve its efficiency and to adapt to those who were in the greatest need. Observers of WHO's activities would be amazed if the management mechanisms in place remained unchanged despite the economic and social upheavals currently taking place, which were giving rise to increasingly serious consequences for the most underprivileged and a growing divide between developed countries and developing countries.
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The proposals made by the special group should be supported as they were objective, fair and realistic, and offered a chance to set up balanced mechanisms for deciding on how resources should be allocated, as well as in the management of all WHO budgets. The Board should complete its work as quickly as possible and pass the matter on to the Health Assembly. Given that a model was in place and the need for methodological change was so obvious, the Organization must take appropriate action even if it was necessary to continue to reflect on how to improve the methods used. Dr BLEWETT, speaking as Chairman of the special group, thanked Board members for their comments. Despite the arduous nature of the debate, if the terms relating to equity, transparency and objectivity in the criteria used were in fact real, i.e. if resources were to reach the countries most in need, the report under consideration established an unanswerable case for a shift in resources to the African and European Regions. There was, however, an obvious complication as regards the South-East Asia and Western Pacific Regions, since both those areas contained one very large country which created problems as a result of the large population. Attempts had been made to deal with that situation by means of the usual statistical methods. The fact that resources were being considered for transfer from the Americas and the Eastern Mediterranean was recognition of what those Regions had achieved in the past 50 years in terms of health and general development. The reallocation of resources in accordance with objective criteria should therefore be viewed as a matter for praise rather than as a penalty. However, such a reallocation was not of course easy to implement. Much had been said on the subject of indices. However, both the scenarios examined had produced the same general results, i.e. the need to shift resources to Europe and Africa. The reallocation could therefore be undertaken with confidence, even though it would be necessary to refine the strategy implemented over the next four to six years. Provided that major development indices were used (i.e. countries' capacities to furnish resources), the same broad results would be achieved, providing greater resources for Africa, eastern Europe and central Asia. Although it was clearly desirable to take account of extrabudgetary resources, it was not yet possible to do so even in preparing the Organization's budget and assessing its priorities. Once that had been achieved for the overall budget, it would also be possible for regional and country allocations. All in all, given the work already completed and the appreciation shown for it, the necessary shift, albeit marginal, could be made- an action that would honour the Organization's commitments and statements, as applied to the health-for-all programme about to be approved. The CHAIRMAN invited the Board to consider the draft resolution. Dr WILLIAMS requested clarification regarding the timing of the implementation of programme budgets, as referred to in paragraph 2(c) of the draft resolution. Since such an exercise was already under way at country level, it was necessary to act as soon as possible. Mr AITKEN (Assistant Director-General) replied that the Director-General had issued initial allocations to the regions for the biennium 2000-2001 in November 1997. However, in his letter of allocation he had reserved the right to reconsider those allocations at the end of January 1998 in the light of the Board's discussions. Furthermore, it should be made clear that the allocations currently being debated were at country level. Dr ITO (alternate to Dr Nakamura) requested that due account be taken ofDr Blewett's comments on the need for sensitivity in the handling of regional population issues. The phrase "such as 'logarithmic smoothing"' should therefore be deleted from paragraph 2(b) of the draft resolution. It was also necessary to adopt a more flexible approach which could be achieved by inserting "in the most part" before "be guided by" in paragraph 2. Dr MOREL said that he could support the draft resolution with a minor adjustment. The first part of paragraph 2 should be amended to read as follows:
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DECIDES that the Executive Board should develop an objective model for the allocation of country resources in the programme budget based on agreed indices which could include, inter alia, (a) the UNDP's Human Development Index; The rest of the paragraph would remain unchanged. Dr BADRAN (alternate to Professor Sallam), endorsing Dr Morel's proposed amendment, said that if a vote were to be taken, it should focus not on whether to accept or reject the proposal made but on whether to accept the proposal in its current form or consider the matter further. Outright rejection of the proposal would merely undermine the large amount of work already done. Dr SHIN proposed that in paragraph 2(c), the phrase "gradually over two bienniums" should be amended for two reasons: (1) the 2000-2001 programme budget process had already started at country level; and (2) the country budgets in one region would be particularly heavily affected. The changes should be introduced over three bienniums. Given the likely variation in human factors, immunization levels and gross domestic product statistics, the Executive Board might wish to indicate that the model should be readjusted every two bienniums. Since the nature of population adjustment was uncertain and there was a need for a gradual, sensitive approach, the Board might also like to specify that it should receive progress reports. Paragraph 3 of the draft resolution should be amended accordingly. Professor PICO (alternate to Dr Mazza), although commending the special group on its work, continued to think that the subject could well be analysed further. However, in the light of the discussion, he could in general agree to the draft resolution as amended by Dr More I. Referring to paragraph 4, he suggested that the words "to the 2000-2001 biennium" should be replaced by "in future budgets", bearing in mind that the reference in paragraph 2(c) referred to two bienniums. Dr SHIN, referring to the annexes to document EB101/7, drew attention to the wide divergence in percentage allocation between regions and requested clarification of the figures for global country allocations. Mr AITKEN (Assistant Director-General) explained that the model applied in the three annexes of document EB I 0 I17 had been developed using individual country statistics. Annex I dealt only with the regular country budget allocation - the money spent at country level from the regional budget - representing some US$ 320 million out of WHO's total regular budget of around US$ 840 million. Under scenario A, the current country allocation for Africa, for example, was about 30%, whereas the allocation calculated in terms of populations mathematically transformed by squared natural logarithm and multiplied by a "stretching" factor was 44%. Annex 2 showed the same percentage applied to both regular country and intercountry budgets, giving an intermediate picture between Annexes 1 and 3. Annex 3 summarized the regional allocation of regular country, intercountry and regional budgets, amounting to a total of some US$ 560 million. Again, under scenario A and considering the mathematically transformed populations, it could be seen that the country allocation in Africa was 44%, the same as that in Annexes 1 and 2 because the percentages were based on country statistics, which were the same in each case. Differences between the funding levels in scenario A in the three annexes were thus explained by differences in relative expenditure at regional office, intercountry and country level. Regions in which a higher proportion of the regional office budget was currently spent at regional office level would appear to the greatest advantage in Annex I, whereas the reverse would be the case for Annex 3. The current differences in actual allocation of money between regions were based on historical precedent. Dr SHIN asked whether the model would be used to decide the balance to be achieved between expenditure at country and at regional office level or whether that responsibility would remain with the regions. Mr AITKEN (Assistant Director-General) replied that the Director-General and Regional Directors would use their discretion in applying the results that the model produced for each country. Regarding Annex 3, the Director-General, the Regional Directors, the regional committees and the Executive Board could provide
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guidance on the relative allocation of funds between the regional office and country programmes, bearing in mind that there was a minimum requirement to maintain a functioning regional office. Dr BLEWETT, sharing Dr Shin's concern, said that it should be made clear that the draft resolution referred to total regional resources either by including a reference to Annex 3 or by explicitly mentioning regional, intercountry and country allocations together. Decisions on how overall regional resources were then shared out would thus be left to the regions themselves. Professor REINER, speaking as a sponsor of the draft resolution, said that the special group had focused on country allocations as a first step, taking the view that change should be gradual and progressive rather than abrupt. The differences between the three annexes in terms of percentages of allocations were not great. The idea was to establish objective criteria for allocations at country level, then to move on to consider intercountry and regional level allocations. He understood the concerns raised by Dr Shin and would find it acceptable to envisage gradual implementation of the model over three bienniums. In that context, the proposed amendment to paragraph 4 was acceptable. The great advantage of the Human Development Index was that it was very sensitive to changes in the economic situation of countries. However, the amendments proposed by Dr More! were substantive and would prolong the process indefinitely. Although it was right that change should be gradual and flexible, it was imperative to make a start. Dr BLEWETT, speaking as Chairman of the special group, said that the deliberations of the special group had been principally based on overall allocations, those shown in Annex 3, since they allowed for a more realistic comparison between regions. Mr NGEDUP said that the draft resolution reflected the discussion in the special group, in particular by envisaging a smooth process of continuous evolution, rather than a revolution. However, drastic reduction of a regional budget would fall into the latter category. The population factor also required further analysis. Mr JUNEAU endorsed the amendment proposed by Dr More!, which was in line with the overall intention of the draft resolution. Dr FERDINAND said that there was general consensus on the need for redistribution of the budget. However, in view of the importance of the issue, she endorsed the amendment proposed by Dr More!. Dr KOMODIKIS proposed that paragraph 2(c) should be amended so as to specify that implementation would take place as from the financial period 2002-2003. She endorsed the view that the draft resolution should make plain that its provisions applied to regional, intercountry and country allocation as a whole, as reflected in Annex 3. Dr MELONI endorsed Dr More!' s proposal and the amendment suggested by Dr Komodikis. He requested that in future an analysis should be provided not only of country, intercountry and regional allocations, but of the use and allocation of headquarters funds as well. Dr SULAIMAN felt the amendment proposed by Professor Pica to paragraph 4 introduced too much flexibility. Reference to a specific financial period should be retained. In addition, the Regional Directors might be asked, when preparing budgets, to take account of previous budgets. Dr RAI (alternate to Dr Wasisto) stressed the need to implement the new model gradually and in a flexible manner in order to prevent disruption to implementation of important programmes. Mr CREGAN (alternate to Mr Hurley) warned against diluting the overall thrust of the draft resolution by introducing too many amendments. However, he agreed that there was a need for gradual implementation over three rather than two bienniums.
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The CHAIRMAN reminded members of the Board that their task was to submit a draft resolution to the Health Assembly, which was sovereign and might wish to continue the debate. Dr STAMPS said that with the current structure of budget formulation, the resolution need not be passed to the Health Assembly but could be a Board resolution. It was the budget that would be debated by the Assembly. The CHAIRMAN stressed that if it were to decide not to recommend a resolution to the Health Assembly the Executive Board would fail in its duty and fail the special group it had entrusted with the work. All speakers had paid tribute to the group's excellent work; it was therefore the Board's responsibility to ensure that consideration of the matter by the Health Assembly was not further delayed. He proposed two possible ways of proceeding: voting on the draft resolution or setting up a working group consisting of the sponsors of the resolution and those members of the Board who wished to put forward amendments. Dr WILLIAMS, Dr CALMAN, Dr L6PEZ BENITEZ and Dr ITO (alternate to Dr Nakamura) were in favour of setting up a drafting group. Dr STAMPS, supported by Professor REINER and Dr SANOU IRA, suggested that the proposed amendments should be drafted, not by a working group but by the Secretariat.
The proposal to set up a drafting group was rejected by 20 votes to 11, with 1 abstention. The CHAIRMAN suggested that the Secretariat should be asked to prepare, for the Board's consideration at a later meeting, a list of the amendments being proposed. It was so agreed.
(For adoption of resolution, see summary record of the twelfth meeting, section 1.)
The meeting rose at 12:30.
SIXTH MEETING Wednesday, 21 January 1998, at 14:30 Chairman: Professor A. ABERKANE later: Or A. J. MAZZA
WHO REFORM: Item 7 of the Agenda (continued) Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group: Item 7.3 of the Agenda (Resolution EB99.R24; Decision EB99(5); Documents EB101/7 and Corr.1) (continued) WHO regional arrangements (continued) Point (4) - Current status ofrelationship between WHO and PAHO
Dr BLEWETT, speaking as Chairman of the Executive Board special group for the review of the Constitution, said that Article 54 contained a commitment to integrate WHO and PAHO. There had been some debate as to whether integration had occurred, given the legal distinctions that remained and some problems of transparency. The group had therefore recommended that the matter should be the subject of discussions with PAHO, primarily in order to clarify whether Article 54 - in its present, or in an amended form - should remain in the Constitution of WHO. Dr STAMPS remarked that if Article 54 were deleted and the continued existence of the two organizations in the Region ofthe Americas accepted, then Article 44(b), stipulating that "There shall not be more than one regional organization in each area", would have to be amended. Mr TOPPING (Legal Counsel) explained that, historically, the term "regional organization", as used in Article 44, signified a region established by WHO. Were Article 54 to be deleted, there would be no consequences for Article 44, since PAHO was not a regional organization of WHO. In reply to a further question by Dr STAMPS, he said that the intention of Article 54 was that PAHO should be integrated with WHO. There was indeed functional integration in a great many respects. If Article 54 were deleted, the constitutional imperative to integrate was removed but nothing prevented the continued existence of a collaboration agreement between the two organizations. It was true that PAHO, as a completely separate legal entity, could not be an integral part of the Organization but it could still, as it had done in the past, perform many functions on the latter's behalf. Dr STAMPS inquired whether it was legal for officers to be shared, in terms of duties, by WHO and PAHO. Further to that, should Article 54 be deleted? Must the integration that had occurred be reversed? Mr TOPPING (Legal Counsel) said that the special group's recommendation was that WHO should examine the matter with PAHO. If that was done, the legal implications would, of course, be considered. Dr MAZZA remarked that WHO and PAHO had worked together efficiently for 50 years and should continue to do so. He had no objection, however, to the joint discussions as recommended by the special group.
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The CHAIRMAN observed that the group's recommendation was intended to remove any ambiguity from the situation: either the Constitution should be amended or integration should be effected. Dr LOPEZ BENITEZ emphasized the need for open dialogue between the two organizations as separate legal entities which could consult together on equal terms. That - as he understood it - was the purpose envisaged by the group in making its recommendation. It was also his understanding that the Board and the Health Assembly would be informed of the results. Dr ALLEYNE (Regional Director for the Americas) submitted that much of the discussion hinged on what constituted integration. In the present instance, there were equally valid legal arguments to confirm, or deny, that it existed. He himself would contend that, to all intents and purposes, the constitutional provisions were currently complied with. Integration was not the same as assimilation; PAHO and WHO remained separate legal entities, and together had long rendered great services to the peoples of the Americas and of the world. With all due respect for other opinions, he considered that in functional and practical terms, integration had occurred; that Article 54 should be left unchanged.
The recommendation was approved. Point (5) - Criteria for determining regions, assignment ofMember States to regions and location ofregional offices Dr BLEWETT, speaking as Chairman of the special group, said that none of the numerous attempts in the past to establish precise criteria for determining the regions of WHO had been accepted. The group had therefore recommended merely that WHO should cooperate actively with the United Nations in seeking systemwide rationalization. The second recommendation was that the criteria applied to the location of headquarters should apply also to regional offices if at any time new ones were to be established. Dr BADRAN (alternate to Professor Sallam) said he had no objection to the recommendations but wished to recall various decisions taken previously by the Executive Board and the Health Assembly according to which no country would be transferred from one region to another without the approval of both regions concerned.
The recommendations were approved. Point (6) - Representation of the regions in the Executive Board and other bodies Dr BLEWETT, speaking as Chairman of the special group, said that regional representation on the Board had been a matter of concern for some years: the Health Assembly had before it several resolutions on the subject and had decided to await the report of the special group before taking further action in that regard. The proposal to increase the Board from 32 to 34 members would result in one extra representative each from the European and Western Pacific Regions. With the use of the new mathematical formula proposed by the Board member from Japan, that would give fair representation in terms of countries and, unless there were very significant changes in regions, a degree of stability for several years. Dr WILLIAMS supported the recommendations and asked whether the intention of the group was that Article 24 should be amended to read "thirty-four" instead of"thirty-two" or that the formula and the sentiments expressed in paragraph 44 of its report should also be incorporated in the Constitution. Dr BLEWETT, speaking as Chairman of the special group, replied that the only constitutional amendment would be the altered number in Article 24; the Health Assembly, if it accepted the recommendations, would implement the change. Dr WILLIAMS submitted that to constitutionalize the sentiment expressed in paragraph 44 might prevent a repetition of the very long delays experienced in the past in securing increased representation of a region.
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Perhaps the Legal Counsel could suggest a constitutional mechanism whereby the Health Assembly might without the need for further amendments - either increase or decrease the number of members of the Board? Dr VAN ETTEN entered a reservation. The Netherlands Government had adopted a policy of not supporting proposals for expanding United Nations governing bodies, on the grounds that expansion would not necessarily lead to improved decision-making and would involve greater costs. He recalled the decision of the previous Health Assembly to introduce budget savings in the cost of governing bodies and to ensure that most of WHO's money would go to priority programmes. The special group's recommendation on the size ofthe Executive Board was therefore untimely and he was unable to accept it.
Dr STAMPS said that he was the group member who had favoured including a generic statement on the composition of the Board in the Constitution. The formula described in paragraph 43 of document EBlOl/7 for determining the theoretical number of seats for each region would guide the Health Assembly without preempting its final decision, and would put an end to the tortuous arguments and the need to go through the whole process of amending the Constitution every time circumstances changed. Countries did not have to leave one region and join another for the number of countries in a region to change; for example, the African Region had gained a country with the creation ofEritrea, and the number of countries in the European Region had practically doubled. Moreover, Article 24 was the only article in the Constitution to impose such a definitive obligation on Members of the Organization. A generic formula would, he repeated, be flexible and would allow the Health Assembly to increase or diminish the number of members on the Executive Board as it saw fit. Dr MELONI argued that the proposal put forward by the special group, in response to a variety of social, political and administrative considerations, carried with it the implication of regular changes in Article 24, which currently specified that the Board would consist of 32 members. Remarking that those members were designated by Member States but served on the Board in a personal capacity, and that the proposed increase in the number of members did not reflect demographic changes, he sought clarification of the reasoning behind the proposal and the other options considered by the special group. The CHAIRMAN said that, as he saw it, the special group had proposed what it considered to be the most appropriate formula to guide any decision to expand the Executive Board. At issue, therefore, were both the choice of formula and whether the number of members should be increased. Dr BLEWETT, speaking as Chairman of the special group, explained that there had been dissatisfaction for some years over the perceived underrepresentation of certain regions on the Board. The special group had endeavoured to produce a formula that gave all countries a fair chance of designating a Board member. That could be achieved without a constitutional change of numbers, but only by reducing the representation of some regions in order to increase that of others, an option which had found little support in the special group. Increasing the total number of members to 34 should, on the other hand, mean that every region was fairly represented. He added that the semi-permanent presence of permanent members ofthe Security Council on the Board was a further complication, and one felt particularly keenly in certain regions. Dr MELONI said that although the redistribution of the existing number of seats would not solve the problem of regional underrepresentation, as the special group had no doubt concluded, that option might deserve further consideration. He asked whether the special group had examined the administrative costs and the impact of its proposal on the country allocation of resources in accordance with agreed priorities. He reiterated his conviction that the allocation of resources could not be adequately analysed without taking into account their overall distribution; that included the level of funding earmarked for headquarters. The CHAIRMAN said that the Board could accept the proposed formula and the concomitant increase to 34 members, as proposed by the special group; or it could look more closely at possible formulas for redistributing the 32 existing seats. A further option would be to examine the formula proposed by the group and submit it to the Health Assembly for consideration, leaving to that body any decision on whether or not to increase the number of Board members.
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Dr STAMPS clarified the formula used to calculate the theoretical number of seats on the Executive Board allocated to each region; each region was allocated a baseline of three seats and the excess seats were divided according to the proposed formula. Unfortunately, a misplaced bracket in the heading to the third column in the table (paragraph 43 of document EB 10 1/7) suggested that the theoretical number excluded the baseline seats. It was possible that using the number of Member States in a region gave a distorted result- some regions, for instance, had many small States - but that was unavoidable, since the State was the fundamental unit of membership of the Organization. With regard to the financial implications of increasing the membership of the Board from 32 to 34, he said it would probably take eight to 10 years for the amendment to be passed and therefore the question of additional costs would not arise for at least a decade. Even then, an increase of, at most, 6% in costs was a relatively small amount. He took the opportunity to reiterate his support for the inclusion of a flexible generic formula in the Constitution, to allow for eventualities. Dr MAZZA fully agreed that there was a need for equitable representation on the Board, but said that simply altering the number of seats would not ensure that and, furthermore, would run counter to the basic objective of reducing, or, at least, not increasing, the administrative costs of the Organization in particular. He would prefer consideration of possible formulas for determining the distribution of seats without increasing the total number of members. Dr SANOU IRA wondered on what basis current membership had been fixed at 32. If it was based on the number of countries in a region, a formula should be sought that would allow any future changes to be reflected in the composition of the Board. If no such objective criteria had been used, it would still be useful to adopt a suitable formula for future use. Dr BADRAN (alternate to Professor Sallam) endorsed the special group's proposal. Under the formula explained by Dr Stamps the modest addition of two seats would ensure reasonably equitable representation; attempts at redistributing the current number of seats would surely lead to problems. Dr MOREL cautioned against any increase in the number of members of the Board since it would entail higher spending. It would be better to adjust regional representation to ensure equity. Professor REINER recalled that the members of the special group, and the 30-40 other participants who had attended its meetings, had considered many other options during discussions, including reducing the number of members on the Board to the original 18. However, that solution was not thought to be in the interests of democracy within the Organization, as it would make it even less likely that small states would be able to designate a member, while the problem of the semi-permanent members would be exacerbated. If the figure of 32 was retained, and regions were to be equitably represented, at least one region would lose a seat; there had been a good deal of resistance to that idea during the discussions. The special group and other participants in its meeting had thus reached a consensus on the figure of 34, as a compromise which would ensure a more or less fair distribution of seats. Dr AL VIK said there was a need to establish fairer representation on the Board as soon as possible, and while other options could be considered in the future she supported the special group's proposal to increase the total number of seats to 34. It would challenge Board members to keep their interventions brief and to the point. Dr AL-MOUSA WI said that the special group had discussed a number of options and also the cost implications, which were trivial. He supported the group's proposal, and asked the Secretariat to provide information about the size of corresponding bodies in other international organizations. Mr CREGAN (alternate to Mr Hurley) said that the Board should support the proposals of the special group, which had given careful attention to all the issues involved and made a fair proposal. He observed with concern that the Board sometimes did not appear to have complete confidence in the groups it set up, especially when they dealt with technical matters.
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Mr VOIGTLANDER fully supported the special group's proposal as it stood. Redistributing all the seats on the Board was not realistic. Dr CALMAN, supported by Dr SHIN and Dr FIKRI, said he accepted the special group's proposal and strongly agreed with the point made by Mr Cregan. The Board established subcommittees and special groups because it needed their help in making its decisions. There had been ample opportunity in the special group to discuss all the issues involved, and yet the Board had discussed them again at length. It should begin to trust the groups it established. Mr NGEDUP endorsed the special group's proposal. Dr MUL WA said he joined in that endorsement. Noting that many of its members had attended meetings of the special group as observers, he urged the Board to take seriously the recommendations made by that group. The alternative was to do away with special groups and for the Board to spend several days discussing each item before it. Dr SANOU IRA said the fact that the Board was discussing the proposals of the special group did not mean that it did not have confidence in that group; it simply meant that it needed to understand fully the issues involved. Dr WILLIAMS asked about the extent of the amendment that was intended, saying that he favoured the proposal made by Dr Stamps. Dr MELONI said special groups were very useful and the present one had done some good work. However, the Board needed to ask questions and request further information because not all its members had attended meetings of the special group. It did not represent a lack of confidence. Dr MAZZA, noting that it would be unwise for the Board to accept the findings of its subcommittees and groups without discussion, observed that there was clearly no consensus regarding the special group's proposal. He himself opposed any proposal to increase the total number of seats on the Board at a time when the Organization's policy was to reduce headquarters and administrative expenditure.
The recommendation was approved by 23 votes to 4, with 4 abstentions. Mr TOPPING (Legal Counsel) said that two proposals to amend the WHO Constitution had been placed before the Forty-ninth World Health Assembly: one, from the Regional Committee for Europe, had been to amend Article 24 to enlarge the Board from 32 members to 33; the second, from the Cook Islands, had been to increase its membership from 32 to 34. The Health Assembly had decided at the time to defer consideration of either proposal pending the Board's constitutional review, so both proposals were effectively in suspension and remained before the Health Assembly. In view of the Board's endorsement of the special group's proposal, its simplest course of action at the present juncture would be to incorporate an appropriate item when it reviewed the agenda for the Fifty-first World Health Assembly. The Director-General would then ensure that appropriate documentation would be made available to the Health Assembly.
It was so agreed. Point (7) - Term ofoffice of Regional Directors: qualifications and method of selection Dr BLEWETT, speaking as Chairman of the special group, said that the only proposal was that the term of office of Regional Directors should be the same as for the Director-General, namely five years, renewable once and not applying to present incumbents.
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Dr LOPEZ BENITEZ said that presented a slight problem for the Region of the Americas where the term of office of the Regional Director of the Pan American Health Organization (PAHO) was four years. Extending it to five years would require a possible amendment to PAHO's Constitution. Dr ITO (alternate to Dr Nakamura) supported the special group's proposal but regretted that, as far as the selection procedure of Regional Directors was concerned, there were no measures to strengthen the participatory role of the Board in the process. In his opinion the Board should select Regional Directors from more than the one candidate proposed by regional committees. Dr SULAIMAN also supported the proposal, but asked whether the special group had discussed selection criteria and whether the regions were independent and enjoyed flexibility in that regard. Dr BLEWETT, speaking as Chairman of the special group, said those matters were for the regions to decide themselves, but they should consider whether the criteria and selection procedures employed for the Director-General and the Regional Director for Europe were useful and applicable to them.
The recommendation was approved. Mr TOPPING (Legal Counsel) said that when the same matter had been considered by the Health Assembly in respect of the Director-General's term of office it had amended its Rules of Procedure to include a provision to the effect that the term of office would be five years renewable once, it being understood that the rule would not be applicable to the incumbent. The Board would presumably wish to do likewise, bearing in mind the constitutional provision of PAHO to the effect that the term of office of its Regional Director was four years. In order to avoid possible constitutional conflicts between otherwise closely integrated and cooperating organizations, a reference might be inserted in the Rules of Procedure to the effect that subject to Article 54 of the Constitution the term of office of Regional Directors should be five years renewable once. The present session of the Board might wish to request the Director-General to prepare a draft resolution incorporating such a text to be presented for adoption by the Board at its session in May 1998. That draft resolution - to amend the Board's Rules of Procedure - might also include a request to the governing bodies of PAHO to consider changing its own Constitution and Rules of Procedure accordingly. It was so agreed.
Point (8) - Mission and functions ofregional committees; frequency ofregional committee sessions
The Board took note of the special group's comments. Point (9) - Relationship between regional and country offices and impact of this linkage on the work of the Organization
The Board took note of the special group's comments. (For continuation, see summary record of the eighth meeting, section 2.)
Or Mazza took the chair.
WHO country offices: Item 7.1 of the Agenda (Documents EB101/5 and Corr.1 and Corr.2) The DEPUTY DIRECTOR-GENERAL ad interim, introducing the item, recalled the recommendations of the Executive Board's Working Group on the WHO Response to Global Change in 1993, the subsequent establishment of a development team on the future role of WHO at country level, the team's report and recommendations submitted to the Executive Board at its ninety-sixth and ninety-seventh sessions, and the
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progress reports to the Executive Board at its ninety-eighth, ninety-ninth and 1OOth sessions. The report now before the Board outlined the present situation on WHO representation by WHO region, discussed strengthening WHO representation in countries in greatest need, suggested a grouping of Member States according to economic and health status, and proposed mechanisms for adjusting WHO representation at country level taking into account the health needs, economic development and population size. The report provided statistical information in the form of tables, together with analytical data and suggestions. A section was devoted to WHO coordination and the recent United Nations reform proposals. Budget allocations were analysed and the criteria applied were very much in line with the Board's discussions earlier in the afternoon. Finally, he drew attention to the five recommendations for action by the Executive Board contained in paragraph 24, with particular emphasis on the consultations to be carried out at the regional level. Dr ITO (alternate to Dr Nakamura) supported the position that closure, or replacement with liaison offices, of country offices in certain Member States whose economies had developed to some extent should be seriously considered and welcomed the arguments along those lines in the document before the Board. Specific plans for enhancing the efficiency of WHO country offices should be drawn up and implemented. A country wishing to keep its WHO office even though that was not considered necessary by WHO on the basis of agreed criteria should bear or share the costs of WHO representation in that country. Clearer criteria than those set out in the document should be established, in consultation with Member States. Of the eight points contained in Board decision EB97(13), only point (1) was addressed in the report under consideration, and he would appreciate information on progress made in respect of points (2) to (7). Dr BLEWETT said that the long-awaited document now before the Board was well researched and for the first time addressed core issues. He strongly endorsed the statement made by the Regional Director for the Americas at the 1OOth session of the Board that limiting the topic to country offices had narrowed the discussion to how WHO should express itself in countries and how far countries should have a channel of communication to some focus in the Organization, and that the only way to resolve the question of the role of WHO country offices was to look at the structure WHO should have in terms of its functions at different levels. The point was that the extent and character of WHO representation at country level derived directly from WHO's role in the country concerned- the nature of its involvement and the priority of associated activities - which differed from country to country. A number of questions about country-level representation should be considered together. Specifically, the criteria for assessing the need for country-level representation and the type of representation should be considered in conjunction with questions of WHO's functions at country level, the type of personnel required to perform them effectively, the structural relationship with other levels of the Organization, and the interrelationship with the activities of other United Nations agencies, nongovernmental organizations and donor governments at country level. He endorsed the analysis and findings contained in the report, such as the criteria set out in Table 4, the suggested groupings, the graduated representation at country level proposed in Table 3 and the proposed approach to funding. He stressed the importance of paragraph 23, but was less satisfied with the recommendations for action in paragraph 24, since, important though it was for the regional committees to be consulted and to hear the views of the regions, it was crucial to maintain the global momentum initiated by the document. As the paper showed, there were very great differences in the types of representation relative to needs in the regions. For instance, it could be seen that in some regions, group 3 and even group 4 countries had a full country office, whereas in other regions there were group 2 countries with only a national liaison officer. Only the Western Pacific Region appeared to make use of shared country offices to cover several small states, even though that model would make sense in other regions. Again, only the European Region made significant use of national liaison offices, although the model was an excellent one for countries where national institutions were already well developed. In the interest of maintaining a global focus, therefore, he suggested that the Board should accept the criteria for the assessment of country needs and the graduated levels of country representation, and begin to use that typology for determining the allocation of budget resources. Finally, the forthcoming informal presentation of the recent major independent study of WHO support to programmes at country level undertaken on the initiative of certain Member States (the Oslo phase 11 study) would provide a further interesting contribution to the Board's discussion of the item.
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Mr VOIGTLANDER said he was gratified to note that the question of the coordination of WHO activities with the work of other United Nations organizations and programmes at country level had been addressed in the report. He agreed that WHO Representatives performed a dual role, having to promote WHO's policies and strategies while being involved in concrete programme development and implementation in cooperation with national governments. Both tasks should be undertaken with due regard for discussions within the United Nations system on an integrated and unified United Nations presence at country level. He would strongly support the full integration of WHO activities into the resident coordinator system and the United Nations Development Assistance Framework (UNDAF). As a logical consequence, the members ofthe WHO country office should be integrated into the planned "United Nations houses". Such concentration could improve the efficiency of activities, would avoid duplication and would be more economical because of the common use of services and premises. Where appropriate and feasible, the possibility of having one country office for two or more neighbouring countries with similar problems should also be considered. Professor REINER welcomed the fact that the solutions proposed in the report could be tied in with the ongoing reforms in WHO. The Regional Committee for Europe took the view that WHO should be represented in all Member States, even developed countries. The report reasserted that view: depending on the individual country's level of development and health needs, six mechanisms were proposed for WHO representation (Table 3) designated to take charge of coordinating activities at country level needed a great deal of time to adapt to local conditions: that made it more difficult for them to find adequate methods of cooperating with local health authorities in emergency and humanitarian actions, which were the most common arena for their involvement. WHO Representatives had two main responsibilities- representational activities and technical cooperation with governments. An additional, important function was to help countries in implementing health strategies and meeting health targets. Those functions must be carried out equitably. Table 1 clearly pointed to a need for improvements: the variations in average allocation per country and the number of country offices per region were quite striking. The European Region had no funds to reallocate to benefit the countries in greatest need by establishing a country presence there, even though a review had shown that that was indeed necessary. Once each regional committee had reviewed its region's situation, therefore, consultations should be held with the Director-General to determine the sources from which the necessary funds might be drawn. There was every justification for seeking objective criteria for classification of countries on the basis of the size and type of WHO presence there, as the report suggested. However, the indicators listed in Table 4 required further refinement to facilitate accurate comparisons. For example, depending on the indicator chosen, his country might currently fall into any one of three groups, 2, 3 and 4. Referring to the future structure of WHO at the global, regional and country level, he pointed out that the changes likely to emerge from the reform of the United Nations system might result in a single "United Nations house" in each country with the UNDP resident coordinator as the United Nations country coordinator. It had been agreed that WHO must maintain and further develop its position as the leading agency in global health. But it must also assume the leadership role in health at country level. Since organizations other than WHO were increasingly dealing with health issues and health care at that level, the WHO Representative should act as the United Nations country coordinator in health matters. Within the framework of common resources outlined by the Secretary-General at the fifty-second session of the General Assembly, there had to be identifiable sources for coordinated implementation of health programmes. Closer coordination with other United Nations and intergovernmental organizations involved in the health field had to be established, not only at country, but also at regional and headquarters level. He therefore urged that the question be placed on the agenda for a future session to give the Board a better insight into the whole process. He understood that a great deal had already been done, including by the Division of Interagency Affairs. Finally, in Annex 1 of the Director-General's report, the figure given for infant mortality in Croatia in 1995 should be less than nine per 1000, not 10 per 1000 as stated. Dr V AN ETTEN observed that the report provided a framework for ensuring that country offices were allocated according to the needs of Member States, and rightly emphasized, in paragraph 18, that adjustments for particular countries should be made on the basis of specific information on emergencies, absorptive capacity and other factors. He endorsed Mr Voigtliinder' s comment on the integration of country offices into the common "United Nations house", an option that should be added to those listed in Table 3 of the report. Though he
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concurred with the analysis set out in the report, he agreed with Dr Blewett that the action proposed in paragraph 24 was rather weak and should be strengthened. The Board should resume discussion of the topic following the informal presentation of the Oslo phase II study, by which time the working group looking at paragraph 24 might have produced a revised proposal. Dr AL VIK said that the report clearly demonstrated the need to review and revise the present system of resource allocation to give higher priority to countries in greatest need. A similar conclusion had been reached by the team that had carried out the independent study mentioned by the previous speaker. One of the main findings, based on 12 case studies, had been that neither the size of the country offices nor the size of the country programme budgets was related to the countries' needs or capacities. She welcomed the proposal to widen the options for WHO representation in countries; such an approach would favour a more flexible system, easier to tailor to specific situations. Likewise welcome was the proposal to distinguish more clearly in the budget between costs relating to the separate functions of country offices: representational activities and technical cooperation. WHO must coordinate its activities with other actors in the health field, especially those within the United Nations family, in order to avoid overlap, ensure a division of responsibilities based on the strengths of each organization and encourage synergies, where possible. Finally, she supported the suggestion that the Board should resume discussion of the item after the informal presentation of the Oslo phase 11 study. Dr SANOU IRA welcomed the report which took account of concerns expressed over many years. WHO was, she believed, the organization with the strongest representation at country level. Its country presence should be reinforced to conform to the new vision of health for all in the twenty-first century. The consultation mechanisms proposed in the report would promote maximum involvement of citizens in decision-making, facilitating the subsequent implementation of decisions adopted. Some Board documents revealed a lack of understanding at country level of how WHO operated. In defining the role of country offices, stress should be laid on the information function, and on ways of promoting grassroots awareness of the Organization's mission and functions. Mr NGEDUP said the subject at hand was nothing less than WHO's global and technical leadership and the assertion of the Organization's identity. Country offices were the base upon which to build strong technical leadership and forge good relations with other organizations. Collaboration with other agencies was currently very limited, both in magnitude and vision. Yet the crisis in UNAIDS had shown that combined operations were not necessarily the solution. Technical staff who should be exercising technical leadership were serving in bureaucratic, administrative positions, while staff without technical qualifications were coordinating work on highly sensitive, technical issues. The report should have addressed some of those concerns. Dr STAMPS expressed concern at the vague language used in the report and failed to share the enthusiasm shown by other members of the Board. Table 1 showed that there were few prospects for development in the African Region unless WHO resumed its leadership role in respect of fundamental health concerns. Mr Ngedup had rightly alluded to the disastrous performance of UNAIDS, which had effectively destroyed the Global Programme on AIDS in most countries. It had opened the door to attempts, not to save people from the disease, but to exploit their misery for commercial or political advantage. Because UNDP was providing leadership, development concerns had taken centre stage, while health concerns had been set aside. Countries were even being told that they were too poor to afford treatment for patients suffering from a fatal disease - an immoral and offensive stance. Moreover, in 1997, the Executive Board had adopted resolution EB99.R13, in which the importance of achieving economies was set alongside "taking into account WHO's comparative advantage as a leader in global health". The two were incompatible: an organization could not be a leader when obsessed with effecting economies. By joining with other agencies, international or nongovernmental, that had such different objectives, WHO would compromise its leading role. Dr SULAIMAN advocated an approach that would combine caution, by giving careful thought to the implications of the proposals in the report, and boldness, to overcome any weaknesses in the recommendations and to assert WHO's leadership role. WHO should not be overshadowed by the non-technical organizations working alongside it. The regional offices must therefore provide full support to country offices in order to
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ensure their effective functioning. Country offices were usually quite small and often cost very little to run, but they needed a unifying concept and the terms used to describe them should be consistent across the regions. Mr CREGAN (alternate to Mr Hurley) observed that the report made a useful contribution to the reform process, and expressed the hope that greater attention would be given to collaborative action in the discussions on the health-for-all policy. It was clear that scarce resources must be concentrated in the areas of greatest need. Moreover, support to country offices was crucial to the development of the Organization as a whole, not only for humanitarian reasons but also for WHO's credibility at country level. Paragraph 23 of the report summed up the issues involved and might be taken as a basis for action. The Board was in a position to concentrate analysis, reflection and proposals for action on areas that were central to the strategic direction of the Organization. He therefore supported the view that the question of WHO country offices should continue to be placed on the Board's agenda. Dr CALMAN welcomed the report which highlighted the flexibility of the possible mechanisms for WHO coordination at country level and the need for their ongoing review at regional level. He supported the views expressed by Dr Blewett, Dr Alvik and Mr Cregan. The report could well be used to support WHO's leadership role. It reflected the need to have the organizational capacity to deliver health-for-all objectives, and therefore provided a direct link with item 8 of the agenda, health-for-all policy for the twenty-first century. Or BADRAN (alternate to Professor Sallam), supporting the views expressed by Dr Sulaiman and other speakers concerning the importance of country offices, said that there was no overlap between the functions of regional and country offices. As almost all regions encompassed Member States with widely differing health needs, WHO Representatives were often in the best position to respond to specific country needs and to establish satisfactory cooperation between WHO headquarters, the regional offices and Member States. There had been a marked difference in his country since the establishment of the country office which, at little cost to WHO, was located within the Ministry of Health and had close relations with all institutions concerned with medical and health issues. He therefore recommended the establishment of country offices and endorsed the DirectorGeneral's recommendations. Or WASISTO expressed satisfaction at the proportion of regular budget funds allocated to the regions that went to countries, as indicated in paragraph 5 of the report. That allocation ensured decentralization, which was of particular importance for country policies and programme development. He supported the recommendation that countries should be classified in four groups according to the level of economic development and health status, as a basis for possible adjustment of WHO representation at country level. In a number of countries in each region, in particular those in group 3, WHO coordination needed to be more cost-effective and efficient. Dr LOPEZ BENITEZ considered that the report provided a good basis for re-establishing WHO's identity in the general context of the change of recent years. Regarding WHO's leadership role at the regional and country level, he stressed the need to focus efforts on improving WHO's technical capacity without which it was impossible to sustain leadership at all levels. Lengthy debate in his country had led to the conclusion that the primary function of WHO country representation should be to cooperate with national governments in formulating health policies and their implementation. The specific needs of countries must be taken into account: in certain cases external criteria that did not correspond to country needs had been imposed and applied, whereas the main objective to be pursued was to improve health services and strategies. Careful selection of WHO Representatives at country level was therefore important. Stressing the need to establish guidelines that would enable the Organization and countries to achieve their common goals, namely to improve the health and welfare of the population, he expressed the view that action at the country level should determine that at the regional level, which should in turn determine that at the international level, not vice versa. It was essential to work from country level upwards. Dr MUL WA welcomed the solutions recommended in the report, which would facilitate WHO's representation at country level. The subject had been discussed extensively in his Region by the Regional Director, the Regional Committee and the WHO Representatives or liaison officers, but it was essential to continue to improve the running of country offices, particularly in the changing socioeconomic conditions. He
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asked whether it was possible to obtain a copy of the report of the Oslo phase 11 study, and when an evaluation report might be expected on the pilot project running currently in 11 countries and relating to the UNDAF exercise. Or MELONI attached great importance to country offices and the priority given to the results achieved through cooperation in countries and hence to the analysis before the Board. Nevertheless, the use of certain indicators, including the classification of countries into groups according to level of economic development, required further consideration. For example, for group 3 the figures indicated a gross national product per capita ranging from approximately US$ 2000 to US$ 9000, which represented a broad and heterogeneous range of countries, but did not reflect certain other factors such as the needs and capacities in the sphere of public health expenditure and national commitments to debt servicing, which placed considerable restrictions on internal expenditures. Moreover, any reallocation of resources with a view to achieving greater equity and efficiency must take into account the way in which those resources were utilized, and should not be restricted to any specific part of the budget, for example, the regular budget, without taking into account extrabudgetary funds, or country allocations without taking into account those at headquarters. Or VAN ETTEN announced that a draft text for a decision or resolution on the subject of country offices was being prepared for consideration by the Board. The DEPUTY DIRECTOR-GENERAL ad interim, replying to questions, said that the report had been intended as a working tool, to provide background information for the Executive Board. The information had been based on the past three years of research and was the fourth report of its kind to be made to the Board. Regarding UNDAF, he said that the pilot exercise had started in October 1997 in 11 countries and involved all the organizations working jointly within the United Nations system at country level. An evaluation of the pilot phase would be carried out in July 1998. Replying to Professor Reiner' s remarks on infant mortality in Croatia, he regretted that the figures provided to WHO might sometimes be slightly out of date: every effort was made to update all statistics. All views expressed by members of the Board would be taken into account in future consideration of the issue. He confirmed that the debate on the item would continue following the informal presentation of the report on the Oslo phase 11 study. (For adoption of decision, see summary record of the twelfth meeting, section 1.)
The meeting rose at 17:40.
SEVENTH MEETING Thursday, 22 January 1998, at 9:30 Chairman: Professor J. ABERKANE
1.
WHO REFORM: Item 7 of the Agenda (continued) Item 7.2 of the Agenda (Decision EB99(2); Document
Programme budget evaluation: EB101/6)
The CHAIRMAN drew attention to the following draft resolution proposed by Dr Blewett, Dr Calman, Dr Van Etten, Dr Ferdinand, Mr Juneau, Dr Mazza, Dr More! and Professor Reiner: The Executive Board, Recalling resolutions WHA48.25 and EB99 .R13 on continued development of a strategic approach to programme budgeting, including evaluation mechanisms; Welcoming the efforts of the Director-General to develop a methodology to evaluate the programme budget; Recognizing the constraints inherent in making available before the year 2000 audited accounts for the 1998-1999 biennium so as to report the results of the evaluation in full; Noting the need for timely information on trends in expenditure and for comparisons with previous bienniums before the Executive Board can make recommendations on approval of the 2000-2001 programme budget at its 103rd session in January 1999, REQUESTS the Director-General: (1) to continue preparation of the programme budget evaluation as outlined in his report on the matter; 1 (2) to present to the 103rd session of the Executive Board in January 1999 an interim report on the results of the evaluation to complement the proposed programme budget for 2000-2001 providing: (a) to the extent possible, details of actual expenditure in the first year of implementation of the programme budget for 1998-1999, together with the amounts committed to specific programmes, subprogrammes and activities; (b) comparisons with previous bienniums, and trends; (c) details of adjustments or significant changes in programmes, made as a result of evaluation and the lessons learned; (3) to continue to develop the "activity management system" in order to permit presentation of interim results for future reviews of programme budgets. Mr CREGAN (alternate to Mr Hurley, Chairman of the Programme Development Committee) said the main issue before the Committee (PDC) had been the availability of reliable financial data to enable the Board to make informed decisions. At its third meeting in January 1997, PDC had agreed that an evaluation report on the implementation of the previous programme budget should be submitted to the Health Assembly together with the financial report. The guidelines for monitoring and evaluating biennial programme implementation
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developed by the Secretariat had been welcomed. However, it had been pointed out that there were certain difficulties in providing accurate figures for financial expenditure within the timetable originally proposed, and so it had been suggested that an interim reporting arrangement would be made, taking into account the fact that once the activity management system was available at all levels of the Organization, it should permit members of the Board rapid access to financial and programmatic information, and possibly also to trend analysis over a longer period. The draft resolution reflected the views of PDC and Mr Hurley wished to be listed among the proposers. Mrs PERLIN (alternate to Mr Juneau) endorsed the report contained in document EB I 0116, and welcomed the progress made in programme budget evaluation. Evaluation was a very important part of the strategic budgeting approach, and the report marked a significant step forward. Introducing the draft resolution on behalf of the sponsors, she said that several Board members had considered that it would be useful to formulate the conclusions ofPDC as a resolution. The text before the Board requested that the programme budget evaluation exercise be continued, that an interim report on the results be presented to the Board's session in January 1999, and that such reports be made on a systematic basis to assist the Board in future reviews of programme budgets. Professor WHITWORTH (alternate to Dr Blewett) said that development of strategic programme budgeting had been one of the most important reforms made in WHO over the past few years. A means should now be found of evaluating programme outcomes against programme plans, and that exercise should become a standard element in the budget cycle. While appreciating the effort put into preparing the guidelines referred to, she pointed out that the tracking of outcomes against performance indicators and targets for each programme presupposed an overall strategic plan setting out the objectives, indicators and targets for each programme or programme component. Useful progress had been made in ensuring that the planning process followed a top-down approach, and she would be glad to receive the latest information in that regard. It would also be useful to know the extent to which the Organization had defined the data it required to support programme indicators, and on the progress made in putting data collection systems in place. It should not be necessary to wait a further three years before comparing budget allocations and expenditure. An audited financial report for the 1996-1997 biennium would be made available in April 1998, and an attempt should be made to relate the results to the 1996-1997 programme budget. That comparison, even if imperfect in terms of evaluation of programme outcomes, could nevertheless indicate any areas of major variance between allocation and expenditure, and provide valuable guidance. The comparison could be made over the course of the year, and a report made to the Board at its 103rd session. Evaluation was not an end in itself: its aim should be to produce information that was useful for decision-making, and it should be timely and relevant if it was to contribute to budget preparations. Professor REINER recalled that resolution EB99.Rl3 had requested inter alia the development of programme budgeting mechanisms for determining expected outcomes, in order to facilitate priority-setting. The aim had been to permit estimates of which programmes were likely to achieve more health gains and should therefore be given priority. There was a need also to make retroactive evaluations to estimate what health gains or health outcomes had been achieved by programmes in the past. The preparation of guidelines for monitoring and evaluating biennial programme implementation gave grounds for optimism, and should make the Board's task easier in the future. He trusted that the evaluation would be successful, since the publication of evaluation data had been shown to be very useful. The data provided in The world health report 1997 indicated that global health status had changed for the better, notably with a reduction in infant mortality, an increase in life expectancy, and a 90% immunization coverage of the world's children. Further diversification in the monitoring and evaluation process should contribute to greater transparency in programme budgeting, and also provide unbiased indicators for health outcomes and consequently for health gains, which were the ultimate purpose of all health actions and interventions. He urged Board members to support the draft resolution. Dr CHOLLAT-TRAQUET (Division of Development of Policy, Programme and Evaluation) confirmed that considerable effort had been put into the evaluation exercise. It would remain a strategic evaluation, since
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detailed programme-by-programme evaluations would be made under the new evaluation system now being developed. The aim was not only to achieve greater transparency, but also to improve the programmes themselves. While many successes had been achieved, there were still important tasks to be accomplished, and systematic evaluation of the programme budget would reveal whether priorities had been properly allocated and, if not, how they should be changed. The new information system being set up, which would cover both management and health, would provide data that were more accurate and less expensive to collect. The proposed evaluation was a very costly exercise, and because of the need to keep the ratio between management costs and programme costs as low as possible, it was important to develop the information system simultaneously with the evaluation system.
The resolution was adopted. 1
2.
HEALTH-FOR-ALL POLICY FOR THE TWENTY-FIRST CENTURY: Item 8 of the Agenda (Documents EB101/8, EB101/9 and EB101/INF.DOC./9)
The DEPUTY DIRECTOR-GENERAL ad interim, introducing the item with the aid of overhead projections, said that the renewal of the health-for-all policy had been a major effort, involving the whole Organization, not only the governing bodies but also Member States and the Secretariat. He would first recall the main reasons why the governing bodies had asked that work begin on renewing the policy more than three years earlier, next describe how the renewal process had been carried out and outline the content of the new policy, and finally indicate what steps were planned for the future. As Board members were aware, the decision to renew the policy had been made as a response by the Organization to major changes taking place in the world. Those changes had included: the spread of poverty, which had a close relation to health, and an increase in inequalities both between countries and within countries; demographic changes related to population growth and ageing; epidemiological changes, including a rise in the incidence of tuberculosis, HIV/AIDS, and noncommunicable diseases, particularly in the developing countries, as well as in the incidence of injuries and violence; environmental threats, both global and local; the spread of new technologies, either in direct forms, such as biotechnology, or indirect, such as telematics; the evolving of partnerships between organizations and bodies of the United Nations system, intergovernmental organizations and nongovernmental organizations; and, lastly, globalization, which brought with it great opportunities for health but also the risk of marginalization of substantial population groups. The renewal process had included extensive consultation, first and foremost with Member States, and then with nongovernmental organizations and the private sector, both at global and regional levels, with academic and research institutions, with organizations of the United Nations system as well as with WTO, and, finally, with hundreds or even thousands of members of the staff of the Organization itself at all levels. The guidance and support of the Task Force on Health in Development had been invaluable. The consultation process had enabled countries to feel that the new policy belonged to them and had been devised with their needs and concerns in mind; it had also provided a large body of background information and evidence, which was available for consultation. Analysis of the issues involved had been carried out in discussions at recent sessions of the Executive Board and of the regional committees. The draft world health charter/declaration had likewise emerged from the consultation process, and it was suggested that the Executive Board should set up a group to consider it more closely so as to ensure that it reflected the message that WHO wished to convey on the occasion of its fiftieth anniversary. Document EBlOl/8 was more positive and less prescriptive in tone than previous versions. It was also more action-oriented, although PDC had considered that that aspect needed to be more clearly reflected in the text. Additional elements incorporated included injuries, the spiritual dimension of health, financial feasibility coupled with technical capability, and the capacity for the policy to be implemented. Contributions from the Board, the regional committees, the Global Policy Council and others had been taken into account. A meeting hosted by Finland on health systems and WHO consultations on human rights and telematics had also provided
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useful input. The vision of health for all was clearly defined in chapters 1 and 3 of the document. Health for all remained valid as a call for social justice, as underlined by the Task Force on Health in Development. The new policy built on the process started following the Alma-Ata Declaration and recognized the current important period of transition in preparation for the challenges of the next century. The core values to be upheld in the attainment of health for all were: the right to health; equity and solidarity; ethics; and gender sensitivity. The ethical dimension of health service provision remained vitally important. Equity could not be achieved without solidarity, which must be demonstrated through action and decisions, and not merely words. Greater efforts must be made to focus on women and close the gap between the sexes. There were three clear goals defining the health-for-all-vision: increase in life expectancy and quality of life; equity in health; and access to quality health care. The health outcomes resulting from those goals included healthy development throughout life and control, elimination and eradication of diseases. The policy incorporated two strategic lines of action: making health central to human development; and the creation of sustainable health systems that would meet people's needs. Global targets had been set to guide implementation and define priorities. It was recognized that such targets would have to be adapted to suit regional and national requirements. Looking to the future, a number of steps would have to be taken to enhance implementation. The commitment of Member States was fundamental, since the document was primarily for them. Some selection of global international priorities would be required, assessing what was feasible and aligning resources accordingly. Coherence between values and action must be maintained. Lastly, the right conditions for implementation must be created through good governance, partnerships and above all capacity-building in the developing world. In conclusion, he recalled that the main purpose of the document, which would be submitted to the Fiftyfirst World Health Assembly, was to provide a basis for the Organization's work as it moved beyond its fiftieth anniversary and into the twenty-first century. Mr CREGAN (alternate to Mr Hurley, Chairman of the Programme Development Committee) said that, at its last meeting, PDC had devoted considerable time to the document "Health for all in the 21st century" (document EB 10 118). The draft had already been the subject of extensive consultation and revision resulting in significant improvements and, subject to some further changes and redrafting, was more or less ready for submission to the Health Assembly. However, rather than spend more time on detailed redrafting, PDC had concentrated on overall structure. PDC had recommended that the executive summary should be revised, in particular to make greater reference to the need for adequate investment in resources for health, building and maintaining human resources for health, and promoting international solidarity. Furthermore, the executive summary should be complemented by a brief for political decision-makers. In its consideration of the health-for-all policy, PDC had concentrated on three main strategic issues: goals and targets; the role and functions of WHO; and the need for follow-through and implementation. There had been general support for the goals and targets set in the document, albeit with some reservation regarding the extent of their ambition, although the expression of such ambition would serve as an impetus towards the achievement of health for all. Likewise the definition of the role of WHO had been welcomed, although some rewording would be necessary for the sake of completeness. With regard to follow-through and implementation, particular emphasis had been laid on the need for investment in health and the possible economic benefits. It would also be necessary to strengthen collaborative efforts through imaginative mechanisms to build and maintain new partnerships for health at various levels. As for the draft world health charter/declaration (document EB101/9), PDC had considered that, for legal reasons, a declaration would be more appropriate, particularly in the light of the success of the Alma-Ata Declaration. Perhaps a group could be established to draft a somewhat shorter and simpler text, in cooperation with the Director-General and his staff and taking into account the comments of the Board and PDC, for consideration at the next Health Assembly. If such a proposal was acceptable to members, he suggested that the group should be chaired by Dr Lariviere, who had taken part in PDC discussions on the subject. In conclusion, stressing the importance of the documents under consideration, he welcomed the timely reaffirmation of the health-for-all policy.
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The CHAIRMAN invited members to comment on the document entitled "Health for all in the 21st century" (document EBIOl/8). Dr MUL WA, referring to the suggestion to expand the executive summary of document EB I 0118, recalled a point he had raised during the deliberations ofPDC. Following the Alma-Ata Declaration of 1978, WHO had launched the slogan of "Health for all by the year 2000". That slogan had been somewhat misleading; the Organization should be wary of setting targets that were too difficult to achieve. He welcomed the new slogan of "Health for all in the twenty-first century", for more time was needed to sensitize decision-makers. They must grasp that health for all was an ongoing process whereby all health determinants must be guaranteed. That was the concept he wished to see reflected in the executive summary of the document. Professor LEOWSKI said that, although the document before the Board was well formulated, he did not find it entirely satisfactory. Instead of proposing specific ways of changing WHO's priorities and policies, it appeared merely to reiterate what had been said over the past I 0 years in different words. During the past decade, new challenges had had to be faced as a consequence of worldwide demographic and epidemiological changes, certain diseases had re-emerged and in the political and economic domain, the birth of new democracies in the central and eastern parts of Europe, together with changed circumstances in Africa and Asia, had had important health consequences. WHO was about to elect a new chief executive officer whose task would be to make priority changes, at the behest of the international community. Also, in the past two years a lot of work had been done in order to prepare for the changing priorities. The Organization was certainly in the process of defining essential public health functions through a variety of bodies, such as the Executive Board special group for the review of the Constitution and various Secretariat working groups, yet the document under consideration devoted barely six lines to the subject (Box 9), while all other priority actions were explained in far greater detail. He could not avoid the conclusion that the importance of those functions had still not been clearly understood. In his view, the Director-General should establish a strong interdisciplinary interprogramme development team at divisional level which would report directly to the Deputy Director-General, would be given resources to help countries in assessing the level of implementation of essential public health functions, develop programmes which confirmed performance standards for each essential function, and help countries strengthen implementation of all such functions. Preparations had also been made with a view to proposing specific actions to increase the extent and improve the efficiency of WHO assistance to different countries. In addition to the Secretariat activities referred to, there was a specific need to establish a country programme development team with the task of determining the basic minimum functions to be performed by all WHO country offices and developing practical procedures and guidelines for WHO country programmes, for it was at that level that WHO was clearly visible and was in a position to appreciate the political dimension. He also believed that the time had come to begin experiments in creating new prototype country programmes and offices in - for example - large and small African countries; less or more developed Asian countries; and the newly independent states in the Caucasus where WHO was already very active. He warmly endorsed the key values set out in the document, especially the unequivocal statement that everyone should enjoy the full right to health. But a fundamental question had still to be addressed: was health a public or an individual good? If it was a public good, then, according to WHO's strategy, health care should be provided and dispensed by governments. But was the Organization actively promoting that strategy worldwide, notwithstanding the current economic and political climate? For his part, he wondered whether the most important current or foreseeable issues were in fact being addressed. Mr KANEKO (alternate to Dr Nakamura) commended the efforts made to improve the policy document, but suggested that its length made it unsuitable for wide reading by policy-makers and people concerned with health matters throughout the world. He would prefer to see first a succinct document covering three subjects: major issues to be addressed in relation to the health of the world in the twenty-first century; targets to be achieved; and strategies for their achievement. That core document, which might be followed up by a lengthier, more detailed text, should state clearly that WHO's uppermost priority during the first two decades of the twenty-first century would be to tackle communicable diseases, in particular emerging and re-emerging diseases such as Ebola haemorrhagic fever, new variant Creutzfeldt-Jakob disease, and the new strain of influenza.
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Malaria, tuberculosis, HIV/AIDS, diarrhoea and acute respiratory infections in children should also be considered as major priorities. Turning to some details of the document being discussed, he said that sections I and 11 had been much improved, in particular up to paragraph 37. On the other hand, the title of section Ill (Fulfilling the vision: actions for implementation of the policy) did not appear to reflect the actual substance of that section, where he would have wished to find some indication of a framework for concerted action in the implementation of the health-for-all policy, and more specifically in meeting global targets towards the year 2020. On the whole, and probably because the authors had covered all that was relevant, the document lacked a clear focus: remedial action was called for in that regard. Professor REINER commended what he found to be a substantially improved document. In a particularly important year, when a new health policy would be approved in the form of a health charter and decisions taken on changes to the Constitution and regional arrangements, the subject of the health-for-all policy was ripe for debate. It had already been a focus of attention at the Board session in May 1997, where it had been emphasized that the final section of the document under discussion at that time called for a new role to be played by a revitalized, transformed and proactive health sector. Furthermore, it was important that the new health policy be implemented at all levels, global, regional, national and subnational. In September 1997, the Regional Committee for Europe had approved a resolution, the preamble to which remarked, inter alia, that the fact that the renewed European health-for-all policy asserted global health-for-all values and principles, and demonstrated the main challenges, opportunities and socioeconomic health determinants in the region, suggested the need for the compatibility and complementarity of policy documents at global and regional levels, while recognizing fully regional specificity. Such values were obviously very important to all concerned. The Regional Committee had opted for two documents, one comprising a concise presentation for politicians and policy-makers and the other containing a more detailed strategy for implementation as well as guidelines for countries to achieve comprehensive national policies for health for all in the twenty-first century. Concurring with the previous speaker's remarks, he submitted that the document before the Board could with some measure of further refinement - be presented to the forthcoming Health Assembly for discussion. Mr AISTON (alternate to Mr Juneau) expressed satisfaction at what he found to be an improved document, and commended especially the references to equity. After endorsing the remarks by Dr Mulwa, he said thatnot being particularly adept at setting targets - Canada appreciated the guidance and help it offered, notably in relating policy objectives to targets. However, some of the concepts and connections between them might require further clarification. For example, the relationship between social cohesion and health should be explained. Was social cohesion the cause of improved health or was the reverse true? Such questions needed further exploration and development. Although the document was built on some of the best thinking on health policy both within and outside WHO, and explored a number of topics not well understood, such as globalization, some aspects, such as the impact of trade issues on health, should be the subject of further study, and perhaps of a report to the Board by the Director-General. He noted that the document placed strong emphasis on policy capacity and research. Looking ahead, it would be necessary to clarify the Organization's capacity to translate such a policy document into action. One initial measure must be the establishment of a firm transitional phase from the current to the new administration. If plans already existed in that respect, they should be brought to the attention of the Executive Board. Finally, he voiced complete support for the comments by Mr Cregan on the subject of a declaration; a shorter document, which could be used to WHO's advantage and for the enlightenment of the political masters in all countries, would be most welcome. Mr VOIGTLANDER joined in commending the improvements in the document, noting with special satisfaction that the conclusions of regional committee discussions had been incorporated to the extent possible. The stature of the document had been enhanced, and its substance reflected its title more closely. Nevertheless, a box on human rights, referring to the highest attainable level of health and the subject of one of the fundamental requests of the Task Force on Health in Development, had yet to be finalized and introduced in the text.
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Despite the general agreement which existed, the philosophy in certain paragraphs of the document had to be questioned. One example was the role of the State in health care. He called attention to paragraphs 26-28 of the document, which warned that the State was under threat and stated, inter alia, that "From within, corruption has eroded public confidence in many governments and, in some countries, even the structure of government has collapsed. Governments themselves are also decentralizing ... ". It was difficult to see any logical connection between corruption and collapse on the one hand and decentralization on the other. He believed that there should be a separate paragraph dealing with decentralization and the increasing importance of the private sector in some areas, as stressed by the International Conference on Health Promotion in Jakarta. It was also unclear whether the text in question actually reflected, as its title declared, the changing role of the State. Moreover, if it was compared with paragraph 96 of the document, an inherent contradiction quickly became apparent. According to the latter paragraph," ... When the government has the major mandate for, or is the main funder of, health systems, there is more likely to be equity of access, cost containment, and a strong emphasis on preventive and promotive services". Clearly, the State was either the best guarantor of equal access to the health care delivery system or it was not. He added that the opinion voiced in paragraph 96 did not take account of the many contributory health schemes around the world where the State was not the major source of funding. Irrespective of the adequacy or appropriateness of such schemes, the impression should not be given that social security mechanisms of that kind did not exist or did not function effectively. Dr SIKOSANA (alternate to Dr Stamps) welcomed the improved document and agreed with the remarks by Dr Mulwa concerning the targets set by the original health-for-all strategy. The over-ambitious and ambiguous nature of certain of those targets had sometimes brought ministries of health into disrepute. While some of the new targets were beyond the reach of many present health systems, they were at least to some extent realistic. The document rightly emphasized equity and social justice, both within countries and in the international community. One reason for the failure to achieve health for all had been the lack of sustainable investment in health, both in terms of financing and human resources. Further investment was especially called for in the area of prevention. Increasing poverty in some developing countries had also made it difficult to achieve objectives or had undermined any small successes. The wide disparity between developed and developing countries made it difficult to identify priority areas. It was, however, necessary to set priorities in order to maximize achievements. Mr NGEDUP joined in commending the document, which reflected the common will to chart a path for health for all in the twenty-first century. Poverty was obviously a fundamental obstacle to health and overall development, especially in the least advantaged countries and among the most vulnerable population groups, and that was where WHO must promote solidarity. In 1995, the Health Assembly had adopted resolution WHA48.3 on intensified cooperation with countries in greatest need. Three years after the adoption of that critical resolution, it was important to see what had actually been achieved. He therefore called on the DirectorGeneral to report on the implementation of the resolution at the next session of the Board. Dr DOSSOU-TOGBE commended the document and its analysis by PDC. Health for all remained a universal rallying cry which should echo into the twenty-first century. Improving the health-for-all strategy and targeting by decade would enhance coherence and ensure that activities were satisfactorily followed up at all points of the globe. The document pointed in a direction that would surely be followed by Member States. If existing disparities were to be reduced, good governance must be exercised at all levels, from the international level to district and village level, with collaboration at all levels. Next, special attention must be paid to the growing problem of noncommunicable diseases. And lastly, there must be cooperation with the most disadvantaged countries. Those were just a few of the approaches that would enhance the benefit of the healthfor-all strategy. Dr CALMAN endorsed the remarks by Mr Cregan and agreed that a small group should work on the declaration. He considered that the document under consideration, which outlined policy for the beginning of the twenty-first century, would contribute to the setting of priorities. The executive summary, however, required some improvement and, in particular, should mention the targets set out in the policy document. The document itself should be shortened and, as Mr Kaneko had said, there was a need for a framework for concerted action,
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linking global and regional targets, programme budgets and programme activities. Some indication of a methodology for monitoring based on information technology was also called for. Or AL VIK, noting that health for all constituted the underlying vision and policy of so many WHO programmes, said it was gratifying to see that a valuable document had emerged from the consultative processes. The document could, however, be further improved; more particularly, the role of health for all in revitalizing the primary health care approach should be better spelt out. Primary health care systems in many countries were in desperate need of improvement and, as current health challenges differed from those of 30 years ago, the role of such care should be revisited. The development of sustainable health systems was mentioned in the document and should also appear in Box 8 dealing with the functions and role of WHO in the twenty-first century. As other speakers had mentioned, the Regional Committee for Europe had opted for a comprehensive document, together with a shorter document for politicians and organizations outside the health sector. PDC had proposed a shorter document for ministries of health, and she endorsed that proposal, suggesting that the target groups could be extended to include other sectors and politicians in general. While the document under consideration discussed the importance of cooperation with Member States and the scientific community, it should also draw attention to cooperation with other organizations, both within and outside the United Nations system. Professor WHITWORTH (alternate to Dr Blewett), endorsing the conclusions reached by PDC concerning the policy document, expressed concern that the very breadth of the declared objectives might result in the dissipation of commitment and effort. For instance, health for all was described as "an increase in life expectancy and in the quality of life for all". Although a worthy aim, "quality of life" encompassed a concept that went well beyond the domain of health. A more achievable, relevant objective would be "healthy life for all", a state that lay at the heart of WHO's responsibilities and inspired its vision. There were several references in the text to international law and foreign policy. Notwithstanding the link between the wider environment and health, there was a need to achieve a balance between sometimes competing agendas. Certainly, health considerations should inform approaches in other areas, but WHO could not suggest that they were determinant. Similarly, the document should take greater account of the complementary roles of other international agencies in the human rights domain; she would encourage WHO to collaborate with those agencies rather than take the lead role. More generally, the mandatory language in the document should be softened so as to encourage the commitment of partners in implementation. Finally, she supported PDC's proposal that a declaration, rather than a charter, be prepared. Dr ABEDNEGO (alternate to Dr Wasisto) said that the document clearly set out the aims, goals, targets, objectives and functions to be achieved or developed and made plain the links between the original health-for-all strategy, the Alma-Ata Declaration and the new health-for-all policy. It therefore reflected the continuation and adjustment of policy and effort over the past 20 years, and looked ahead to the future. However, the findings of the latest health-for-all evaluation would have to be taken into account to determine the baseline for the new endeavour. He welcomed the emphasis on ethics, in particular the beneficial effect ethical practices could have on socioeconomic development, the environment and the impact of scientific and technological advances. However, greater attention should be given to equity. Despite hard work over the past 20 years, the results were not satisfactory for many Member States. Increasing involvement of the private sector in health development was seen in almost all Member States and was likely to continue. The document should review the role of the private sector, and outline a policy for such involvement, provided it was in line with basic policy. He suggested redrafting of the title of section I as an affirmative statement, not a question. Since the document would be read by people from many other sectors and by lay people, its language should be simplified. Like Dr Mulwa, he was concerned at the omission of any reference to health for all by the year 2000 in the executive summary. He endorsed Mr Voigtliinder's comments with regard to paragraphs 26-28 of the document. Dr VAN ETTEN thought that the document was well structured and presented a clear strategy. It included an important chapter on the key values on which the health-for-all vision was to be based and a welcome new chapter on the role of WHO. The life-span approach was appreciated, while targets had been limited to an acceptable minimum and seemed realistic. He regretted the lack of a systematic overview of the role of WHO at the global, regional and national level. He endorsed the comments on chapter 5 made by PDC in paragraph 10 of its report (document EBlOl/3),
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and drew attention to the need to bring that chapter into line with the proposals on the functions of WHO made by the Executive Board special group for the review of the Constitution in its report (document EBlOl/7). Like Or Alvik, he felt that the paragraphs on partnerships, especially between WHO and other international organizations, were still too weak. Endorsing the comments on the "brain drain" issue made in the PDC report, he suggested that the renewed health-for-all policy should reflect WHO's efforts in human resources development. He agreed with previous speakers that the executive summary should be improved. References in the text to boxes and figures should be systematic throughout. The new positive wording of the heading of Box 4 should be reflected in the text of paragraph 28. He agreed with Mr VoigtUinder on the need for a box on human rights. Professor PICO (alternate to Dr Mazza) agreed that the new document was an improvement on previous versions and reflected most of the suggestions put forward by the governing bodies. It would help to put in place the policies and strategies to achieve the ambitious target of health for all in the twenty-first century, while recognizing the changes taking place in the world and endeavouring to predict future changes. He endorsed the emphasis placed in the document on the criteria of equity and social justice, ethics and the defence of the dignity of the individual. Against the background of demographic, epidemiological and health changes, WHO must take a proactive role by making its strategies and priority programmes as realistic as possible. The document showed clearly that the Organization was making progress towards ensuring health for all. He emphasized the need to direct policies towards achieving greater efficiency, quality and solidarity of health systems, without which social equity would be difficult, if not impossible, to attain. Dr BADRAN (alternate to Professor Sallam) shared the view that the document was rather lengthy and lacked specific targets and measures. It would be difficult to present to decision-makers. The text sometimes referred to health and human rights as if they were two separate issues, whereas health was in fact one of the most important human rights and a requirement for development. The enjoyment of health also pre-supposed adequate access to other rights. The reference in paragraph 50 to "norms, standards and commitments, including some that are legally binding" required revision in the light of the subjects on which WHO had the power to pass binding resolutions. With reference to the need for rapid detection and warning, there was no explanation as to how they should be achieved, except through existing mechanisms. Paragraph 54 could be understood as meaning that WHO would provide surveillance and warning of threats to human rights, whereas a special office of the United Nations already existed for that purpose. He shared Mr VoigtUinder' s comment on the harshness of the reference to corruption and the collapse of governments, which was not necessary in the context. Although the private sector undoubtedly had an important role to play in the provision of health services, governments had to maintain their leadership, be responsible for establishing standards and norms to ensure that no section of the population was deprived of access to health care and ensure that the basic health system was affordable for all. Further, WHO should develop indicators of access to the right to health, devise mechanisms to monitor implementation of that right and report on their findings. Dr MELONI observed that no document, however perfect, was any more than one tool among many and, as such, could not guarantee that the commitments entered into in Alma-Ata in 1978 would be achieved in the twenty-first century. He regretted that the overall strategy had not received fuller treatment. The vision, on which there was general agreement, had to be communicated not only within the health community but also to the many people involved in the renewal of health for all outside the health sector. Perhaps several documents were required to reach the different "clients" involved. He pointed out that health was not necessarily the first priority everywhere within a broader plan for sustainable human development. A dialogue was needed with other sectors of the economy, not necessarily the same dialogue as within the health sector. Firm leadership was required to mobilize the health sector, and it was important to establish links between the reform processes in the health sector in countries and those in WHO and other agencies involved in international health. The problem was fundamentally not one of technical challenges or of the lack of social justice, equity or solidarity, nor even a technocratic problem, but a political one, and the document should take that fact into account. The DEPUTY DIRECTOR-GENERAL ad interim thanked the members of the Board for their suggestions which, in addition to the recommendations ofPDC, would be taken into account in the revision of the executive summary and in the brief for policy-makers.
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In reply to Dr Mulwa, he pointed out that whereas there had been no baseline data when health for all by the year 2000 had been launched in Alma-Ata, health for all in the twenty-first century could build on established principles and more widely available data and evidence. Agreeing with Professor Leowski on the importance of public health functions, not only for the document but for implementation at national level, he said that essential health systems were in fact based on public health functions and the provision of care and as such had received greater treatment in the document than might appear. Some adjustment of headings might, however, be required. With regard to Mr Kaneko's concern about the need to express the targets and strategies more clearly for policy-makers, he agreed that a succinct briefing document would probably be useful. It might also be appropriate to reconsider the focus of the document, but it was important to remember that the document was addressed not only to the Executive Board or WHO, but to almost everyone in the world and would not be able to satisfy every need and perception. A group was working to link the concept of globalization to that of health for all, an aim which had also been discussed at a meeting on the intersectoral importance of health for all, held in Canada. The group was looking not only at the setting of standards but also the globalization of health services. Responding to the concerns ofMr VoigtUinder and Dr Van Etten, he said that a box would be added to the document on the subject ofhuman rights with regard to health. The wording of paragraphs 26-28 would be reconsidered but should be viewed in the context of the overall title of the section, which currently was "Why renew health for all?" but would be replaced by a more affirmative statement as suggested. He agreed that there might be some overlap with the statements made in paragraph 96, which, however, reflected future actions. The third evaluation of health for all by the year 2000 had not been available at the time document EBIOI/8 was prepared; however, some changes had already been made in the light ofthat evaluation, and further use might be made of it in order to clarify the transition to the new policy. Poverty was clearly an important issue, and emphasis had been placed on countries and populations in greatest need. A full report would be available for the next meeting of the Executive Board. A clearer plan of action had been requested. Although the global approach allowed the development of a plan, that plan could be translated into a strategy only when the document had been endorsed by the Health Assembly. As stated by Dr Meloni, the document was not sufficient unto itself but should be an instrument for implementation. Guidelines for the teams that would assist countries in the transition would have to be developed. Dr Alvik's suggestion that Box 8 should reflect the importance of health and development would also be addressed. There appeared to be consensus that equity should be given even greater emphasis. Dr Calman's pragmatic suggestions would be used to produce a more systematic document. Professor Pico had raised the difficulty of ensuring justice and equity while maintaining efficiency, and that problem would also be addressed. Mr Cregan had clearly described the concern of PDC about the outflow from some countries of highly trained professionals in search of more attractive professional and economic opportunities ("brain drain"), and had proposed measures to counteract it. That matter too would be incorporated into the revised version of document EB I 01/8. An aspect that had been discussed in detail by PDC had been linkage of health for all to the reform process, not only at WHO but in the entire United Nations system and at the country level, including the relationships among various organizations. The importance of that linkage would also be reflected in the revised document. Additional information could be obtained from the publications, Interagency Consultation on the New Global Health Policy. Geneva, 9-10 July 1997. Summary report (document WHO/PPE/PAC/97.4); A new global health policy for the twenty-first century: an NGO perspective. Outcome of a formal consultation with nongovernmental organizations held at WHO, Geneva, 2 and 3 May 1997 (document WHO/PPE/PAC/97.3); and a document which contained the data on which many of the affirmations made in document EB I 0 I /8 were based. Reports were also available from the WHO working groups at both headquarters and the regional offices on the six themes of health for all. The CHAIRMAN said that he took it that the Board wished to request that the draft document on "Health for all in the 21st century" contained in document EB I 0118, revised in accordance with the proposals of PDC and the suggestions of members ofthe Board, be forwarded to the Fifty-first World Health Assembly.
It was so agreed.
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The CHAIRMAN drew the attention of the Board to document EBIOl/9, which contained a draft world health charter or declaration. He proposed that, as recommended by PDC, a drafting group be constituted to revise the document, and suggested that Dr Lariviere, who had been involved in the Committee's deliberations, should be asked to chair the group. It was so agreed.
Professor LEOWSKI said that he favoured use of the word "declaration" and not "charter". He suggested that the document should include mention of essential public health functions. Mr VOIGTLANDER strongly endorsed use of the word "declaration". Dr LARIVIERE (alternate to Mr Juneau) noted that the comments made during the disc~ssion of document EBIOI/8 would also be taken into consideration by the group in reviewing the draft declaration. The DEPUTY DIRECTOR-GENERAL ad interim suggested that once the group had completed its review, and if time permitted, it might be requested to prepare a brief document destined for decision-makers. The CHAIRMAN drew the attention of the Board to document EB I 0 1/INF .DOC./9, "Health-for-all policy for the twenty-first century: 'health telematics'". Mr NGEDUP welcomed the attention being given to "health telematics" and thanked the Director-General for his personal initiative in that area which held great potential for the future. Dr SHIN recalling the discussions at the ninety-ninth session of the Board congratulated the Director-General on the remarkable progress made on the subject in such a short time. The rapid development of modem telecommunication techniques gave many countries a unique opportunity to improve the health of their populations and offered developing countries new possibilities for enhancing the quality of their health services. In view of its importance, the programme should be strengthened by implementing the recommendations of the international consultation on "telemedicine", held in December 1997, namely by establishing an advisory committee and an internal task force at headquarters, and developing a network of existing and new WHO collaborating centres for appropriate application of "health telematics" in Member States. Dr MOREL commended the initiative, which would strengthen WHO's role in the field. Dr LOPEZ BENITEZ welcomed the progress made. The initiative was of particular importance for all countries with poor transport communications. WHO country offices should continue to support activities in that area. He had seen himself that "telemedicine" could improve health conditions in areas where other types of communication were lacking. Dr CALMAN endorsed the recommendations in paragraph 9 of the document. He hoped that they would allow initiatives to continue at the country level and would foster the development of collaborative networks. Dr SULAIMAN also endorsed the proposals made in the document. They should be implemented speedily in order to compensate for delays in the past. That would allow the Organization to play a dominant role in the area ofhealth-related communication and would ensure timely distribution of information. Professor PICO (alternate to Dr Mazza) emphasized that it was important for WHO to respond rapidly to technological progress in order to improve technical and administrative efficiency. Dr MELON!, noting the reference in paragraph 7 of the document to potential dangers of advanced information and communications technology, said that countries should be informed of any dangers identified, so that measures could be taken to avoid them.
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Dr MULW A noted that "health telemedicine" had been the subject of a number of recent meetings. The techniques would save the lives of countless women and children, many of whom died while awaiting the outcome of consultations between regional centres and rural areas. He hoped that costs and training would be given greater attention in future policy development. Dr LARIVIERE (alternate to Mr Juneau) said that projects had been developed at meetings of the G7 group of countries to demonstrate how "telematics" could be applied in various sectors, including health care. The aim was to show how hardware and software could be used to improve health systems and for the betterment of mankind. Broad-band links, to provide a very fast, high-capacity Internet system at minimal cost to users, were being developed between countries for the use of governments, academics and researchers. That would eventually allow worldwide connection at a rate of transmission of 500 megabits per second. It was essential that all international, intergovernmental activities in the area of "telemedicine" and "telematics" be closely coordinated. Although some tentative links had been made between WHO and the health-care projects of the G7 group of countries, a structured dialogue needed to be initiated.
The meeting rose at 12:35.
EIGHTH MEETING Thursday, 22 January 1998, at 14:30 Chairman: Professor A. ABERKANE later: Or B. WASISTO
1.
HEALTH-FOR-ALL POLICY FOR THE TWENTY-FIRST CENTURY: Item 8 of the Agenda (Documents EB101/8, EB101/9 and EB101/INF.DOC./9) (continued)
Mr OBADIA (International Occupational Hygiene Association), speaking at the invitation of the CHAIRMAN, welcomed the establishment by WHO of a global strategy on occupational health for all, to which he hoped the necessary resources would be allocated. The aim of occupational hygiene professionals was to ensure that working populations enjoyed the right to the highest attainable standard of health and to protect workers' health and well-being, while safeguarding communities and the environment. The prevention and control of hazards arising from industrialization, unsafe work practices, hazardous occupations and the transboundary movement of hazardous materials contributed not only to better health, but also to sustainable economic and social development. IOHA represented a substantial part of the world's occupational hygiene professionals, and was therefore well placed to help establish worldwide partnerships for the protection and promotion of workers' health. Since the science and practice of occupational hygiene was far more developed in some countries than in others, there was much to be gained by sharing knowledge and experiences in the field. Joint efforts by nongovernmental organizations such as IOHA and international organizations such as WHO could contribute greatly to the globalization of available information. Technological advances were making it increasingly feasible for IOHA to create an international network of occupational hygienists and keep them informed by means of a newsletter and Internet site. It was also concerned with ensuring professional standards of training and certification, and promoting learning relationships tailored to real needs through its mentor programme which linked occupational hygienists from countries where the profession was at different stages of development. IOHA had become an international platform for occupational hygiene, through the organization of international conferences, participation in occupational health and safety meetings and collaboration with international organizations such as WHO or the International Labour Organization. It also contributed to important publications and documents, and was involved in the implementation of the Prevention and Control Exchange (PACE) initiative. It continued to give high priority to collaboration with WHO, with a view to contributing to the achievement of health for all in the twenty-first century. Dr BRYANT (Council for International Organizations of Medical Sciences), speaking at the invitation of the CHAIRMAN, said that document EBlOl/8 was an admirable policy document. He welcomed the proposed addition to the text of a box on health as a human right and especially appreciated the considerable emphasis on ethics and equity in relation to the health of populations. The round-table conference on ethics, equity and health for all, convened by CIOMS in 1997, had increased understanding of that subject, as had the meeting on policy-oriented monitoring of equity in health and health care, cosponsored by CIOMS, WHO and the nongovernmental organization Forum for Health. One practical outcome of the round-table conference was an action plan for a joint CIOMS-WHO initiative on ethics, equity and health for all, which set out the principles, objectives and means for the pursuit of equity in global health. CIOMS would cooperate in implementing that or a similar action plan in association with all organizations which were committed to social justice in health care. As the world's pre-eminent authority on public health, WHO was in a position to make equity an integral aspect of public health; health for all could not be achieved unless equity became its mainspring.
-91 -
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Dr GHEBREHIWET (International Council ofNurses), speaking at the invitation of the CHAIRMAN, expressed appreciation for the participatory and consultative process adopted by WHO in developing the draft policy document. Its emphasis on the fundamental issues of social justice, equity, a gender perspective, ethics and human rights provided a sound context for the renewal of the health-for-all policy. The achievement of health for all depended on concerted action and a renewed partnership between WHO and nongovernmental organizations. In order to foster true partnerships with those organizations, WHO would need to look into meaningful mechanisms for involving them in governance and policy-making. Such partnerships would be based on the various areas of expertise of the partners, and would not view families and communities simply as passive recipients of health care, but as "producers of health". The health care professions were uniquely placed to implement the health-for-all strategy and to act as the public conscience, and must be recognized as key partners in addressing health and development issues. A health-for-all strategy needed to recognize the importance of training health providers, identify the core competencies of health care professionals, ensure adequate investment in health services and support professional organizations in their efforts to maintain high ethical and professional standards. Health policy and reform must be based on the universal right to health, the application of ethics to health care, equity and a gender sensitivity, whilst striving to improve efficiency and cost-effectiveness. Health reform measures must not exclude disadvantaged and vulnerable groups. In that respect, health care providers and their professional associations had a vital role to play as advocates for equity and health for all. ICN reiterated its commitment to the renewal of health for all and looked forward to participating in its implementation. Dr FLACHE (World Federation for Mental Health), speaking at the invitation of the CHAIRMAN, and also speaking on behalf of the World Association for Psychosocial Rehabilitation, the World Psychiatric Association and the International Council on Alcohol and Addictions, said that higher priority should be given to programmes on mental health and substance abuse, which should become an integral part of primary health care. It was universally recognized that mental disorders and the abuse of alcohol and tobacco were among the most important contributors to the current global burden of disease and disability. Not only did they cause tremendous suffering at a huge cost, but they were also a serious handicap to social and economic development. Health for all could not be achieved without well-developed primary health care, which must include a strong component of mental health services. Unfortunately, mental health priorities had not been included in the Declaration of Alma-Ata. He hoped that the review of the health-for-all policy would lead to greater consideration being given to mental well-being as an integral part of primary health care, with the emphasis on the public health aspects of mental health and the prevention of substance abuse. He welcomed initiatives in that direction taken by several regional offices, particularly in the Region of the Americas and the Eastern Mediterranean Region. He enthusiastically welcomed the WHO action programme entitled Nations for Mental Health which had, in a very short time, set up and provided support to 16 country-based strategies and stimulated political awareness and commitment. It focused on underserved populations and supported the provision, within primary health care, of accessible services and the implementation of effective treatments for mental illness and psychosocial rehabilitation. The organizations on whose behalf he was speaking would continue to support the efforts of governments and WHO to protect the mentally ill, not only from abuse but also, more importantly, from neglect. Mrs JETT-ALI (Inter-African Committee on Traditional Practices affecting the Health of Women and Children), speaking at the invitation of the CHAIRMAN, said that if equity and gender sensitivity were to be incorporated in health care, there was an overwhelming need to eliminate harmful traditional practices such as early childhood marriage, female genital mutilation and nutritional taboos. She welcomed the important initiatives taken in that area by WHO and the statement made earlier at the current session by the Regional Director for the Eastern Mediterranean. The Inter-African Committee was committed to further strengthening its partnership with WHO. The multisectoral approach was a key element in a renewed health-for-all policy. It was not enough to change the attitude and behaviour of health workers; the attitude of legislators, government employees, community workers and individuals also needed to be changed. That was why the national committees of lAC had appealed directly to governments to adopt national policies and specific legislation to prohibit female genital mutilation and other harmful traditional practices.
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lAC would participate in any pragmatic, creative action that would ensure that health for all became a reality in the twenty-first century. As set out in article IV of the draft WHO charter/declaration, it was imperative to base action for health on community participation, the active involvement of people, strengthening of the role of a family and mobilization of societal forces in health action. (For continuation, see summary record of the twelfth meeting, section 2.)
2.
WHO REFORM: Item 7 of the Agenda (continued)
Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group: Item 7.3 of the Agenda (Resolution EB99.R24; Decision EB99(5); Documents EB101/7 and Corr.1) (continued from the sixth meeting) Review of provisions of the Constitution The CHAIRMAN drew the attention of the Board to a draft resolution proposed by the Rapporteurs, which read: The Executive Board, Having considered the report of the special group for the review of the Constitution of the World Health Organization; 1 REQUESTS the Director-General to propose for the consideration of the Fifty-second World Health Assembly the draft amendments to the Constitution set forth below, and to transmit such draft amendments to Member States in accordance with the provisions of Article 73 of the Constitution: (in the first indented provision under the first paragraph of the preamble) Delete: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Insert: Health is a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity. Article 7 - Delete and replace by Article 7 (a) (1) If a Member fails to meet its financial obligations to the Organization, the Health Assembly may, on such conditions as it thinks proper: (i) suspend the voting privileges to which the Member is entitled; (ii) exclude such Members from eligibility for election to be entitled to designate a person to serve on the Executive Board; and (iii) exclude the representatives of such Members from eligibility for election as an officer of the Health Assembly.
1
Document EBIOI/7.
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(b)
(2) The Health Assembly may also prohibit the Organization from entering into or renewing any arrangement involving payment for services provided by any Member State which persistently fails to meet its financial obligations without due cause. (3) The Health Assembly shall have the authority to restore such rights and privileges. In other exceptional circumstances, the Health Assembly may suspend the voting privileges and nonessential services to which a Member is entitled. The Health Assembly shall have the authority to restore such voting privileges and services. Article 11 - Delete and replace by Article 11
Each Member shall be represented by not more than three delegates, one of whom shall be designated by the Member as chief delegate. These delegates should preferably represent the national health administration of the Member. Article 21 -Delete and replace by Article 21 (a)
(b)
The Health Assembly shall have the authority to adopt regulations concerning particularly: (i) sanitary and quarantine requirements and other procedures designed to prevent the international spread of diseases; (ii) nomenclatures with respect to diseases, causes of death and public health practices; (iii) standards with respect to diagnostic procedures for international use; (iv) standards with respect to safety, purity and potency of biological, pharmaceutical and similar products moving in international commerce; (v) advertising and labelling of biological, pharmaceutical and similar products moving in international commerce; (vi) standards with respect to transplantation of tissues and genetic engineering, including cloning. The Health Assembly shall have authority to adopt regulations concerning any other health-related matter falling within the functions of the Organization as set forth in Article 2. Article 25 - Delete and replace by Article 25
These Members shall be elected for three years and may be re-elected, provided that of the Members elected at the first session ofthe Health Assembly held after the coming into force of the amendment to this Constitution increasing the membership of the Board from thirty-one to thirty-two the term of office of the additional Member elected shall, insofar as may be necessary, be of such lesser duration as shall facilitate the election of at least one Member from each regional organization in each year. No Member should have a greater right, explicit or implied, than any other Member to designate a person to serve on the Board. Article 50 Delete (g) such other functions as may be delegated to the regional committee by the Health Assembly, the Board or the Director-General. and replace by
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(g) (h)
to foster and promote activities of the Organization at country level; such other functions as may be delegated to the regional committee by the Health Assembly, the Board or the Director-General. Article 55 - Delete and replace by Article 55
The Director-General shall prepare and submit to the Board the budget estimates of the Organization. The Board shall consider and review those budget estimates and submit them to the Health Assembly, together with any recommendations the Board may deem advisable. Mr VOIGTLANDER said that the presentation of the proposed amendments as a group in a single resolution meant that any Board member having a serious objection to one amendment would be compelled to reject the whole set. Dr STAMPS pointed out that the proposed amendments were merely recommendations; any final decision rested with the Health Assembly. Mr TOPPING (Legal Counsel) explained that the draft resolution presented proposed amendments already approved by the Board; discussion of them was now closed. What the Board was being asked to consider at the present juncture was not the substantive elements of the draft resolution but the manner and format of their presentation to the Health Assembly. In reply to a point raised by Dr BLEWETT, he said that all proposed amendments to the Constitution approved by the Board for submission to the Health Assembly came under the provisions of Article 73, which meant that they could not be considered until the Fifty-second World Health Assembly. The only exception was the proposed change to the number of Board members, an issue already before the Fiftieth World Health Assembly, but one on which it had deferred decision pending completion of the special group's deliberations. Dr STAMPS said that in view of the importance of Article 73 it would be useful for the Board to consider what action to take in that connection before discussing the draft resolution.
It was so agreed. The CHAIRMAN invited the Board to consider the draft decision proposed by the Rapporteurs which read: The Executive Board, recognizing the need to accelerate the procedure for the entry-into-force of amendments to the Constitution once adopted by the Health Assembly, decided to defer consideration of the proposed amendment to Article 73 contained in the report of the special group for the review of the Constitution of the World Health Organization, 1 and requested the Director-General to present to the Executive Board at its I 03rd session a study of the legal situation in other international organizations of the United Nations system concerning entry-into-force of amendments, and to propose solutions consistent with international law in order to accelerate the entry-into-force of amendments to the Constitution. Dr STAMPS said he was unhappy about the wording of the draft decision, which seemed to be stating that the Board, while recognizing the need to move fast, had in fact not decided to move at all. While he saw no alternative but to put the proposal forward for consideration as formulated by the special group since it would give the Board an opportunity to embellish it during the next 12 months in the light of further consideration, simple deferral of consideration would amount to continuing the present state of suspended animation. A
1
Document EB 10 117.
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defined period ought to be set for the time during which amendments to the Constitution could remain on the table. Mr TOPPING (Legal Counsel) said that the Board, since it had already, in earlier discussion, taken the decision to defer consideration of the proposed amendment to Article 73 pending further study of other solutions to the problem, could not, under Rule 40 of its Rules of Procedure, reopen the discussion unless so decided by a two-thirds majority. It was merely the format embodying that decision that was at present under consideration by the Board. Dr STAMPS said that he did not recall that the Board had decided specifically that the Director-General's study should be presented to its 103rd, and not its 102nd session, which would delay matters even further. Mr AITKEN (Assistant Director-General) said that in fact the Board had not taken such a decision. The matter had been left ambiguous, and after discussion the Secretariat had come to the conclusion that it would be difficult to complete such a detailed study in time for it to be presented to the 102nd session of the Board to be held in May 1998. Dr STAMPS said that in that case it should be possible to incorporate the proposed amendment to Article 73 in the current draft resolution instead of adopting the draft decision, because in that way the Board at its 102nd session could always have second thoughts and decide on an alternative. Deferring consideration of the amendment to the I 03rd session would mean another 18 months' delay. One of the Organization's biggest problems was its inability to change anything in its Constitution with any degree of certainty. The CHAIRMAN suggested instead that the draft decision be amended so that the Director-General be requested to present the study of the legal situation in other international organizations to the Board at its 102nd session. The decision, as amended, was adopted. 1 The CHAIRMAN invited the Board to return to consideration of the draft resolution. Mr VOIGTLANDER, expressing a reservation, said he was unable to agree with the proposed amendment appearing as Article 21(b) since its effect would be to require Member States to violate their constitutions or other international obligations. Dr STAMPS said that the provisions of Article 22 of the Constitution, which stated that regulations adopted pursuant to Article 21 should come into force for all Members after due notice had been given of their adoption by the Health Assembly except for such Members as may notify the Director-General of rejection or reservations within the period stated in the notice, ensured that there could be no question of any country's sovereignty or constitutional rights being violated. The resolution, subject to the reservation expressed by Mr Voigtliinder, was adopted. 2 The CHAIRMAN invited the Board to formalize its decision regarding the revised text of Article 2 of the Constitution. Decision: The Executive Board requested the Director-General to ensure that the revised text of Article 2, as contained in the report of the special group on review of the Constitution,3 is reviewed at all levels of
1 2
Decision EB101(2). Resolution EB10l.R2. Document EBIOI/7.
3
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the Organization during the course of 1998, and to submit to the Executive Board at its 103rd session a final text reflecting this broad consultative process. 1
3.
IMPLEMENTATION OF RESOLUTIONS AND DECISIONS (REPORTS BY THE DIRECTOR-GENERAL): Item 9 of the Agenda (Documents EB101/10 and Corr.1, EB101/10 Add.1 and Corr.1 and EB101/10 Add.2)
Mr COLLA (Belgium) 2 said that before addressing two specific points under item 9 - cross-border advertising, promotion and sale of medical products through the Internet (section VIII of document EB 10111 0), and prevention of violence (section IV)- he wished to stress the importance of greater personal involvement of ministers of health in the work of WHO and, more generally, of political contacts with specialized bodies, regional organizations, governments and the relevant ministers, as a means of advancing that work. The draft resolution contained in section XIV of document EB 101/10 concerning cross-border advertising, promotion and sale of medical products through the Internet should be seen not as an indictment of the Internet or new telecommunication technologies, but as an endeavour to protect the interests of patients and prevent the uncontrolled sale of unauthorized medical products or products of poor quality. He welcomed the emphasis on better consumer information and on directing consumers towards reliable Internet sites. The responsibility of health professionals and national authorities, in addition to that of WHO, was rightly stressed. He hoped that the text of the resolution would be adopted and widely disseminated. He was gratified to note that positive developments had been reported since the adoption of resolution WHA50.4 in May 1997. International awareness and action, as well as bilateral agreements and regional approaches, were clearly effective. Describing some of the devastating effects of anti-personnel landmines, notably among the most vulnerable civilian populations of the most disadvantaged countries, he said that the havoc wrought had reached epidemic proportions and should be considered as an urgent public health issue, which should certainly be the subject of a WHO resolution. Belgium had played a pioneering role in the campaign for the total elimination of anti-personnel mines and had taken an active part in negotiations leading to the signing by over 120 countries, in Ottawa in December 1997, of the Convention on the Prohibition ofthe Use, Stockpiling, Production and Transfer of Anti-Personnel Mines and on their Destruction. Belgium urged universal respect for the Convention and encouraged States that had not yet done so to become parties to it. Because of the public health component of the issue, WHO clearly had a role to play. It had emerged from the Brussels Conference in June 1997 that many countries, especially the most seriously affected among them, looked to the international community for assistance, including assistance to victims. He hoped that provision would be made in WHO's regular budget for resources to finance the necessary programmes, and appealed to Member States to make a special effort to finance a plan of action to assist the victims of landmines, his own country being prepared to finance the services of an expert responsible for the epidemiological evaluation of the impact of mines on health and on people's lives in general. Belgium had already pledged some 100 million francs in bilateral and multilateral aid under the Convention. He stressed the need for continuing cooperation with the International Committee of the Red Cross and with other agencies and bodies, including nongovemmental organizations, and hoped that WHO's future action would be in line with the coordinated and integrated approach that characterized the "Ottawa Process". Vigorous humanitarian action to alleviate the effects of anti-personnel mines could only encourage the countries most seriously affected to accede to the Convention and broaden its scope. The CHAIRMAN invited the Board to consider document EB101/10 and its addenda and corrigenda section by section.
1 2
Decision EB101(3). Government representative attending by virtue of Rule 3 of the Rules of Procedure.
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Section I. Task force on health in development (Resolution WHA50.23) Dr HERRELL (Health Policy in Development), reporting on WHO's work on health policy in development and particularly the work of the task force on health in development, said that the task force, whose members she commended, had many accomplishments to its credit, especially in placing health at the centre of development and identifying issues which required urgent attention by WHO, its Member States and the international community as a whole. The Executive Board had recognized its achievements and its contribution to the formulation of WHO's vision and mission for the coming millennium, as reflected in the proposed healthfor-all policy and the task force reports. WHO continued to take into account the task force recommendations in areas relevant to the policy directions of the Organization, and Regional Directors were increasingly active in promoting health in the development process. WHO had actively drawn attention to the relationship between health and human rights as a powerful means of focusing on the underlying inequities and discrimination which often led to differences in health status. An informal consultation on health and human rights held in December 1997, bringing together experts in public health, human rights and international law from all regions, had resulted in a report - to be issued shortly recommending ways in which WHO could build or strengthen partnerships and energetically promote the realization of the right to health as well as the progressive realization of other fundamental human rights. A great deal remained to be done, especially in integrating the focus on health as a human right into all relevant WHO programmes. Since taking up her assignment as Senior Adviser in November 1997, she had engaged in the widest possible consultation with WHO staff, taking careful note of the views and concerns about work undertaken in health in development. The current session of the Board had afforded the opportunity to extend those consultations to WHO Regional Directors and to note the Board's strong commitment to those issues. She intended to respond to WHO resolutions related to health in development through a continued process of consolidation within the Organization, and consensus-building with new outside partners where necessary. Dr VAN ETTEN expressed interest in receiving the reports of the October 1997 meeting of the working group of experts in health and in peace initiatives and of the informal consultation on health and human rights held in December 1997. Mr VOIGTLANDER commended the task force on its remarkable work as a think-tank which had extended its concerns to the basic philosophy, vision and mandate of the Organization and its position within the United Nations system. It was gratifying to see that so many of its ideas had been incorporated into the policy document on health for all in the twenty-first century. Examples were the fundamental policy objective of making health central to human development, the positioning of health within the human rights context and the understanding that investments in health were critical to the development of human resources. Those were excellent points offocus for work both within WHO and with other international organizations. He wished to know what the intentions were regarding the future of the task force, in terms of both functions and resources. Dr HERRELL (Health Policy in Development) said that work was proceeding on the implementation of resolution WHA50.23 in regard to the task force's work and resources. Having only taken up her duties in midNovember 1997, she would defer a response to specific questions about the task force's future agenda until the work plan had been drawn up. WHO was exploring the provision of financial and human resources referred to in resolution WHA50.23 to support the efforts of the task force in a timely and effective manner. It was also hoped that donor countries would continue to provide extrabudgetary resources.
The Board took note of section I of the report.
Section 11. WHO collaborating centres (Resolution WHA50.2) Dr MOREL recalled that in 1997 the Board had called for a careful study ofthe collaborating centres; it was encouraging to see that a start had been made and that some data were forthcoming. The information document on the subject (document RPS/WCC/97.1) showed a sharp discrepancy in the number of centres in various regions, ranging from 36 in the African Region to 569 in the European Region. The number of centres
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would obviously depend on a given region's level of development and on the available expertise; nevertheless, it was disturbing to see that they were so densely concentrated in developed countries. The progress in the analysis so far varied widely from region to region, and the matter should be kept under careful review. It was important that information on each centre's location, contact person or institution and field of specialization be accessible, and he proposed recourse to the Internet so that expertise could be rapidly sought and obtained from the 1244 collaborating centres in existence. Dr CALMAN, commending the work of the collaborating centres, agreed with Or More! on the importance of continuing the evaluation exercise and of encouraging WHO to keep the subject under review. He saw the documentation that was before the Board thus very much as a starting point, not an end result. The collaborating centres should be seen as an important part of the Organization, and their skills and expertise should be fully utilized. Dr AL-MOUSA WI commended the criteria adopted for the designation of collaborating centres. At the Board session in May 1997, there had been a call for a list of names of centres and their fields of specialization so as to enable countries to benefit from their work to the fullest extent; he urged that that list be made available as soon as possible. Mr VOIGTLANDER welcomed the fact that the procedure for designation and redesignation of collaborating centres was to be standardized and thought that even the terms used to refer to the centres themselves should be harmonized. He also approved ofthe idea of updating the list of collaborating centres. As to whether that should be done in The world health report or in a separate reference document, he thought that the latter would be more useful in day-to-day activities. Dr LARIVIERE (alternate to Mr Juneau) said the system of collaborating centres clearly needed revitalization, and many of their activities and processes had to be scrutinized with a view to standardization. It was also necessary to see if less formal methods would deliver better results in terms of programme support. The study by Professor Manciaux (summarized in document ACHR35/97.7/Rev.l) had served as one of the bases for the report before the Board and deserved attention for its extensive analysis of the situation. As WHO's resource base dwindled, much more of its technical work would have to be done on a collaborative basis by agencies, universities and institutions in developing countries. WHO would remain the directing body, analytical focus and coordinating centre, but better tools, flexible methods and appropriate methods of collaboration had to be developed. The first meeting of all the WHO collaborating centres in Canada had been held recently. It had been a success, and he commended the idea to other countries. Dr STAMPS noted from the statistical data in section 4 of document RPS/W CC/97 .1 that there had been a decline in the number of collaborating centres in the African Region. That was all the more alarming in view of the heavy burdens of ill-health, disease and impoverishment in the region. There were 26 times as many collaborating centres in Europe as in Africa. In fact, there were currently no more centres in Africa than there had been in 1981, whereas all other regions, with the exception of South-East Asia, had seen the number increase. What were the reasons for the decline in Africa, and what were the defects that had led collaborative relationships with almost a score of African centres to be terminated since 1994? Submitting that there was a case for more centres to be established in Africa, because the competence and resources were already available there, he remarked on the paradox that those who could afford it least had to pay the greatest travel costs to reach a collaborating centre. Dr MELON! commended the document before the Board, but requested some additional information. On what basis were centres established? Was establishment a response to the need for capacity-building in specific regions or, rather, to the availability of such capacity? Did the Organization adopt a proactive approach in searching out centres and concluding agreements, or was that done at the request of interested parties? Recourse to collaborating centres was of fundamental importance, but the fact that they were concentrated in certain regions suggested that there might be greater preoccupation with administrative and procedural concerns than with end results in the Organization's strategy for the use of existing capacities.
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Dr ALLEYNE (Regional Director for the Americas) said the subject had been much discussed, but the principal role of the collaborating centres was sometimes lost from sight. When they had first been established, the intention had been that WHO should not carry out research on its own. In June 1997, at the initiative of the National Council of International Health in the United States of America and a collaborating centre in Chicago, a meeting of United States centres interested in reinvigorating the process had been convened. Agreement had emerged on a number of points. WHO was currently reactive, rather than proactive, in its relations with collaborating centres and the time had come to re-examine the procedures involved. The areas where WHO needed collaboration must be identified and competition among the centres launched to fill those requirements. For the immediate future, WHO should be much more rigorous in designating collaborating centres; redesignation should not be automatic; a programme of work consonant with the priorities of the Organization should be developed; and a certificate should be issued to indicate that a collaborating centre was so designated for a specific time period if at the end of that period the centre had not fulfilled its obligations, it would not be redesignated. National governments should be involved in all initial decisions on the designation of collaborating centres. At the meeting to which he had referred, it had also been decided to establish a permanent focal point, in close collaboration with the clearing-house in Geneva, which - it should be noted - had worked extremely well. All the information on the collaborating centres in the Americas - their electronic address, a brief synopsis of their work and their points of contact- was to be placed on the Internet, with interconnections between them that could only be beneficial.
Dr Wasisto took the Chair. Dr LOPEZ BENITEZ, referring to the large number of collaborating centres and to the need for efficiency in collaboration, proposed that consideration be given to setting up a small group within the Secretariat to coordinate the activities of all the centres. Dr STAMPS, referring to the information document on the subject (document RPS/WCC/97.1), sounded a note of caution with regard to the statement in section 2.3 of that report that some centres, which had been neither officially redesignated nor terminated at the end of a first term, continued to use WHO's name and emblem without continuing work with and for the Organization. It was dangerous for the Organization to become too closely identified with collaborating centres which in some cases might be largely non-medical. Referring also to the recommendation in section 6 of that report that mechanisms be established for reward and recognition of centres, he stressed that care must also be taken to ensure WHO's independence of any commercial interests. Dr MANSOURIAN (Office of Research Policy and Strategy Coordination), in his reply, alluded to the comments of Dr More! and Dr Alleyne, and drew attention to the information contained in document RPS/WCC/97.1, in particular the 14 conclusions and recommendations in Part I. Part 11 of the document contained complementary data based on the conclusions of the study of Professor Manciaux, which had been presented to the Advisory Committee for Health Research for critical review, as well as: reflections from programme managers on the role, criteria and functions of WHO collaborating centres; procedural aspects, mechanisms and fundings; difficulties and problems; the viewpoints of Regional Directors; and an extensive bibliography. Regarding the request that WHO standardize its procedures in relation to collaborating centres, he explained that strict rules already existed in the WHO Manual and that a middle course had to be taken between those in favour of more rigorous procedures and those who sought greater flexibility. Regarding publications, he said that in view of the large number of collaborating centres, the most costeffective solution was to create a web site with appropriate quality control; such a site was being prepared and should be available shortly. At least 12 sub-sites were already available on the Internet through the WHO home page. In reply to Dr Stamps, he felt that the situation should not be over-dramatized, as the review had been intended to be critical so that any weaknesses could be corrected. Regarding the question of some forms of recognition, he said that the average lifetime of a collaborating centre was 12-13 years; once the period of designation was over, a certificate was issued. It had been suggested that a medal or similar award should be
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presented to a collaborating centre in recognition of its contribution to WHO's work. Although until now 90% of science and technology was situated in the north and only 10% in the south, the situation in terms of human resources was changing and that gap might be closing. Secondly, the collaborating centres were not the only collaborating mechanism; for example, the Special Programme for Research and Training in Tropical Diseases had a very extensive network of collaborating institutions which were not formal centres. It was to be hoped that the introduction of modem technologies would lead to rapid development in Africa.
The Board took note of section 11 of the report.
Section Ill. Improving technical cooperation among developing countries (Resolutions WHA43.9 and WHA50.27) Dr MELON! expressed gratitude for the technical support provided by WHO and the more strategic approach which had been adopted to technical cooperation among developing countries and to the development of health systems and health reform. Clearly such support should be coordinated with policy formulation and the renewal of the health-for-all policy. Referring to paragraph 2 of section Ill of document EB101110, he said that further thought should be given to sustainability and coherence in the health-for-all policy. He asked for clarification concerning the internal coordination procedures at headquarters and in the regions for promoting cooperation between countries and the specific procedures for achieving cooperation between WHO collaborating centres and countries. The DEPUTY DIRECTOR-GENERAL ad interim, stressing the importance of technical cooperation between countries, not only for reform but for achieving health for all in the twenty-first century, said that cooperation among less developed countries, through collaborating centres, on both a north-south and a southsouth basis, had proved successful. WHO headquarters had intensified its programme of technical cooperation with countries, in association with the Non-aligned Movement. Moreover, virtually all WHO programmes included a technical cooperation component in their plans of action. It was intended that further opportunities would be provided for technical cooperation in future, particularly through improved subregional procedures and increased liaison with WHO headquarters.
The Board took note of section Ill of the report.
Section IV. Prevention of violence (Resolution WHA50.19; Document EB101/INF.DOC./6) The CHAIRMAN informed the Board that section IV of the report would be discussed at a later meeting. (For discussion, see summary record of the ninth meeting, section 1.)
Section V. Health systems development (Resolutions WHA50.27 and EB100.R1) Dr FERDINAND, stressing the importance of giving increased attention to health systems as part of health and human development and ensuring coordination and cooperation between health teams, welcomed the emphasis given to health systems development in the health-for-all strategy to be presented at the next Health Assembly. Nursing and midwifery resources and services were an integral part of health systems development. As a member of the Global Advisory Group on Nursing and Midwifery, she wished to inform the Board of the major recommendations of the Group's fifth meeting held in Geneva in April1997. In addition to extensive discussion and preparation of a contribution to the draft report on health for all in the twenty-first century, the Group had recommended that Member States should strengthen the development of nursing and midwifery personnel and services and that the Director-General and the Regional Directors should be requested: to strengthen the nursing input in all relevant WHO programmes; to prepare a policy document to guide Member States on the reduction of cross-infection and drug resistance; and to encourage examination of nursing, midwifery and medical education in the light of changing needs and realities. The Director-General should also ensure that all posts in WHO associated with nursing were filled by appropriately qualified personnel.
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Dr SHIN recalled that in 1996 the Executive Board had appointed an ad hoc group to review the status of health systems development, which had led to the adoption of resolution EB100.R1 calling for the launching of a global initiative on health systems development, in collaboration with national institutions. An external advisory group had been set up subsequently to advise on the development of that initiative. The group had requested WHO to develop a strategy for the initiative in close collaboration with different programmes. It had clarified the concepts and contents of health systems development, a subject relevant to all the Organization's programmes. The group had welcomed the establishment of an inter-programme working group to ensure the sustainability of national technical activities. Unless country capacities were enhanced, those activities might come to a halt when external agency support ceased. Health systems, health policies, financing alternatives and decentralization were being addressed by many other international organizations and bilateral and multilateral agencies. WHO should take the initiative, not to pre-empt those agencies and donors but with a view to collaborating with them. He looked forward to the further developments to be discussed by the advisory group in April 1998. Professor REINER said that it was clear that, in addition to WHO, other bodies such as the World Bank, UNICEF and UNDP were also engaged in health systems development activities. Hence the great importance of interagency cooperation as a basis for achieving more effective results. However, experience had shown that support from other organizations was not always directed to action that was consistent with WHO's health-forall policy- hence the need for a careful approach. If the goals that had been set were to be achieved, WHO must maintain its leadership role in international health, all Member States must have their own health-for-all policy and strategy, and other organizations must accept the basic determinants that had to be present in each specific national health-for-all strategy and policy. Dr STAMPS endorsed the views expressed by Professor Reiner. He stressed the paramount importance for WHO's leadership role of strengthening the Organization's analytical capacity in order to benefit from experiences in national health sector reforms, as mentioned in paragraph 6 of section V of the report. Dr MELONI, welcoming the health systems development initiative, said that WHO's leadership could only be built up or rebuilt through appropriate coordination and cooperation between the Organization, at all levels, and countries. Health systems development was closely interrelated with the other topics that the Board had been discussing, such as health and development, cooperation among countries, collaborating centres, WHO reform and renewal of health for all. WHO's internal coordination procedures must be carefully reviewed in order to encompass all those aspects. Dr LOPEZ BENITEZ endorsed the views expressed by Professor Reiner. In developing health systems it was important to bear the health-for-all strategy constantly in mind. Once countries clearly defined their objectives and strategies it was much easier to negotiate aid. In Honduras, for example, the clear definition of future goals for health systems development had led to success in negotiating aid, both reimbursable and nonreimbursable. That phase had been followed by coordinated implementation of health policies in different parts of the country to achieve the desired goals, with the result that maternal and child mortality rates had been reduced. The report should reflect the importance of developing national capacity in negotiating assistance with external partners. Dr ALLEYNE (Regional Director for the Americas) agreed that the development of health systems was fundamental to the progress of the health-for-all strategy. It would therefore be preferable for the Board to have the opportunity to consider detailed proposals for the plan of action before any meeting of potential donors. He suggested that the Board should return to the subject at a later date once it had a copy of the plan before it. Dr EL-SHAFEY (adviser to Professor Sallam) said that many countries had recently embarked on major health sector reforms, many of which were supported by various organizations and donors. The support and leadership of the Organization was essential to ensure that such reforms were in accordance with WHO's healthfor-all strategy, and to strengthen the capacity of Member States to implement the strategy, formulate their own policies and strategies, and develop their human resources. She would like to have seen a more elaborate plan of action, incorporating more detailed policy proposals and a plan of action in regard to regional offices.
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Dr STAMPS said that without additional information it was difficult to see how the plan of action would function and asked whether an outline could be made available during the current session. Dr LARIVIERE (alternate to Mr Juneau) noted that since previous discussions on health systems development, changes had taken place in WHO which had altered the resources available for the implementation of activities in that area. He asked for information on the current capacity of the Secretariat at headquarters in regard to such work. Dr KONE-DIABI (Assistant Director-General), replying to comments, said that a number of points in resolution EB 1OO.R1 had already been taken into account and observed that document EB I 01110 did not present the plan of action but rather the process by which it would be developed. A WHO inter-programme group had been established and would meet in February 1998 to develop proposals which would take into account research, human resources and country-level support. As envisaged by the external advisory group, it should be possible to produce in April 1998 the first draft of a document, which would have already been circulated throughout the Organization. At its 1OOth session the Board had recommended that The world health report 1999 should be devoted to health systems. To that end data collection had already begun in close collaboration with other United Nations organizations such as UNICEF and the World Bank. The results would also serve as a basis for the design and implementation of the global initiative on health systems development requested by the Board. Dr STAMPS expressed his concern at the lack of capacity at headquarters in the area of health systems development and asked whether reductions in staff in that area had delayed development of the initiative. Dr KONE-DIABI (Assistant Director-General) confirmed that there had been a reduction in the resources available in the area of health systems development, despite its importance. Dr MELONI agreed with Dr Shin that health systems development should involve the whole Organization, headquarters, regional offices and country offices, and that strategies should be developed with WHO collaborating centres and Member States. Health systems development was essential for effective progress in achieving health-for-all objectives. Clearly, if it had been identified as a priority it should receive adequate resources. The CHAIRMAN invited the Board to consider whether it wished to request that a progress report on the proposed initiative for health systems development be submitted at its 103rd session, as set out in section XIV of document EB101/10. Dr SHIN, referring to the suggestion made by Dr Alleyne, proposed that the whole process should be reviewed and a further report, setting out a detailed plan of action, should be presented to the Board at its 102nd session in May 1998. Dr KONE-DIABI (Assistant Director-General) assured the Board that a more detailed document would be prepared. Dr STAMPS considered that the action proposed was not sufficient. He agreed with Dr Meloni that everyone must be involved in the process but stressed that there must be a leader at headquarters to collate information and transform it into readable form. The health system development programme appeared to be among the smallest at headquarters with only limited resources to devote to such an important topic. He asked what reductions had been made over the past 12 months to that section. Dr KONE-DIABI (Assistant Director-General) replied that one-third of the staff who had been involved in health systems development, namely some six to eight professionals, as well as support staff, had left the programme during the period mentioned. Mr AITKEN (Assistant Director-General) added that, following the creation of the health systems development programme, three divisions had been brought together for a period of about one year. At the end
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ofthat initial review period, one division, now known as the Division of Intensified Cooperation, had reverted for the most part to its former function. As Dr Kone-Diabi had pointed out, that had entailed the transfer of about one-third of the total numbers in the specific area under discussion. Dr CALMAN expressed the hope that the senior nurse clinical scientist who had been working on the programme would be replaced as soon as possible. Dr FERDINAND welcomed Dr Calman's proposal and pointed out that staff who had moved within the Organization were not carrying out the same work as they would have done with the programme. Dr SHIN, referring to the action required of the Executive Board, proposed that an interim report on the plan of action be submitted for consideration at its I 02nd session so that members could comment further on the plan's development. Also, as many speakers had noted, the issue was one for the whole Organization and he wished to have further details on the methods envisaged in that regard. Decision: The Executive Board requested that a progress report on the proposed initiative for health systems development should be submitted to its I 02nd session. 1 Dr STAMPS asked whether members of the Board could be given an amended plan of action before the end of the current session. Mr AITKEN (Assistant Director-General) said that he would liaise with Dr Kone-Diabi and her staff and endeavour to produce the information requested before the end of the Board session.
The meeting rose at 17:45.
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Decision EB101(4).
NINTH MEETING Friday, 23 January 1998, at 9:30 Chairman: Professor A. ABERKANE
IMPLEMENTATION OF RESOLUTIONS AND DECISIONS (REPORTS BY THE DIRECTORGENERAL): Item 9 of the Agenda (Documents EB1 01/10 and Corr.1) (continued) Section IV. Prevention of violence (Resolution WHA50.19; Document EB101/INF.DOC./6) (continued) The CHAIRMAN drew attention to section IV of the Director-General's report (document EB101110), and to the draft resolution entitled "Concerted public health action on anti-personnel mines", proposed by Dr Alvik, Dr Blewett, Dr Hembe, Mr Juneau, Dr L6pez Benitez and Dr Morel which read: The Executive Board, Agreeing with the priority areas defined in the information document on prevention of violence' with particular reference to landmines, RECOMMENDS to the Fifty-first World Health Assembly the adoption ofthe following resolution: The Fifty-first World Health Assembly, Noting with great concern the dramatic consequences of anti-personnel-mine injuries which particularly affect civilian populations, and are uniquely tragic, so that they deserve special attention; Recalling the Ottawa Declaration of 5 October 1996, the Brussels Declaration of 27 June 1997, and noting the progress made by the international community towards a global ban on anti-personnel mines, as well as the relevant decisions and initiatives taken in other forums; Recalling Article 6 of the Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-Personnel Mines and on their Destruction, adopted in Oslo on 18 September 1997, which provides that assistance for the care and rehabilitation of mine victims and for mine awareness programmes may be provided, inter alia, through the United Nations system, international, regional or national organizations or institutions; Recalling operative paragraph C.2 of resolution EB95.R17 on emergency and humanitarian action, which requests the Director-General "to advocate the protection of non-combatants and the setting-up of effective treatment and rehabilitation programmes for the victims of anti-personnel landmines, as well as the systematic management of delayed health effects of mental and physical injuries in situations of collective violence"; Recognizing the serious consequences for health caused by anti-personnel mines as they, inter alia, limit population mobility, prevent access to arable land, resulting in malnutrition, hamper access to health services, contribute to the spread of communicable diseases like poliomyelitis and hinder their eradication, and, lastly, generate significant psychosocial disorders; Recognizing that a total ban on anti-personnel mines will be an important contribution to global public health;
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Document EBIOI/INF.DOC./6.
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Welcoming the participation of over 120 Member States in the ceremony for signing of the Ottawa Treaty from 3 to 5 December 1997; Recognizing that WHO should contribute to coordinated activities of the United Nations system against anti-personnel mines by developing public health programmes for anti-personnelmine injury prevention and control, I. DECLARES that damage caused by the use of anti-personnel mines is a public health problem; 2. URGES all Member States to ratify the Convention as soon as possible;
3. URGES governments of affected States to incorporate anti-personnel-mine injury prevention and assistance to victims, including treatment and rehabilitation, as a priority in national health plans; 4. URGES Member States to give due attention to the public health aspects of the Convention and provide the necessary resources to support implementation of the WHO plan of action referred to below, bearing in mind the need for an integrated and sustainable approach; 5. REQUESTS the Director-General, within the limits of available regular and extrabudgetary resources and in close cooperation with governments, appropriate organizations of the United Nations system and nongovernmental organizations: (1) to strengthen the capacity of affected States for the planning and execution of programmes for: (a) better assessment of the effects of anti-personnel-mine injuries on health through the establishment or reinforcement of surveillance systems; (b) the promotion of mine awareness and prevention programmes through health education, in cooperation with interested parties; (c) strengthening and improvement of emergency management of anti-personnelmine injuries, including treatment and rehabilitation, with special attention to psychosocial rehabilitation; (2) to establish, with other interested parties and as part of an integrated United Nations database, a clearing-house for information on public health aspects of the use of mines to support policy and programme planning; (3) to present a plan of action to the Fifty-first World Health Assembly. Dr BADRAN (alternate to Professor Sallam) endorsed the presentation of prevention of violence in the report (document EBIOl/10). He drew attention to the fact that as a result of a recent decision by the Supreme Court to uphold a decree of the Ministry of Health, the practice of female genital mutilation was now prohibited in Egypt under all circumstances. He hoped that other developing countries would take the same steps. Or LOPEZ BENITEZ commended the Secretariat and all those who had contributed to progress made in the prevention of violence. However, two matters warranted consideration. The first was the impact of violence in the media. Perhaps the Board and the Health Assembly might look into ways of ensuring that there was less violence, particularly in television programmes watched by children worldwide. The second matter - also of global concern- was the effect of anti-personnel mines on innocent people. The frontier areas of his country had been heavily mined during wars in neighbouring countries. International cooperation had played a vital role in the demining operations under way, which would hopefully be completed by 1999. Given the importance of international cooperation, the draft resolution was submitted for consideration so that WHO could take a stance on the issue, which had been presented by the Minister of Health of Belgium at the previous meeting. Or HEMBE acknowledged the efforts that had been made to ensure implementation of resolution WHA50.19 by Member States.
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Concerning action on anti-personnel mines, she remarked that in Angola, the country in the world worst affected by landmines, women and children were maimed every day. Indeed, it had been reckoned that there was one landmine per inhabitant. The consequences for the health sector were obvious. As emergency services operated with scant resources, blood safety could not be ensured, thereby increasing the risk of HIV/AIDS infection. Endorsing both the report and the draft resolution, she expressed gratitude to all those who were striving for the elimination of landmines as well as to those countries which had signed the Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-Personnel Mines and on their Destruction. Or ALVIK joined in welcoming the Organization's involvement with regard to landmines and their consequences. The "Ottawa process" had been unique in creating a worldwide movement to ban anti-personnel mines. As the leading international public health agency, WHO could enhance efforts under way and should take an active part in the follow-up process, given the expectations raised at Ottawa and the pledges by governments of financial support. As a first step, WHO could, by providing advice on how the physical rehabilitation of victims could be incorporated in overall health policies and programmes, strengthen the capacity of the afflicted Member States to plan and implement their own action. Subsequently, the need for an integrated approach encompassing psychological and social rehabilitation should also be addressed. There was a need for improved assessment of the effects of anti-personnel mines, the burden they imposed on health services and capacities to respond. In that regard, WHO should join in international efforts to establish comparable data, perhaps based on work undertaken by the Division of Emergency and Humanitarian Action and the unit for Safety Promotion and Injury Control. Moreover, possibilities of greater cooperation and partnership with nongovemmental organizations should be explored. Although the draft resolution before the Board was addressed to the Fifty-first World Health Assembly, she hoped that the recommendations it contained would be followed at once. Dr CALMAN hoped that the Organization would pursue its commendable involvement in the prevention of violence. His annual report on the state of public health in the United Kingdom emphasized domestic violence, and an extensive programme of work on that topic was under way. He would comment at a later stage on the draft resolution before the Board. Dr SANOU IRA welcomed the fact that WHO and the international community had finally recognized violence as a major health problem worldwide and were giving it due attention. She endorsed the strengthening of the unit responsible for safety promotion and injury control at headquarters, which should provide support to regional offices as required. She would, however, welcome more information on the composition and functions of the institutional network established to support implementation of the plan of action. Also, she wondered why the Task Force on Violence and Health set up by the Director-General, instead of the unit she had just referred to, would be responsible for coordinating input from collaborating centres. Dr VAN ETTEN welcomed the establishment of an institutional network and the strengthening of WHO capacities. He was also pleased to note the attention given to violence against women in the report - a matter of great concern to the Netherlands. · Referring to the draft resolution, and supported by Professor REINER, he suggested the insertion of the words "and post-emergency" after the word "emergency" in paragraph 5(l)(c) of the resolution recommended for adoption by the Health Assembly. Professor PICO (alternate to Dr Mazza), after expressing support for the basic thrust of the report, stressed the importance of domestic violence, which should be considered as a priority public health issue. He endorsed the comments by Dr Lopez Benftez regarding violence and the media, expressing the hope that WHO would make headway in that domain. Dr STAMPS said that the report did not lay sufficient emphasis on several very important aspects. He drew attention to the growing number of mainstream films that glorified violence, a matter of particular concern given the virtually unlimited access to such films. Steps should be taken to bring the situation under control, possibly in cooperation with UNESCO. Greater attention should be paid by WHO, also in collaboration with
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other partners, to the increase in violence against children and minors, not only in zones of war, but also in the home and in institutions; violence amongst children, not infrequently as a consequence of hatred - fanned by the media - on grounds of race, colour or geographical origin, was also a most serious issue. As for the draft resolution on anti-personnel mines, paragraph 5(2) of the recommended resolution was somewhat infelicitously worded and needed some rearrangement; subject to that being done, he wished to confirm his desire to be considered as a cosponsor. Mr JUNEAU welcomed the attention being paid by WHO to the problem of landmines. Urging Member States which had not yet done so to sign the Convention, he said that Canada would continue to devote considerable financial resources and pursue diplomatic efforts to further the "Ottawa process". It was greatly to be hoped that WHO would continue its own work in the area, in close cooperation with other organizations of the United Nations system. Dr DOSSOU-TOGBE said that national and international institutions faced the challenge of working together to raise awareness about how the quality of life influenced the existence or otherwise of violence. The wide-ranging measures outlined in the report before the Board highlighted the importance of international cooperation, education, and indeed a holistic approach in preventing violence in all its social manifestations. He supported the draft resolution, commending its emphasis on the concept of an integrated and sustainable approach. The CHAIRMAN, speaking in a personal capacity, welcomed the report on the prevention of violence, and called attention to paragraph 5, which mentioned an international colloquium on contemporary forms of violence and the "culture of peace", organized by the National Observatory of Human Rights in Algeria, in cooperation with UNESCO and WHO. The colloquium had focused on three major themes: forms of violence linked to internal conflict arising from the expression of fanaticism, extremism and intolerance; violence stemming from the uncontrolled expansion of urban areas; and violence related to the development of the media and new communication technologies. The 200 participants and experts representing various disciplines and associations in civil society had agreed on the need to maintain a consensual approach and to establish an international centre for studies relating to contemporary forms of violence and the promotion of the culture of peace. The principal tasks of such a centre would be to propose a global approach based on practice and grassroots experience as well as research into the origins of violence in the modem world, and encompassing methods for the compensation, rehabilitation and reintegration into society of victims of violence, and for the promotion of the culture of peace. In the spirit of the colloquium and bearing in mind both the urgency of the current situation and the long-term perspective of peace, such a centre might join with other existing institutions in launching new initiatives concerning the investigation and containment of violence. Algeria was going through a new and dramatic period of its history. Emerging from the long night of colonialism, its unhappy people were now paying an extraordinarily heavy tribute to violence in many forms, whose devastating effects on individuals and communities alike must be taken in hand. The establishment on its soil of an interregional Mediterranean centre would - he submitted - constitute a fitting and indeed necessary response to the resolution on violence and the culture of peace adopted by the UNESCO General Conference in 1995 and to that in which WHO defined violence as a public health issue. Dr KARIBURYO emphasized two insidious forms of violence which had perhaps involuntarily been neglected in the report under consideration: firstly, the use of embargoes as a political weapon; and secondly, the incitation to violence by what he called the "media of hatred". It had become increasingly obvious that throughout the world countries or political groups used embargoes in relation to other countries, or enclaved parts thereof, very often as a means of bringing political leaders to order. But in general it was entire populations who suffered and - more particularly - the most vulnerable groups, including children denied immunization or other forms of health care, and pregnant women, who were unable to give birth in proper conditions. As to the media, radio broadcasts and newspapers were not infrequently used to disseminate messages of hatred, calling for violence and murder. In documents of the type being discussed by the Board, the two forms of violence he had just mentioned should be roundly condemned.
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Dr BASSANI (Division of Emergency and Humanitarian Action) noted with satisfaction that the importance of coordinated action on violence had been mentioned by all speakers; that principle was reflected in the internal and external collaboration in which his division was engaged. For WHO, violence clearly had interdivisional dimensions. For example, an interdivisional task force had been set up by the Director-General to ensure a coordinated approach to the subject, while Family and Reproductive Health had prepared a package entitled Violence against women. External collaboration had been established with other bodies of the United Nations system as well. To take another example, as one element of the reform measures launched by the Secretary General of the United Nations, the Department of Peacekeeping Operations in New York had been designated as the focal point for action on landmines; WHO was a member of the steering committee, and was participating in other relevant groups, such as the working group on assistance to victims. Concerning the international colloquium on contemporary forms of violence held in Algiers, he said that close contacts had been established with UNESCO in order to promote the health aspects of combating violence and the creation of a culture of peace. The media issue was a sensitive one, but WHO was committed to doing everything possible to remedy negative phenomena. Violence against women and children was a common problem, of great concern to the Organization, which acted in collaboration with UNICEF in tackling that issue. He had taken note of Dr Sanou Ira's inquiry with regard to the institutional network of activities and relations with the collaborating centres. His division worked closely with WHO regional bodies, especially in Africa, and efforts were being made to develop the institutional network, to assist the division in discharging its responsibilities more effectively. Dr SAMBA (Regional Director for Africa) underscored the fact that 22 of the Region's 46 Member countries were affected by some form of civil strife. Landmines were becoming a real menace to innocent nonparticipants in the conflicts. Concerning another form of violence, he observed that most cases of female genital mutilation occurred in Africa. Other forms of violence against women were also an extremely serious matter. It was regrettable that the resources for tackling such issues were - despite the adoption of resolutions - so limited. Dr BERLIN (European Commission) said that the Commission was also developing its actions to combat violence and that the WHO programme offered valuable guidance in that regard. The European Union was deeply concerned by the issue of landmines and, apart from the United Nations, was the leading sponsor of clearance and related actions in the countries where anti-personnel mines were found in abundance. It had recently placed special emphasis on the need to increase the assistance provided to victims of landmines and enhance the significance of education in awareness. The European Union would therefore be providing up to US$ 9 million to the International Committee of the Red Cross (ICRC) in response to its special appeal for those purposes. Great store was set by improved international coordination, possibly beyond the United Nations system; the Board might wish to reflect that in the draft resolution. The CHAIRMAN invited the Board to address the draft resolution, noting that a number of amendments had already been proposed. Dr CALMAN proposed four amendments: in the third preambular paragraph of the resolution recommended for adoption by the Health Assembly, the addition of the phrase "and open for signature on 3 December 1997" to follow the phrase "adopted in Oslo on 18 September 1997"; in paragraph 5(1 )(c) the addition of the phrase "and post-emergency", as suggested by Dr Van Etten; at the end of paragraph 5(1)(c), the addition ofthe phrase "and within the context of integrated health service delivery"; and, in response to the remark by Dr Stamps, the modification of paragraph 5(2) to read: "to establish a clearing house for information to support policy and programme planning on public health aspects of the use of mines". Dr ZAHRAN (alternate to Professor Sallam), acknowledging that public health action on anti-personnel landmines, was a matter which lay within WHO's competence, reminded the Board that it had been debated at ICRC, as well as the Ottawa Conference. He noted that the draft resolution did not appear to refer to the preventive aspect - to ways and means of putting an end to mine-laying and removing the threat to civilians and the consequent public health risk.
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Calling particular attention to the situation in Africa, he remarked that in Egypt, some 23 million mines had been laid during the Second World War and the Arab-Israeli War. The countries responsible for laying those mines had not been held responsible for their clearance in financial terms or otherwise. Given such circumstances, which also existed elsewhere, it should be stated in the draft resolution that countries responsible for laying mines in the past during periods of occupation should make it clear where the mines were to be found, assume financial responsibility for their clearance and ensure that populations were protected against possible detonation. Adoption of the resolution should be postponed until all aspects of the issue had been incorporated. Mr VOIGTLANDER fully supported the draft resolution, with the amendments proposed, on the understanding that, while other United Nations forums dealt with landmines, the public health aspects fell within WHO's mandate. He suggested a further amendment to paragraph 5(3) of the recommended resolution, to the effect that the plan of action should be presented to the Fifty-second, rather than the Fifty-first World Health Assembly. Dr DOSSOU-TOGBE drew attention to the danger of proliferating recourse to anti-personnel mines, exacerbated by media coverage of their deployment and the human propensity to copy the behaviour of one's neighbours. A basic task of WHO should thus be to work with governments of countries that had not yet adopted such behaviour. Remarking that countries which constituted the biggest markets were not producers, he said that the countries in which anti-personnel mines were manufactured bore a heavy responsibility for ensuring that production was reduced and, by limiting supply, bringing about a reduction in use. Dr LOPEZ BENiTEZ, on the subject of prevention, observed that weapons of human destruction would exist as long as war itself existed. The third preambular paragraph of the recommended resolution referred to the Convention on the Prohibition of the Use, Stockpiling, Production and Transfer of Anti-Personnel Mines and on their Destruction, but that Convention addressed only part of the problem of prevention. Should not attention also be called to the need to promote the worldwide culture of peace and to educate human beings in conflict resolution through dialogue, not violence? Dr CALMAN, referring to paragraph 5 of the recommended resolution, proposed that intergovernmental organizations should be mentioned, as well as "appropriate organizations of the United Nations system and nongovernmental organizations," so as to allow for cooperation with bodies such as the European Union. Dr AL VIK supported most of the proposed amendments, in particular that put forward by Dr van Etten. Regarding the amendment to paragraph 5(3), proposed by Mr VoigtHinder, however, she wished the plan of action to be presented to the Fifty-first World Health Assembly. Dr STAMPS observed that the Board could not recommend a resolution to the Fifty-first World Health Assembly, and, at the same time, expect a report envisaged by that resolution to be presented to the same Health Assembly. Further, while sympathetic to the concerns raised by Dr Zahran, he considered that the active prevention of mine-laying went beyond WHO's capacity. Perhaps the draft could be amended to include encouragement for the concept of prevention. Dr ZAHRAN (alternate to Professor Sallam) said that the draft resolution would be incomplete if it failed to address the removal of the huge numbers of anti-personnel mines already laid and recognize the responsibilities of the countries that had laid those mines. Not only should WHO assist the civilian victims of Iandmines, the draft resolution should also recognize the responsibility of countries that had laid mines to indicate the location of mines and to assist in mine clearance. He therefore proposed an additional operative paragraph to read as follows: URGES governments that have planted mines on the territories of other countries to provide the latter with the necessary maps and identification of the mine-fields which they planted and assist financially and technologically in mine clearance efforts in the countries concerned;
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Dr AL VIK, referring to paragraph 5(3) of the recommended resolution, recognized the logic in the amendment proposed by Mr Voigtllinder and the comment by Dr Stamps but stressed the importance of presenting a plan of action to the Fifty-first World Health Assembly. She therefore suggested that the text concerned should be removed from the resolution and proposed that the Board instead make a separate request to the Director-General to provide a plan of action to the Fifty-first World Health Assembly. Dr CALMAN sympathized with the sentiments expressed by Dr Zahran but questioned the appropriateness of his proposed amendment in the context of public health action. Dr STAMPS said that, while it was right that those using landmines should be held financially and morally responsible, it was not always easy to apportion responsibility. For example, it would be unfair to hold the current Government of South Africa responsible for landmines laid by the previous apartheid regime. Since the landmines Convention contained almost exactly the same requirement as that proposed by Dr Zahran, which WHO was not in a position to enforce, one way of dealing with that serious concern was, as set out in paragraph 2, to urge States to ratify the Convention as soon as possible. The CHAIRMAN, speaking in a personal capacity, endorsed Dr Zahran's proposal. Some donors of extrabudgetary funds were also producers of anti-personnel mines and it might be possible to use a proportion of those resources for mine clearance. Mr VOIGTLANDER, recalling his earlier statement, emphasized that he had endorsed the draft resolution on the understanding that it would deal solely with the health and, in particular, the public health aspects of the problem, those aspects being within WHO's competence. He supported the comments made by Dr Calman. Mr JUNEAU also endorsed Dr Calman's views, although he shared the feelings of Dr Zahran. The approach suggested by Dr Stamps offered a solution, otherwise there was a risk of entering areas that were outside WHO's mandate and thereby diluting the public health impact of the draft resolution. Professor PICO (alternate to Dr Mazza), recognizing the importance of the problem, endorsed the remarks made by Mr Juneau, Dr Calman and Dr Stamps. Dr ZAHRAN (alternate to Professor Sallam) agreed that countries should be urged to ratify the Convention but stressed that the Convention alone was not enough to deal with the problem of anti-personnel mines, since it failed to deal adequately with the responsibility of countries that had laid mines in the territory of others. Although other organizations, both within and outside the United Nations system, were working on the problem of landmines, WHO would be failing in its duty to civilians under threat if it did not at least encourage Member States responsible for laying mines to indicate the position of those mines and assist in clearance. In the case of South Africa, surely the army would be able to indicate the location of mines. Dr FIKRI said he too was in favour of including a paragraph aimed at dealing with the problem of landmines at source instead of after their effects had been produced. In view of the number of proposals put forward, the CHAIRMAN suggested that consideration of the issue should be deferred until the following day. It was so agreed.
(For continuation, see summary record of the twelfth meeting, section 3.)
Section VI. Fellowships programme and policy (Resolution EB87.R23; EB101/INF.DOC./2 and Corr.1)
Documents
Professor REINER praised the information document (documents EB 10 1/INF.DOC./2 and Corr.1) for the wealth of detail it provided. Some of the developments it highlighted were to be welcomed, for instance the
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greater participation of women in fellowships in the European Region, the general increase in beneficiaries in South-East Asia and the predominance of public health sciences in most regions. But the overall downward trend in awards was worrying, and he urged members of the Board to consider what could be done to reverse it.
Dr VAN ETTEN recalled that in 1994 the External Auditor had been critical of the fellowships programme. The report to the Health Assembly should therefore also give information on what progress had been made since 1994, especially with regard to such important matters as selection, cost of training, matching fellowships with national plans, and evaluation. Where no progress had been made, an explanation should be given. Dr BLEWETT was gratified that the report had remedied the concerns expressed by the Board with regard to lack of content in the previous year's report. Consideration of the fellowship programme by the Board was important on three counts: the programme made a major contribution to WHO's role in strengthening health systems and health personnel; it accounted for one-twentieth of total regular funds; and, as Dr van Etten had pointed out, it had been criticized by the External Auditor. The merit of the report lay in the issues it raised, for example how well fellowships were distributed in terms of countries' needs. Table 2, for instance, showed the number of awards for Jamaica to be nearly half that of India, even though Jamaica's population was only one-fourhundredth of India's and its needs less by any development measure. There was a similar discrepancy between the figures for India and Nepal. Second, Figure 5 showed that, the improvement in the European Region notwithstanding, women's access to fellowships overall had stagnated at around 35%. That disappointing trend should prompt the Board to take action to raise the number of female beneficiaries; a figure approaching 50% of the total by 2005 did not seem unrealistic. Third, he was concerned at the decline in longer-term fellowships compared with study tours and pointed out that the External Auditor had expressed concern at the cost-effectiveness and efficiency of the latter. While he did not advocate abandoning study tours, which were an important part of the programme, the trend was worrying. He suggested that the next report should contain details of the distribution of fellowships across all countries; an explanation of some ofthe anomalies he had mentioned; information on the relative weight given to longer-term fellowships compared with study programmes; and information on human resources development in relation to women. The regional offices should examine, and report to the Executive Board at its 103rd session on, the role and effectiveness of regional offices in the selection of fellowship holders, since that had a bearing, in particular on human resources development and women's access to fellowships, and how the fellowships fitted in with regional human resource development programmes. Lastly, he requested information on compliance with selection guidelines and the ability of the selection process to deliver fellowships which met countries' needs and objectives. An indication of how regions assessed the quality and cost of training would also be useful and might, for instance, throw light on whether the shift towards study tours was rooted in dissatisfaction with longer-term fellowships. Mr DEBRUS (alternate to Mr Voigtlander) said it was important to keep the fellowship programme within the scope of the available financial resources. Programme implementation should be made more transparent by ensuring that applicants had sufficient knowledge of at least one of WHO's official languages and were committed to the programme rather than to sight-seeing. Institutions at which fellows were placed clearly wanted to know the selection criteria and, if they were not met, would not be willing to accept any more fellows from WHO. The information flow between the regional offices and from WHO to health ministries should be improved, for example regarding the precise date of arrival of fellows, to enable proper arrangements to be made for study tours or programmes. He endorsed the proposals put forward by Dr Blewett and Dr van Etten. Dr STAMPS drew attention to the discrepancy between Africa's need and the extent to which it was being served. Only the European Region had fewer awards, as Figure 2 showed. Table 4 illustrated the non-availability of fellowships for undergraduate studies in the African Region; only 13% of awards were for undergraduate studies which tended to be frowned upon as fellowships were generally supposed to be awarded to people who had already demonstrated ability in an academic sphere. The expenditure for the African Region, shown in Table 1, was insufficient considering the backlog of need in terms of human resources in the Region.
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The desperate needs of Africa were not being properly met by the current system of awarding fellowships and should be made a special priority. Dr MELONI, stressing the importance of fellowships for the development of health systems and services, especially in strengthening national capacities, said he shared the views expressed by previous speakers, particularly Dr Blewett. There appeared to be no clear direction or priorities in the fellowship programme. In his country and region, fellowships were awarded in response to requests from applicants, rather than on the basis of a proactive policy by public health departments or the Organization itself. The explanation lay partly in the decline in the priority attached to human resources development and a shift in focus from academic and other training institutions towards health sector reform in many countries. He therefore called for a clearer policy on the part of countries and WHO at regional and country level. The next report should spell out those intentions still more clearly. Dr NAKAMURA said that the document reflected real progress, but that further efforts were still needed, for example, fellows should be required to submit a final report before payment of allowances. Strong leadership at headquarters level was crucial to improving further the implementation of the fellowship programme. Dr SANOU IRA stressed the need to maintain and strengthen the fellowship programme, since the development of health services required competent personnel of sufficient quality and quantity at all levels of the health system. Of course, at some point it had become necessary to rationalize the use of the fellowships within the context of reforms undertaken by the Organization. While WHO could not on its own meet the fellowship needs of countries, it could nevertheless set a good example by encouraging other bodies to become involved in training. With regard to the first line of paragraph 3 of section VI of document EBlOl/10, she felt that since WHO always contributed to drawing up health policies it was involved in the selection of fellows, and not the other way round. Dr BADRAN (alternate to Professor Sallam) said he too was concerned at the decline in funds allocated to fellowships, considering that they were one of the most important avenues for channelling WHO's technical assistance to Member States, especially developing countries. The purpose of fellowships should not be for undergraduate studies but rather for short-term training, especially with regard to new developments in various medical and health fields. Professor PICO (alternate to Dr Mazza), noting that most of his concerns had been covered by other speakers, said that it was essential to improve human resources if health services were to improve. Every effort should be made to provide the regions and countries with sufficiently trained personnel to bring about effective change. The fellowships programme should thus be continued, with more clearly defined policies and strategies, so that the investment would benefit the entire Organization. Dr KONE-DIABI (Assistant Director-General), said in response to the point raised by Dr van Etten that an evaluation ofthe fellowships programme, tested in the field in 1997, had been carried out by the Organization and had so far elicited responses from 60 countries, or 50% of the countries involved. Definitive conclusions could not yet be drawn; however, data would continue to be collected, and a full report ofthe evaluation would be presented to the Board at its 103rd session. She assured Dr Blewett that all of the supplementary information requested would be provided, as had been the case the previous year. She agreed with Professor Reiner that the downward trend in fellowships financing should be reversed. One method might be to develop and strengthen the capacities of regional institutions to host fellows, at a lower cost than in developed countries, bringing balance to the administration of resources at the country level. The administration of fellowships was now decentralized, as it came under the Regional Directors, who would be able to respond to the specific questions that had been raised with regard, for instance, to selection criteria and the distribution of fellowships awarded to women.
The Board took note of section VI of the report.
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Section VII. Revised drug strategy (Resolution WHA49.14) Dr VAN ETTEN, noting mention in paragraph 4 of section VII of document EB 101110 of a strategy resulting from a round table review and assessment of the effectiveness of the WHO Ethical Criteria for Medicinal Drug Promotion, asked whether a copy of the strategy could be made available. He urged WHO to implement such a strategy. He reported that guidelines for drug donations, discussed in paragraph 6, had been established in the Netherlands on the basis of the interagency guidelines. The Director-General had agreed to a suggestion of the Dutch Minister of Health that a meeting of experts and other interested parties should be convened to discuss the quality of raw materials for essential drugs destined for both developed and developing countries. The meeting would be funded by the Netherlands. Mr VOIGTLANDER said that, taken together, the elements of the revised drug strategy formed a remarkable framework. The guidelines for drug donations had been particularly welcomed in Germany. The identification of issues relevant to drug policies in WTO agreements was equally important and should be pursued. The interdependence of the market and the objectives of national drug policies should be evaluated carefully in order to obviate negative effects and to protect access to and the safety of drugs in the interests of public health. Each strategy should involve solutions that took fully into account the large differences between countries and between regions. The aim was to find not a single solution but ways of meeting practical needs in various situations. Dr STAMPS said that Zimbabwe had made huge advances in establishing a list of essential drugs, promoting rational and generic prescribing, and improving the access of a large proportion of the population to drugs. Like many other African countries, however, it had suffered severely from the declining purchasing power of its currency, and the economic consequences ofthe structural adjustment programmes imposed by international funding organizations. Although Zimbabwe had adopted the drug donation guidelines, as described in paragraph 6 of the Director-General's report, donations through nongovernmental organizations of outdated drugs that were genuine but past their expiry date had increased, particularly to mission hospitals, clinics and rural district health centres. Moreover, the WTO agreement on pharmaceutical manufacturing resources had had a negative impact on drug production in his country, which would now have to obtain drugs from its closest neighbour, where they were more expensive than anywhere else in the world. Quality control would thus lead to increased cost. Some of the labelling requirements for drugs were blatantly ignored by major multinational drug companies, as they considered Zimbabwe to be an insignificant market. He looked to WHO for protection against such treatment. He condemned the campaign instituted by certain international pharmaceutical organizations to discredit certain persons working for the revised drug strategy at WHO. A strong rebuttal should be issued to the mendacious remarks that had been made with the obvious intention of destroying the generic drug policy. If the availability of drugs continued to be manipulated by large companies, there was little hope of equitable distribution to the poorest and most vulnerable. It might be necessary to formulate a resolution to that effect. Professor REINER was pleased to note that the revised drug strategy had been implemented in more than 120 countries and that more than 70 had national drug policies. Member States were thus regulating the sensitive matter of the production, distribution and consumption of medicines. Consumption was growing steadily, and was becoming a major problem in most countries, as had been made clear at the first meeting of European ministers of health on the reform of health systems. His country had formulated a national drug policy and implemented the third edition of the guidelines for rational pharmacotherapy, to try and limit the uncontrolled increase in consumption. Croatia had been one of the initiators of the guidelines for drug donations, in the light of its recent experience of donations of medicines that were past their expiry date. He echoed Dr van Etten' s request for documentation on the WHO Ethical Criteria for Medicinal Drug Promotion; he also asked for information on pricing, discussed in paragraph 7. Dr BADRAN (alternate to Professor Sallam) reiterated the concern already expressed with regard to the effects of implementation of WTO recommendations and the GATT agreement on the availability and affordability of drugs to all sectors of the population, especially in developing countries. WHO should stress firmly that health for all was more important than any other issue. National drug production might be severely .
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affected by the proposed system, and the prices imposed by multinational drug companies would place many drugs out of the reach of the poorer segments of society. Drugs were not a commodity that could be governed by free market forces. Professor PICO (alternate to Or Mazza) noted with satisfaction the progress that had been made in establishing national drug policies, in implementing WHO's Ethical Criteria for Promoting Drugs and in the quality assurance of pharmaceutical products moving in international commerce. WHO country support programmes, and those ofPAHO in his Region, had made it possible for Argentina to establish a national drug control administration that also served neighbouring countries. It was therefore now possible to control the quality, safety and effectiveness of drugs, thereby contributing to an improvement in the health of the populations concerned. Or MELONI noted that the subject was of fundamental importance and of high priority. Peru had collaborated with WHO since 1975 to make progress in its essential drugs programme, including improved access to drugs, sustainability, and rational prescription and use of drugs. Further efforts should still be made, however. Many developing countries needed strengthened training and support for health personnel and professionals with regard to prescription. Regulation and quality control were critical in the framework of the process of globalization of international trade and competition among multinational drug companies. Clearly, the matter must be addressed at the international level, and the Organization should continue to support countries and to develop the programme. The WHO Ethical Criteria for Medicinal Drug Promotion were obviously useful, but they were not effective, as they had not been acknowledged or agreed to by industry. He therefore welcomed the intention of WHO to intensify its work in the areas of regulation and quality control in collaboration with WTO. Mr JUNEAU supported those speakers who had stressed the importance of the relationship between national drug policies and international trade policies. Canada's experience had shown that those in the health sector needed to play a much more active part, both individually and collectively, in international trade discussions. Regrettably, industrial or intellectual property considerations often took precedence over health concerns in current trade negotiations. Moreover, the complexity of such discussions often made it more difficult to argue the health case. Much better international data on prices were needed, and he would urge WHO to collaborate with OECD, which had a significant effort under way in that connection. Referring to paragraph 2 of the Director-General's report, he said he would have liked more emphasis to have been given to the importance of integrating national drug policies with national health policies. OrALVIK said the report, and the comments made on it, demonstrated that drug policies were primarily a health issue and not a commercial one. As such, they should be given continuous attention by WHO, since international advice and international solutions were essential if those policies were to be a success. Or MUL W A said he was pleased to note that such a large number of countries had now national drug policies. Developing countries, particularly in the African Region, had .long been used by multinational pharmaceutical companies as a dumping-ground for drugs that did not meet the standards of developed countries, with the result that ineffective drugs, including antibiotics, were often seen for sale on the streets. The adoption of national drug policies would help to halt such unethical practices. Or STAMPS pointed out that the use of the word "drugs" could give rise to confusion, since it was often associated with the illicit drug trade. For that reason, his own country had substituted the word "medicines", and he suggested that "revised drug strategy" be amended to read "revised medicine strategy". Mr CREGAN (alternate to Or Hurley) welcomed the work being done on the revised drug strategy, and supported the points made by earlier speakers regarding quality assurance ..·At the Health Assembly in May 1996, reference had been made to a price review carried out 18 months earlier, and also to a further review due to be completed by the end of that year. He asked whether those reviews were now available.
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Dr LOPEZ BENiTEZ said that Member States themselves, as well as WHO, had responsibilities in the area of drug management. It was incumbent on Member States to apply strict internal regulations in order to avoid receiving low-quality products, which some countries manufactured in large quantities for export to the Third World. His own country, Honduras, had a number of control measures in place to ensure that both the public and the private sector received only products that met the strict standards of its drugs register. Of course, that clashed with the interests of international trade and, in view of the trend toward globalization, countries might perhaps consider the deregulation of some products. His country had not yet reached that stage, since it considered the quality of the products it received to be of great importance. The DEPUTY DIRECTOR-GENERAL ad interim thanked all Board members who had spoken in support of the essential drug concept and in support of the integration of national drug policies with national health policies. He was pleased to note that, despite recent attacks by the media, the Board had reaffirmed the importance of the Action Programme for Essential Drugs, which WHO had for many years been doing its best to implement, in cooperation with Member States and in accordance with resolutions of the Board and the Health Assembly, within the limits of its resources. The issue of pricing was very important, and mechanisms would need to be created to ensure greater efficiency and fairness, as well as to ensure a proper balance between safety, quality and access. He wished to take the opportunity to thank all donors to the Programme for their part in enabling the work to go forward. Dr IDANPAAN-HEIKKILA (Division of Drug Management and Policies) said a number of speakers had highlighted the importance of quality assurance of drugs or pharmaceutical products. WHO had launched a three-year programme, focusing on countries with limited resources, which aimed to promote good manufacturing practices by providing training and advice to help upgrade local production. Guidelines for good manufacturing practices for the manufacture of active ingredients were also in preparation, as well as a manual on how to regulate generic products. Work was continuing on maintaining and updating the WHO Model List of Essential Drugs. The List had been recently revised and would be published shortly. A model formulary designed to meet local needs was being developed, which should help to promote the rational prescribing of medicines. WHO was also working to improve the trade in raw materials by extending the guidelines incorporated in the WHO Certification Scheme to cover them. In addition, it was supporting countries willing to set up national drug regulatory agencies by providing them with model legislation and training in drug assessment and quality control. Dr QUICK (Action Programme on Essential Drugs), responding to questions raised, said that the revised drug strategy now under discussion had three main objectives: equity of access, rational use and drug quality. Member States could be proud of what had been achieved over the past 20 years. Nevertheless, one-third of the world's population still lacked access to essential drugs. In the poorest parts of Africa, less than one-half of the population had such access, and the situation in some of the newly independent States and in parts of Asia was worsening. A large proportion of drugs were still not being used rationally and drug quality was a growing concern. The priority for the next two years would be to move from policy to action through participatory and impact-oriented national drug policies, to expand access to drugs in the context of health sector reform and changing economic conditions, to broaden rational drug use, and generally to put standards into practice. There continued to be two complementary headquarters programmes, as well as active units in each of the six regions, and they had never worked together more closely or with greater unity of purpose. The WHO Ethical Criteria for Medicinal Drug Promotion had been approved as early as 1988, and could be provided to Board members on request. It was expected that the revised strategy document would be completed and ready for distribution in a few months' time. The key elements of the strategy were more active dissemination of, and advocacy for, ethical criteria, with production of educational materials, more evaluation of the extent to which the criteria were being implemented, and more willingness to work with governments on supportive regulatory efforts. Problems of drug promotion continued worldwide; indeed WHO had recently been misrepresented in advertising material.
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While drug donations could save lives and were thus of great benefit, unnecessary and expired drug donations simply added disaster to disaster, and more and more countries were now adopting the criteria that had been set to regulate the problem. The guidelines for drug donations were currently being evaluated in discussions with interested parties, and would be revised if necessary on the basis of experience. There were several publications on pricing policies and strategies which could be made available to Board members, as well as a monthly newsletter published by the International Trade Centre. The Secretariat was currently preparing an inventory of pricing sources for essential drugs. With regard to the role ofWTO, it was clear that over-reliance on economic considerations as a driving force for development would not lead to a better world. From a health perspective, WHO's concerns in that regard were the effects of trade agreements on access to essential drugs (particularly new products to treat drug resistant malaria, tuberculosis and meningitis) and on drug quality. Again, there were several publications on the subject, which could be made available to Board members, and a programme of work to address the concerns of Member States. Mr VAN DER HEIDE (Consumers International), speaking at the invitation of the CHAIRMAN, said that consumers continued to be faced with extremely wide variations in the prices of both generic and brand-name drugs, with the result that many of them often had to pay more than they could afford. Health Action International (HAI), a global network of health, development and consumer groups with which Consumers International (Cl) worked closely, welcomed WHO's continued efforts to encourage the use of generic drugs, which helped to keep costs down, and to exchange information on international prices. HAI was also pleased to note that WHO had been working to identify aspects ofWTO agreements that were relevant to drug policies and access to essential drugs. There was continued need for WHO's guidance to ensure that public health was not sacrificed in interpreting those agreements. Although a decade had passed since the adoption of the WHO Ethical Criteria for Medicinal Drug Promotion, inappropriate promotion, and notably the cross-border promotion and sale of drugs through the Internet (to be discussed under section VIII of document EB101/10) was continuing both in developing and developed countries. Methods being employed on the new medium were similar to those encountered in the past, involving misleading claims, promotion disguised as education and promotion of unapproved indications. Moreover, the unethical promotion of antimicrobial agents contributed to the development of antimicrobial resistance, which in turn added to the cost of health care as relatively inexpensive antibiotics lost their power. The WHO Ethical Criteria must be fully implemented in order to deal with such problems. Despite WHO's efforts, few national governments had incorporated the WHO Ethical Criteria into their legislation on drug promotion, and enforcement of both legislation and self-regulatory codes was weak. The Criteria were still little known among the public, health professionals, industry and government officials. Cl hoped that a comprehensive revised drug strategy, including guidelines for the development of model legislation and for implementation of regulations based on the Ethical Criteria, would be prepared in time for the 1998 World Health Assembly. It would continue to work closely with all WHO's programmes and divisions which were concerned with the essential drugs concept.
The Board took note of section VII of the report. (For consideration of draft resolution, see summary record of the sixteenth meeting, section 12.)
The meeting rose at 12:35.
TENTH MEETING Friday, 23 January 1998, at 14:30 Chairman: Professor A. ABERKANE later: Dr M. FIKRI
IMPLEMENTATION OF RESOLUTIONS AND DECISIONS (REPORTS BY THE DIRECTORGENERAL): Item 9 of the Agenda (Documents EB 101/1 0 and Corr.1) (continued) Section VIII. Cross-border advertising, promotion and sale of medical products using the Internet (Resolution WHA50.4) The CHAIRMAN invited the Board to consider section VIII of document EB I 0 Ill 0 together with the relevant draft resolution contained in section XIV which recommended a resolution for consideration by the Fifty-first World Health Assembly. Dr NAKAMURA proposed that paragraph 1 of the resolution recommended for adoption by the Health Assembly should be replaced by the following text: 1. URGES all Member States: (I) to review existing legislation, regulations, and guidelines to ensure that they are applicable and adequate to cover questions of advertising, promotion, and sale of medical products using the Internet and to develop, evaluate, and implement strategies for monitoring, surveillance and enforcement; (2) to collaborate with other Member States on the issues raised by use of the Internet, especially (a) the dissemination of information on difficult cases, (b) the advertising, promotion, and sale of medical products using the Internet, and (c) specific national measures for enforcement; to designate contact points for such collaboration; and to disseminate this information through WHO to all Member States;
The intention of the proposed amendment was to ensure and promote collaboration among Member States to address what was an important issue, and to make necessary changes in order to avoid confusion and potential misunderstanding. Paragraph I (1) was not implementable as originally drafted because current pharmaceutical legislation was generally constructed on the "territorial principle" and a government's authority could be exercised only in respect of persons or entities infringing national legislation within its territory of jurisdiction. Even after reviewing existing legislation, regulations and guidelines, it would not be possible to ensure that they were applicable and adequate to cover the areas concerned. Similarly there might be difficulties in implementing paragraph I (2), since enforcement was implied. The Internet was a fairly new medium and it was questionable whether it was possible to establish appropriate preventive measures. With the proposed amendments, the draft resolution would be more realistic and broader in its implications, while still fostering collaboration among Member States. Mr DEBRUS (alternate to Mr Voigtliinder) said that the draft resolution had been formulated in a wellbalanced and comprehensive manner and deserved wide support as there was clearly a need for intensive international cross-border collaboration. He favoured the original version because of its wider cross-border approach.
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Or SULAIMAN asked whether "medical products" included "medical services" because to his knowledge such services were being sold through the Internet. If medical services were not included, had any resolutions been adopted to enact legislation regarding their advertising and sale through the Internet and, if not, would it be possible to devise a mechanism to deal with the problem? Or CALMAN, expressing his support for the draft resolution, as well as for the comments made by Or Nakamura, said it was his assumption that it did not include medical devices. He proposed that the sixth preambular paragraph of the recommended resolution should be amended by inserting the words "and regional" after the first "national" and replacing the second "national" by "these". Professor REINER supported the recommendations of the ad hoc working group as set out in section VIII of document EB101/10 and the draft resolution but drew attention to the provisions of Article 21(d) of the WHO Constitution, which stated that the Health Assembly had authority to adopt regulations concerning standards with respect to the safety, purity and potency of biological, pharmaceutical and similar products moving in international commerce. In his view, the advertising, promotion and sale of medical products through the Internet was such a case, so it would be necessary to consider the option that strict regulatory standards should be established. Recalling the frustrations experienced in the area of tobacco control he suggested that resolution WHA49 .17, which called for the development of an international framework convention for tobacco control, might serve as an example. Mr CREGAN (alternate to Mr Hurley) supported the draft resolution and said that in the country he knew best, the advertising, promotion and sale of medical products through the Internet were subject to controls and to a European Union directive; likewise the sale and supply of medical products by mail order was prohibited, and carried heavy penalties, including terms of imprisonment. Internet providers required persons establishing web-sites to comply with the laws of the state in which they operated. However, the cross-border nature of the Internet clearly gave rise to problems, which explained the importance of the draft resolution. The difficulties were obvious: laws might differ from state to state and products might be classified differently - as a medicinal product in one country, as a cosmetic product in another and as a food supplement in a third. There was also a need for clarification regarding the term "medical product". At present it lacked definition, and he wondered whether it was intended to cover more than medicinal and pharmaceutical products. Did it include medical devices and diagnostic products? Or SANOU IRA welcomed the ad hoc working group's recommendations; the measures advocated went in the right direction to counter the inappropriate and in some cases illegal distribution of some products. However, paragraph 1(3) of the resolution recommended for adoption by the Health Assembly perhaps asked too much of countries. She would have preferred that they be urged "to promote the use of the Internet for obtaining medical product information". Or BERLIN (European Commission), speaking at the invitation of the CHAIRMAN, said that the subject had been discussed by the European Union Health Council. The European Union was concerned with both the trade and health issues involved. It had been invited by Member States to take action. The present draft resolution would therefore be of great value to the European Commission. It might be desirable if its text were to make appropriate references to regional competence in the field, as had been proposed by Or Calman. The DEPUTY DIRECTOR-GENERAL ad interim, said that, in principle, the term "medical products" should not include medical devices. However, it appeared that the ad hoc working group had recommended that the spectrum of medical products should be broad and include more than just medicines. He said it was clear from the debate that further consultations would clearly be required. Mr AITKEN (Assistant Director-General) summarized the amendments proposed by Or Nakamura, Or Calman and Or Sanou Ira, and noted the possibility that Board members might also wish to consider amending the recommended resolution by replacing the term "medical products" with "medicinal products".
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Dr IDANPAAN-HEIKKILA (Division of Drug Management and Policies), clarifying the ad hoc working group's position, said that it had preferred the term "medical" to "medicinal" products as being broader and covering more than just medicines and pharmaceutical products, and also on grounds of consistency with resolution WHA50.4 and its title. There being no definition of"medical devices", it was difficult to say whether they would be included; however, the group had included medical devices in its report. The group had not been of the view that medical services were included. Basically, the term was considered to cover anything that was used for medical purposes, including therapy and diagnosis. The CHAIRMAN said that in the light of that explanation, and indeed as a matter of logic, it would be preferable to keep to the term "medical" products. Dr CALMAN specified that the point at issue was legislation and the difficulties some countries might have in implementing paragraph I (I) of the recommended resolution if it covered products other than strictly medicinal products, which on the whole were well provided for in existing legislation. The CHAIRMAN, speaking in a personal capacity, commented that the issue of cross-border advertising, promotion and sale of products also involved products for diagnostic and increasingly for therapeutic purposes, as could be observed in some developing countries. He would prefer to retain the term "medical products" as being a more comprehensive one. Professor PICO (alternate to Dr Mazza) suggested the use of the term "products for medical use", which might be easier to adapt to legislation in many countries. Mr CREGAN (alternate to Dr Hurley) endorsed the point made by Dr Calman. The term "medical products" took the issue into less well-defined spheres, whereas "medicinal products" would keep it focused on more realistically attainable targets. Dr SIKOSANA (alternate to Dr Stamps) expressed some doubts as to whether the term "medicinal products" would cover such products as condoms: defective condoms were currently entering developing countries by way of advertising on the Internet. Dr SANOU IRA said that she, too, would prefer the broader term, i.e. "medical products", even if that meant more work for countries in reviewing their existing legislation and regulations to ensure that they were applicable and adequate to cover the whole range of activities under discussion. Dr SULAIMAN said that the most inclusive term should be used, covering both drugs and other products. Dr CALMAN explained that he had raised the point not because of any disagreement with the term "medical products" but out of a concern for enforceability. He reiterated that the wording of paragraph I (I) might entail difficulties for some countries which did not have the necessary legislation to cover products other than drugs. The CHAIRMAN wondered whether any information was available on how many countries already had legislation concerning advertising on the Internet. Dr IDANPAAN-HEIKKILA (Division of Drug Management and Policies) said that it was concern about the point just raised by Dr Calman that had prompted the ad hoc working group to recommend that Member States should be urged to review existing legislation to ascertain whether it was applicable to Internet advertising and sales and to endeavour to make good any shortcomings in that regard; alternatively, they might be content to control only medicinal products, for which legislation was already in force. Examples of advertising for potentially risky products included diagnostic kits, home abortion kits and self-sterilization methods and showed that there was a growing problem regarding all types of medical products.
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Professor PICO (alternate to Dr Mazza) said that the question went far deeper than mere wording. As a matter of long-term vision it was necessary to consider not only the countries that were in a position to carry out the requests made of them by WHO but also those which were just embarking on such an endeavour. The efforts of the former might usefully be taken into account in assisting the latter. On the question of condoms, the authorities of his country had conducted a market survey and had now regulated the market, including advertising, to ensure better protection against the transmission ofHIV. When legislating and proposing change, it was important to think ahead and to foresee more ambitious action than that which already existed. Dr CALMAN said he was glad to accept the term "medical products". He had merely wished to draw attention to the implications involved; the ensuing discussion had been most instructive. The CHAIRMAN invited the Board to take note of section VIII of the report and to consider the draft resolution contained in section XIV, as amended by Dr Nakamura and Dr Sanou Ira, and retaining the term "medical products".
The Board took note of section VIII of the report and adopted the resolution, as amended. 1
Section IX. Ethical, scientific and social implications of cloning in human health (Resolution WHA50.37; Document EB101/INF.DOC./3) Mr VOIGTLANDER referred to the many statements made at the previous Health Assembly on the issue of human cloning for reproductive purposes and the two interregional and interdisciplinary meetings on cloning held in the interim. In the meantime, however, other international forums had addressed the issue, namely the "Group of7+1", in the final communique of the Denver Summit held in June 1997; UNESCO, in the Universal Declaration on the Human Genome and Human Rights ofNovember 1997; and the Council of Europe, in its Additional Protocol to the Convention for the Protection of Human Rights and Dignity with regard to the application of biology and medicine on the prohibition of cloning human beings, adopted in November 1997 and since signed by many Member States. In view of those international developments, which were regrettably not even mentioned in any of the documents before the Board, he asked what the role of WHO would be. While paragraph 8 of document EBIOl/INF.DOC./3 stated that it was generally agreed that there was a need for international guidelines and that action was needed quickly, paragraph 9 stated that it was too soon to come to conclusions. His impression was that it was another area in which the initiative might be taken out of the hands of WHO, which should act soon and not wait until other players occupied the field. The situation was similar in regard to xenotransplantation; some early guidance from WHO in view of the many medical, ethical, cultural and societal problems the technique raised would be more than welcome. Dr MOREL, referring to resolution WHA50.37 said that concern in his country about human cloning for reproductive purposes went back a long time, and legislation adopted in January 1995 strictly prohibited the genetic manipulation of human germ cells. The National Technical Commission on Biosafety had formally and legally prohibited human cloning in July 1997. While welcoming the information provided in the documents before the Board, he was most surprised to read the rather bland conclusion in paragraph 9 of document EB I 0 1/INF .DOC./3 that it would be appropriate to continue with a moratorium on the use of cloning for reproductive purposes, which contrasted sharply with the strongly worded, unequivocal resolution adopted at the Fiftieth World Health Assembly. That was a dangerous way to treat such a serious question, which posed radically new and difficult challenges to humanity. WHO should play a much more active role in the dissemination of sound and readily understandable information at a time when the general public was being led to believe that human cloning was merely another form of human reproduction. Relevant research and human cloning were still unregulated in several parts of the world. He therefore fully agreed with the concern expressed in the Director-General's report about the need to protect developing countries from the risk of irresponsible and unregulated expatriate research involving human subjects.
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Professor WHITWORTH (alternate to Dr Blewett) welcomed WHO's role in promoting informed discussion on so critically important a topic and supported the need for ongoing dialogue and for coordination with other United Nations organizations working on cloning and with relevant national agencies and experts in the fields of medicine, ethics, science and the law. In relation to genetic and hereditary disorders, she stressed the primacy of confidentiality of data, the indivisibility of testing and counselling, and the pivotal role of education, particularly public education to assist people in distinguishing somatic cell gene therapy as a medical therapy comparable to other forms of treatment from germ-line gene therapy, which was for most people ethically unacceptable. Dr LOPEZ BENiTEZ referred to the Universal Declaration on the Human Genome and Human Rights which had been adopted unanimously by the General Conference of UNESCO at its twenty-ninth session in November 1997, after a long drafting process. No scientific advance in biology or genetics could take precedence over the dignity and rights of the human person. The integrity of the human genome should be declared a human right, with a view to preserving the rights of future generations of the human species. Cloning must be considered from the ethical, moral, legal, sociological and all other relevant standpoints, and WHO's action must be coordinated with that of all national and international bodies addressing the issue. Mr JUNEAU felt that implementation of resolution WHA50.37 had not gone far enough. The resolution had taken a very clear position on cloning for human reproduction, but the conclusion in paragraph 9 of the information document that a comprehensive international debate was needed and the moratorium on cloning should be continued fell short of that position. He could not support that conclusion without some explanation of the reasoning behind it. Nowhere in the document was it made clear whether WHO was for or against cloning for human reproduction, and as for human cloning for nonreproductive purposes, not even a moratorium was proposed, and again, WHO's position was unclear. A more unequivocal statement should be offered, more like the one made at the Fiftieth World Health Assembly that WHO opposed cloning for human reproduction and considered that cloning should be permitted for research purposes alone, and under strictly controlled conditions. The position on xenotransplantation was equally ambiguous. He fully endorsed the principle of precaution mentioned in paragraph 14 of document EBlOl/INF.DOC./3, but was troubled by the statement that "a balance of risks, not a total absence of risk" was expected. The two concepts - principle of precaution and balance of risk - were difficult to reconcile. In conclusion, he was anxious to hear from the Secretariat what would be the future approach to the issue. Dr ZAHRAN (alternate to Professor Sallam) said the work on the topic was informed by resolution WHA50.37 condemning the use of human cloning. Scientific research was beneficial when it was in line with revealed faiths and ethics and was intended for the good of humanity. It had useful applications for the field of health in general and disease control in particular. But awareness had to be promoted, especially in developing countries, of the dangers of research and experiments that failed to respect certain ethical criteria or beliefs. Meetings held under the auspices of WHO had helped to clarify the dimensions of the issue. In addition, a number of seminars had been held, including one in his country from which had emanated a recommendation on the enactment of legislation on human cloning that would prevent abuse of scientific research and ensure control, supervision and registration of every fertilization undertaken for research purposes. Developing countries also sought to guarantee the right of the foetus not to be misused. Controls should be established over expatriate activities that failed to respect religious and ethical criteria in connection with cloning procedures. National genetic research centres should be strengthened and the applications of cloning in various fields should be enhanced, including in agriculture, livestock reproduction and the development of vaccines to combat epidemics. Research on how to fight hereditary diseases should be stepped up: the causative genes of approximately 5 000 such diseases had been identified. The achievements of other international bodies, particularly of UNESCO, in promoting full compliance of cloning procedures with human rights principles, norms and criteria should be used to full advantage. In conclusion, he urged the Director-General and the regional directors to follow the issue closely and to transmit any new information that could assist WHO in its efforts. Professor REINER pointed out that an innovation in biology and medicine had seldom attracted the interest of the public at large to the extent that cloning had. It was therefore not surprising that many countries
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were adopting positions on the issue. There were both huge advantages to be derived from cloning, and tremendous hazards involved in the cloning of humans, which was already technically feasible. He fully agreed with Dr More)' s comments in that regard. The President of the United States of America had recently announced his intention of proposing to Congress a five-year ban on experiments aimed at facilitating or introducing human cloning. WHO's governing bodies could perhaps learn from that initiative and recommend Member States to adopt similar legislation. A substantial effort had been made in that direction by the Council of Europe, which was clearly firmly against human cloning, taking a stance much stronger than that expressed in the mild wording of the documents before the Board. That fact might serve as an impetus for WHO to draft a resolution along the lines of resolution WHA50.37. Professor PICO (alternate to Dr Mazza) drew attention to the letter and spirit of resolution WHA50.37 prohibiting cloning in human reproduction as being ethically unacceptable, fundamentally demeaning to human dignity and contrary to the most basic human rights. The need for scientific research to forge ahead was irrefutable, but it should not transcend the boundaries of defence of human rights. Cloning procedures not directly linked to human reproduction might be permitted, provided they did not impinge on the principle according to which man was the fundamental object and subject of action in the health field. Life began at gestation, and WHO had to defend life by promoting good birthing, good living and good dying. He therefore firmly advocated the prohibition of cloning for human reproduction. Dr HU Ching-Li (Senior Adviser to the Director-General), responding to comments by members of the Board, said the Secretariat had been following up on the Health Assembly's resolution on cloning for human reproduction, which affirmed that the use of cloning for the replication of human beings was ethically unacceptable and contrary to human integrity and morality. The information paper submitted to the Board provided facts about that follow-up, with descriptions of the three meetings held on the subject, and outlined the views of expert panels that had reviewed current developments, including in its paragraph 22 the unequivocal opinion that human cloning for reproductive purposes was not ethical and should not be permitted. Other parts of the paper were less emphatic, leading some Board members to complain that it represented a step back from the stance taken in resolution WHA50.37. It should be recalled, however, that developments in cloning technology had a wide range of potential applications and that there was a correspondingly wide range of views on those matters. WHO had merely sought to provide a forum for the exchange of such views. Representatives of the Organization had attended the relevant meetings of UNESCO, the Council of Europe and other international bodies on those subjects. On those occasions they had put forward the Organization's views and drawn attention to the relevant Health Assembly resolution. Developments were occurring at a rapid pace in cloning, and WHO needed to be aware of them as it defined its position on the issues involved. The Health Assembly had already set the tone for the Organization's position, but had also called for a thorough exploration of the ethical, scientific and social implications of cloning. Dr HEYMANN (Division of Emerging and Other Communicable Diseases Surveillance and Control), responding to Mr VoigtU:inder, said that WHO had issued two documents on xenotransplantation. One provided recommendations on the actual procedures involved, including mechanisms to ensure safety, information on research, quality assurance, source animals, risk assessment, counselling of recipients and contacts, and ethical considerations for both human and animal welfare, and on guidelines for the establishment of national safety review boards. The other provided guidance for research on communicable disease prevention and management in xenotransplantation in response to the concern that a new or unknown disease present in animals might be transmitted to humans through xenotransplantation. Dr LOPEZ BENITEZ, noting that two speakers had mentioned the need to provide guidance on legislation to countries, particularly developing countries, said that actual practice in a field was often well in advance of the regulatory legislation needed. It would therefore be helpful if WHO could develop model legislation to guide States in adopting legislation on cloning. Dr MOREL, drawing attention to two recent news reports, said that on 20 January 1998, Le Monde had revealed that The Lancet had condemned the attempts of the United States of America and the European Union
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to prohibit cloning, while on 11 January 1998, Reuters had reported that experiments in human cloning could begin in the United Kingdom as early as in 1999. Resolution WHA50.37 had been drafted and adopted by the Health Assembly without the usual procedure of prior discussion by the Board because human reproduction by cloning had been considered such a pressing issue. However, it was now unclear whether the intention had been to initiate action or merely to promote debate. In any event, research on cloning was still continuing. What mechanisms did WHO have to enforce the Health Assembly's resolution? The CHAIRMAN proposed that the Rapporteurs be asked to draft for consideration by the Board a resolution to reflect the Board's concerns with regard to cloning.
It was so agreed. In response to a question by Mr JUNEAU, Mr AITKEN (Assistant Director-General) said the text would include a draft resolution for transmission to the Health Assembly. It would deal both with the approach that States should take on cloning and with future work on the topic by WHO.
The Board took note of section IX of the report. (For adoption of resolution, see summary record of the sixteenth meeting, section 12.)
Section X. Health promotion (Resolution WHA42.44) Dr SHIN said that both WHO staff and the Indonesian organizing committee were to be commended on the success of the Fourth International Conference on Health Promotion held in Jakarta in July 1997. The Jakarta Conference had endorsed the Ottawa Charter on Health Promotion both for developed and developing countries and marked an important step in the further development of health promotion. He would like to see the Jakarta Declaration circulated officially by the Director-General to all Member States. He would also like the Director-General's report to the Health Assembly to include a reference to progress made in health promotion and follow-up action to the Jakarta Conference and Declaration. He asked what follow-up action was in view at WHO headquarters and the regional offices. Dr WASISTO emphasized the importance of the Jakarta Conference, the first of its kind to be held in a developing country and at which more than half of the participants had come from developing countries. The Jakarta Declaration was a major document reflecting a commitment to expand and intensify health promotion in the future in order to cope with increasingly complex health problems despite dwindling resources. It also reflected the need for partnership involving the private sector and industry in health development. In his country, private sector companies had contributed greatly to health promotion, in particular in connection with promotion of the national immunization day. He asked what human resources were available in Member countries and in WHO offices for implementation of health promotion programmes and what practical follow-up to the Jakarta Conference was being envisaged. Dr LOPEZ-BENiTEZ endorsed Dr Shin's proposal that the Jakarta Declaration should be circulated officially by WHO to ensure that consideration of health promotion was not confined to one region or country, but would involve the whole Organization. Mr JUNEAU welcomed the success of the Jakarta Conference, to which his country had contributed both human and financial resources. The follow-up to the Conference should include evaluation of outcomes and the setting of priorities. In his view, the health promotion effort should focus on children. Mr CREGAN (alternate to Mr Hurley) welcomed the Jakarta Declaration on leading health promotion into the twenty-first century. WHO had already played a catalytic and advocacy role in Member States, which had been of considerable value in dealing with commercial interests regarding lifestyle problems. He endorsed the emphasis on partnerships in the area of health promotion, which was certainly one that could not be developed solely by health ministries. The Ottawa Charter and the Jakarta Declaration would be equally valuable in
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developing future policies. It was important, in view of the political and financial considerations affecting evaluation and development policies, to demonstrate the value of health promotion and ensure that it continued to be part of the Organization's agenda in the future.
Or Fikri took the chair. Professor REINER, observing that his Region was devoting increasing attention to health promotion, stressed the importance of the Ottawa Charter and the Jakarta Declaration. Over the last decade a number of movements had been established which had resulted in health promotion being linked closely with human settings - for example the "healthy cities" movement which now covered over 600 cities in Europe and aimed eventually at involving the largest possible number of people, and health-promoting schools, hospitals and workplaces, areas in which an increasing number of people, including health professionals, were devoting considerable energy. Professor LEOWSKI, observing that the Jakarta Conference had provided an excellent forum for planning for the twenty-first century, commended the organizers on its success. The Jakarta Declaration was important for all parts of the international community concerned with health promotion, calling for partnership from all sectors of society. He asked what action had been taken since the Conference to ensure that its momentum was not lost, and proposed that the Board should consider adopting a draft resolution on health promotion in order to ensure the fullest possible implementation by WHO of the Jakarta Declaration. Dr BADRAN (alternate to Professor Sallam) considered that the report ought also to have emphasized the links between health promotion and aspects such as urbanization, housing, relations with nongovernmental organizations and local communities. WHO provided an important lead in health promotion, particularly in regard to health in development; it was hoped that the relevant task force, which had done much good work, would be enabled to complete its activities and report on them to the Board and the Health Assembly. Dr FERDINAND said that in her subregion, for which a charter for health promotion existed, countries were using health promotion as one of the supporting strategies for achieving goals and targets in six specific priority areas. Dr AL-MOUSA WI endorsed the view that WHO should take the Jakarta Declaration as a basis for achieving further progress in health promotion in the twenty-first century. He further endorsed the suggestion that WHO should take specific steps to follow-up the Jakarta Conference and Declaration. Dr UTON RAFEI (Regional Director for South-East Asia), replying to questions raised, said that the output from the Jakarta Conference had been used by the Region as a framework for planning collaboration with Member States in the field of health promotion. The Declaration had been distributed to all countries in the Region for implementation in their health promotion programmes. Intercountry follow-up meetings had been organized, including a regional consultation on control of tobacco and alcohol abuse and an intercountry consultation on health-promoting schools. There had been publication of an advocacy brochure for healthpromoting schools and elaboration of guidelines for the development of monitoring and evaluation for health promotion and health education programmes, for use by Member States. The Region would be working closely with WHO headquarters in the follow-up to the Jakarta Declaration. Most countries in the Region also had "healthy cities" programmes; good progress was being made in that respect in Bangladesh, India, Nepal and Thailand. Dr KICKBUSCH (Division of Health Promotion, Education and Communication) responding to questions raised in the debate, expressed warm gratitude to all those who had been involved in the success of the Jakarta Conference. The health promotion unit at WHO headquarters had six professionals, two of whom were regular staff members, the others being secondments, consultants and associate professional officers, and two other professionals in the Division focused their work on health promotion. That did not, however, reflect the totality of health promotion activities within WHO. There were also health promotion advisers in all the regional offices, the collaborating centres and the networks and movements referred to by Professor Reiner. Although
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the Division had lost staff over recent years because health promotion was not defined as a priority programme, that situation was balanced by creativity and momentum. The Jakarta Declaration reflected the fact that Member States' commitment to health promotion and investment in health was not yet strong enough - notwithstanding the great deal of lip-service paid to health education, health promotion and prevention, funds were not channelled into those areas; strengthened investment in health and emphasis on health promotion in development policies were called for. Follow-up measures to the Jakarta Conference included: a document on the five-year action plan on health education and promotion; the circulation of the Jakarta Declaration and its translation into more than 10 languages; follow-up at country level, especially in the South-East Asia Region; a project entitled "The megacountries project" in which seven of the world's most populous countries had met to discuss health promotion investments; accessibility to Conference products through a website; the publication of a glossary and a handbook on health promotion, as well as a paper on health promotion research; and the publication of a work on health promotion evaluation by the Regional Office for Europe. The existing network of health-promoting schools had been strengthened and new partnerships set up with: sports associations on active-living programmes; tourism organizations on healthy tourism; and cooperation with the Prince of Wales' Business Forum to explore further the role of health promotion in the private sector. The next major health promotion conference would be organized for the Commonwealth countries in Wales in September 1998. Dr GHEBREHIWET (International Council of Nurses), speaking at the invitation of the CHAIRMAN, remarked that the Jakarta Conference had been held against the backdrop of increasing concerns about equity and access to essential health services. To that end, the Jakarta Declaration offered new hope and a new era of innovative partnerships for creating healthy settings. The International Council of Nurses (ICN) wished to associate itself with that Declaration and plan of action and, more specifically, to endorse collaboration and networks for health development, the mobilization of resources for health promotion, the sharing of knowledge on best practice, the enhancement of community capacity and empowerment of the individual, and the promotion of social responsibility for health. As a token of its commitment to health promotion and support for the Jakarta Declaration, ICN had disseminated the Declaration to all its member associations in 118 countries, calling on them to translate the Declaration into action. ICN's efforts were geared towards mobilizing millions of nurses worldwide beyond care and the alleviation of suffering into the areas of prevention and health promotion. The Council looked forward to using the Jakarta Declaration as a sound framework for enhancing the competencies of nurses and other health professionals, as well as enabling individuals, families and communities to "produce their own health" in the places where they lived and acted. ICN called on WHO and governments to lay greater emphasis on the training of health care professionals and health promotion activities. It also urged the Organization to play a leading role in shifting health care systems of the twenty-first century from the dichotomies of cure versus care and prevention versus promotion to an integrated continuum of health care rooted in health promotion, disease prevention, and home and community care, with referrals to appropriate levels as needed. Dr PANDURANGI (Commonwealth Association for Mental Handicap and Developmental Disabilities), speaking at the invitation of the CHAIRMAN, said that the association he represented had been established in January 1983 with the aim of preventing mental handicap in developing countries and establishing professional links between developed and developing countries. It had had official relations with WHO for collaborative programmes since 1990, enjoyed observer status at triennial meetings of the Commonwealth Health Ministers, and had been accredited to the Edinburgh United Kingdom Commonwealth Heads of Government Meeting in 1997. Since 1985, it had arranged 15 regional workshops in five regions of the Commonwealth, three PanCommonwealth global workshops and an exchange programme for birth attendants and ophthalmic surgeons. Some of the workshops had been cosponsored with WHO. CAMHADD therefore had experience in partnership developments, which was one of the three objectives of the Jakarta Declaration. It was pleased to associate itself with the Declaration on "Leading health promotion into the twenty-first century" and he informed the Board that CAMHADD planned to expand its partnership with WHO by adding a programme on the prevention of childhood blindness to its priority programme on the prevention of brain damage due to birth asphyxia. A joint consultative meeting could be organized on that topic.
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He appealed on behalf of CAMHADD for resources to be made available at WHO headquarters and regional offices to finance training workshops, launch community-oriented applied research and conduct shortterm exchange fellowship programmes for a period of eight to 10 weeks for professionals and frontline workers in developing countries. Those programmes would help in the development of human resources at all levels. He added that CAMHADD's principal concern was to develop partnerships for the promotion of health and the prevention of handicaps in accordance with WHO's new global health policy for the twenty-first century. In conclusion, he stressed that although children might be born as the victims offate, they should not be the victims of neglect. Mrs HERZOG (International Council of Women), speaking at the invitation of the CHAIRMAN, said that the Council she represented was the largest women's international nongovernmental organization affiliated in 78 countries, enjoying consultative status at the United Nations and official relations with WHO since 1980. The Council deemed it a privilege to be a partner of WHO in its determination to promote the health and wellbeing of people by raising awareness of governments and nongovernmental organizations to the importance of healthy lifestyles and interrelationships between individuals, the environment and development and to such issues as the gender perspective, prevention of violence, cloning and other ethical matters. The Board had already discussed technical cooperation and empowerment of citizens; ICW, like WHO, believed that an important determinant of health for all was helping people to help themselves. One forthcoming activity of the Council was an international seminar to be held in October 1998 on leadership development which would focus on know-how and principles of project planning, launching, management and evaluation. The drafting of plans, preparation of budgets, removal of constraints, organization of monitoring and writing of reports - all of them being tools applicable to projects of all kinds - would also be covered. The practical results of the seminar would be evaluated after a year. Many of the issues under item 9 of the Board's Agenda were interrelated; they were all determinants of health for all. Nevertheless, the prevention of violence was rightly given high priority by WHO. Violence had become pandemic throughout the world and was very difficult to cure. Emphasis should therefore be placed on preventive intervention beginning with the young in schools and continuing into neighbourhoods at all levels. The reduction of alcohol and drug abuse, which were also contributory factors to domestic and other forms of violence, together with counselling on coping with stress, could be very helpful measures. On behalf ofiCW, she commended the Director-General and members of the Secretariat and the governing bodies of WHO for their continued efforts to adapt policies to changing needs. Special thanks were due to the focal points and to the Division of Family and Reproductive Health, for their assistance, guidance and attention to the specific health needs of women. The CHAIRMAN noted that some speakers had asked for a draft resolution on health promotion to be prepared. If such was the wish of the Board, the Secretariat could prepare a text for the next day.
It was so agreed. The Board took note of section X of the report. (For adoption of resolution, see summary record of the twelfth meeting, section 3.)
Section XI. Infant and young child nutrition (Resolutions WHA33.32 and EB97.R13; Document EB101/INF.DOC./4) Dr TURMEN (Executive Director, Family and Reproductive Health) said that the documents before the Board reported for the eleventh time since 1980 on infant and young child nutrition. During that period, the Health Assembly had adopted no fewer than I 0 resolutions urging Member States to take specific action. All resolutions advocated breast-feeding for infants in all societies, as offering unique health, nutritional, immunological, social and economic advantages while ensuring optimal growth and development of infants and young children. Although reporting in the current year covered the major issues related to the enormous global burden of hunger and malnutrition among infants and young children, there was clearly an abiding interest among Member States and others in the specific area of infant and young child feeding, and in the International
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Code ofMarketing of Breast-milk Substitutes. In response, WHO would take a number of measures. Firstly, the Director-General would convene a global technical consultation to review the latest scientific evidence relating to infant and young child feeding practices, including the current status of and trends in breast-feeding and complementary feeding and the implications of the situation for the growth, development, and nutritional status of children; recommendations would be made for action by governments, the international health development community and other parties concerned. In preparation for that consultation, the Director-General had also decided to convene a technical consultation in April1998 on infant feeding and HIV. As background, and in response to an urgent need for information, WHO and UN AIDS would finalize two important documents, based on the most recent scientific findings: a guide for policy and decision-makers on HIV and infant feeding; and an inventory of tools for health workers on that topic. The outcome of the consultation would be presented to the Fifty-first World Health Assembly. Secondly, in collaboration with interested parties, WHO would initiate a process for identifying, examining and overcoming the main obstacles to implementation by all countries of the International Code and related subsequent resolutions. The results of the action and the outcome of the consultations would be the subject of reports and recommendations to the 103rd session of the Executive Board and to the Fifty-second World Health Assembly. Dr STAMPS welcomed the evidence of progress on a very fundamental issue relating to health. But the report was also disturbing, indicating as it did that the so-called developed countries were persisting in bad habits induced by the commercialization of the birth and growth of babies and young children. Zimbabwe had introduced legislation circumscribing very strictly the activities of infant formula and follow-on food manufacturing companies and had received a degree of cooperation from them. Paragraph 4 of the DirectorGeneral's report, read in conjunction with paragraph 5, was extremely significant: infant formula manufacturers had been known to use and even distribute growth reference curves to the detriment of long-term health in populations because of their indirect contribution to the growing epidemic of obesity in children. Especially in urban areas of countries which had an industrialized base, the curves had induced anxiety in young mothers, causing them to switch from breast-feeding to less suitable and more expensive methods. He was also concerned that one of the major manufacturers of infant formula should have hosted a collaborative meeting on the advancement of women, and paid most of the expenses, while defending its supposed right to promote its formula to working mothers who were- in the words of one of the company's proprietors- "not able to breastfeed". Such an arrangement showed a disturbing readiness on the part of a United Nations agency to yield to the blandishments of commercially-oriented activists. For its part, Zimbabwe continued to support the UNICEF Baby-friendly Hospital Initiative, particularly since infant formula was often advertised and promoted within health services and maternity units; there was a particular need to guard against the exploitation of the fears of women in relation to HIV; and to better understand the mechanism whereby the virus might be transferred through breast milk, especially when many countries in the African Region could not afford the modem drugs that could interrupt transmission of infection. Finally, he hailed the success of salt iodization programmes in the African Region, paying particular tribute to Botswana's initiative in making iodine available to local salt producers. Dr SULAIMAN observed that despite the many resolutions on infant and child nutrition adopted by the Health Assembly, the desired results had not been achieved. The slight fall in the prevalence of protein-energy malnutrition was far short of the target figure, and there was an urgent need to step up action and cooperation with nongovemmental organizations in that domain. He was also concerned that the increase in the number of countries implementing the International Code of Marketing of Breast-milk Substitutes was not reflected by an increase in the percentage of children being breast-fed, which was actually falling. Endorsing the various proposals, he singled out the collection of more precise data for growth reference curves as a matter that would benefit from cooperation between WHO and other international organizations. Dr VAN ETTEN welcomed the expressed intention that WHO should take a more proactive role in examining the obstacles to the implementation of the International Code. He requested the Director-General to report on that subject to the Executive Board at its 103rd session. He said he took it that UNICEF would also be involved in the technical consultations on HIV and infant feeding.
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Or HEMBE observed that malnutrition remained a major concern in the African Region and that breastfeeding continued to be the best choice for babies, especially in the developing world, where they often fell victim to contaminated water or other foodstuffs. She was pleased that WHO was taking the lead in studying the vertical transmission of HIV, which was another issue of great importance in Africa, reflected in the increasing numbers of orphans. She suggested that a scientific committee would be the best forum for discussion of the problems of HIV and infant feeding. She commended attempts to overcome obstacles to the implementation of the International Code, which - in her view - could best be achieved through dialogue between all the partners concerned. She emphasized the need for governments to adapt WHO technical advice to their own particular circumstances. Dr AL VIK said that the report before the Board was not quite what had been called for in the relevant resolutions of the Health Assembly; more than half of it was on nutrition rather than on breast-feeding and related matters. Moreover, it was somewhat vaguely drafted, and made no mention of several major initiatives and studies undertaken by Member States. One of the tasks of the global technical consultation announced by Dr Tilrmen should be to update the report in time for the next session of the Health Assembly. Member States would surely be happy to provide the necessary information, as long as they knew well in advance what information would be required. The need to promote breast-feeding and thereby help to prevent malnutrition was as strong as it had been when the matter had first been the subject of a resolution of the Health Assembly, 20 years earlier. The proposed consultation would be a step in the right direction. Dr SANOU IRA, referring to paragraph 4 of the Director-General's report, remarked that the new growth reference curves that the Organization was seeking to establish should enable health workers at grassroots level to monitor infants' growth more easily. The countries seeking to participate in the study would probably also wish to be kept informed about its progress. Dr DOS SOU-TOGBE observed that nutrition was one of the most important components of infant and young child health care. The aim of the International Code was twofold: to protect and promote breast-feeding, and to ensure that substitutes, where necessary, were used correctly. For those aims to be achieved, there must be adequate information on infant nutrition, and the marketing of substitutes must respect the rights of the people and the child. Great progress had been made in both developing and developed countries since the adoption of the Code, with measures having been taken by governments, international organizations, nongovernmental organizations and the manufacturers of breast-milk substitutes. It was especially important to educate mothers in the use of complementary foods. He endorsed the general approach outlined in the Director-General's report, including the consultation on breast-feeding, the preparation of guidelines on HIV and infant feeding, and cooperation between all those involved in the implementation of the International Code. Or MOREL observed that the joint WHO/UNICEF policy statement on HIV and breast-feeding mentioned in document EBIOI/INF.DOC./4 had been based on studies which suggested that women with HIV who breastfed their babies had a one-in-seven chance of passing on the virus to their babies. In the light of that, more information on the specific guidelines mentioned in paragraph 22 of that document and enlarged upon by Dr Tiirmen should be made available at the coming Health Assembly. Delay in providing that information would only discourage the practice of breast-feeding and delay the implementation of the International Code. Dr ABEDNEGO (alternate to Or Wasisto) said that with over 900 million people still suffering from goitre, the problem of iodine deficiency needed to be tackled quickly, and should receive higher priority. There were still about 20 million people in Indonesia living in iodine deficient areas despite comprehensive efforts by the government to iodize salt and improve the distribution of iodine. Professor PICO (alternate to Or Mazza) expressed the belief that the members of the Board were all agreed on the need to develop strategies for improving the quality of life of people around the world. Breast-feeding was one of the simplest strategies available to achieve precisely that. Not only did it offer nutritional benefits, but it also strengthened family ties, which would help the child to avoid health and social problems later on. A breast-fed child from a stable family would be less likely to become violent or get involved with drugs or alcohol. He further supported the implementation of the Convention on the Rights of the Child, and the
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promotion of child-friendly hospitals. Progress was being made in those areas, but governments could do much more to turn their commitments into reality. The implementation of the International Code of Marketing of Breast-milk Substitutes would also contribute greatly to the attainment of the goal for health for all in the twenty-first century. Mr DE SILVA welcomed the. emphasis given to breast-feeding in the report. In Sri Lanka, the Government was campaigning hard to popularize breast-feeding, but was faced with practical difficulties such as the urbanization and the changing lifestyles of modem societies. People had been led to believe that breastmilk substitutes offered the same nutritional value as breast milk. In order to resolve the question, wider technical consultation was necessary; the technical consultations proposed in the report should involve all interested parties.
The meeting rose at 17:45.
ELEVENTH MEETING Saturday, 24 January 1998, at 9:00 Chairman: Professor A. ABERKANE
1.
IMPLEMENTATION OF RESOLUTIONS AND DECISIONS (REPORTS BY THE DIRECTOR-GENERAL): Item 9 of the Agenda (Documents EB101/10 and Corr.1) (continued)
Section XI. Infant and young child nutrition (Resolutions WHA33.32 and EB97.R13; Document EB101/INF.DOC./4) (continued) Mr CREGAN (alternate to Mr Hurley) acknowledged the continuing importance of the International Code of Marketing of Breast-milk Substitutes as a basis for action to ensure the provision of safe and adequate nutrition for infants. The documentation provided pointed to the need to take stock of developments in the field of infant nutrition. He therefore welcomed the progress made in implementing the Code and collaborating with concerned parties. The technical consultations proposed would also serve a useful purpose, in particular the priority attached to HIV and infant feeding.
Mr JUNEAU and Mr DEBRUS (alternate to Mr Voigtlander) endorsed the comments made by Mr Cregan. Dr LOPEZ BENITEZ suggested that discussions on breast-feeding by HIV -positive mothers should be accelerated so that appropriate guidance could be given in that regard. Dr FERDINAND also endorsed the comments made by Mr Cregan and expressed the hope that consideration would be given to regional and international measures in addition to the national measures for giving effect to the International Code referred to in paragraph 29 of document EBlOl/INF.DOC./4. She expressed appreciation for the development of new growth charts that could be applied to children in all areas of the world. Dr TURMEN (Executive Director, Family and Reproductive Health) noted the concerns expressed by Dr Stamps, in particular in relation to the United Nations meeting on the advancement of women. She pointed out that the Baby-friendly Hospital Initiative was a joint WHO/UNICEF venture that was being enthusiastically pursued by both organizations. In response to Dr Alvik, she said that document EBlOl/INF.DOC./4 had been provided in pursuance of resolution EB97.R13 which requested the continuation of a two-year reporting cycle for collecting and evaluating information on various aspects of infant and young child nutrition. A report containing more countryspecific data was being prepared for submission to the forthcoming World Health Assembly. In response to Dr van Etten's comments at the previous meeting as to the involvement of UNICEF, she indicated that all related United Nations organizations would be invited to participate in the technical consultations on HIV and breast-feeding. She too hoped that the consultations would bring some clear, sciencebased answers to an important public health dilemma. Ms EGAL (Food and Agriculture Organization of the United Nations), referring to the strategy of health for all in the twenty-first century and the Jakarta Declaration, emphasized the importance for good health of good nutrition. People must have the necessary information available in order to be able to make fully informed choices when selecting, preparing, handling and storing food in the home. Cooperation between FAO and WHO - 131 -
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should continue in the area of safe nutrition in order to strengthen the work already done, for example in producing national food guidelines. Ms THIAGARAJAG (International Organisation of Consumers Unions (Consumers International)), speaking at the invitation of the CHAIRMAN, and on behalf of the International Baby Food Action Network, said that for many years her organization had tried to bring into effect the International Code of Marketing of Breast-milk Substitutes and all relevant Health Assembly resolutions. It would continue to do so, and also to report to WHO on matters of concern. In the debate surrounding the long-running controversy, it was easy to lose sight of the objectives of consumers' organizations, which were to protect the health of all mothers and infants, and to ensure that they received sound advice from unbiased, independent and knowledgeable sources. An essential part of her organization's work was to ensure transparency and clarity of purpose. WHO's suggestion concerning the initiation of a process, to support all governments in overcoming the obstacles faced when bringing the International Code and Health Assembly resolutions into their legislative framework was to be welcomed. Mr BORASIO (International Special Dietary Foods Industries), speaking at the invitation of the CHAIRMAN, said that his organization, in conjunction with the International Association of Infant Food Manufacturers (IFM) had maintained official relations with WHO since 1987. IFM had always recognized the superiority of breast milk alone for the first four to six months of life. It was also aware that infants needed nutritious and safe foods, in addition to breast milk, after that period. The food industry played an important and constructive role in research, development, manufacturing and marketing in respect of foods for infants who were not breast-fed, and for young children. IFM had always expressed support for the International Code of Marketing of Breast-milk Substitutes, not only in words but also through actions, and therefore welcomed WHO's proposal to initiate a process for overcoming obstacles to the implementation of the Code by all countries. IFM looked forward to contributing to that initiative and collaborating with WHO and other organizations concerned to that end. Dr DELANGE (International Council for Control of Iodine Deficiency Disorders), speaking at the invitation of the CHAIRMAN, said that iodine deficiency disorders were the main cause of potentially preventable brain damage and mental retardation. In the early 1990s around 1.5 billion people had been affected worldwide, with 600 million suffering from goitre and 43 million from retardation. Following resolutions adopted by the Health Assembly (resolution WHA43.2) and the World Summit for Children, a remarkable commitment had been made with a view to achieving the virtual elimination of the disorders by the year 2000. Thanks to the combined efforts of governments, countries, United Nations and nongovernmental organizations, bilateral organizations and private donors, the proportion of the global population suffering from iodine deficiency disorders had decreased from 28.9% in 1994 to 13.7% in 1997. However, 13% of the world's population were still at risk, often in parts of the world to which access was very difficult. Those areas should be identified, reasons ascertained as to why universal salt iodization was so difficult to apply - despite major efforts - and appropriate solutions found. Attention should be focused on quality assurance and monitoring, as exemplified in WHA49.13, in particular to avoid the occasionally unfavourable side-effects of iodization resulting from poor quality control. Finally, iodine deficiency disorders were dietary diseases resulting from a lack of iodine in the soil; they therefore re-emerged as soon as prevention measures were neglected, as seen in the countries of the former USSR and in the former German Democratic Republic. Sustainability was therefore a key element. His organization was ready to support governments of countries affected, WHO and others in their combined efforts to reach the goal of sustainable elimination of the disorders by and beyond 2000. The CHAIRMAN took it that the Board wished to take note of section XI of the report, was pleased to learn of the Director-General's initiatives to hold a technical consultation on infant feeding and HIV, and a global meeting on issues related to the current status of infant and young children, and welcomed the proposed initiation of a process to overcome the main obstacles to the health and well-being of children by fully implementing the International Code and subsequent related resolutions. It was so agreed.
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Section XII. Tuberculosis (Resolution WHA46.36; Document EB101/10 Add.2) The CHAIRMAN invited the Board to consider section XII of the Director-General's report (document EBIOI/10) together with the draft resolution contained in document EB101/10 Add.2. Dr KOCHI (Global Tuberculosis Programme) said that the Programme's management advisory body had met on 3 and 4 November 1997 and had made several recommendations to the Director-General, copies of which were available. The first was that the global tuberculosis control goals - successful treatment of 85% of new sputum-positive cases identified and a detection rate by the year 2000 of 70% of such cases - should be maintained; they remained appropriate in epidemiological terms and were also achievable in many countries. Secondly, the targets set for the year 2000 should not be postponed until a later date, even though only about I 00 countries were likely to achieve them in time; 60 others, including 17 which accounted for 75% of the global tuberculosis burden, would probably not reach such targets. The main reason for the recommendation was that by postponing the targets countries with a good chance of achieving them on time might be discouraged from so doing. Thirdly, a clear distinction should be made between countries achieving the targets and those failing to do so. Dissemination of such information might be uncomfortable for some countries, but that was essential if all countries were to reach the targets set for the year 2000 as soon as possible. The penalty for those failing to do so would be severe; each year of delay would result in 2.2 million new cases and one million additional deaths. Finally, WHO should do much more than in the past to assist Member States to achieve the targets. In that connection, five further specific recommendations had been made. Firstly, high-level ministerial meetings should be organized at minimum cost to analyse constraints and develop a concrete plan to accelerate implementation of the directly-observed treatment, short course (DOTS) strategy. Secondly, WHO should advocate legislative reform in the area of compulsory reporting of tuberculosis cases, tuberculosis control performance and control of over-the-counter antituberculosis drugs. In addition, national and local nongovernmental organizations should be assisted in undertaking social mobilization and other measures to expand DOTS coverage. Donor coordination should be strengthened in order to increase the availability of highquality antituberculosis drugs. Dr VAN ETTEN said that paragraph 6 of section XII of document EBIOl/10 stated that WHO's global targets would not be met by the year 2000. However, the conclusion that a lack of political commitment rather than the technical content ofthe DOTS package was holding back expansion of DOTS coverage was too general. WHO should conduct an analysis on a country-by-country basis; about 20 countries were involved and WHO should determine the specific constraints in each one. It was clear that postponing the target date was likely to hinder the current momentum and would serve as a disincentive to countries which would otherwise meet the targets. The new action plan should be revised and should establish new deadlines, which must be realistic but should not be seen as an excuse for countries to relax their efforts. Following informal consultations, he wished to propose several amendments to the draft resolution before the Board. In paragraph 1(4) of the resolution recommended for adoption by the Health Assembly, the words "which are not expected to meet the targets by the year 2000" should be inserted after "disease", and a new subparagraph should be added to read: (b) to review the constraints faced in meeting the targets, if necessary with support from WHO, development institutions or nongovernmental organizations. Subparagraph (b) would become subparagraph (c) and a new subparagraph (d) should be added to read: (d) to develop a detailed plan to meet the targets as soon as feasible after 2000, clearly specifying the type, amount and phasing of support to be provided by their governments, WHO, donors or nongovernmental organizations as appropriate; In paragraph 3 a new subparagraph (4) should be added to read:
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(4) to take all possible steps to maintain WHO's regular budget contribution for global tuberculosis control; Subparagraph (4) would be renumbered accordingly. The amendments were designed to examine the constraints faced in meeting targets in each country and to propose more specific action, taking into account the needs of the various countries. Dr SHIN said that tuberculosis killed three million people and affected more than eight million throughout the world each year. As indicated in document EB 10 Ill 0, it killed more adults than any other infection, thereby depriving societies of their most productive members. The disease had been well understood for many years and was in fact completely controllable; effective methods of prevention and treatment at affordable costs were well established. In 1991 and 1993 the Health Assembly had set global targets for the coverage rates of effective treatment and for the detection of new cases by the year 2000. However, the performance record was far from being successful. If the campaign was not accelerated and intensified, i.e. if the current level of activity was maintained, tuberculosis incidence would continue to increase and more than 10 million new cases could occur each year. WHO should re-evaluate its efforts and level of commitment. The following factors should be assessed; whether the programme possessed the necessary technical competence; whether all the available resources were adequately deployed where they were needed; and whether the programme received sufficient support from WHO. If the latter was not the case, support must be mobilized from other United Nations, international and nongovernmental organizations. Technical intervention alone could not fulfil the desired objectives; the key to success was the political commitment of Member countries. WHO should exert its leadership authority to the fullest extent possible in implementing the tuberculosis programme, as it had done in its global campaign to eradicate poliomyelitis. Dr NAKAMURA agreed that control of tuberculosis now hinged largely on political will, since effective and affordable measures to counter the disease were widely available. He welcomed WHO's efforts to advocate and promote political commitment and its plans to launch new activities in that connection. He expressed support for the draft resolution, as amended by Dr van Etten. Dr FERDINAND, after endorsing Dr Shin's comments, said she failed to understand the lack of political commitment with regard to implementation of the DOTS strategy, since there was no doubt that it represented the most effective means of dealing with the disease. Member States should be encouraged by the Organization to adopt that form of treatment with a view to achieving the objectives set for the control of tuberculosis within the established time-frame. She supported the draft resolution. Dr MELONI concurred with the view that emphasis must be laid on greater political commitment by Member States and the international community in order to attain the tuberculosis control objectives set by the Organization. He welcomed the recommendations of the management advisory body; their implementation was proving effective in his country. Professor REINER endorsed the comments of previous speakers, in particular regarding political commitment. The DOTS strategy seemed to be the only means of halting the sudden rise in morbidity and mortality from tuberculosis, and Member States, especially those with the highest levels of tuberculosis, must be warned yet again of the disastrous consequences of failing to implement it. It was worrying that the majority of the 22 countries that accounted for 80% of the disease burden would be unable to meet the relevant WHO control goals by the year 2000 and that it was unlikely that global targets for tuberculosis mortality would be achieved. He therefore urged all Members to support the draft resolution, with the amendments proposed by Dr van Etten. Dr BADRAN (alternate to Professor Sallam) shared concerns expressed regarding the gravity of the situation both for the developed and developing world, particularly in view of the emergence of multi drugresistant strains of the causative agent. Tuberculosis was not only the responsibility of health authorities, since
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poverty and poor living conditions were important contributing factors; a multidisciplinary approach was required. Such an approach, comprising routine therapeutic measures using the DOTS strategy and strong political commitment, and involving nongovernmental organizations and the media, was proving particularly successful in Egypt, where tuberculosis was the second major health problem. He supported the draft resolution. Dr SULAIMAN commended the Global Tuberculosis Programme, while recognizing the problems encountered in its implementation and the consequences for the realization of global objectives. Resolutions adopted by the Health Assembly and at regional conferences should serve to enhance the political commitment of Member States. The regional offices ought to play a more effective role in ensuring the implementation of those resolutions. Increased funding was required to ensure full implementation of the Programme and to achieve better results in controlling the disease, which affected all sectors of society. Dr ABEDNEGO (alternate to Dr Wasisto) shared the concerns expressed regarding the low rates of tuberculosis treatment and case detection. Much work could still be done to enhance the implementation of the DOTS strategy; WHO must continue to support and strengthen its coordination and media components. In Indonesia, one rnultidisciplinary national committee was responsible for coordinating the strategy, thereby ensuring a better evaluation of results, especially relating to the non-technical contents of the package. Moreover, wide-ranging media support heightened public awareness and strengthened commitment. The recent success of the national campaign against poliomyelitis, in connection with the WHO goal of eradication of the disease by the year 2000, had raised expectations of better results for the implementation of the DOTS strategy in future. Ms ADERHOLD (alternate to Mr Voigtliinder) was in favour of the draft resolution, which reflected the deliberations of the management advisory body of the Global Tuberculosis Programme. The DOTS strategy was the best means of combating tuberculosis. Close cooperation between the Global Tuberculosis Programme, related WHO programmes and multilateral and bilateral projects, including those of nongovernmental organizations, was essential to enhance implementation of the strategy. In the longer term, effective preventive tools should be developed and environmental factors should be given further study. Dr SIKOSANA (alternate to Dr Stamps) observed that the DOTS strategy failed to take account offactors contributing to the rise in tuberculosis aside from the HIVIAIDS pandemic. The situation was exacerbated in Africa by the current economic climate and its effects on the performance of the health sector, where a shortage of drugs, dwindling resources and low staff morale all hampered the implementation of the strategy. Zimbabwe had adopted the DOTS strategy, but not without some difficulty. Although it achieved a high cure rate, it could only be applied to those cases that had been identified by the health system, and identification of cases was merely the first stage in the long process of disease prevention and control, which required considerable laboratory support and investment. As with other communicable diseases, including malaria, what was required was a holistic approach to the problem. The solution therefore lay in an improvement of the overall economic situation as well as technical support to reform the health sector and enhance health services delivery systems. Dr AL VIK said that tuberculosis control was a good example of the importance of public health thinking and action at national and international levels. WHO must take the lead in the area, as suggested by Dr Shin. She agreed on the need for a holistic approach to combating the disease through, inter alia, improving living conditions and poverty levels. She supported the draft resolution as amended by Dr van Etten and suggested a further amendment to the second preambular paragraph ofthe resolution recommended for adoption by the Health Assembly, namely the addition of the words "and inadequate control of antituberculosis drugs" after the words "and that poor treatment". Dr MUL WA said that the combined threat of tuberculosis and HIVIAIDS had been greatly diminished by the introduction of DOTS, which was likely to lower tuberculosis morbidity and mortality rates, and eventually eliminate the disease. However, countries required assistance in expanding implementation of the strategy.
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Or HENDERSON (Assistant Director-General) welcomed the comments made by members, which indicated their clear understanding of the need for a holistic approach and for WHO leadership to enhance the political commitment of Member States. He endorsed all the amendments proposed to the draft resolution.
The resolution, as amended, was adopted. 1 The Board took note of section XII of the report.
Section XIII. Global elimination of blinding trachoma The CHAIRMAN invited the Board to consider section XIII of the report together with the relevant draft resolution contained in section XIV. Or CHOVET (International Agency for the Prevention of Blindness), speaking at the invitation of the CHAIRMAN, said that his organization represented the majority ofnongovernmental organizations working throughout the world to combat blindness and ensure the rehabilitation of the blind. The exemplary cooperation between those organizations and the WHO programme for the prevention of blindness, through the Alliance for the Global Elimination of Trachoma, made treatment, preventive action and joint projects more effective in dealing with the disease, which accounted for one-sixth of vision loss in the world. The "SAFE" strategy, which combined antibiotic and surgical treatment, as well as hygiene measures, had been developed in cooperation with WHO. It should be implemented swiftly and widely in the poorest regions of the world - those worst affected by the disease. The strategy would form part of the primary health care policy, would be based on participation at grass-roots level and would encourage different intersectoral approaches. WHO still had time to mobilize efforts and, with the support of governments and people, to achieve success in controlling the disease in the next 20 years. He urged the Board to adopt the draft resolution which would encourage the nongovernmental organizations he represented to step up their efforts to eliminate blinding trachoma and strengthen their already exemplary cooperation with WHO.
The resolution was adopted. 2
2.
DISEASE PREVENTION AND CONTROL: Item 10 of the Agenda
Control oftropical diseases: Item 10.1 of the Agenda (Document EB1 01/11) Chagas disease Or MOREL said that the success of the programme to control Chagas disease was a major victory for public health in the Region of the Americas and a major achievement, in particular in terms of cost-effectiveness and cost-benefits. The experience and success of the Southern Cone Initiative should be extended to the Andean and Central American countries. He therefore welcomed the draft resolution contained in paragraph 20 of document EB I 01111; together with Or L6pez Benitez, Or Meloni and Professor Pico, he wished to propose three amendments to take into account the fact that the situation in the Andean and Central American countries was not exactly the same as in the Southern Cone region in terms of insect vector distribution and heterogeneity. A new penultimate preambular paragraph should be inserted in the resolution recommended for adoption by the Health Assembly to read: "Aware of the need for additional entomological and epidemiological data to support these initiatives;". In paragraph 4, "including vector distribution, behaviour and sensitivity to insecticides"
1 2
Resolution EB10l.R4. Resolution EB10l.R5.
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should be added after "full extent of the disease". Paragraph 6(4) should be replaced by "to report back to the I 05th session of the Executive Board on the progress achieved". Dr ITO (alternate to Dr Nakamura) supported the draft resolution. Political commitment at the highest level was clearly essential. In that connection, he reported that, as a result of a proposal by the Prime Minister of Japan at the summit meeting of the "Group of 7+ 1" countries in Denver in June I997, a group of scientists and experts in parasite control, together with government officials, had begun discussions on the preparation of a report on the control of the world's parasitic diseases to be presented to the 1998 summit. The report would give special emphasis to targets and strategies to enhance current efforts to control parasitic diseases. WHO was also collaborating in the process. He expressed the hope that the initiative would have a fruitful outcome. Dr HENDERSON (Assistant Director-General) reported that WHO had warmly and actively supported that initiative, and agreed that political visibility would be very helpful in combating a large number of parasitic diseases. He endorsed the amendments proposed by Dr Morel. While the Board's practice in the past had been to include in almost every resolution a specific date for the submission of a progress report to the board, the target dates for reporting had not always fitted in with a programme's needs or progress. More recently, therefore, efforts had been made to avoid setting such dates. While the Director-General was perfectly willing to prepare a report by the date proposed, it might be preferable to omit reference to the particular Board session in the formal resolution, thus allowing greater flexibility. Dr MOREL replied that the reason for mentioning the I 05th session was that the Board was due to consider the Southern Cone Initiative at that session, which would be an appropriate occasion to consider the situation in respect of Chagas disease in the Andean and Central American countries. Dr ALLEYNE (Regional Director for the Americas), welcoming the opportunity to present some good news, announced that in the previous week Uruguay had been declared free of Chagas disease. That was a tremendous achievement in which all concerned should take pride; it was also a monument to cooperation among countries. Professor PICO (alternate to Dr Mazza) said that the considerable support to the Southern Cone Initiative given by the WHO Division of Control of Tropical Diseases and the Special Programme for Research and Training in Tropical Diseases had advanced progress in controlling the transmission of Chagas disease. He agreed with Dr Alleyne that emphasizing the achievements so far would provide encouragement to continue the work. He supported the draft resolution with the amendments proposed by Dr More I, which he also sponsored. Dr LOPEZ BENiTEZ recalled that in 1996 the world had first been alerted to the high levels of prevalence and incidence of Chagas disease in Central America. Since then, progress had been made and the region could benefit from the experience gained in the Southern Cone area. He thanked all those who had worked on the control of the disease at WHO and in the Region of the Americas. If technical and economic support continued to be forthcoming from organizations such as WHO, PAHO and friendly governments, it should be possible to make real headway.
The resolution as amended, was adopted. 1
Leprosy Dr VAN ETIEN suggested that when the report was revised prior to submission to the Health Assembly it should contain a reference to the need to develop a strategy on issues related to the social exclusion and to the rehabilitation ofleprosy patients, in accordance with the conclusions and recommendations of the WHO Expert Committee on Leprosy.
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Dr ITO (alternate to Dr Nakamura) said that leprosy remained a significant public health problem in Japan. Welcoming the progress made, for example in the increased use of multi drug therapy, and fully supporting the draft resolution, he drew attention to the importance of rehabilitation and community involvement in leprosy control. Cooperation, not only between Member States but also with various nongovernmental organizations, would be essential in the implementation of the resolution. A national foundation had long been supporting control of and research into leprosy in collaboration with WHO; and in June 1998 Japan, in cooperation with patients' associations, and domestic and international nongovernmental organizations, would host an international conference on the dignity of patients. Professor SALLAM voiced regret that the subject of malaria was not on the agenda. That was a most important issue, of particular concern in Africa, and it would have been good to discuss the work under way. The CHAIRMAN invited the Board to adopt the draft resolution on the elimination of leprosy as a public health problem, contained in document EB101/11.
The resolution was adopted. 1 Lymphatic filariasis The CHAIRMAN invited the Board to consider document EB101/INF.DOC./7. Professor SALLAM warmly welcomed WHO's initiative for the elimination of lymphatic filariasis, in collaboration with a major pharmaceutical company, and emphasized the need for sound planning for implementation. Dr CALMAN also commended the announced collaboration in the project for treating large numbers of people. He hoped that the Board would be involved in the follow-up and receive feedback on the results of implementation.
Revision of the International Health Regulations: progress report: Item 10.2 of the Agenda (Resolution WHA48.7; Document EB101/12) Mr JUNEAU said that, in Canada's view, the collective priorities in the matter of international health regulations were, firstly, to help Member States to improve national disease surveillance; secondly, to strengthen WHO's capacity to monitor and coordinate global disease surveillance; and thirdly, to develop and maintain an effective early response system that would help countries to control disease when an outbreak exceeded their domestic capability. A system was evolving under the leadership and coordination of WHO. Canada had very recently signed a memorandum of understanding with the Organization to design and support a global disease monitoring project whereby, as from May 1998, outbreaks of disease throughout the world would be followed by a computer-based system that would continually scan sources such as news wires, the Internet and Promed. The acquired information would be transmitted to WHO for verification and appropriate action with relevant authorities. It was to be hoped that the project would contribute to the creation of an international surveillance and control system, but much remained to be done before the needs of all Member States were met. WHO, and especially the Division of Emerging and other Communicable Diseases Surveillance and Control, was increasingly mobilizing the expertise of Member States through collaborating centres and other mechanisms. The arrangement between WHO and Canada was the first of its kind; he hoped that other Member States would consider similar measures. He endorsed the ongoing plans for further development and implementation of the revised International Health Regulations. Professor REINER recalled that the International Health Regulations - which had his absolute support were being revised in accordance with resolution WHA48. 7 adopted by the Health Assembly in 1995 which had
1
Resolution EBIOI.R7.
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introduced the obligation of Member States to report a number of defined clinical syndromes, with the aim of rapid recognition and reporting of outbreaks of new or unusual infectious diseases. Another proposal had been for the introduction of measures to reduce constraints on international travel and trade, which could affect national economies. The objective of those measures was effective action to prevent epidemics. Noncommunicable diseases were, however, the major health problem in both developed and - increasingly developing countries, and they were equally or even more dangerous than communicable diseases. The International Health Regulations ought, therefore, to cover those diseases as well. Under WHO's tobacco or health programme, for example, consideration might be given to the drafting of regulations that could ultimately lead to an international ban on advertising of tobacco and tobacco products in all Member States. Mr DEBRUS (alternate to Mr Voigtliinder) welcomed as timely the revision of the International Health Regulations and approved the syndromic approach to notification, provided that the syndromes were clearly defined. Care should be taken to ensure that notification criteria were compatible with other international registration systems, for example the communicable diseases network planned by the European Union. Successful prevention depended on successful prophylaxis, based on conditions of efficient surveillance in the countries of origin. Since those conditions were not directly determined by the International Health Regulations, there should be consultation in Member States as to how national surveillance systems could at least be bolstered through them. Indicating inappropriate measures in the operational guidelines, as suggested in paragraph 7 of the document, would appear to be unnecessary if the appropriate measures were described. In any case, it would be difficult to reach agreement on what was inappropriate. Experience of the coordination with, and participation of Member States had not always been good. Official national focal points had been appointed, but offers of cooperation had not been well received by WHO: reports in the Weekly epidemiological record were hardly sufficient in that connection. As the work progressed, all Member States, and especially those which had given a commitment in writing, should be explicitly involved. The Committee on International Surveillance of Communicable Diseases should allow the official focal points to participate in the precise definition of the defined clinical syndromes, and in the drafting of an interim report on the field-testing of the provisional definitions and a well-founded final proposal. The recommendations on the revision of the International Health Regulations should first be submitted to the focal points for evaluation before transmission to the Health Assembly. Finally, the International Health Regulations should be of a recommendatory rather than admonitory nature. Dr ITO (alternate to Dr Nakamura) said that Japan was one of the countries in which the revised International Health Regulations were being field-tested in order to confirm their effectiveness in developed countries where communicable diseases were less prevalent. WHO should maintain good communications with Member States in the revision exercise, and the legal as well as the technical aspects of any revisions should be addressed. Japan looked forward to presentation of the revised Regulations at the Health Assembly in 1999. Professor SALLAM said that the International Health Regulations should be viewed against the background of the changing worldwide pattern of communicable diseases. New standards were required, and a new network of communication - via the Internet - should be established to provide health regulators in all Member States with information on action to be taken and on the relevant regulations. ·Countries should, moreover, be encouraged to review their own health regulations in the light of the revised Regulations. Populations should not be alarmed unnecessarily, as had been the case, for instance, when the proper information on bovine spongiform encephalitis had not been immediately disseminated; action should be based on clearly defined standards. The latter should be constantly updated to reflect events around the world; changes should be communicated immediately to the authorities responsible for communicable disease control. In short, the system should serve as a keenly maintained tool for early warning about the extent of disease and the delivery of accurate information about the control measures that had been or should be taken. Dr SULAIMAN agreed with Professor Reiner that the issue went beyond the strictly clinical framework of notification about communicable or noncommunicable diseases. Professor Sallam had correctly remarked that accurate information was more important than advice which might or might not be followed. Clinical syndromes should be precisely defined and in good time; in that connection, and referring to the phrase "after
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confirmation of the diagnosis" in paragraph 2 of the document, he pointed out that diagnosis times varied and some countries might react precipitately and inappropriately to certain situations, as had occurred following the outbreak of bovine spongiform encephalitis. Dr HEYMANN (Division of Emerging and other Communicable Diseases Surveillance and Control) reported that the revision of the International Health Regulations was proceeding as scheduled. Case definitions for notifiable syndromes were being evaluated in 20 countries, and the draft revised Regulations would be presented to all Member States for review and comment within a few weeks. With the completion of revision, the new global alert and response system would be implemented, it was hoped in the year 2000. The system was conceived as interactive with countries, involving electronic communication between ministries of health, with the exchange of information not only about disease outbreaks of international importance but about what should and should not be done in the case of a particular syndrome.
The Board took note of the Director-General's report.
3.
REPORTS OF ADVISORY BODIES AND RELATED ISSUES: Item 11 of the Agenda (continued)
Report on the thirty-fifth session of the global Advisory Committee on Health Research (ACHR): Item 11.1 of the Agenda (Documents EB1 01/15 and Add.1) Professor FLIEDNER (Chairman, global Advisory Committee on Health Research), speaking at the invitation of the CHAIRMAN, said that the terms of reference of the Committee were to harmonize research efforts for effective global synthesis, to review, monitor and evaluate the results of research and to formulate global priorities for health research. Harmonization of WHO's research efforts had been achieved at country, regional and interregionallevels, with support from the Regional Directors. The regional advisory committees on health research (ACHRs) were bringing science and technology to bear on health development. The global ACHR discussed the activities and promoted interaction and cooperation with the regions. The report of the work of the Committee (document ACHR35/97.20) described that interaction. All of the members of the ACHR system had contributed to development of a policy on the use of science and technology in supporting global health. The report also described the Committee's activities in the review, monitoring and evaluation of research results from the viewpoint of scientific and technical policy. The subjects that had been addressed were organ transplantation, health measurement, neuroscience, geographical information systems and health and development in border areas. The Committee had formulated global priorities for health research, and a synopsis of that work, entitled "A research policy agenda for science and technology to support global health development" (document WHO/RPS/ACHR/97.3) and a draft background document (document WHO/RPS/ACHR/97.4) were available. He reminded the Board of the steps that had been taken to develop a health research policy. The Forty-third World Health Assembly had adopted resolution WHA43.19 in which the Director-General was requested inter alia to use appropriate mechanisms, in close collaboration with the global and regional ACHRs: to assess new and emerging areas of science and technology; to investigate evolving problems of critical significance to health; to identify appropriate methodologies for trend assessment and forecasting; to develop further a clearly enunciated health research strategy for WHO in order to translate the research goals, priorities and programmes into coherent and coordinated action; to promote the harmonization of science and research policies in health between WHO, the United Nations system and other international agencies and organizations; and to develop more effective institutional arrangements for strengthening the research capabilities of Member States. The Board had been informed regularly of the progress made by the Committee and had had occasion to endorse its work. In particular, it had supported efforts to propose a research policy and agenda to complement renewal of the health-for-all strategy and to mobilize the scientific community and scientific knowledge in support of international health. A total of 223 people within the ACHR system and scientific consultants had participated in developing the scientific and technical research policy. The Committee had sought imperatives
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and opportunities for research, and it was to be hoped that those would be implemented. Factors such as population growth, industrialization, environmental pollution, socioeconomic transition, migration and urbanization all had direct effects on health for all at various levels. All scientific competence should be brought to bear on the complex health problems of the world. Not only biomedical sciences but also environmental sciences, physical sciences and engineering, information and communication technology, public health sciences, social and behavioural sciences, educational sciences and economic sciences should be mobilized to that end. In order to analyse health deficits from the points of view of all of the relevant sciences, computerized visual health information profiles had been developed, which took into account a large number of variables and showed progress made in each area. The details of each determinant could be called up on screen. A new approach had been developed to the implementation of research imperatives and opportunities: "intelligent research networks" had been established in order to increase the knowledge base required for public health decision-making at a global level. They involved all of the scientific and technical disciplines implicated in research and development in the regions, and the approach would thus involve the entire intellectual community in solving health problems. The networks would be based on advanced information and communication techniques, in order to build and strengthen research capacity in all parts of the world. The global ACHR had prepared a draft resolution on research for health, presented in document EBI01/I5 Add.l, which he hoped would be adopted and transmitted to the Fifty-first World Health Assembly. He also hoped that the Assembly would confirm that science and technology were essential to support global health in all its complexity and that the scientific community should be mobilized and encouraged by governments to bring its skills, knowledge and enthusiasm to bear fully on the problems of health to be faced in the twenty-first century. Ms ADERHOLD (alternate to Mr VoigtUinder) said that Professor Fliedner's presentation had highlighted the need for a renewed focus on health research. While the draft resolution contained in document EB I 0 l/I5 Add .I was somewhat brief, she took it that its purpose was to emphasize the need to strengthen health research, as well as the need to strengthen the role of WHO in that research. She endorsed the resolution, and hoped that a new concept of health for all would soon be adopted. One target set under that new concept was the strengthening of institutional mechanisms in the field of health by the year 20IO. It would be important for the new Director-General to ensure WHO's continued leadership in a global network of all stakeholders. Professor WHITWORTH (alternate to Dr Blewett) said a number of fundamental questions arose from a reading of the report (document EB I Ol/I5), notably in regard to the planned research policy agenda for science and technology. She would like to know what the analytical basis for that policy was, to whom it was directed, how it was to be implemented, and what would be WHO's role in that implementation. The nature of global research investment and epidemiological patterns suggested that the Organization could not get by with a "one size fits all" research policy agenda, based on a broad listing of areas for investigation. Rather, there was need to look strategically at research capacities and priorities across countries and agencies, and to tailor efforts to objectives that would yield the best and most cost-effective health outcomes. Research was fundamental to cost-effective, quality health care and health training, and as such it should be seen as an investment rather than a cost, and as an integral part of all aspects of health care delivery. That was not to suggest that all countries and agencies should follow the same research agenda. While the links between fundamental, curiosity-driven biomedical research and applied, goal-oriented research were critical, the balance between them would differ between developed and developing States, and models applicable to one country would not necessarily translate to others in different circumstances. Where investment capacity was limited, the key was to set research priorities not only in the light of needs, but in the light of feasibility. The rapid evolution of information technology had provided an extraordinary powerful tool to draw in and apply the findings of research from around the world. WHO could provide strong leadership in promoting and disseminating research results, as well as in building applied research capacity but it had to recognize that it was only one of many players in the international field. Research training was valuable in helping to develop the critical climate essential for a quality health care infrastructure. She would like WHO activities to inform, and be informed by, national research agencies and their agendas. For example, Australia's National Health and Medical Research Council, which had links with both the national and the international research community, as yet had no formal links with WHO or its global and regional health research committees.
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While she could accept the draft resolution in principle, she was not clear as to how its recommendations were to be put into effect. There was need for a much more specific analysis of the role, capabilities and potential contributions of the various institutions involved, a clearer strategic framework for an international research agenda, and a clearer indication of how global capacities could be focused to achieve it. She suggested that the Director-General be asked to prepare a detailed report on the subject, and that consideration of the resolution be deferred until the Board's 103rd meeting. Dr CALMAN supported most of the points made by the previous speaker. Research underpinned all WHO's work, and was linked directly to the renewed health-for-all policy that had been under discussion. He noted that paragraph 9 of the report indicated that a draft research agenda policy document was available. He himself had not yet seen that document, although the Board had been shown some of the background to it. It was very important that the Board should have the necessary documentation to address the issue in depth. Like other speakers, he found the draft resolution contained in document EB 101/15 Add.1 very weak, in the light of the importance of the subject. The text should at least contain a reference to research training. He endorsed the suggestion that the Board should defer adoption of the resolution, and return to it in January 1999 at its I 03rd session to allow time for a thorough discussion of the issues involved. Mr JUNEAU shared those views. In developing any research agenda, the Organization needed to be guided by a policy framework in order to ensure that it was relevant. Professor LEOWSKI said that, although he was not entirely satisfied with the report, it did allow the Board to review the most important aspects of any future research agenda. Since, according to paragraph 4 of the report, a monograph on new concepts of health measurement was in preparation, he wondered whether in the light of the Board's current consideration of a proposal to change the definition of health in the Constitution, the subcommittee on health measurement might have some advice to offer on how to measure the spiritual dimension of health. Professor REINER, agreed that research was imperative in all matters concerning health. The report rightly emphasized the importance of implementation, and of stimulating the activities of collaborative centres and establishing a collaborative network. Although there were already a large number of such centres, especially for primary health care, he doubted whether there was yet sufficient cooperation between them. The report also emphasized the importance of geographical information systems. Little was known in Croatia's health sector about such systems, although they were clearly the best means of analysing data on a territorial basis, which permitted better understanding and also facilitated comparisons. He joined in the suggestion that a more strongly worded resolution should be submitted by the Board to the Health Assembly. Dr DOSSOU-TOGBE said the report was of great interest, particularly paragraph 11, relating to nursing and midwifery research, and paragraph 24, relating to the research activities of the International Council of Nurses. In view of the high proportion of women in nursing, the importance of their increasing share in the work of the Organization should be stressed and greater attention given to research training, so that nurses and midwives could acquire the necessary skills to engage in research activities. Dr SANOU IRA, noting that the report was directed to developing a coherent approach to research at global level, said that efforts were already being made in countries to develop national health research strategies; it was important that those efforts be supported by the establishment of health research networks. There should be no problem in integrating national or regional strategies into the global strategy, since the latter would be bound to encompass the topics that were being dealt with in countries either through pure or, more particularly, applied research. She agreed that the draft resolution should be amplified by references to those areas of research that should be given most emphasis. Dr MELONI suggested that as part of the effort to develop a research agenda for science and technology it would be useful, in order to determine appropriate priorities, to assess the research capacities of all the various
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countries and regions. In recent years, scientific and technological know-how had advanced so rapidly that the disparities between countries in that respect were probably greater than the disparities in terms of health indicators. The policy would therefore have to take account of such inequalities, which appeared to be on the increase, if health systems were to be able to provide global responses in line with the vision of health for all in the twenty-first century. Dr BADRAN (alternate to Professor Sallam) said that while he welcomed the Committee's report, and particularly the emphasis it gave to cancer research, he would have liked more attention to have been given to applied research, which dealt with the solution of the practical problems that hindered attainment of health for all and the progress of health sector reform. Professor FLIEDNER (Chairman, global Advisory Committee on Health Research) said that the comments made by the Board on health research in 1996 had been taken into account when developing the health research agenda. Some 80% of all scientific knowledge developed throughout the world came from some 20% of the Member States of WHO. By setting up "intelligent research networks", the Committee aimed to decrease the gaps between different countries by making that accumulated knowledge globally available, and by strengthening research capabilities. The networks would therefore include training as well as research. The scientific community needed encouragement from the Health Assembly and from governments if it was to engage in research on globally relevant issues; that encouragement could only be given at the global level. In view of the great complexity of the factors influencing health, he welcomed the recommendation that mobilization of health research at global level should be brought to the attention of the Health Assembly as soon as possible. The CHAIRMAN said that, in the light of the discussion, he took it that it was the wish of the Board to take note ofthe report, and to defer further consideration of the issue, and ofthe draft resolution, until its 103rd session in January 1999.
It was so decided.
Report on meetings of expert committees and study groups (including report on appointments to expert advisory panels and committees): Item 11.2 of the Agenda (Documents EB101/16 and Add.1) Professor REINER, making a general observation, pointed out that some expert committee reports contained footnotes to the effect that the reports were either already published or being prepared for publication. If that was the case, it would seem that any comments that the Board might make on them would come too late. Such reports reflected the opinions and positions of a group of experts who had been entrusted with developing a particular line of enquiry. He wondered whether members of the Board would be entitled to question or change positions arrived at by those with more expertise in the matter, and who could, and should, have an influence on the health policy of WHO. In deciding health policy, the Board was faced with a dilemma in regard to the relationship between the role of the expert committees, which made their conclusions public in a report, and the role of WHO's governing bodies. In the event that the Board's views should differ from those of the experts, what was the likelihood of them being reflected in the report? Mr TOPPING (Legal Counsel) recalled that the Board had considered the matter at its ninety-ninth session on the basis of a report by the Director-General, following a similar question raised at its ninety-eighth session. The topic had also been considered even earlier in the Organization's history. In the 1950s, the Board had had the authority to decide whether or not to publish the reports of expert committees, a task that had apparently given rise to lengthy and acrimonious discussion. In 1960, the Board had decided that the Director-General, not the Board, should decide whether to publish expert committee reports. Following further review in the late 1970s, the Regulations for Expert Advisory Panels and Committees had been revised in 1982. In considering the whole issue, the Board had felt on balance that it was best to maintain the independence of expert committees
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and leave it to the Board to look into the public health implications of their scientific conclusions. Regulation 4.23, concerning reporting to the Executive Board, as revised at that time, remained in force. The matter had been considered again in the late 1980s and the Board had again decided that it would be best to maintain the independence of expert committees, that whether their reports should be published should be determined by the Director-General, and that the Board should comment on the public health aspects and implications for the WHO programme of action, but not on the scientific conclusions. At its ninety-ninth session, the Board had decided to maintain the existing practice with regard to expert committee reports, making it clear that the expert committees were viewed as independent. The Director-General's report was to be more substantive in looking at the public health implications and impact on WHO's programme of work, and the Board was to comment on the Director-General's report. Professor REINER said that there was, nevertheless, a fine distinction between discussing the content of an expert committee report and considering its implications for WHO's programme of work which the general public was unlikely to make. A document published by WHO would probably be seen as reflecting WHO's position. Bearing in mind the comments made by the Legal Counsel, he considered that there was little point in the Board discussing the reports of expert committees at any great length.
WHO Expert Committee on Biological Standardization: Technical Report Series, No. 872, in press) There were no comments.
Forty-sixth report (WHO
Programming for adolescent health: Report of a WHO/UN FPA/UNICEF Study Group (WHO/UNFPA/UNICEF. Action for adolescent health: towards a common agenda. Recommendations from a joint Study Group. Geneva, World Health Organization, 1997; Document WHO/FRH/ADH/97 .9) 1 Dr STAMPS said that the report was disappointing in that it did not touch on the most important areas affecting adolescent health: declining employment opportunities; limited education opportunity, especially at secondary level; the distortion of values by the media; broken homes and domestic violence; and unsuitable housing. The report did not address any concept of services for adolescents, for example, school health services. He wondered what the Study Group had actually discussed and, observing that the Group had met in 1995, wondered why it had taken so long for the report to be submitted to the Board. He wondered whether it was worthwhile continuing the existence of the Group. Dr FERDINAND said that many of the health problems affecting adolescents were social in origin and there was a need to develop programmes to improve the social environment of adolescents. In her country, special polyclinics were undertaking activities for adolescents at risk. Another important factor was the involvement of adolescents themselves in planning and implementing programmes. There was also a need to develop a programme for out-of-school youth who might not be attracted to programmes in a formal setting. She called on WHO to find ways of strengthening programmes for adolescents. Ms FERGUSON (Adolescent Health and Development) said that the summary in the Director-General's report unfortunately did not do justice to the full report which indeed dealt with some of the social origins of adolescent health problems related to unsafe sexual activity, substance abuse, poor nutrition and violence. The Study Group had tried to identify and describe interventions that were needed, including increased access to health services, better programmes of information and skill-building in schools as well as in other community organizations, family and community support to adolescents, and the need to target young people particularly at risk. Within countries, increasing attention was being paid to programmes aimed at adolescents, bearing in mind the need for coordination between the health services and other sectors, especially the educational sector.
1
To be published in the WHO Technical Report Series.
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She hoped that the technical consensus reached through collaboration between WHO, UNFPA and UNICEF in the Study Group would help to support and accelerate activities in countries.
WHO Expert Committee on Leprosy: Seventh report (WHO Technical Report Series, No. 874) Dr STAMPS drew attention to the problem faced by countries where, although leprosy was no longer considered to be a public health problem, there were a few leprosy cases. In Zimbabwe, for example, 19 cases had been diagnosed in 1996 but 38% of them already had disabilities. Although expensive, it was important to enable health practitioners to keep up to date in order to ensure early diagnosis and appropriate treatment regimes. He also asked for clarification ofthe implications of immunodeficiency, either acquired or natural, in the recrudescence of leprosy in small communities. He stressed that great efforts were needed to eliminate leprosy in Africa. Dr NOORDEEN (Action for the Elimination of Leprosy) said that the problem of maintaining skills for early diagnosis of leprosy when leprosy became a relatively insignificant disease was indeed important. On the basis of the recommendations of the WHO Expert Committee on Leprosy, WHO was working towards further simplification of diagnostic and treatment procedures so that the disease could be dealt with by the most peripheral health workers at an early stage. With regard to the effect of immunodeficiency, several studies carried out in countries, including countries in Africa, had found no adverse effects of the HIVI AIDS pandemic on the occurrence of leprosy.
Food safety issues associated with products from aquaculture: Joint WHO/FAO/NACA (Network of Aquaculture Centres in Asia and the Pacific) Study Group (WHO Technical Report Series, in preparation) Or STAMPS asked what views the experts held on the prohibition by the European Union of imports of fish from Africa because of a cholera occurrence. Dr KAFERSTEIN (Food Safety) welcomed the question, although it was not related to the report of the Study Group. WHO was very concerned about the effects of trade embargoes imposed on certain products from countries affected by cholera. A fact sheet on cholera had recently been issued indicating that an embargo was not the method of choice to cope with the spread of the organism internationally. The Director-General was in the process of drawing up a formal communication (circular letter) addressed to all Member States along those lines. He recalled that, in 1992, when the cholera epidemic had reached the American continent, a similar communication had been issued. Dr STAMPS asked what could be done to prevent countries taking such an approach. Professor SALLAM suggested that the International Health Regulations should set out a unified approach regarding food safety, dealing not only with the transmission of disease but also with the regulations to be implemented within countries. The embargo referred to by Dr Stamps lacked a scientific basis and was therefore unacceptable. The International Health Regulations should establish a code of practice applicable throughout the world. Food safety should be a priority for WHO, while intersectoral cooperation was needed to ensure the supply of food acceptable to all. Those remarks applied equally, for example, to genetically engineered food. Dr SULAIMAN asked for clarification of the legality of the trade barriers imposed. The DEPUTY DIRECTOR-GENERAL ad interim said that the International Health Regulations concerned countries, not regions. The current embargo on the export of fish from possibly affected countries was thus not fully within the spirit of existing international legislation. WHO was working with FAO on the Codex Alimentarius in the context of overall regulation of food safety. The two Organizations were also collaborating to face challenges emerging from WTO.
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Dr STAMPS asked what mechanisms were available to countries to redress the situation, observing that no compensation was available. Mr TOPPING (Legal Counsel) said that countries could ask the Director-General, under Article 93 of the current International Health Regulations, to use his good offices to try to resolve the disagreement on the issue. Revised regulations under discussion envisaged an accelerated procedure to settle disputes but such a mechanism was not yet available. Decision: The Executive Board considered and took note oftlie Director-General's report on the meetings of the following expert committees and study groups: 1 WHO Expert Committee on Biological Standardization, forty-sixth report,2 WHO Expert Committee on Leprosy: seventh report, 3 Programming for adolescent health: Report of a WHO/UNFPA/UNICEF Study Group, 4 and Joint WHO/FAO/NACA (Network of Aquaculture Centres in Asia and the Pacific) Study Group (Food safety issues associated with products from aquaculture V It thanked the experts who had taken part in the meetings and requested the Director-General to follow up their recommendations, as appropriate, in the implementation of the Organization's programmes, bearing in mind the discussion in the Board. 6 The CHAIRMAN invited comments on the report by the Director-General on appointments to expert advisory panels and committees contained in document EB101/16 Add.1. Dr MELONI requested clarification of WHO policy concerning expert committees and their functions, including their composition, tasks, responsibilities, time-span, and the use of their reports by the Secretariat and Member States. Dr STAMPS drew attention to the discrimination against the African Region, and African women in particular, in terms of membership of expert committees. Mr AITKEN (Assistant Director-General) suggested that a comprehensive report to answer those questions should be submitted to a future session of the Board. Following a comment by Dr FERDINAND, he agreed that the report would be submitted to the Board at its 102nd session in May 1998. The CHAIRMAN took it that the Board wished to take note of the Director-General's report and proposed that a report be prepared on WHO policy concerning expert committees. It was so agreed.
The meeting rose at 12:25.
1
Document EB101116. WHO Technical Report Series, No. 872, 1998. WHO Technical Report Series, No. 874, 1998.
2 3 4
WHOIUNFPAIUNICEF. Action for adolescent health: towards a common agenda. Recommendations from a joint Study Group. Geneva, World Health Organization, 1997 (document WHO/FRH/ADH/97.9); to be published in the WHO Technical Report Series. 5
WHO Technical Report Series (in preparation). Decision EB101(5).
6
TWELFTH MEETING Saturday, 24 January 1998, at 13:20 Chairman: Professor A. ABERKANE
1.
WHO REFORM: Item 7 of the Agenda (continued)
WHO country offices: Item 7.1 of the Agenda (Documents EB101/5, Corr.1 and Corr.2) (continued from the sixth meeting) The CHAIRMAN drew attention to the draft decision proposed by Dr AI-Mousawi, Dr Blewett, Dr Calman, Dr Dossou-Togbe, Dr van Etten, Dr Ferdinand, Dr Fikri, Mr Hurley, Dr Komodikis, Professor Leowski, Dr Mulwa, Professor Reiner, Dr Sanou Ira, Dr Shin, Dr Sulaiman, Mr VoigtUinder, Dr W asisto and Dr Williams which read: The Executive Board ( 1) endorsed the principle of utilizing a common set of objective criteria to determine the nature and extent of WHO representation at country level; (2) requested the DirectorGeneral to develop further the criteria for classifying countries on the basis of need, in conformity with those provided in the resolution on regular budget allocations to regions, and to report the results of his refinement ofthe criteria to the Executive Board's 102nd session; (3) requested that the refined criteria should be applied in a flexible manner, in order to guide decisions on the nature and level of WHO representation at the country level, taking into account the activities of other organizations and countries; (4) requested that any changes in WHO representation at the country level resulting from the application of these criteria should be introduced over the next three bienniums; (5) requested WHO to cooperate fully with other organizations and bodies of the United Nations system at country level in the framework of the Resident Coordinator system, bearing in mind the role of WHO as the directing and coordinating authority for international health work, and urged the incorporation of WHO country representation, wherever possible, practical and cost-effective, in common premises with other organizations in the United Nations; (6) requested the Director-General to report to the Executive Board at its 103rd session on the outcome of the pilot phase of the United Nations Development Assistance Framework, which is being conducted in 19 countries. Dr VAN ETTEN recalled the Board's previous discussion on the issue, explaining that the draft decision was being proposed to ensure that appropriate follow-up action was taken. Two editorial changes to the original wording proposed by the sponsors had been introduced by the Secretariat. The first concerned point (4), in which the original words "phased in over the next three bienniums" had been changed to "introduced over the next three bienniums". His feeling was that that was not correct, since it would leave the matter open for another three years, whereas the point was that action should be taken soon and finalized within the next three bienniums. The second change was in point (5), where the words "bearing in mind the leadership role of WHO in United Nations health activities" now read "the role of WHO as the directing and coordinating authority for international health work", which he understood was in conformity with Article 2 of the Constitution. On a matter of substance, the proviso in point (5) that WHO country representation should be incorporated in common premises with other organizations in the United Nations "wherever possible, practical and costeffective" had been introduced to provide some flexibility, to take account of the fact that there were instances of arrangements for housing WHO offices in perfectly satisfactory and more cost-effective alternative premises such as ministries of health, thus precluding the need for a single United Nations house.
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Mr SILBERBERG (alternate to Mr Voigtliinder) expressed support for the draft decision and endorsed the previous speaker's comments. Dr STAMPS expressed strong opposition to point (5), which he considered to be a sure way of destroying the effectiveness of WHO at country level, since it meant that WHO would have no direct relationship to the national government but would have to work through the Resident Coordinator. His own country's experience of the Resident Coordinator's intervention in three areas illustrated his point. UNAIDS had effectively destroyed the HIVIAIDS control programme in Zimbabwe, which had a high prevalence of the disease. Large numbers of staff had left the national programme which was now being run by nongovernmental organizations. With regard to UNFPA activities, Zimbabwe, under the aegis of the World Bank and the Resident Coordinator had now been reclassified in terms of needs and placed on a par with Singapore. The Resident Coordinator had also destroyed relationships with UNICEF by directing it to deal principally with the Ministry of Education and the Ministry ofNational Affairs, Employment Creation and Cooperatives, with the result that Zimbabwe now paid for every vaccine from scarce government resources and immunization coverage was declining. The matter was to be taken very seriously; what was proposed in point (5) heralded the end of meaningful work by WHO at country level and was a first fatal step towards the takeover of WHO centrally by UNDP, an organization which consistently spent more than 25% of its budget on administration and was one of the most inefficient bodies in the United Nations system. Was it the function of WHO to save money or was it to save lives? Professor REINER said he saw no reason why the important reference to WHO's leadership role in health matters in countries should be deleted simply to ensure conformity with the text of the Constitution; he would prefer the reference to be retained in order to stress that role. WHO should have a very strong presence in countries, where it should be the leading authority for health issues. Or SULAIMAN pointed to an error in the Arabic version of the draft decision, in which the word "bienniums" in point (4) had been rendered by "years". Dr CALMAN suggested that, since the resolution on regular budget allocations to regions had not yet been adopted, it might be worth considering that resolution in conjunction with point (2) of the draft decision. He agreed with Dr Stamps and Professor Reiner that WHO's leadership role should be stressed, but noted that emphasis also needed to be laid on the importance of cooperation with other United Nations organizations. Those concerns might be met by reversing the order of the wording of point (5), beginning with "bearing in mind the role of WHO as the leading, directing and coordinating authority for international health work," continuing with "requested WHO to cooperate fully with other organizations and bodies of the United Nations system at country level;" and deleting the remainder of that point. That would emphasize WHO's leadership role and then the importance of coordination, without necessarily saying that they needed to be conducted in the same premises. Professor PICO (alternate to Dr Mazza) said he shared Dr Stamps' views. Although the WHO Representative at country level should work in coordination and collaboration with other agencies, he must be fully independent in all matters relating to health. With reference to the statement by Professor Reiner, he wished to dispel any misunderstanding by making it quite clear that, although WHO could play a guiding role in ensuring close links with the health authorities in a country, sole responsibility for public health issues in any country lay with the national authorities. He therefore urged caution in the choice of words. Dr STAMPS said that the wording proposed by Dr Calman was an improvement, but he took Professor Reiner's point about emphasizing WHO's "leadership role" at the beginning of the section; the words "bearing in mind" were somewhat vague. He further noted that most of the sponsors of the draft resolution came from countries and regions where there were no WHO country offices, which might explain why they had suggested incorporating WHO into the Resident Coordinator system. Dr VAN ETTEN said that the original draft had read "bearing in mind the leadership role of WHO in United Nations health activities", which could be placed at the beginning of the section.
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Professor REINER, noting that his intentions had been misunderstood, said he fully shared Professor Pico's views. The most appropriate addition to the text would be a reference to the WHO Representative in the countries as the United Nations national health coordinator. Mr SILBERBERG (alternate to Mr VoigtHinder) said, with reference to point (5), that only full and active participation in the coordination mechanism of the United Nations Resident Coordinator system would enable WHO to take the leadership role in United Nations health activities. However, he endorsed the order of wording proposed by Dr Calman. With regard to the proposed incorporation of WHO country offices into common United Nations premises, he believed that the formulation "wherever possible, practical and cost-effective" afforded WHO the necessary flexibility. Both the strengthening of the Resident Coordinator system and the idea of common United Nations premises formed part of the United Nations Secretary-General's "two-track" reform package and had been supported by the international community at the United Nations General Assembly in November and December 1997. WHO, as a modem and reform-oriented organization, should take the lead in supporting the Secretary-General in implementing those reform proposals. Dr STAMPS took exception to Mr Silberberg's comments. "Possible, practical and cost-effective" did not connote "desirable". Such accommodation under a landlord obsessed with saving money could have a negative effect, especially in Africa. Mr AITKEN (Assistant Director-General), summing up the proposed amendments, said that in point (4) the word "introduced" would be replaced by "phased in", and the Arabic text amended to bring it into line with the other language versions. Taking account of the suggestions in respect of point (5), the text might be amended to read: "(5) emphasizing the leadership role of WHO in United Nations health activities and its role as the directing and coordinating authority for international health work, requested WHO to cooperate fully with other organizations and bodies of the United Nations system at country level;". Point (6), unchanged, would follow. The decision, as amended, was adopted. 1
Review of the Constitution and regional arrangements of the World Health Organization: report of the Executive Board special group: Item 7.3 of the Agenda (continued) WHO regional arrangements (continued) Point (3) - Regular budget allocations to regions (continued from the fifth meeting) The CHAIRMAN drew attention to a revised version of the draft resolution on regular budget allocations to regions, indicating the amendments to paragraphs 2 and 4 of the resolution recommended for adoption by the Health Assembly proposed in the course of the lengthy discussion of the issue at the fifth meeting of the current Board session, which had been prepared by the Secretariat and which read: The Executive Board, Having considered the report of the Executive Board special group for the review of the Constitution on regional allocations, RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution: The Fifty-first World Health Assembly, Recalling resolution EB99.R24 on regional arrangements within the context of WHO reform; Noting that allocations from the regular budget to regions have not been based on objective criteria but rather on the basis of history and previous practice;
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Decision EBI01(6).
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Concerned that, as a result, each region's share of such allocations has remained largely unchanged since the Organization's inception; Recalling that two basic principles governing the work of WHO are those of equity and support to countries in greatest need; and stressing the need for the Organization to apply principles which Member States have adopted collectively; Noting the very uneven economic development in different regions of WHO, in particular over the last decade, and concerned at the dramatic deterioration in socioeconomic conditions in Africa and in many of the countries in the eastern part of the European Region; Noting that other organizations of the United Nations system, particularly UNICEF, have already adopted models based on objective criteria to ensure a more equitable distribution of programme resources to countries, 1. THANKS the Executive Board and its special group for the review of the Constitution for the comprehensive study of allocations from the regular budget to regions; 2. DECIDES that the global [regional, intercountry and] country allocation in future programme budgets approved by the Health Assembly should be guided [for the most part] by a model that,
[2. DECIDES that the Executive Board should develop an objective model for the allocation of country resources in the programme budget based on agreed indices which could include,
inter alia: (a) the UNDP's human development index, ... ] (a) is based on UNDP's Human Development Index, adjusted for immunization coverage; (b) incorporates population statistics of countries calculated according to commonly accepted methods, sueh ss "l6gsrithmie sm66thing"; (c) can be implemented gradually over [two] [three] bienniums, as from the financial period [2000-2001] [2002-2003]; 3. DECIDES FURTHER that the model should be applied in a flexible, rather than a mechanical manner so as to minimize, to the extent possible, any adverse effects on countries whose budgetary allocations will be reduced; 4. REQUESTS the Director-General to report to the 103rd Executive Board and to the Fiftysecond World Health Assembly on the details of the model and the [regional, intercountry and] country allocations to be applied [in future budgets.] to the [2000-2001] [2002-2003] biennium [,taking into account extrabudgetary allocations in the previous three bienniums.] In the interim, a further revised text had been put forward, incorporating amendments to paragraph 2, proposed by Dr AI-Mousawi, Dr Blewett, Dr van Etten, Dr Hembe, Mr Juneau, Dr L6pez Benitez, Dr Meloni, Dr More!, Dr Nakamura, Professor Reiner, Dr Shin, Dr Stamps and Dr Wasisto. He invited the Board first to consider, one by one, those amendments, which read: 2. DECIDES that the global [regional, intercountry and] country allocation in future programme budgets approved by the Health Assembly should be guided [for the most part] by a model that, (a) [is hssed 6n] [draws upon] UNDP's Human Development Index, [possibly] adjusted for immunization coverage; (b) incorporates population statistics of countries calculated according to commonly accepted methods, sueh ss "l6gsrithmie sm66thing"; (c) can be implemented gradually over three bienniums, as from the financial period 2000-2001,
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and that has been reviewed, and refined by a group of experts on modelling applied to health systems, in a report to be presented to the Executive Board at its 102nd session; Professor REINER said the group that had proposed the amendments had remained undecided about the first amendment in the introductory part of paragraph 2. The original proposal had read "global country allocation", while the proposed amendment was to insert the words "regional, intercountry and" before "country". Some Board members had argued that not only country allocations but also regional allocations should be covered by the new model, because expenditure by regional offices varied widely. That argument was attractive, but ran counter to the actual data. There was a substantial difference in the costs incurred by regional offices depending on the country in which they were located: for some services costs could show a six- to I 0-fold difference. Budgets also differed between the regions so that 25% of a budget could represent two quite different figures, depending on the budget's magnitude. The model was intended to provide objective criteria for country allocations, based on country parameters, so that each country received the right amount of funds and knew in advance what that amount was. Incorporating in the resolution a reference to regional allocations would give the Regional Directors and regional committees the power to decide not to give a designated amount to a given country. He therefore opposed the amendment set out in the text and proposed that it be further amended by the deletion of the word "regional". Dr MELONI agreed with Professor Reiner in that the criteria outlined clearly applied to country allocations more than to regional ones. Given the Organization's specific functions at the regional level, there was no reason for the application of population statistics or the UNDP Human Development Index. Even with adjustment for immunization coverage, that Index would not be appropriate for use at the regional level. In the Region of the Americas, improvements in immunization had been achieved not by a broad development of health services but by a strong political will at country level and specific programmes and campaigns. If the Organization applied the model's criteria at the regional level, the result might be counterproductive. However, he could accept the reference to adjustment for immunization coverage provided the word "possibly" was included, as in the amended version of subparagraph (a). Dr STAMPS agreed with Professor Reiner that the proposed changes should be instituted gradually so that their practical effect could be monitored. The main aim was to channel allocations to country level, where they were most needed. The resolution should not be construed, however, as precluding Regional Directors or regional committees from adjusting allocations in the light of actual experience or events. In the event of a cholera epidemic, for example, it should be possible to reduce allocations to other countries in favour of helping the country affected. The basic formula should be applied with flexibility, and any adjustments reported on and substantiated. Inclusion of the word "possibly" in subparagraph (a) perhaps overdiluted what was a trial parameter that could be dropped after a biennium if found inappropriate. While not a major contributor to the model, its use would increase the transparency or the procedure. Dr SANOU IRA pointed out that whenever standard solutions had been sought for application to all countries, there had been difficulties, especially in countries at the periphery. True, models were needed, but they must serve primarily as reference points for application by those responsible for implementing the budget with a view to improving the allocations system. The Regional Directors, in collaboration with countries and regional committees, were already working in that manner. Dr BLEWETT, addressing the points raised by Professor Reiner, said that the model had indeed been based on country statistics, but with the intention of combining those statistics to determine the funding packages for the various regions. Adoption of Professor Reiner's further amendment would entail a major shift in policy, since it would mean that countries were entitled to the amounts specified in the relevant documentation and that only in the special circumstances mentioned by Dr Stamps would those amounts be revised. The Regional Directors and the Director-General would no longer have the flexibility to adjust country allocations where necessary. He therefore favoured the original amendment without the further change proposed by Professor Reiner.
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Professor REINER reiterated that the inclusion of the words "intercountry and country" reflected the realistic basis for the application of the model and represented a compromise solution. Everyone agreed on the need for the model's gradual implementation: the regional element could be added later. Dr MOREL said that a gradual approach to implementation did not imply putting a brake on the process, but was instead a means of ensuring it was successful. If the entire logic behind the allocation of funds was changed at one level but not another, the resulting hybrid would perhaps not be viable. He favoured application of the new index at all budgetary levels, including the regional level. Professor LEOWSKI endorsed Professor Reiner's proposal: the Board should adopt, as a compromise solution, the phrase "intercountry and country". In almost all regional offices, many country programmes were financed through intercountry arrangements. Though the original idea had been to improve country allocations, the difference between country and intercountry allocations was only a matter of regular budget allocations to specific regions. Dr CALMAN said the model was based on country allocations, but because there were links between countries, he supported the use of the phrase "intercountry and country". That would inevitably affect the component of regional budgets related to countries, but there would have to be a separate component to deal with regional functions that went beyond the country model. The whole purpose of the exercise was to shift resources within the Organization to country level for those that needed them most. The measure outlined in paragraph 2 of the recommended resolution was the first stage, not the end result, of that process; later discussion would focus on adjustments to the model. Dr AL-MOUSA WI supported the proposal by Professor Reiner for insertion of the phrase "intercountry and country", on the understanding that, as Dr Stamps had pointed out, there would be sufficient flexibility to deal with any emergencies that arose. Mr MENDIS (adviser to Mr de Silva) said that budget allocations, whether regional, subregional or country-based, should be structured using a formula that ensured a level playing field with a reasonable degree of flexibility and of predictability. Mr JUNEAU endorsed the views expressed by Dr Blewett and Dr Morel. Dr STAMPS said he understood Dr Blewett's concerns, since in Annexes 2 and 3 to document EBlOl/7, the proportions allocated to regions differed widely. However, he had understood that there was to be no further extended discussion ofthe issue, the Board being asked to decide, by a vote if necessary, on the amendments already on the table. Dr MELONI recalled that the purpose of the proposed change was to achieve a better resource distribution to provide more support for developing countries. In some regions, however, there were very few country offices and resources were provided primarily at the regional level. Would any adjustments be made to take that into account? Mr AITKEN (Assistant Director-General) said the new model allowed for sufficient flexibility to enable country budgets to be supplemented from funding allocated to the overall regional level or for any savings made in regional expenditure to be transferred to country level. In response to remarks by Professor REINER and Dr Al-MOUSA WI, Mr TOPPING (Legal Counsel) said that three options were before the Board in respect of the beginning of paragraph 2 of the resolution recommended for adoption by the Health Assembly: firstly, the original proposal, which read "country allocation"; secondly, the proposal to amend that text to read "regional, intercountry and country allocation"; and thirdly, a compromise proposal to read: "intercountry and country allocation". In accordance with the Rules of Procedure, the Executive Board should first decide on the amendment furthest removed in substance from
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the original proposal, i.e. "regional, intercountry and country allocation". If that amendment were rejected, the third option would be considered; failing agreement on that amendment, the original proposal would stand. Professor REINER suggested that the compromise text he had proposed might be immediately acceptable to the Board. Or LOPEZ BENITEZ said he could agree to that intermediary, compromise text. Or BLEWETT said that, in order to advance matters, he was prepared to accept the proposal for "intercountry and country allocation"; he continued to believe, however, that in the course of six years of implementation, the inadvisability of neglecting one level of allocation would become apparent. Or MOREL said that he continued to favour the initial amendment, and would vote accordingly. The CHAIRMAN invited members to vote on the amendment furthest from the original proposal.
The amendment was adopted by 13 votes to 8, with 8 abstentions. The CHAIRMAN invited the Board to consider the insertion of the phrase "for the most part" after the words "should be guided" in paragraph 2 of the recommended resolution. Or ITO (alternate to Or Nakamura), speaking as its author, said that the proposal was intended to enable at least a certain portion of the budget to be used flexibly in response to emergency situations such as major outbreaks of infectious diseases or an economic crisis in a particular region. Or REINER submitted that the phrase "for the most part" was too vague to be acceptable. Professor PICO (alternate to Or Mazza) requested that the Spanish rendering of the phrase "for the most part" be improved. On that understanding, the CHAIRMAN suggested that the inclusion of the phrase "for the most part" be put to the vote.
The amendment was adopted by 13 to 10, with 7 abstentions. The CHAIRMAN invited the Board to consider the proposed amendments to subparagraph 2(a).
The amendments were adopted. The CHAIRMAN invited the Board to consider the proposal to delete "such as 'logarithmic smoothing"' from subparagraph 2(b) of the recommended resolution. Or REINER considered that it would be most dangerous to delete the phrase, as it had emerged from the discussions that logarithmic smoothing was probably the most efficient method of calculation. Failure to apply it would, moreover, have extremely unwelcome effects on the pattern of allocation. Or BLEWETT concurred, pointing out that the matter would in any case be reviewed by a group of experts on modelling. Or AL-MOUSA WI argued that the deletion would leave recourse open to other indicators, not necessarily instead of and perhaps as well as logarithmic smoothing. Or MOREL conceded that the phrase "according to commonly accepted methods" would in fact cover logarithmic smoothing, but said he tended to favour an explicit reference.
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Dr AL VIK, Dr FIKRI and Mr HURLEY, stressing the importance of logarithmic smoothing, supported that view. Dr LOPEZ BENITEZ suggested that, for greater clarity, "such as" be replaced by "including". The CHAIRMAN put the proposal for deletion to the vote.
The amendment was rejected by 17 votes to 8, with 4 abstentions. The CHAIRMAN invited the Board to consider the proposed text for subparagraph 2(c) of the recommended resolution. Dr SULAIMAN recalled that certain members of the Board had voiced a preference for the new model to be implemented as from the financial period 2002-2003, rather than 2000-2001, as was now proposed. lfthere was a consensus on the latter period, he would not object.
The amendment was adopted. The CHAIRMAN invited the Board to consider the proposed insertion of the last two lines in paragraph 2 of the recommended resolution.
The amendment was adopted. Paragraph 2 of the recommended resolution, as a whole, as amended, was approved. The CHAIRMAN suggested that the text of the first sentence of paragraph 4 of the recommended resolution should be amended to read" ... and the regional, intercountry and country allocations to be applied to the 2000-2001 biennium," in order to reflect the amendments made to paragraph 2.
The amendment was adopted. The CHAIRMAN invited the Board to consider the proposed addition of a concluding phrase in paragraph 4: "taking into account extrabudgetary allocations in the previous three bienniums". Professor REINER, supported by Dr SHIN, considered that it would be inadvisable to include a reference to allocations from extrabudgetary resources, since the volume of those resources could fluctuate from one year to the next. Once adopted, on the other hand, the regular budget had stability. Dr AL-MOUSA WI argued that extrabudgetary resources were an important source of funding and that the thrust of the recommended resolution should encompass all income. Mr AITKEN (Assistant Director-General), replying to an inquiry by Dr STAMPS concerning the nature of the extrabudgetary funds in question and their relevance to country allocations, said that extrabudgetary allocations went primarily to priority programmes across the Organization but that only a relatively small proportion was made available specifically to the regional offices or to country operations. Extrabudgetary allocations, as reported in the documentation, sometimes excluded and sometimes included the PAHO allocations. It was possible that the new United Nations accounting standards might oblige WHO to exclude those allocations from the next budget because of the absence of control over them by its governing bodies. Dr MOREL observed that the fact of a country receiving extrabudgetary funds could have an inhibiting effect on its regular budget allocation: he was therefore not in favour of including the reference to those funds in paragraph 4.
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Dr DEBRUS (alternate to Mr Voigtliinder) sought an explanation of the significance of the term "taking into account". Was some kind of adjustment envisaged? Dr STAMPS suggested that consensus might be reached on alternative wording whereby the DirectorGeneral would be requested to report on extrabudgetary allocations in the context of regional, intercountry and country budgets. That would imply taking those allocations into account but not suggest any deduction from allocations under the regular budget. Mr HURLEY endorsed Professor Reiner' s comment. If a lot of the work done in putting together the resolution was not to be unravelled, it would be sensible to separate the two types of allocation and not to include extrabudgetary allocations in the text. The suggestion by Dr Stamps might be helpful: information on extrabudgetary allocations could be provided without there being any question of amending country or regional allocations. Dr FERDINAND agreed with Professor Reiner and Mr Hurley. The amendment called for retrospection: there was no guarantee that the same amount of extrabudgetary resources in any "previous three bienniums" would be injected into the system in the coming two or three years. Professor PICO (alternate to Dr Mazza) shared the concern expressed by Dr More!, and was inclined to favour Dr Stamps' suggestion. Dr SULAIMAN said that the amendment by Dr Stamps was very different from the amendment before the Board which - as he saw it - provided for the possibility of a negative effect on some programmes in certain countries which might be affected by adjustments to regional budgets under the new system. He strongly favoured that amendment. Dr CALMAN did not support the amendment. Supported by Dr SHIN, he said that at some time in the future, it would perhaps be possible to take informed account of the extrabudgetary dimension, but that was not the case at present. The CHAIRMAN put to the vote the proposal to include "taking into account extrabudgetary allocations in the previous three bienniums" in paragraph 4 of the recommended resolution.
The amendment was rejected by 20 votes to 5, with 4 abstentions. Dr STAMPS, reverting to his earlier suggestion, proposed that a new paragraph 5 be added to the recommended resolution, to read: FURTHER REQUESTS the Director-General to report to the Executive Board at its 103rd session and to the Fifty-second World Health Assembly within the context of the request in paragraph 4 above, on the use of extra budgetary allocations in regional, intercountry and country programmes in the previous three bienniums.
The amendment was adopted. The resolution, as amended, was adopted. 1
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Resolution EBlOl.RlO.
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2.
HEALTH-FOR-ALL POLICY FOR THE TWENTY-FIRST CENTURY: Item 8 of the Agenda (continued from the eighth meeting)
The CHAIRMAN drew attention to a draft resolution, proposed by a drafting group following discussions at the Board's seventh meeting, entitled "Health-for-all policy for the twenty-first century": The Executive Board, RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution: The Fifty-first World Health Assembly Recalling resolution WHA48.16, ADOPTS in the sense of Article 23 of the Constitution the World Health Declaration annexed to the present resolution.
WORLD HEALTH DECLARATION
We, the Member States of the World Health Organization (WHO), reaffirm our commitment to the principle enunciated in its Constitution that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being; in doing so, we affirm the dignity and worth of every person, and the equal rights, equal duties and shared responsibilities of all for health.
11 We recognize that people's health and well-being are the ultimate aim of social and economic development. We are committed to the ethical concepts of equity, solidarity and social justice and to the incorporation of a gender perspective into our strategies. It is imperative to pay the greatest attention to those most in need, burdened by ill-health, receiving inadequate services for health or affected by poverty. We emphasize that health improves when social and economic inequities are reduced. We reaffirm our will to promote health by addressing the basic determinants and prerequisites for health. We acknowledge that changes in the world health situation require that we give effect to the "Health-for-All Policy for the twenty-first century" through relevant regional and national policies and strategies. Ill
We recommit ourselves to strengthening, adapting and reforming, as appropriate, our health systems, including essential public health functions and services, in order to ensure universal access to health services that are based on scientific evidence, of good quality and affordable, and that are sustainable throughout life for present and future generations. We intend to ensure the availability of the essentials of primary health care as defined in the Declaration of Alma-Ata 1 and developed in the new policy. We will develop health systems to respond to the current and anticipated health conditions, socioeconomic circumstances and needs of the people, communities and countries concerned, through appropriately managed public and private actions and investments for health.
Adopted at the International Conference on Primary Health Care, Alma-Ata, 6-12 September 1978, and endorsed by the Thirty-second World Health Assembly in resolution WHA32.30 (May 1979).
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IV
We recognize that in working towards health for all, all nations, communities, families and individuals are interdependent. As a community of nations, we will act together to meet common threats to health and to promote universal well-being. V
We, the Member States of the World Health Organization, hereby resolve to promote and support the rights and principles, action and responsibilities enunciated in this Declaration through concerted action, full participation and partnership, calling on all peoples and institutions to share the vision of health for all in the twenty-first century, and to endeavour in common to realize it. Dr CALMAN submitted that, in view of the importance of the subject, further reflection was required and proposed that the discussion be resumed by the Board later in the session. It was so agreed.
(For adoption of resolution, see summary record of the sixteenth meeting, section 11.)
3.
IMPLEMENTATION OF RESOLUTIONS AND DECISIONS (REPORTS BY THE DIRECTOR-GENERAL}: Item 9 of the Agenda (Documents EB101/10 and Corr.1 and EB1 01/10 Add.2) (continued)
Section IV. Prevention ofviolence (Resolution WHA50.19) (continued from the ninth meeting) The CHAIRMAN reminded the Board that a draft resolution entitled "Concerted public health action on anti-personnel mines", proposed by Dr Alvik, Dr Blewett, Dr Hembe, Mr Juneau, Dr L6pez-Benitez and Dr More! containing a resolution recommended for adoption by the Fifty-first World Health Assembly, had been presented and discussed at the ninth meeting. In the course of the discussion, a number of amendments had been proposed, which he recapitulated. After the Board's preambular paragraph, a new operative paragraph would be added, to read: I. REQUESTS the Director-General to submit to the Fifty-first World Health Assembly a plan of action for a concerted public health response to anti-personnel mines;
The original operative paragraph would be numbered "2". In the third preambular paragraph of the resolution recommended by the Board for adoption by the Health Assembly, after "adopted in Oslo on 18 September 1997", the phrase "and opened for signature on 3 December 1997" would be added. In the seventh preambular paragraph, "ceremony for signing of the Ottawa Treaty" would be replaced by "Ottawa Treaty Signing Ceremony". A new operative paragraph 5 would be inserted, to read: 5. ENCOURAGES governments that have planted mines in the territories of other countries to provide the latter with the required maps and identification of the minefields they planted and assist in minefield clearance, financially and technically, in the countries concerned; Former paragraph 5 would be renumbered "6", and amended by inserting", and intergovernmental and" after "United Nations system". In paragraph 6(1)(c), after "improvement of emergency", the words "and postemergency" would be added. In paragraph 6(1)(c), after "psychosocial rehabilitation", the phrase "and within the context of integrated health service delivery" would be added. Paragraph 6(2) would be replaced by:
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(2) to support policy and programme planning by establishing, with other interested parties and as part of an integrated United Nations database, a clearing-house for information on public health aspects of the use of mines; Paragraph 6(3) would be deleted. Dr LOPEZ BENITEZ considered that the proposed new paragraph 5 was not viable and should be set aside from what was essentially a humanitarian resolution. He could approve the other proposed amendments. Mr SILBERBERG (alternate to Dr VoigtUinder) reiterated his view that WHO was not the appropriate forum for discussion of the issue raised in the proposed paragraph 5 which- as other speakers had said- would diminish the impact of the resolution. He therefore urged that the proposed paragraph not be included. Professor SALLAM said he found the previous speakers' views most surprising. Was it not an essential function of WHO to prevent danger to health, whether from disease, accident or injury? Prophylaxis was very important - especially when poverty and lack of resources hindered remedial action - and he failed to understand reluctance to encourage governments to take the measures proposed. Only a few weeks earlier, he had himself seen children at Alamein whose lives and limbs could have been spared by such measures. Dr STAMPS agreed that prevention was a major preoccupation of WHO and considered that the proposed paragraph would strengthen rather than weaken the Organization's position on what was indeed an urgent issue. The CHAIRMAN, speaking in his personal capacity, stressed the importance of adopting the resolution because of the encouraging effect it would have on countries to maintain and support preventive operations with extrabudgetary funds channelled through the intermediary of WHO. Moreover, the proposed wording showed exactly where responsibility lay. To encourage action by governments was, in any case, not to impose on them. Dr CALMAN agreed with Dr L6pez Benitez in accepting all the amendments other than the proposed paragraph 5, the substance of which was already covered in the Ottawa Declaration referred to in the recommended resolution. Mr AKASAKA (alternate to Dr Nakamura) said that Japan had taken an important step in signing the Convention in Ottawa, with a pledge of 10 billion yen to be spent over the next five years on humanitarian assistance in that context. He shared the concern ofDr L6pez Benitez and Dr Calman in regard to the proposed new paragraph 5, believing it inappropriate to introduce a political element that might be detrimental to WHO's effectiveness into a text which was essentially related to humanitarian assistance. He had no particular objection to the other amendments, but said that he favoured adoption of the original proposal. Dr MUL WA said that notwithstanding arguments that the matter under discussion was one for the United Nations Security Council rather than WHO, disaster and emergency prevention indeed fell within the mandate of the Organization. Beyond the action taken in Oslo and Ottawa, it was very important to impress on States which had interfered or intervened in the affairs of other countries by planting landmines that they had placed non-combatant lives in danger. He consequently supported the proposed new paragraph. Dr AL-MOUSA WI said that if injuries received from mines were a health problem, then WHO must obviously take a stand on the subject. Prophylaxis was more important than treatment. Not only could there be no harm in adopting the new paragraph 5, it would strengthen the agreement reached in Oslo. He favoured adoption of the draft resolution as amended. Dr FIKRI said he had already voiced the opinion that the problem was a health-related one and that WHO should endeavour to encourage prophylactic measures, especially as the injuries inflicted by anti-personnel mines were suffered mainly by civilians, including women and children. The proposed new paragraph would constitute an encouragement to the governments concerned and he therefore endorsed the views of speakers who had advocated its inclusion.
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Mr JUNEAU said that although he supported preventive and prophylactic measures in general, and had no quarrel with the spirit of the new paragraph, its substance was being dealt with in another international setting. Therefore he agreed with Dr L6pez Benitez and others that the paragraph not be included in the recommended resolution. Dr KARIBURYO said that the people of Burundi were confronted daily with the terrible mutilation and deaths caused by anti-personnel and anti-tank landmines. Board members agreed that the consequences of that scourge were primarily of a medical and social nature and everything possible should be done to deal with them. Moreover, the refusal to transmit information on the precise location of landmines to the countries concerned surely amounted to non-assistance to persons in danger. WHO should be in the forefront of international efforts to eradicate landmines, and he was therefore in favour of retaining the proposed paragraph, which enriched the recommended resolution. Dr MOREL said he was always in favour of prevention by all possible means, but had doubts about whether the proposed paragraph would actually add anything to the "Ottawa Process". Perhaps the DirectorGeneral could be requested to bring WHO's authority to bear on countries that were responsible for planting mines? At any rate, it would be most unfortunate if members had to vote on an issue on which they were in broad agreement. Dr ALVIK, speaking as a sponsor of the original draft, and supported by Mr NGEDUP, said that it would be most unfortunate if a vote was needed when members were in agreement on the need for preventive action. Perhaps discussion of the item should be postponed for a day or two? In reply to a question from Dr AL-MOUSAWI, she explained that such a delay might permit the authors ofthe draft resolution and the various amendments to consult on a solution that expressed the true sentiments of the Board. Dr W ASISTO said that the subject had been discussed at length. What was essential was to prevent additional victims to the thousands who existed already. He favoured the draft resolution, with the proposed amendments. Professor SALLAM submitted that although it might have come out more strongly, the Board could hardly come out less strongly in favour of preventive action on mines. Initiatives undertaken elsewhere had by no means been completed, or even fully launched. A resolution by WHO, based on strongly humanitarian concerns, could not but be of use. After a brief procedural discussion, in which Dr MUL W A, Dr MOREL and Mr TOPPING (Legal Counsel) took part, the CHAIRMAN invited the Board to vote by show of hands on Dr Alvik's proposal to postpone until later in the session the debate on the proposed amendments to the draft resolution on concerted public health action on anti-personnel mines.
The proposal was approved by 17 votes to 11, with 2 abstentions. (For adoption of resolution, see summary record of the sixteenth meeting, section 12.)
Section X. Health promotion (Resolution WHA42.44) (continued from the tenth meeting) The CHAIRMAN drew attention to the following draft resolution on health promotion, proposed by Dr AlMousawi and Dr Shin: The Executive Board, Having considered the report of the Director-General on health promotion, RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution:
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The Fifty-first World Health Assembly, Recalling resolution WHA42.44 on health promotion, public information and education for health and the outcome of the four international conferences on health promotion (Ottawa, 1986; Adelaide, Australia, 1988; Sundsvall, Sweden, 1991; Jakarta, 1997); Recognizing that the Ottawa Charter for Health Promotion has been a worldwide source of guidance and inspiration for health promotion development through its five essential strategies to build healthy public policy, create supportive environments, strengthen community action, develop personal skills, and reorient health services; Mindful that there is now clear evidence that: (1) comprehensive approaches that use combinations of the five strategies are the most effective; (2) certain settings offer practical opportunities for the implementation of comprehensive strategies, such as cities, islands, local communities, markets, schools, workplaces, and health facilities; (3) people have to be at the centre of health promotion action and decision-making processes if they are to be effective; (4) access to education and information is essential in achieving effective participation and the "empowerment" of people and communities; (5) health promotion is a "key investment" and an essential element of health development; Mindful of the new challenges and determinants of health and that new forms of action are needed to free the potential for health promotion in many sectors of society, among local communities, and within families; Appreciating that there is a clear need to break through traditional boundaries within government sectors, between governmental and nongovernmental organizations, and between the public and private sectors; Confirming the priorities set out in the Jakarta Declaration for Health Promotion in the Twenty-first Century, 1. URGES all Member States: (a) to promote social responsibility for health; (b) to increase investments for health development; (c) to consolidate and expand "partnerships for health"; (d) to increase community capacity and "empower" the individual in matters of health; (e) to secure an infrastructure for health promotion;
2. CALLS ON organizations of the United Nations system, nongovernmental organizations and foundations, donors and the international community as a whole: (a) to mobilize Member States and assist them to implement these strategies; (b) to form global health promotion networks; 3. CALLS ON the Director-General: (a) to enhance the Organization's capacity with that of the Member States to foster the development of health promoting cities, islands, local communities, markets, schools, workplaces, and health facilities; (b) to implement strategies for health promotion throughout the life span with particular attention to the vulnerable groups; REQUESTS the Director-General: (a) to take the lead in establishing an alliance for global health promotion and in enabling Member States to implement the Jakarta Declaration; (b) to support the development of health promotion within the Organization.
4.
Ms IN GRAM (alternate to Dr Blewett) proposed that, in order to highlight the importance of taking an appropriate approach to health promotion, the words "evidence-based" should be inserted before "health promotion" in paragraphs 1(e), 2(b), 3(b) and 4(b) of the resolution recommended for adoption by the Health Assembly. It would then be made absolutely clear that interventions must be scientifically informed.
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Dr CALMAN supported Ms Ingram' s proposal, and suggested that intergovernmental organizations should be included in the list of organizations in paragraph 2. Dr STAMPS remarked that all health promotion was surely based on evidence. Besides, even if a particular country had no evidence of its own to show, say, that smoking increased the incidence of lung cancer among its people, it could still campaign against smoking. He agreed that health services and health concepts should be evidence-based, but to apply the concept to health promotion was to define health promotion too narrowly. Dr KICKBUSCH (Division of Health Promotion, Education and Communication) said that participants in the Fourth International Conference on Health Promotion held in Jakarta had identified areas of health promotion in which clear evidence did exist, and those areas were listed in the third preambular paragraph of the draft resolution. The health research and promotion community was well aware that the term "evidencebased" often referred to clinically oriented methods and criteria, and recognized that other forms of evidence and research were appropriate to approaches to health promotion linked to social and behavioural interventions. IfMs Ingram's proposal was adopted, the recommended resolution could be interpreted as suggesting that only evidence based on particular research methods, such as randomized controlled trials, was acceptable. Dr Stamps' position reflected the consensus at the Jakarta Conference. Dr AL VIK suggested that, as a compromise, the words "using an evidence-based approach where feasible" could be added at the end of the fourth preambular paragraph. Ms IN GRAM (alternate to Dr Blewett) indicated that that was acceptable. The CHAIRMAN invited the Board to adopt the draft resolution, as amended by Dr Alvik and Dr Calman.
The resolution, as amended, was adopted. 1
4.
DISEASE PREVENTION AND CONTROL: Item 10 of the Agenda (continued)
Emerging and other communicable diseases: antimicrobial resistance: Item 10.3 of the Agenda (Resolution WHA48.13; and Document EB1 01/13) The CHAIRMAN drew attention to a number of amendments proposed by Dr Blewett and Mr Juneau to the draft resolution contained in document EB101/13. The following should be added to the preamble of the resolution recommended for adoption by the Health Assembly: Concerned about the rapid emergence and spread of human pathogens resistant to available antibiotics; Aware that antimicrobial resistance is increasingly hampering treatment of infectious diseases as a result either of totally ineffective current available antibiotics or of the high cost of"new generation" agents; Concerned about the extensive use of antibiotics in food production, which may further accelerate the development of such resistance, In paragraph 1(1 ), "volumes and patterns of use of antimicrobial agents and" should be added after "monitor". Finally, the following two new subparagraphs should be added to paragraph 1:
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(4) to strengthen legislation preventing the manufacture, sale and distribution of counterfeit antimicrobial agents and the sale of antibiotics on the informal market; (5) to take measures to ensure the appropriate and prudent use of antibiotics in animal food production; Mr DEBRUS (alternate to Mr Voigtliinder) recommended that WHO should devote attention to the problems related to animal feed additives and veterinary drugs. He therefore proposed that "this should include antibiotic use in hospitals, in the community and in animal husbandry" should be added to the end of paragraph 1(3) ofthe resolution recommended for adoption by the Health Assembly. In paragraph 2(2), "not only in human medicine, but also in animal husbandry" should be inserted after "rational antimicrobial use". He would also like to have seen greater reference to those problems in the Director-General's report (document EB101/13). He would have preferred paragraphs 8 and 9 of document EB 101/13 to have stated clearly that, for certain species of pathogens, the limits of currently permitted antimicrobial chemotherapeutic agents had been attained. With regard to solution (1) described in paragraph 10, it should be recognized that not all Member States were in a position to provide the necessary resources immediately for establishing a standardized microbiological diagnostic system, and would need appropriate support if they were to implement the solution. With regard to solution (4), he would welcome a more detailed account of the research into the cost-benefit ratio. Finally, when the report was revised and transmitted to the Health Assembly, it should be borne in mind that it was not the infection that became resistant but the infectious agent. The word "infections" should therefore be replaced by "infectious microorganisms" where appropriate. Professor REINER said it was unfortunate that the most common and most dangerous microorganisms had become resistant to the most widely used antibiotics. Meanwhile, the classic antibiotics were the cheapest but were becoming ineffective, while the new ones were very expensive and therefore not available in many developing countries. About half of all the antibiotics available were used in agriculture, particularly in animal and fish farming. WHO had little influence in those sectors, and must therefore cooperate more energetically with other agencies, such as FAO. The Health Assembly should also adopt a resolution proposing regulations, in accordance with Article 21 (d) of the Constitution, to impose standards with respect to the use of antimicrobials. Such a move would make it possible to restrict significantly the use of antibiotics in animal or fish farming, and would make a substantial contribution to reducing antimicrobial resistance. Dr BADRAN (alternate to Professor Sallam) said it was not a matter ofthe financial burden on countries, because even if expensive new antibiotics were developed, microorganisms would develop resistance to them with the passage of time. Unfortunately, in many countries, anyone could go to a pharmacy and acquire an antibiotic; indeed, sometimes pharmacists themselves prescribed antibiotics for viral diseases. He therefore proposed the addition of a new paragraph 1(4) to the resolution recommended to the Health Assembly to read: (4) to develop the necessary measures to prohibit the dispensing of antibiotics in particular and active medicines in general without the prescription of a physician. Dr STAMPS said that in that case the definition of a physician would have to be broadened: in some countries, people who were not physicians, such as clinical officers and senior nursing staff, were permitted by law to prescribe drugs. In his view, the recommended resolution should include wording to draw attention to the occupational hazards to health workers from resistant organisms and the need for their protection. Dr HEYMANN (Division of Emerging and other Communicable Diseases Surveillance and Control) welcomed the efforts of Board members to strengthen the draft resolution. Countries with laboratory facilities needed training to make better use of antimicrobials and of their laboratory facilities as well as improvements in infection control and follow-up of patients to detect treatment failures; countries without laboratory facilities needed to focus on better use of antimicrobials, infection control and monitoring outcome of treatment and needed assistance to establish appropriate laboratory support. The cost implications were not yet fully understood, and research was needed to compare the treatment costs for infections caused by resistant microorganisms with those for infections caused by non-resistant microorganisms, and to determine the costeffectiveness of getecting resistant organisms. Similar research was needed in animal husbandry, agriculture
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and fish farming. Research was also needed in order to develop new tools to improve the detection of antimicrobial resistance at all levels. The key elements of an implementation and containment strategy based on the recommended resolution would be stronger surveillance; education and training in the prudent use of antimicrobial agents wherever they were used; statutory regulations for the control of the prescription, sale and promotion of antimicrobials; and research to find new diagnostic tools. Dr BALE (International Federation of Pharmaceutical Manufacturers Associations), speaking at the invitation of the CHAIRMAN, said that IFPMA embraced more than 55 national associations and represented not only international research companies but also producers of generic prescription medicines. The industry's prime purpose was research and development into new therapies, and in the current year alone the worldwide pharmaceutical industry would be spending more than US$ 30 billion to that end, a significant amount of which would involve the discovery and development of new antivirals and antibacterials. Strong intellectual property protection was essential, and any attempts to weaken it would also critically weaken the necessary new research and development that was vital to all countries. The pharmaceutical industry supported surveillance and the rational prescribing and use of medicines, and was working with WHO to improve the monitoring of antimicrobial resistance. On the subject of rational prescribing and use of medicines, the primary focus in the past had been on the allegation that drug consumption had been driven simply by industry promotion: few had referred to other elements, including consumer demands for medicines, access to medicines without prescription and the frequently perverse incentives under some health care financing systems to overprescribe and underutilize medicines, including antimicrobials. The industry believed that regulation, including self-regulation under IFPMA's Code of Marketing and Promotion Practices, and strong efforts to protect patients from receiving substandard and counterfeit medicines were very important. The dumping of substandard and counterfeit medicines on the markets of many developing countries was a serious problem; the industry had found that in some developing markets up to 8% of prescription medicines were counterfeit, with antibiotics being the most counterfeited category. Within the past year the industry had formed the Pharmaceutical Security Institute, which was a group of more than 20 companies that were cooperating with WHO and national regulatory and police authorities in an attempt to reverse the expansion of a pharmaceutical underworld supplying many fake antibiotics that did not work and helped to spread resistance. The impact of counterfeit and substandard medicines on resistance levels needed serious investigation. He urged WHO to take up those problems in any discussions on trade and health. The IFPMA Code of Marketing and Promotion Practices was included in the latest edition of its publication Health horizons, available in English, French and Spanish. Complaints about inappropriate promotion were investigated by IFPMA and were taken up at the highest level with the company concerned. He was pleased to note that WHO would be making a complaint under the IFPMA Code in respect of alleged misrepresentation of WHO in a company brochure, to which attention had been drawn at an earlier meeting. He hoped that the matter would be speedily resolved. The pharmaceutical industry pledged its continued cooperation with WHO in efforts to attain health for all in the twenty-first century. The CHAIRMAN proposed that further consideration of the draft resolution be postponed, pending the preparation of a revised text incorporating the proposed amendments. It was so agreed.
(For adoption of resolution, see summary record of the sixteenth meeting, section 13.)
Noncommunicable disease prevention and control: Item 10.4 of the Agenda (Document EB101/14) The CHAIRMAN drew attention to the following draft resolution, which had been proposed by Dr Komodikis, Professor Leowski, Professor Reiner and Dr Sulaiman:
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The Executive Board, Having reviewed the Director-General's report on noncommunicable disease prevention and control; Recalling resolutions WHA29.66, WHA35.30, WHA36.32, WHA38.30, WHA42.35, WHA42.36 and WHA42.39 on various aspects of epidemiology, prevention and control of major noncommunicable diseases; Concerned about the latest trends in the increase of morbidity and mortality from noncommunicable diseases and related costs worldwide, especially in countries with a "double burden" of disease; RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution: The Fifty-first World Health Assembly, Having considered the report by the Director-General on noncommunicable disease prevention and control; Recalling The world health report 1997 which describes the high rates of morbidity from major noncommunicable diseases, led by cardiovascular diseases, and the resulting mortality, which accounts for nearly half of all deaths, a considerable part of them premature; Alarmed by the rising trend and the bleak forecast for the twenty-first century as a consequence of the demographic and epidemiological transition, and the globalization of economic processes; Recognizing that they cause enormous human suffering and threaten the economies of Member States, where costly treatment will further deprive the poor and powerless and increase the inequities in health between population groups and countries; Mindful of common major behavioural and environmental risk factors that are more amenable to modification through the implementation of concerted essential public health action, as has been demonstrated recently in several Member States; Aware that, with diminishing resources, health professionals, particularly those in the forefront of health care delivery, often become the major source of health information as well as the providers of care and support to individuals and communities; Recognizing the importance of, and continued need for, broad international action and cooperation aimed at the development and promotion of policies and strategies to assist Member States in meeting the growing challenge of chronic noncommunicable diseases in the most costeffective way, 1. ENDORSES the proposed framework for the integrated prevention and control of noncommunicable diseases, including the provision of public health services and the major involvement of health and medical professions in improving the health of individuals and communities; 2. URGES Member States to collaborate with WHO in developing a global strategy for the prevention and control of noncommunicable diseases based on best practices and operational research, as part of their health-sector reforms, in order: (a) to promote health and reduce major common risk factors for chronic noncommunicable diseases through essential public health action and the integration of preventive measures within the functions of health services, and particularly in primary health care; (b) to collate information and set standards in order to ensure appropriate case detection and management; (c) to monitor scientific data and support research in a broad spectrum of related areas, including human genetics, nutrition and diet, matters of particular concern to women, and development of human resource for health; 3. REQUESTS the Director-General: (1) to develop a global strategy for prevention and control ofnoncommunicable diseases within the framework of the renewed WHO health-for-all policy for the twenty-first century
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and in consultation with Member States and the agencies and professional organizations concerned, to give priority to such activities; (2) to ensure, while developing the strategy, an effective managerial mechanism for collaboration and technical support involving all programmes concerned at different levels of the Organization, as well as WHO collaborating centres, emphasizing the development and strengthening of global and regional demonstration projects; (3) to solicit the support of nongovernmental organizations and other international agencies by creating a forum for the exchange of experience and results of research; (4) to encourage cooperation with the private sector so as to mobilize extrabudgetary resources for the implementation of plans at the global and interregionallevel and to promote capacity-building at the national level; (5) to submit the proposed global strategy and a plan, with a timetable for its implementation, to the Executive Board and the Health Assembly in 1999. Professor REINER said that the Health Assembly had adopted six resolutions on the subject, but none in the past nine years, during which the situation had worsened in both developing and developed countries. To some extent the developed countries had solved the problem of communicable diseases, but unfortunately the developing countries had had to add to their communicable disease burden a rapidly growing proportion of noncommunicable diseases. One of the essential elements listed by the Director-General in his report (EB 101114) was collaboration and coordination and it was therefore not clear why there were two programmesIntegrated Programme for Community Health (INTERHEALTH) and Countrywide Integrated Noncommunicable Diseases Intervention (CINDI) - with the same objectives. One of the solutions was to promote primary prevention and to engage in health promotion. The draft resolution before the Board was a step in that direction. He proposed that the words "to help Member States develop corresponding national policies and programmes" be added after the words "priority to such activities" in paragraph 3(1) of the resolution recommended for adoption by the Health Assembly. Dr SULAIMAN said that the topic was very important and he hoped that the draft resolution would be adopted by consensus. Dr MOREL, supported by Dr LOPEZ BENITEZ, said with regard to the second preambular paragraph of the resolution recommended for adoption by the Health Assembly that The world health report 1997 in fact stated that the high rates of morbidity from major noncommunicable diseases were led by mental diseases and not by cardiovascular diseases. He therefore proposed that the relevant part of the paragraph be amended to read: "led by mental and cardiovascular diseases, and the associated mortality, which". Dr MELON! wanted a clearer explanation of the objective being sought by paragraph 3(4) of the recommended resolution and of whether the private sector was being regarded as a service provider or as a producer, for example, of drugs. Professor LEOWSKI suggested that as there were other noncommunicable diseases which caused morbidity and death it might be preferable to delete the reference to particular diseases in the preamble. Dr TSECHKOVSKI (Assistant Director-General ad interim) said that INTERHEALTH and CINDI were networks based on the same principles, but the former was global while the latter covered 23 countries in Europe and Canada. CINDI had moved from demonstration projects, which was the major focus of INTERHEAL TH, to support for the formulation of national policies on prevention and control of noncommunicable diseases. He agreed that the reference to cardiovascular diseases in the recommended resolution was misleading and should be amended in accordance with either of the proposals made. The intention of the reference to encouraging cooperation with the private sector in paragraph 3(4) had been to bring the resolution in line with the Jakarta Declaration, which had stressed the necessity of working with the private sector. Dr MELON! said that, as it stood, paragraph 3(4) had serious potential implications in terms of conflict of interest; he reiterated that the wording should be much clearer.
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Dr MOREL, recalling the point made by Professor Leowski, proposed that the second preambular paragraph be amended to read: Recalling The world health report 1997 which describes the high rates of mortality, morbidity and disability from major noncommunicable diseases, which account for nearly half of all deaths, a considerable part of them premature. Mr MENDIS (adviser to Mr de Silva) observed that in the past two decades there had been no drastic reduction in noncommunicable diseases despite all the technological advances and medical innovations. He asked what specific strategies were to be implemented in relation to research and development, education, information, regulatory measures, and the contribution of WHO. Professor REINER explained that the basic idea behind the drafting of paragraph 3(4) had been, in line with the Jakarta Declaration, to encourage cooperation with the private sector predominantly with respect to health promotion; obviously, there was no intention to stimulate any unethical practices or any influences on the part of the pharmaceutical industry which might jeopardize the objective to be achieved. Dr MELONI said he understood the basic idea behind the operative paragraph, but its wording was far too broad in its scope; the precise meaning should be spelled out. Mr AITKEN (Assistant Director-General) said that there were guidelines for WHO's cooperation with the private sector, and if the words "within the current guidelines of WHO" were to be inserted in paragraph 3(4) after the words "private sector", Dr Meloni's concerns might be to some extent allayed. The CHAIRMAN invited the Board to consider the draft resolution with the amendment to the preamble proposed by Dr More!.
The resolution, as amended, was adopted. 1 (For continuation, see summary record of the sixteenth meeting, section 2.)
The meeting rose at 17:05.
1
Resolution EBIOI.R9.
THIRTEENTH MEETING Monday, 26 January 1998, at 9:00 Chairman: Professor A. ABERKANE
DIRECTOR-GENERAL: Item 5 of the Agenda (continued) Nomination for the post: Item 5.1 of the Agenda (continued from the third meeting)
The meeting was held in private.
The meeting rose at 13:00.
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FOURTEENTH MEETING Monday, 26 January 1998, at 14:30 Chairman: Professor A. ABERKANE
DIRECTOR-GENERAL: Item 5 of the Agenda (continued) Nomination for the post: Item 5.1 of the Agenda (continued)
The meeting was held in private.
The meeting rose at 17:20.
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FIFTEENTH MEETING Tuesday, 27 January 1998, at 9:30 Chairman: Professor A. ABERKANE
The meeting was held in private from 9:30 to 13:00 when it resumed in public session.
DIRECTOR-GENERAL: Item 5 of the Agenda (continued) Nomination for the post: Item 5.1 of the Agenda (continued) Dr VAN ETTEN, Rapporteur, read out the resolution on the nomination for the post of Director-General adopted by the Board in private session: 1 The Executive Board I. NOMINATES Dr Gro Harlem Brundtland for the post of Director-General of the World Health Organization, in accordance with Article 31 of the Constitution;
2.
SUBMITS this nomination to the Fifty-first World Health Assembly.
Draft contract: Item 5.2 of the Agenda (continued) Dr SANOU IRA, Rapporteur, read out the resolution on the draft contract of the Director-General adopted by the Board in private session: 2 The Executive Board, In accordance with the requirements of Rule 109 of the Rules of Procedure of the Health Assembly, SUBMITS to the Fifty-first World Health Assembly the draft contract3 establishing the terms and I. conditions of appointment of the Director-General; 2. RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution:
1 2
Resolution EBlOl.Ril. Resolution EBIOI.RI2. The contract, when approved, will be reproduced in WHA51!1998/REC/l.
3
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The Fifty-first World Health Assembly,
Pursuant to Article 31 of the Constitution and Rule 109 of the Rules of Procedure of the Health Assembly, APPROVES the contract establishing the terms and conditions of appointment, salary and other emoluments for the post of Director-General;
II Pursuant to Rule 112 of the Rules of Procedure of the Health Assembly, AUTHORIZES the President of the Fifty-first World Health Assembly to sign this contract in the name of the Organization. At the invitation of the CHAIRMAN, Dr VAN ETTEN, Rapporteur, read out a further resolution entitled "Expression of appreciation to Dr Hiroshi Nakajima" adopted by the Board in private session: 1 The Executive Board, In deep appreciation of the outstanding services rendered by Dr Hiroshi Nakajima to health and development the world over throughout his long career in the World Health Organization, and in particular as its Director-General from 1988 to 1998, RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution: The Fifty-first World Health Assembly, Expressing its profound gratitude to Dr Hiroshi Nakajima for his outstanding services to health and development the world over throughout his long career in the World Health Organization, and in particular as its Director-General from 1988 to 1998; Paying tribute to his personal qualities of integrity, sincerity and his deep commitment to WHO and everything it stands for, DECLARES Dr Hiroshi Nakajima Director-General Emeritus of the World Health Organization as from the date of his retirement. The CHAIRMAN, speaking on behalf of the members of the Board, said that the moral, scientific and cultural eminence of all the candidates for the post of Director-General was a tribute to WHO. The transparency and serenity of the democratic voting process for the nomination of Director-General honoured both the Board and the Organization. The Board hoped that its choice of Dr Gro Harlem Brundtland would bring stability, strength and progress to WHO. He congratulated the nominee for the post of Director-General, and invited her to say a few words. Dr Gro Harlem BRUNDTLAND thanked the Chairman. The day and the moment were special not only for her but also, she was sure, for all present. In whatever capacity, all had been involved in the long process of nominating the new Director-General of WHO. As dedicated spokesmen and spokeswomen for world health, all had taken very seriously their responsibility to find the best way to serve the Organization. The nomination process had been new and different, and she believed that it had served the aims of open and transparent decision-making. All the candidates had addressed common global concerns, and they had all been given support and the opportunity, within WHO headquarters, to meet Board members, their delegations, the Director-
1
Resolution EB!Ol.Rl3.
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General and his staff. She believed that all the candidates were gratified to have been able to participate in such an open process. In one way or another, all would be working together in the future as colleagues and collaborators, to do their best for the Organization and for world health. Speaking personally, she said that the past week had been very inspiring. The discussions in the Board had convinced her even more that in WHO she would be working as part of an exciting and very competent team. She looked forward to that opportunity. She thanked the Chairman and members of the Board for the great honour bestowed upon her. She thanked the Director-General and all the dedicated members of the Secretariat, and congratulated Dr Nakajima on his nomination as Director-General Emeritus. She thanked everyone again, and said that she was looking forward to working with them. (Applause). The DIRECTOR-GENERAL, congratulating Dr Gro Harlem Brundtland, said that it was a source of great satisfaction and encouragement to him, and he was sure to all his colleagues, to see the work of the Organization being carried on with so much impetus and promise for the future. From a group of exceptionally gifted candidates, the Board had selected and nominated a highly competent personality for the post of DirectorGeneral of the Organization. On the threshold of a new century, there was a great opportunity to complete the process of renewal of international health work begun a few years previously. Throughout his own term of office, his concern had been to promote solidarity between all people, countries and cultures, in the interests of world health. With the Health Assembly's blessing, he would entrust that task with every confidence to Dr Gro Harlem Brundtland, and he was convinced that he was speaking for everyone in assuring her of wholehearted support. With the best interests of the Organization at heart, he warmly wished the next incumbent every success as its Director-General. His own years of service with WHO would soon be drawing to a close but he would continue to support its work in whatever way he could. He called on all WHO's Member States, regions and partners in health development to come together in support of the new leadership, to promote the universal values of health, solidarity and human dignity which the Organization represented. (Applause) The CHAIRMAN said that, at such a moving and historic moment, many members of the Board would surely have wished to take the floor. Unfortunately that would not be possible in view of the large amount of work still to be done.
The meeting rose at 13:15.
SIXTEENTH MEETING Tuesday, 27 January 1998, at 14:30 Chairman: Professor A. ABERKANE
The meeting was held in private from 14:30 to 15:20, when it resumed in public session.
1.
AWARDS: Item 18 of the Agenda
Or A.T. Shousha Foundation Prize (report of the Or AT. Shousha Foundation Committee): Item 18.1 of the Agenda Decision: The Executive Board, having considered the report of the Dr A.T. Shousha Foundation Committee, awarded the Dr A.T. Shousha Foundation Prize for 1998 to Dr Awad Hussein Abudejaja (Libyan Arab Jamahiriya) for his outstanding contribution to the improvement of the health situation in the geographical area in which Dr Shousha served the World Health Organization. 1
Jacques Parisot Foundation Fellowship (report of the Jacques Parisot Foundation Committee): Item 18.2 of the Agenda Decision: The Executive Board, having considered the report of the Jacques Parisot Foundation Committee, awarded the Jacques Parisot Foundation Fellowship for 1998 to Mr Boinikum Benson Konlaan (Ghana). 2
Sasakawa Health Prize (report of the Sasakawa Health Prize Committee): Item 18.3 of the Agenda Decision: The Executive Board, having considered the report of the Sasakawa Health Prize Committee, awarded the Sasakawa Health Prize for 1998 to: (1) Ms Roselyn Mokgantsho Mazibuko (South Africa); (2) Dr Ahmed Abdul Qadr AI Ghassani (Oman); and (3) the Gondar College of Medical Sciences (Ethiopia). The Board noted that Ms Mazibuko and Dr AI Ghassani would receive an amount of US$ 30 000 each and that the Gondar College of Medical Sciences would receive US$ 40 000 for their outstanding innovative work in health development. 3
United Arab Emirates Health Foundation Prize (report of the United Arab Emirates Health Foundation Committee): Item 18.4 of the Agenda Decision: The Executive Board, having considered the report of the United Arab Emirates Health Foundation Committee, awarded the United Arab Emirates Health Foundation Prize for 1998 to 1 2 3
Decision EB 10 1(7). Decision EB101(8). Decision EB101(9).
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Mrs Hillary Rodham Clinton (United States of America) for her outstanding contribution to health development. The Board noted that Mrs Clinton would receive US$ 40 000. 1 The CHAIRMAN said that the Executive Board, at its private meeting, had also considered several proposed amendments to the Statutes and the implementing regulations and guidelines governing the awards. The Dr A.T. Shousha Foundation Committee had considered WHO Executive Board decision EB100(10) and decided to amend its Statutes (Article 2) to the effect that, henceforth, the Dr A.T. Shousha Foundation Prize should be presented at a meeting of the Regional Committee for the Eastern Mediterranean. Accordingly, the presentation of the Prize had been placed on the provisional agenda for the Committee's forty-fifth session. The Board had taken note of that decision. In accordance with Article 8 of the Statutes, the revision would be transmitted for information to the next World Health Assembly. The Jacques Parisot Foundation Committee had considered WHO Executive Board decision EB 100(1 0) and agreed to amend the Implementing Regulations and Guidelines for the Award of the Jacques Parisot Foundation Fellowship to provide for the establishment of a Selection Panel, in addition to the Foundation Committee, the role of which would be to make a recommendation to the Executive Board regarding the choice of a candidate for the Fellowship. The Jacques Parisot Foundation being governed by the Swiss Civil Code, the amendments were subject to any additional action that might be required by Swiss Laws. The Jacques Pari sot Foundation Committee had also taken note of a recommendation of the European Advisory Committee on Health Research to the effect that assistance should be provided to candidates for the Fellowship in the preparation of their research proposal and that the results of the research carried out by the Prize laureate should be evaluated by the regional Advisory Committee on Health Research. The Board had taken note of the action taken by the Jacques Parisot Foundation Committee. The Sasakawa Health Prize Committee had considered the recommendation contained in WHO Executive Board decision EB 100(1 0) and agreed to revise its Statutes2 to the effect that the Prize Committee would be replaced by a Prize Selection Panel, composed of the Chairman of the Executive Board, a member of the Board and the representative of the Founder. In accordance with Article 9 of the Statutes, the proposed revisions had been submitted to the Board. At its private meeting, the Board had considered and approved the amendments, which were as follows. In Articles 4, 6, 7 and 9, the words "Prize Committee" and "Committee" would be replaced by "Selection Panel". Article 5 would be amended to read: Article 5 Selection Panel The Selection Panel entitled the "Sasakawa Health Selection Panel" shall be composed of the Chairman of the Executive Board, a member elected by the Executive Board from among its members for a period that may not exceed his or her term of office on the Executive Board, and a representative appointed by the Founder. The presence of all members of the Selection Panel shall be required for the taking of decisions. Finally, in the last sentence of Article 6, "the members present" would be replaced by "its members". In accordance with Article 9 of the Statutes, those revisions would be reported for information to the Fifty-first World Health Assembly. The United Arab Emirates Health Foundation Committee had considered a recommendation contained in decision EB 100(1 0) concerning the replacement of the Foundation Committee by a Selection Panel composed of the Chairman ofthe Executive Board and a representative of the Founder. The Foundation Committee had decided that that matter should be submitted to the Founder of the Prize and re-examined at the next meeting of the Foundation Committee in January 1999.
1 2
Decision EBIOl(IO). Resolution EB73.Rl3.
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2.
DISEASE PREVENTION AND CONTROL: Item 10 of the Agenda (continued)
Noncommunicable disease prevention and control: Item 10.4 of the Agenda (Document EB101/14) (continued from the twelfth meeting) Ms DE FIGUEIREDO (International Society and Federation of Cardiology), speaking at the invitation of the CHAIRMAN, said that ISFC represented some 130 national societies of cardiology and heart foundations in 80 countries throughout the world. Cardiovascular diseases caused high morbidity, disability and mortality in most countries, with two-thirds of total global deaths occurring in developing countries. By the year 2020, coronary heart disease and stroke would become the two leading causes of death in the developing world. The cost of treatment was enormous, while such diseases affected younger age groups in developing countries than in industrialized ones. Action was thus urgent and ISFC had increasingly been focusing its activities on developing countries and on eastern Europe. Although, during its 40 years of collaboration with WHO, ISFC had continued to expand its activities to meet country needs, WHO's programme on cardiovascular diseases had been shrinking in terms of staff and funds. It was now imperative for the Organization to take account of the increasing requirements of developing countries, especially for training, for norms and standards and for ensuring that WHO guidelines were adopted by national health systems. Collaboration between WHO and ISFC would continue to be essential in assisting developing countries and economies in transition to combat cardiovascular diseases more effectively. The recent memorandum of understanding signed between WHO, UNESCO and ISFC was aimed at developing a programme of work to promote heart health in children, especially in developing countries, through prevention of rheumatic heart disease and Chagas disease, promotion of healthy lifestyles and reduction of risk factors for cardiovascular and other noncommunicable diseases. It was essential to introduce well-tested and simple strategies, in particular for prevention and low-cost management of patients with cardiovascular disease, for the integrated prevention and control of noncommunicable diseases, many of which shared common risk factors with cardiovascular diseases, especially in countries where resources were limited. Wide-ranging prevention practices were of prime importance. As the epidemic of cardiovascular and other noncommunicable diseases advanced in developing countries, ISFC welcomed the strong resolution adopted by the Board (resolution EB 10 l.R9) and was prepared to assist in developing a global strategy that would protect the health of future generations. Ms WILLIAMS (International Diabetes Federation), speaking at the invitation of the CHAIRMAN, said that diabetes and other serious noncommunicable diseases affected both developing and developed countries creating a growing economic and social burden. Currently, 135 million people suffered from diabetes worldwide- a figure expected to rise to 300 million by the year 2025, with most of the increase in the developing countries. Diabetes, the direct cost of which already amounted to 5-l 0% of national health care budgets, was closely associated with other noncommunicable disorders such as heart disease, stroke and hypertension. The Federation worked with 147 member associations in 122 countries to enhance the lives of people with diabetes and to promote primary, secondary and tertiary prevention. Collaboration between the Federation and WHO had included: the major Saint Vincent programme in Europe and the subsequent Declaration of the Americas; the preparation of World Diabetes Day and work in a number of areas including national diabetes programmes, diabetes education and access to insulin; and the sharing of expertise with a view to developing an integrated approach to the prevention of major chronic diseases. Prevention, as an important function of health care, was a key objective for all those concerned with noncommunicable diseases; the combination of preventive and curative measures proposed by WHO was welcomed. The Federation urged WHO to give the highest priority to action against noncommunicable diseases including diabetes, encouraging governments to adopt and apply national prevention and control policies and implementing a global plan of action for the prevention and control of noncommunicable diseases. Dr MILTON (World Medical Association), speaking at the invitation of the CHAIRMAN, said that the Association as a global body covering approximately 77 countries, included more than eight million physicians, members of their national medical associations, who were all an integral part of the health care delivery and management systems in their respective countries. Since they spanned all sectors of the health care spectrum, the Association could also contribute significantly to the collection of data and generation of essential health care management information. Although as in the past the Association had focused mainly on ethics and the
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highest possible standards of medical education, it now also played a more prominent role in the democratization process and the generation and dissemination of relevant health care information. In this, particular attention was given to the physicians' role in preventive care and health promotion. One area for fruitful collaboration between WHO and WMA was that of noncommunicable diseases. The Association believed that the medical profession, which hitherto had concentrated mainly on curative aspects of health, should now expand its activities in the field of prevention and health promotion - an area in which a joint project with WHO was envisaged.
3.
COLLABORATION WITHIN THE UNITED NATIONS SYSTEM AND WITH OTHER INTERGOVERNMENTAL ORGANIZATIONS: Item 12 of the Agenda
General matters: Item 12.1 of the Agenda (Document EB1 01/17) Mr SILBERBERG (alternate to Mr Voigtllinder) welcomed the report contained in document EB I 0 l/17, although it did not yet take into account the latest resolutions of the General Assembly of the United Nations concerning the Secretary General's two-track reform package. WHO should be encouraged to make use of all opportunities to cooperate with the newly formed United Nations development group and the Department of Economic and Social Affairs. He fully endorsed the conclusions in paragraph 5 of the report concerning operational activities for development. However, WHO should not only be closely involved in the review of the newly established coordination mechanisms - country strategy notes and the United Nations Development Assistance Framework- but also in the practical application of those new instruments. Or LARIVIERE (alternate to Mr Juneau) stressed the importance of the two-track process for the whole of the United Nations system. However, in recent years WHO had made considerable progress in its own reform, developing, in terms of programme management, approaches that could prove useful for other organizations in the United Nations system. Or BERLIN (European Commission) said that, although not mentioned in the report, collaboration between the European Commission and WHO had continued and strengthened, extending to a number of new areas. The entry into force of the Treaty of Amsterdam would considerably strengthen public health in the European Union, one key requirement being that all other community policies would have to take health into account in order to ensure a high level of health protection. The recent bovine spongiform encephalopathy crisis had led to the establishment by the Commission of a number of scientific advisory committees in the field of consumer health, for which WHO expert group opinions would be of value. One major achievement in the field of health had been the political agreement on community legislation to ban tobacco advertising. In its white paper on smoking prevention, the Commission had considered the possibility of active support for the development by WHO of a tobacco convention, an area in which he hoped rapid progress would be made. Other areas of collaboration with WHO included: efforts to improve the reliability of statistical health data; health promotion, including the Fourth International Conference on Health Promotion held in Jakarta; and epidemiological surveillance and rapid response to epidemics, in collaboration with the Regional Office for Africa and USAID. He hoped that further efforts would be made to strengthen collaboration between the European Commission and WHO. Or ALLEYNE (Regional Director for the Americas), referring to paragraph 2 of the Director-General's report, inquired what decisions were being taken concerning the establishment of a United Nations development group. Mr AITKEN (Assistant Director-General) said that the development group would report directly to the Secretary-General of the United Nations. The question of liaison and access to that group by the specialized agencies would be discussed at the forthcoming April session of ACC.
The Board took note of the report.
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WHO/UNICEF/UNFPA Coordinating Committee on Health: (Resolution EB100.R2; Document EB101/18)
Item 12.2 of the Agenda
The CHAIRMAN said that document EB101/18 was presented in two parts: Part I contained a summary of the recommendations made by the UNICEF/WHO Joint Committee on Health Policy (JCHP) at its thirty-first session while Part 11 was a progress report on the establishment of its replacement, the WHO/UNICEF/UNFPA Coordinating Committee on Health (CCH). Dr WILLIAMS, introducing Part I of the document, said the text was self-explanatory. Any questions thereon should be directed to the Secretariat. Decision: The Executive Board took note of the report of the UNICEF/WHO Joint Committee on Health Policy on its thirty-first and final session 1 held in Geneva on 19 and 20 May 1997, and endorsed the recommendations made by the Committee. 2 Dr TURMEN (Executive Director, Family and Reproductive Health), introducing Part 11 of the document, outlined the steps since the Executive Board session in January 1997 leading to the establishment of the proposed WHO/UNICEF/UNFPA Coordinating Committee on Health, pointing out that the proposed terms of reference were based on those of the existing Joint Committee on Health Policy constituted by UNICEF and WHO, expanded to include coordination in the field of maternal, child, adolescent, women's health and reproductive health, especially at country level. A number of amendments had been proposed by the UNICEF and UNDP/UNFPA Executive Boards concerning both procedural matters and more substantive issues relating to coordination in the field of child, adolescent, women's health and reproductive health, focus on the needs of countries and due regard for the respective mandates ofthe organizations involved. The representatives of the organizations involved had met informally on 14 November 1997 to discuss follow-up to the various technical issues of common concern and procedures proposed for conducting the sessions of the new Committee. The Board might wish to take note of the progress made in that regard and, in the spirit of United Nations reform aimed at better collaboration within the United Nations system, agree that the preliminary meeting of CCH should be held in 1998. That meeting should take fully into account the suggestions made by the Executive Boards of UNICEF and UNDP/UNFPA in order to consider further the outstanding aspects of its terms of reference with a view to making a final recommendation in that connection and to discuss items of common concern falling within those terms of reference on which there was already agreement. The Board might also wish to ask its Chairman to inform the Presidents of the UNICEF and UNDP/UNFPA Executive Boards of that decision and request WHO to make the necessary arrangements to convene the preliminary session of CCH. The report of the deliberations of the new Committee would be submitted to the subsequent session ofthe WHO Executive Board in 1999. Dr SULAIMAN, speaking as a participant at the May meeting of the JCHP, said that the recommendations and amendments proposed by the UNICEF and UNDP/UNFPA Executive Boards did not affect the essence of the subject and related essentially to procedural matters. He therefore hoped that the Board would find them acceptable and endorse the document. Decision: The Executive Board, having considered the report of the Director-GeneraV agreed that a preliminary meeting of the WHO/UNICEF/UNFPA Coordinating Committee on Health should be held in 1998. 4
1 2 3 4
Document JCHP31197.6. Decision EBIOI(ll). Document EBIOl/18, Part 11. Decision EB101(12).
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Environmental matters: Item 12.3 of the Agenda (Documents EB101/19 and EB101/20 and Corr.1) Ms ADERHOLD (alternate to Mr VoigtUinder) said that discussions on the new health-for-all policy had highlighted the adverse impact of global environmental hazards such as climate change as one of the major challenges of the future. Sanitation had also been identified as a key environmental determinant of human health. She therefore endorsed the draft resolutions set out in the two documents under consideration, as important steps in defining the future role of WHO in the field of environmental health. She particularly welcomed the integrated approach of the two resolutions. With regard to climate change, she agreed that WHO should place emphasis on climate impact assessment studies, which seemed to have been neglected, as it was anticipated that changes in factors such as the range of vector-borne diseases would have an impact on entire communities or populations. With regard to the strategy on sanitation for high-risk communities, she drew attention to the fact that those most vulnerable in such communities were children and women of child-bearing age. Dr LARIVIERE (alternate to Mr Juneau) said that the report on strategy on sanitation in high-risk communities could have given greater emphasis to the link between environmental sanitation, or the lack of it, and transmission of communicable disease. He hoped more attention could be given to the point in the documentation on the subject to be submitted to the Fifty-first Health Assembly. The CHAIRMAN invited the Board to consider the resolution on strategy on sanitation for high-risk communities contained in paragraph 21 of document EB 101119.
The resolution was adopted. 1 The CHAIRMAN invited the Board to consider the draft resolution on climate change and human health contained in paragraph 13 of document EB 101120, with the corrections set out in document EB 101120 Corr.1. Dr CALMAN supported the draft resolution with the corrections submitted. Dr VAN ETTEN suggested that a reference to the Kyoto Protocol could usefully be added to the DirectorGeneral's report and urged that funds should be made available from the regular budget for related types of activity. With regard to the corrections set out in document EB 101120 Corr.1, he recalled the Board's earlier discussion on the proliferation of promotional days and suggested that the reference to institution of a World Melanoma Awareness Day should be deleted from the proposed new paragraph 2(4), which should then end with the words "public awareness programmes and actions;".
The resolution, as amended, was adopted. 2 International Decade of the World's Indigenous People: Item 12.4 of the Agenda (Document EB101/21) Dr LARIVIERE (alternate to Mr Juneau) drew attention to the importance of the item for WHO, the United Nations and, indeed, for his own country. He urged that WHO should continue its work with the programme of action for the Decade and to develop national plans of action, based on the work done at regional and global level, in partnership with other United Nations organizations, nongovernmental organizations and representatives of first nation or aboriginal populations, in order to address the health issues affecting those populations and ensure their full participation in the process.
1 2
Resolution EB10l.Rl4. Resolution EB10l.Rl5.
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Dr MELONI, endorsing those views, said he would also like greater stress laid on aspects such as fuller cooperation with other United Nations bodies working in the area, with special reference to population groups suffering from social exclusion, especially in the area of health. The CHAIRMAN took it that the Board wished to take note of the report and encourage WHO in its efforts. It was so agreed.
Reports of the Joint Inspection Unit: Item 12.5 of the Agenda (Document EB1 01/22) Mr MEZZALAMA (Joint Inspection Unit), observing that several Joint Inspection Unit reports were contained in document EBlOl/22, on subjects ranging from the advancement of women in the United Nations system to a comparison of methods of calculating equitable geographical distribution within the system, said that although the fact might not be immediately apparent, all the subjects were of general interest and important for the Organization, as Board members would realize in examining the reports, particularly in the light of the current reform of the United Nations system. Dr MELONI, referring to paragraph 14 of the report, suggested that the word "modest" was inappropriate in the context of an initiative on "Health as a bridge for peace". Decision: The Executive Board, having considered the reports of the Joint Inspection Unit entitled "The advancement of women through and in the programmes of the United Nation system: what happens after the Fourth World Conference on Women?", "The involvement of the United Nations system in providing and coordinating humanitarian assistance", "Strengthening of the United Nations system capacity for conflict prevention", "Coordination of policy and programming frameworks for more effective development cooperation", "Review of financial resources allocated by the United Nations system to activities by nongovernmental organizations", and "Comparison of methods of calculating equitable geographical distribution within the United Nations common system", thanked the Joint Inspection Unit for its reports and expressed its agreement with the Director-General's comments thereon. 1 It requested the Director-General to transmit those comments to the Secretary-General of the United Nations, the participating organizations of the Unit, the Chairman of the Joint Inspection Unit, and the External Auditor of WHO, for their information and perusaJ.2
4.
MATTERS RELATED TO THE PROGRAMME BUDGET: Item 13 of the Agenda
Efficiency plan for the financial period 1998-1999: Item 13.1 of the Agenda (Document EB101/23) The CHAIRMAN invited the Board to consider a draft resolution proposed by Professor Aberkane, Dr AlMousawi, Dr Alvik, Dr Blewett, Dr Calman, Dr Dossou-Togbe, Dr van Etten, Dr Ferdinand, Dr Fikri, Dr Hembe, Mr Juneau, Professor Leowski, Dr L6pez Benitez, Dr Mazza, Dr More!, Dr Mulwa, Dr Nakamura, Professor Reiner, Dr Badran (alternate to Professor I. Sallam), Dr Sanou Ira, Dr Shin, Dr Stamps, Dr Sulaiman, Mr Voigtliinder, Dr Wasisto and Dr Williams, which read:
1 2
Document EB 101122. Decision EB101(13).
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The Executive Board, Recalling resolution EB99.Rl3 on programme budgeting and priority-setting, and resolution WHA50.26 on "proposed programme budget for the 1998-1999 biennium: reallocation to priority health programmes of amounts resulting from measures to increase efficiency"; Recognizing the need to ensure that specific high-priority health activities receive the most substantial financing possible, as recommended by the Executive Board at its ninety-ninth session, 1. NOTES the report by the Director-General on the efficiency plan for the financial period 1998-1999;
2.
REITERATES its request to the Director-General: (1) to develop and present a comprehensive efficiency plan for the Organization, based on a review of the six appropriation sections, that clearly identifies specific administrative savings and more effective means of programme delivery; (2) to specify clearly in the development of the efficiency plan a systematic approach to save, through measures of efficiency, 3% from the administrative and overhead costs in the six appropriation sections during the 1998-1999 biennium, and to reallocate these amounts to priority health programmes; (3) to report to the Fifty-first World Health Assembly on the efficiency plan, clearly specifying savings to be made and indicating the health programmes to which such savings should be reallocated, and on the progress made in the implementation of resolution EB99.R13; (4) to report in detail to the Fifty-first World Health Assembly on the action taken to respond to the requests of the Executive Board in resolution EB99.Rl3.
Mr AITKEN (Assistant Director-General), introducing document EB 101/23, said that it set out an attempt to develop a strategic efficiency plan which did not, however, seem to have received approval by the members of the Administration, Budget and Finance Committee of the Executive Board (ABFC). Furthermore, the purport of the draft resolution, which a large majority of the Board had sponsored, was to have the plan recast. That would be done, should the draft resolution be adopted, as would its request to report on the action taken to the Fifty-first Health Assembly, rather than to a subsequent session of the Board. Mr CREGAN (alternate to Mr Hurley) noting that the item had been discussed at the joint meeting of the Programme Development Committee of the Executive Board (PDC) and ABFC, said that although he endorsed the overall thrust of the draft resolution, he could not support the proposal to report to the Health Assembly on the matter, which was essentially one of management and execution and as such fell within the purview of the Executive Board. An observation had been made during the current session that sometimes the Executive Board did not pay sufficient attention to the deliberations of its special groups and committees; in that context, it should be noted that the joint PDC/ABFC meeting had considered that there was a need for further reporting on the efficiency plan to the Executive Board as well as to ensure that efficiency savings were made across the range of programmes and transferred to priority areas. Although some members of the Board might find the report disturbing, the analysis therein, although somewhat concise, appeared in essence to be correct. While committed to the reform process, he was increasingly convinced that the policy of static growth adopted had hindered the Organization from performing effectively and that the continuing financial uncertainty identified in the report inhibited proper forward financial planning. If the wish was to enhance the credibility of WHO, improve its morale, and give the incoming Director-General an opportunity to make a significant impact, he believed that maintaining a financial stranglehold on the Organization would be counterproductive. Given the tight schedule of the Fifty-first Health Assembly, the appointment of a new Director-General and the importance of the renewed health-for-all policy, he believed that presentation of the draft resolution to the Assembly would strike the wrong note and might be construed as being unnecessarily adversarial and divisive at the beginning of a new era, besides being of questionable operational value. He therefore suggested that it would be more effective to allow the new Director-General time to assess the situation and return to the Board with a definitive stance. Since the Board was calling on the Organization to display efficiency, it should
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make the same demand of itself. He therefore proposed that the draft resolution be referred in the first instance to a future session of the Executive Board, and not to the Health Assembly. Professor REINER endorsed those views. A further concern was that at a time the Board was being asked to consider detailed administrative issues such as amendments to the Staff Rules, adjustment of salary schedules and consolidation of post adjustment classes, it had proved impossible to propose an efficiency plan as the Health Assembly had requested. The large number of sponsors of the draft resolution was a measure of the Board's recognition of the great need for such a plan. Dr BLEWETT questioned whether acceptance of the proposal to report to the Executive Board rather than the Health Assembly would prevent implementation of any action during the 1998-1999 biennium. Mr AITKEN (Assistant Director-General) said that with regard to the report, it had been the DirectorGeneral's view, in the context of the strategic budget, that it would be unwise for the Organization to commit itself to a plan containing minute details on how to proceed. However, since it was evident the Board wished for more than had been provided, planning on those lines it indicated would be initiated immediately after the present session, a report submitted to the Board or Health Assembly as appropriate, and every effort made to implement the resultant efficiency plan during the 1998-1999 biennium. Dr MELONI said that in paragraph 3 of resolution WHA50.26, the Fiftieth World Health Assembly had requested the Director-General to report in detail to the 101st session ofthe Executive Board on the progress made in the implementation of resolution EB99.R13. However, the report now under consideration was fairly general and contained no specific details. He would like to see that rectified and, in particular, to have a clear separation made between two concepts - ensuring adequate funding and making savings in administrative services and staff- that were superimposed in the present document. Mr VOIGTLANDER said that resolution WHA50.26 set its aim out clearly as being to achieve an "efficiency savings" target of 3% and to reallocate those amounts to activities of priority health programmes. He found it difficult to support the philosophy behind the report- to achieve the same ends with less money, since it reduced the request made by the Health Assembly to a mere mathematical procedure. By its decision, the Health Assembly had intended to allocate a greater share, even if only 3%, of resources to priority areas, thus increasing the visibility of the Organization. That was why adoption of the draft resolution was important. Dr MAZZA endorsed, like others, the procedure set out in the draft resolution. Since there had already been considerable discussion of the efficiency plan in both the Health Assembly and the Board, further work on it should not be delayed but should take place in the period leading up to the Fifty-first Health Assembly. Dr SIKOSANA (alternate to Dr Stamps) asked whether there had been any change in the situation relating to outstanding arrears set out in paragraph 9 of the report, since such arrears would play an important role in the discussions in progress. Mr AITKEN (Assistant Director-General) said that the situation had not in fact changed. Long-term arrears for the 1998-1999 biennium were projected to be around 3%. Such arrears were those which were two years or more behind the due date and were not covered by internal borrowing. Provision would have to be made for them. Dr SIKOSANA (alternate to Dr Stamps) said that at previous Health Assemblies concern had been expressed that certain countries had not paid their arrears although expected to do so. Was that still the case and was it the reason for the problems being encountered in the current discussion? Mr AITKEN (Assistant Director-General) explained that the long-term arrears were not so much from countries who "could pay but would not pay" as from those who faced economic and financial constraints. Short-term arrears, however, were of a different nature.
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Dr LARIVIERE (alternate to Mr Juneau) said that the issue of reporting either to the Board or to the Health Assembly or to both had still to be resolved. In the light of the discussions at the joint ABFC/PDC meeting, there was perhaps room for reporting to both bodies although in slightly different ways. In response to resolution WHA50.26, which was associated with adoption of the budget and with identification of resources for investment in priority programmes at country level, the meeting had considered that 3% of the overall budget could be shifted out of administrative costs. According to Mr Aitken, the Health Assembly would wish to hear how its resolution was being implemented, whether savings were being made even though they might not come in line until nearer the end of the biennium. However, the issue should also be kept under scrutiny by the Executive Board: it should receive a strategic presentation of alternate means of doing business and reducing overheads and support costs allowing it to make strategic decisions relating to new ideas and methods of work that would generate savings. Mr AITKEN (Assistant Director-General) said that if the Board accepted the suggestion made by Dr Lariviere, a report could be prepared for the Health Assembly and a strategic analysis carried out for submission to the Board at its 103rd session in January 1999. Mr CREGAN (alternate to Mr Hurley) said that in that case it would be necessary to amend paragraph 2(4) of the resolution recommended for adoption by the Health Assembly and to report in detail to the Executive Board rather than to the Health Assembly. Paragraph 2(3) would cover the point made by Dr Lariviere. Mr WARRINGTON (adviser to Dr Calman), endorsing the proposal made by Dr Lariviere, said that the desired effect could perhaps be achieved by deleting the words "in detail" in paragraph 2(4), and then adding at the end of the sentence "and in detail to the 103rd Executive Board".
The resolution, with the amendments proposed by Mr Warrington, was adopted. 1 Programme budgeting and priority-setting: Item 13.2 of the Agenda (Resolution EB99.R13; Document EB101/24) The CHAIRMAN recalled that PDC had considered the report contained in document EB 101124 prior to the start of the Executive Board session, and had subsequently informed the Board of its discussion during consideration of item 6 (document EB10113). Mr WASLANDER (alternate to Dr Van Etten) commended the report which offered a model that would provide a "bottom-up" approach to establishing priorities and, by means of a consultation process, ensure that unity within the Organization would be maintained. Given, however, that the model was rather abstract in nature, it would be useful to be informed about the outcome of the field-testing that was announced. Dr SHIN said that evaluation of the programme's main purpose was very important for the future of WHO. However, that also necessitated the installation and operation of the computerized management activity system currently being developed. Noting that systematic application of the analytical framework was envisaged in the 2002-2003 programme budget, he suggested that closer examination of the feasibility of such a measure was called for. The new priority-setting method was necessary throughout the programme management area, but more especially in the evaluation of the current programme budget implementation and for extrabudgetary dialogue. Since the main operation, with mobilization at the country and regional levels, was not due to start until 2002, it was important to seek a parallel method, or "proxy", that could be introduced at headquarters as soon as possible, perhaps in 1999. The Board might make a recommendation to that end. He wished to know whether the global evaluation programme would incorporate certain basic core modules, corresponding for example to the 50 items in the programme accounting process, or whether a different system of classification would be used. Against the background of the programme priority development effort,
1
Resolution EBIOI.R16.
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installation of the activity management system must be accelerated as a prerequisite for the implementation of a high-level evaluation programme. Dr DEBRUS (alternate to Mr Voigtliinder) observed that for the first time a persistent fundamental problem had been addressed in a basic and systematic fashion. The main objective was to set priority objectives and provide the necessary financial means. The document before the Board clearly presented the methods to be adopted at country, regional and global levels, and took account of a number of basic aspects which might all influence the decision-making process. The participation of Member States in all priority-setting was essential. Similarly, the financing of corresponding programmes should be the subject of comprehensive consultations with Member States. Indeed, it was a matter of principle that participation should be reflected in continuous, rather than episodic discussion. Another important aspect not adequately reflected in the report concerned the ordering of the various priorities, since not all of them could be realized fully or simultaneously. It would be necessary to decide on criteria for determining the order of the various priorities. Certainly, any new procedure of setting priorities should be tested. However, was such a process only to be carried out in two countries per region and in one regional office, as stated in the document? To his mind, a larger number of countries and all regional offices should be subject to testing. Dr SHIN said that broader involvement in priority-setting in the longer term might be discussed at a later stage; what immediately concerned him was the establishment of the programme budget for the biennium 20002001. As one who had taken part in the exercise, he knew that priority -setting for the period 1998-1999 had resulted in extremely limited recommendations of doubtful applicability and relevance. Clearly, the whole matter required thorough analysis. Dr MELONI agreed on the fundamental importance of a method for setting priorities. However, it should be remembered that priorities were established for the allocation of resources. When considering the report of the special group for the review of the Constitution, the Board had discussed a number of criteria that needed to be refined relating to the allocation of resources at country, intercountry and regional levels. The two matters were closely linked. How were they seen as complementing and reinforcing each other? Dr CHOLLAT-TRAQUET (Division of Development of Policy, Programme and Evaluation), acknowledging that the comprehensive exercise under consideration was an innovation, said that the prioritysetting methods described in the report would need to be tested and, on the basis of the findings, adjusted as necessary. In response to concerns expressed regarding links between the different management systems, she explained that the aim was to put such methods to good use in developing other components of the managerial process in WHO, in particular with respect to the general programme of work, the programme budget and plans of action. The priority-setting system was also closely linked with the evaluation system discussed earlier in the session. By resolution EB 10 1.R1, the Board sought a more systematic evaluation, notably to complement the programme budget proposed for 2000-2001. Dr Shin could rest assured that an evaluation exercise would be conducted before the establishment of the programme budget for that period and the methodology described in the report would be applied as far as possible, to the extent that tests had borne out its trustworthiness. Programme management would also be supported by the activity management system which was expected to provide timely information at reduced costs. The new methods would allow for a more rational approach to the ongoing consultations already under way among Member States; moreover, their application should enable priorities to be classified, notably for the purposes of budget allocations. As for testing the priority-setting methods in more regional offices she pointed out that resolution EB10l.R1 already placed a heavy burden ofwork on programme managers in relation to programme budget development, evaluation activities and the preparation of the plans of action. The report before the Board focused above all on the programme budget for the 2002-2003 biennium, since that would be the first programme budget ofthe Tenth General Programme of Work, the Board having already set its priorities for the Ninth General Programme of Work.
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In the absence offurther remarks, the CHAIRMAN said he took it to be the Board's understanding that the Director-General would give the Board's proposals due consideration when finalizing the methods for priority-setting and applying the corresponding analytical framework. It was so agreed.
5.
FINANCIAL MATTERS: Item 14 of the Agenda (Document EB101/4)
Status of collection of assessed contributions, including Members in arrears to an extent which would justify invoking Article 7 of the Constitution: Item 14.1 of the Agenda (Resolutions WHA50.7 and WHA50.8; Documents EB101/25 and EB101/26) The CHAIRMAN drew attention to the draft resolution contained in paragraph 15 of the report by the Director-General on the status of collection of assessed contributions (document EB 10 1/25).
The resolution was adopted. 1 The CHAIRMAN invited the Board to take note of the report on Members in arrears to an extent which would justify invoking Article 7 of the Constitution (document EB I 0 1/26), as recommended by the Administration, Budget and Finance Committee (ABFC). It was also suggested that the Board should request ABFC to review at its ninth meeting the list of countries concerned (taking into account resolution WHA41.7) and to formulate recommendations thereon to the Fifty-first World Health Assembly based on the status of those countries' arrears at that time. Dr STAMPS said that the matter could not be allowed to pass without comment. Most of the nations whose votes had been suspended were in a terrible predicament. Moreover, it was paradoxical that countries which had the worst health problems in the world would be unable to participate in decision-making at the Health Assembly, leaving the determination of events to countries that were able to meet their payments, not to mention those which manipulated their payments in order to put pressure on the Organization to reduce expenditure in certain areas. He drew particular attention to the plight of Iraq, whose population, through no fault of its own, was suffering serious health problems as the consequence of United Nations sanctions on the Government. Declining to accept the report before the Board as presented, he sought the support of members for a draft resolution recommending restoration of the voting privileges of all the countries concerned for the Fifty-first World Health Assembly only, on the understanding that their individual positions would be reviewed before the Fifty-second World Health Assembly. The measure he proposed would seem to be an appropriate way for Members to mark together the Organization's jubilee. He would not go so far as to suggest debt forgiveness, but merely the renewal of the dignity of the countries concerned by restoring their voting privileges and thereby ensuring the participation of the entire global family in the celebration of the Organization's fiftieth anniversary and the installation of a new Director-General. Dr EL BINDARI-HAMMAD (adviser to Professor Sallam) supported the proposal by Dr Stamps. Mr AITKEN (Assistant Director-General), referring to the table in Annex I of the report, provided clarifications on the status of the countries concerned, which were listed under four different headings. Action concerning the first three groups had already been taken by the Health Assembly. However, since the financial situation of the IO countries in the fourth group might well change before the Fifty-first World Health Assembly,
1
Resolution EB l 0 l.Rl7.
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it would be reviewed by ABFC. ABFC would normally then make recommendations directly to the Health Assembly, taking the views of the Board into account. The CHAIRMAN, speaking in a personal capacity, supported the proposal by Or Stamps in view of the Organization's fiftieth anniversary and the particularly difficult situation of the countries involved. Mrs PERLIN (alternate to Mr Juneau) observed that some poor countries managed to pay their contributions in full and on time, while other wealthier nations sometimes failed to do so. It was incumbent on the Board to recognize the efforts of those countries that had met their obligations; that might not be the case ifDr Stamps' proposal were accepted. She would therefore prefer to follow past practice, namely to examine the situation of the countries in question on a case-by-case basis at the Health Assembly. Or STAMPS submitted that given the number of countries involved, it would not be feasible to examine the situation of all of them in detail before the next Health Assembly. He reiterated that he was by no means suggesting a waiving of liabilities for countries in arrears, but merely the restoration of the full privileges of all Member States on the occasion of the Organization's fiftieth anniversary. Calling for a stronger focus on the plight of countries that were unable to meet payments of their contributions due to special circumstances, and remarking in particular that whether or not one felt sympathy for the situation of Iraq, that country had a significant contribution to make to the Health Assembly, he suggested that the process alluded to by Mrs Perlin, which would involve a great deal of investigation, could be carried out during the following year. Or WILLIAMS expressed support for Or Stamps' proposal. Mr MOUT (alternate to Or van Etten), Mr WARRINGTON (adviser to Or Calman) and Or NAKAMURA endorsed Mrs Perlin's suggestion. Or STAMPS observed that adoption ofMrs Perlin's suggestion would have the effect of depriving the Member States concerned of the opportunity to express their opinion on the appointment of the new DirectorGeneral. Mr AITKEN (Assistant Director-General) suggested, by way of compromise, that in the report on the subject of arrears of contributions that the Director-General would be preparing for the Health Assembly, there might be a paragraph reflecting the discussion that had just taken place, including the argumentation by Or Stamps and by those who had opposed his recommendation. In its turn, ABFC, having examined the situation of the fourth group of countries concerned, would be reporting to the Health Assembly, so that the latter body should be in a position to make an informed recommendation. Or STAMPS said that it might be more appropriate to conduct a straw poll on his own proposal before proceeding to consider options put forward by the Director-General. The CHAIRMAN explained that he had asked the Assistant Director-General and the Legal Counsel for advice as to a possible solution that would be in conformity with the rules. Speaking in his personal capacity, he asked whether the Board might not request ABFC to consider the matter prior to the Health Assembly, with a view to allowing for and perhaps facilitating the participation of the Member States in question in the election of the new Director-General and in the fiftieth anniversary celebrations, on the occasion of which invitations were to be extended to national leaders. Or STAMPS, pointing out that according to Article 7 of the Constitution, the Health Assembly alone had the authority to suspend or restore voting privileges and services, said that were ABFC to be invited to report to it on the matter, it would surely benefit from the results of a straw poll conducted at the current meeting. Mr KALBITZER (alternate to Mr Voigtlander) said that, should a vote be taken, he would be in favour ofMrs Perlin's proposal, but would prefer to avoid a vote, believing the solution offered by Mr Aitken to be a sound one. By way of clarification, he proposed that the Board's resolution or decision should note the different
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views that had been expressed during the discussion and request ABFC to consider the matter in the light of those views prior to the Health Assembly, to which it would make a proposal. Finally, as stated, the Health Assembly would decide on the matter. Mr de SILVA said that Article 7 of the Constitution was very clear as to the Health Assembly's authority. By reporting to the Health Assembly that some Member States had failed to comply with their financial obligations, the Executive Board would not be taking a decision but merely doing its duty and providing guidance for the Health Assembly, which, when taking its decision, would take due account of the grounds for non-payment by each defaulting State. Dr STAMPS pointed out that the list of Members contained in Annex 1 of document EB I 0 I /26 was not a comprehensive list of all Member States in arrears, excluding as it did certain major contributors. He failed to see why those which, by failing in part to pay their dues, owed very substantial amounts should be protected while others, which owed far smaller amounts and most of which had major health problems, should be exposed. His proposal was not for the examination of each case in turn and an inquiry into the justifications for nonpayment, which at the beginning of the Health Assembly would be an impracticable and perilous exercise, but for restoration of all voting rights for the Fifty-first Health Assembly, without creating prejudice or precedent, so that WHO's Member States could on that occasion present a unified face to the world and manifest their solidarity towards global health in the next millennium. The Organization had been much criticized in recent years, and such a gesture would be a magnanimous one that would not cost anything; on the contrary WHO would benefit from the opinions and votes of the full membership. The CHAIRMAN said that the Board could still abide by the usual procedure of submitting any decision or resolution to the sovereign Health Assembly, through ABFC. In the present instance, the Board could advise ABFC, for its enlightenment, that, while some Members had favoured the customary practice of examining each case on its merits, others had been in favour of an exceptional gesture to mark the circumstances of the election of a new Director-General, the Organization's fiftieth anniversary and the advent of the third millennium. Dr ZAHRAN (alternate to Professor Sallam) said that the Board was seized of a proposal to waive the penalty of suspension as an exceptional gesture. It should be borne in mind that those Member States that were in arrears had economic problems and faced similar difficulties in paying their dues to other international organizations. He therefore supported the proposal by Dr Stamps. The CHAIRMAN said that he, too, had just made what amounted to a proposal. Dr STAMPS invited his colleagues to take note of the fact that the total amount of the arrears due by all the countries listed in Annex I, with the exception of one - heavily in arrears for well-known reasons - was less than that due by one country which refused to pay its contribution in full and which, to the best of his knowledge, had never set out in writing its reasons for defaulting. He appealed again for the demonstration of a sense of humanity and recognition of the valuable contributions that could be made by even the poorest and smallest members of the global society. Dr LOPEZ BENITEZ endorsed the Chairman's clear and consensual proposal to reflect the two points of view expressed in the Board's decision and leave it to the Health Assembly, after consideration and recommendation by ABFC, to decide whether the countries in question should be allowed to participate on the occasion of the Organization's fiftieth anniversary. The CHAIRMAN asked whether the Board could agree to a decision reading: The Executive Board, having discussed the possibility of recommending that, for the Fifty-first World Health Assembly, which marks the fiftieth anniversary of WHO, voting rights be restored to countries which, in accordance with Article 7 of the Constitution, had lost that privilege, decided that that proposal, which was to be seen as an exceptional measure and not an exemption from financial obligations, should be considered, in the light of the comments made by some members of the Board
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concerning the careful examination of each case, by the Administration, Budget and Finance Committee before being presented to the Fifty-first World Health Assembly. Dr ZAHRAN (alternate to Professor Sallam) said that although he would have preferred a recommendation that simply allowed all countries to vote from the beginning of the session, he would go along with the Chairman's suggestion, provided that the matter was raised at the very beginning of the Fifty-first Health Assembly, so that the countries concerned would be able to vote during that Assembly if the recommendation of the Administration, Budget and Finance Committee was positive in their case. Dr SIKOSANA (alternate to Dr Stamps) said that the Chairman's suggestion was acceptable.
The decision was adopted. 1 The Board took note of the report contained in document EBlOl/26.
Casual income: Item 14.2 of the Agenda (Document EB101/27) The Board took note of the report.
Follow-up to the report of the External Auditor: EB101/28)
Item 14.4 of the Agenda (Documents
The CHAIRMAN drew attention to the recommendation of ABFC in document EBIOI/4 that it should authorize the Committee to pursue the question of expanding its terms of reference to include matters pertaining to that of an audit committee, and to request the Committee to report further to the Board as soon as possible, including on the issue of a separate committee. Dr BLEWETT said he endorsed the External Auditor's proposal to establish a separate audit committee and was not in favour of expanding the existing mandate of ABFC, which already had a heavy workload. The establishment of a separate internal audit committee would help build outside confidence in WHO's financial practices. The CHAIRMAN pointed out that the issue of expanding the mandate of ABFC to include the functions of an audit committee remained to be clarified, and referred the Board to resolution EB93.Rl3. He took it that the Board wished to endorse ABFC's recommendation. It was so decided.
Amendments to the Financial Regulations and Rules: Item 14.5 of the Agenda (Document EB101/36) The CHAIRMAN invited the Board to consider the report by the Director-General (document EB I 01 /36) on proposed amendments to the Financial Regulations and Rules which were set out in the Annex to the document. He drew attention to the draft resolution on the subject contained in paragraph 6, adoption of which had been recommended by ABFC. Mrs PERLIN (alternate to Mr Juneau) asked how the measures proposed in paragraphs 2 and 3 were to be implemented. With respect to paragraph 2, would the accounting procedures clearly indicate which credits against arrears were derived from the attribution of benefits from casual income and which from the payment of arrears? How would the measures described in paragraph 3 be presented to ensure that expenditure against
1
Decision EB101(14).
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casual income was visible? What was the magnitude of the sums involved? Which part of the United Nations System Accounting Standards justified the change? Mr AITKEN (Assistant Director-General) said that a special table would be produced prior to the start of the biennium showing the breakdown of the casual income credited to States that was used for paying their arrears. That would be separate from payments by Member States in settlement of arrears. On the second question, he said the accounts would continue to show both expenditure and income under a given heading: the net balance would not simply be presented as such: Member States would thus be able to see how much was received and how much was spent. On the magnitude of the amounts involved in the new casual income procedures not relating to arrears, he said it was not large. Finally, he could not at present answer the question about the specific provision of the United Nations System Accounting Standards that applied to the new procedures, but he would provide Mrs Perlin with a more detailed answer in writing. Mr UHDE (Division of Budget and Finance), returning to the question about the magnitude of the sums involved, said the amount of expenditure directly related to income would be disclosed in the financial report for the biennium in question: under no circumstances would it exceed the income. Garage rental income, for example, was around US$ 600 000, while expenditure on painting, security, etc., amounted to some US$ 300 000, in a given biennium.
The resolution was adopted. 1
6.
REAL ESTATE FUND: Item 15 of the Agenda (Document EB101/29)
Professor REINER said he regretted the fact that summary amounts were given for the various regions: he would have preferred a detailed breakdown. By his calculations, obligations for the European Region totalled about US$ 476 000, which ranged from three to 27 times less than the amount for other regions. He requested an explanation for that disparity. Dr LARIVIERE (alternate to Mr Juneau) said the amount of available resources estimated to be available at the end of 1997 was slightly less than 50% of the total funds channelled into the Real Estate Fund since 1970. For a variety of reasons, those resources had not been used in the way intended. As a result, a good amount of interest earnings had been generated. The main source of financing for the Real Estate Fund being casual income, he thought the interest generated by available resources should be returned to casual income rather than kept in the Fund. That would provide Member States with a much clearer picture of the implications of expenditure from the Real Estate Fund on specific projects. Mr MANI (Division of Conference and General Services), replying to Professor Reiner, said the Regional Office for Europe had received extensive support from the host country. Expenditure from the Real Estate Fund was made, not in terms of proportions for individual regional offices, but on the basis of need, and as requested by regional offices. It was indeed true that the Regional Office for Europe had not made extensive use of the Fund. Consideration could certainly be given to Dr Lariviere's suggestion that when interest accrued from resources allocated to the Fund was not used immediately, it should be credited to casual income. The Fund would, of course, be left with fewer resources, so that when the Director-General recommended a project and the Fund could not cover it, an additional appropriation from casual income would have to be requested. The Director-General could look into the consequences of the proposal and report back to the Board.
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Resolution EB101.R18.
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The CHAIRMAN said he took it that the Board wished to note the report by the Director-General on the Real Estate Fund, the progress made on the various projects financed by the Fund and the recommendations made by Dr Lariviere, inter alia.
It was so agreed.
7.
PERSONNEL MATTERS: Item 16 of the Agenda
Statement by the representative of the WHO staff associations on matters concerning personnel policy and conditions of service: Item 16.1 of the Agenda (Document EB101/INF.DOC./5) Mrs CONWA Y-FELL (representative of the WHO and IARC staff associations) congratulated Dr Brundtland on her nomination for the post of Director-General. The staff hoped that the Organization would become a genuine leader in international health under her stewardship. As indicated in document EB 10 1/INF .DOC./5, the issues taken up by the representative of the WHO and IARC staff associations at the Executive Board in May 1997 remained of concern, but there were other issues to which she wished to draw attention as well. WHO was accountable not only to its governing bodies but also to the general public, as its funds came from government treasuries. The staff therefore sincerely hoped that WHO's public image could be improved and that it would once again be seen as an honest broker. It must be seen to be open to change and completely open to scrutiny. It was very much to the Board's credit that WHO had been the first organization to change the rules of procedure for electing the Director-General, making it an open process. At WHO headquarters and the Regional Office for Europe, the staff believed that consultations with management had considerably improved and that that was proving to be of benefit to both parties. But there was always room for improvement. Two areas that came to mind were the Jack of consultation in the development of new personnel policy and the insecurity experienced by staff whose regional offices were being relocated. As WHO needed the best calibre of staff, it was necessary to ensure that only the most highly qualified staff were recruited, that credentials were checked to ensure that the information given was correct and to avoid undue criticism in the international press, and that the Organization resisted political pressure to employ individuals for posts for which they were not the best qualified candidates. The staff, in turn, pledged its honest and loyal contribution to the Organization. As the new millennium approached, the staff hoped that the Member States, together with the new Director-General, would regard dialogue between management and staff as an essential process. Dr CALMAN, supported by Dr STAMPS, expressed his thanks to the staff of the Organization for the remarkable amount of work they carried out at global, regional and country level. The CHAIRMAN, endorsing the view of the two previous speakers, thanked the representative of the WHO and IARC staff associations for her statement and said the Board had taken due note of it.
Employment and participation of women in the work of WHO: Item 16.2 of the Agenda (Resolution WHA50.16; Document EB101/30) Dr BLEWETT, speaking as Chairman of the Steering Committee on the Employment and Participation of Women in the Work of WHO, said the report by the Director-General (document EB 10 1130) showed that WHO's progress towards achieving its target in respect of the employment of women had been disappointing. There were some signs of a new sensitivity in the Organization, which it was to be hoped would yield results in the years ahead. The Steering Committee had identified a number of ways in which the rate of progress could be increased: increased responsibility and accountability on the part of Assistant Directors-General, executive directors and programme managers for improving the situation were needed; data should be more detailed in order to permit
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appropriate assessments; more formal links should be established between the Steering Committee and the Board; and the Secretariat must work closely with Member States in nominating women for appointment to staff and committee positions and in promoting participation in the fellowship programme and in scientific and technical meetings, for that was often a springboard into staff appointments. Improving the employment and participation of women was also the responsibility of Member States. They needed to consider how to increase the representation of women in the governing bodies. The Director-General should report to the Steering Committee in May 1998 on the practical implications of various options that the Committee would be submitting earlier in the year. At the Board's next session, a decision could then be taken on the steps to be taken, including on any financial support needed, to push forward those initiatives. Mr MELONI endorsed the previous statement and requested information from the Regional Directors on the measures being taken in their regions. Dr STAMPS asked for an explanation for the discrimination being practised against African women in particular and black women in general. If an African man and a non-African woman were suitable for a given position, which candidate would be given preference? Dr LARIVIERE (alternate to Mr Juneau) endorsed the comments made by Dr Blewett and encouraged Board members to become involved in the work of the Steering Committee, from which they could glean a great deal of enlightening information. Though dismally slow progress had been made so far, there was now a commitment within the Organization, to enable better results to be achieved. Resources also had to be committed to the process, however. Mr AITKEN (Assistant Director-General), replying to Dr Stamps, said that any form of discrimination was anathema to an international organization such as WHO; no discrimination was practised against any sector, group or society whatsoever. In making appointments, the three key criteria were the capacity, quality and sex of the candidates, as well as geographical distribution, which entered into the equation in terms of countries, not continents. If two individuals had identical qualifications, the present practice was to appoint the woman candidate, even if she was from a country that was overrepresented in the Secretariat. The CHAIRMAN took it the Board wished to note the Director-General's report and invite the DirectorGeneral to pursue all possible efforts to improve the employment and participation of women in the work of WHO and report further to the Board at its I 03rd session.
It was so agreed.
Report of the International Civil Service Commission: Item 16.3 of the Agenda (Document EB101/31) Mr KALBITZER (alternate to Mr VoigtUinder), commenting on the recommendations of the International Civil Service Commission, said that it was essential to avoid any measures which would lead to further increases in the contributions of Member States. Budgets everywhere were under pressure and, in Germany, the Parliament had expressed concern about the ever-increasing contributions to international organizations. Every opportunity should be taken to avoid further increases, possibly by postponing salary increases for six months, which had become common practice in many Member States.
The Board took note of the report.
Confirmation of amendments to the Staff Rules: EB101/37)
Item 16.4 of the Agenda (Document
The CHAIRMAN reminded the Board that the report by the Director-General contained in document EBIOl/37 had been considered by its Administration, Budget and Finance Committee. He invited the Board
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to consider draft resolution 1 contained in paragraph 10 of the report which confirmed the amendments to the Staff Rules listed in the Annex.
The resolution was adopted. 1 The CHAIRMAN invited the Board to consider draft resolution 2 in paragraph 10 of the report which recommended to the Health Assembly a modification in the gross and net salaries for ungraded posts and for the Director-General.
The resolution was adopted. 2
8.
REPORTS OF THE PROGRAMME DEVELOPMENT COMMITTEE AND THE ADMINISTRATION, BUDGET AND FINANCE COMMITTEE OF THE EXECUTIVE BOARD: Item 6 of the Agenda (continued from the second meeting)
Mr CREGAN (alternate to Mr Hurley, Chairman of the Programme Development Committee) recalled that the Committee (PDC) had indicated that it would consider the scope and timing of an external assessment of PDC and the Administration, Budget and Finance Committee (ABFC), in the light of discussions with the latter and the work of the Board at its current session, towards the end of the session. At that meeting PDC had re-emphasized its view that the efficiency of PDC and ABFC could be enhanced by earlier provision of documentation and by better interaction between the Secretariat and Committee members, not just during sessions but throughout the year. It had been pointed out that the two committees had not long been established and it would take time for them to work to the optimum level. It had been felt that a comprehensive external evaluation of the committees was not required, but that the views of someone from outside with experience of committee structures in large international organizations would be beneficial. PDC would continue to reflect on its work with a view to making the best possible contribution to the Board.
9.
COLLABORATION WITH NONGOVERNMENTAL ORGANIZATIONS: Item 17 of the Agenda
Applications of nongovernmental organizations for admission into official relations with WHO: Item 17.1 of the Agenda (Document EB101/32) Review of nongovernmental organizations in official relations with WHO: Item 17.2 of the Agenda (Document EB101/32) Review of overall policy on collaboration with nongovernmental organizations: Item 17.3 of the Agenda (Decision EB99(18); Document EB101/33) The CHAIRMAN said that the three subitems under agenda item 17 had been considered by the Standing Committee on Nongovernmental Organizations. Dr FERDINAND, speaking as Chairman of the Standing Committee on Nongovernmental Organizations, introduced the report contained in document EB 101/32, drawing attention to the draft resolution and two draft decisions for the Board's consideration contained in section IV. The draft resolution proposed that six nongovernmental organizations should be admitted into official relations with WHO. The Committee had discussed each application separately and was satisfied that the criteria for admission were met. The draft
1 2
Resolution EB10l.Rl9. Resolution EB10l.R20.
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resolution also noted that the International Committee of the Red Cross (ICRC) was no longer in official relations with WHO. The first draft decision, concerning the review of nongovernmental organizations in official relations with WHO, was based on the Committee's consideration of a document containing reports on collaboration and other information provided concerning relations with 65 nongovernmental organizations, which were listed in the Annex to its report. The Committee had recommended that official relations should be maintained with the 54 organizations whose names were marked with an asterisk and that relations should be maintained for a further year with I 0 of those remaining, their status to be reviewed by the Board at its I 03rd session. The status of the other nongovernmental organizations was the subject of paragraph 2 of the draft resolution she had just introduced. The second draft decision concerned the review of overall policy on collaboration with nongovernmental organizations. The Committee's main comments were set out in section Ill of its report. The report contained in document EB I 01/33 considered the advantages and disadvantages of revising current policy to permit the admission into official relations of nongovernmental organizations from sectors other than health and related fields, and with national, regional and subregional nongovernmental organizations at the global level. The Committee was aware of the need to consider how WHO would work together with its various partners into the twenty-first century but felt that WHO's relations with other sectors required further consideration. It had therefore recommended that the Board should encourage increased contact with nongovernmental organizations whose main area of competence lay outside the health and health-related fields, request a report on the results of a consultation process to be initiated on official relations between WHO and such organizations, and take note of the revised United Nations Economic and Social Council resolution on arrangements for consultations with nongovernmental organizations. In response to questions from Dr SANOU IRA and Dr ZAHRAN (alternate to Professor Sallam) about why ICRC no longer maintained official relations with WHO, Mr TOPPING (Legal Counsel) explained that ICRC was at the same time a nongovernmental organization established under national law and an organization with special status in international law, including specific functions under the Geneva Conventions. At the request of the ICRC and in view of its special situation, the Director-General had decided, in line with similar changes at the United Nations, to grant it observer status at the Health Assembly, similar to that enjoyed by the Holy See since I949 and by the Order of Malta. That change would have no effect on the extensive collaboration between ICRC and WHO. Dr LARIVIERE (alternate to Mr Juneau) expressed reservations about the WHO policy on collaboration with nongovernmental organizations, which excluded national, subregional and regional bodies. WHO already enjoyed official relations with two national organizations which had strong international programmes, and he considered that such partnerships should be fostered, particularly in the light of the Board's discussions about the need for additional, imaginative mechanisms for collaboration. The CHAIRMAN invited the Board to adopt the draft resolution contained in document EBIOl/32. The resolution was adopted. 1 Decision: The Executive Board, having considered the report of its Standing Committee on Nongovernmental Organizations, 2 decided to maintain official relations with 53 of the 65 nongovernmental organizations reviewed at its I 0 I st session. It welcomed with thanks the contribution ofthese nongovernmental organizations to the work of WHO in such diverse fields of mutual interest as the ethical dimensions of health care, enhanced epidemiological capabilities and health records management at the national level, and to implementation of a number of WHO resolutions, for example, WHA48.8 on the reorientation of medical education and medical practice for health for all. Training and continuing education remained an important joint activity, for example, in laboratory medicine, surgery,
1
Resolution EB10l.R21. Document EBIOl/32.
2
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and support to building up technical and managerial capacity for management of health systems infrastructure in developing countries. Another aspect of collaboration was the organization's contribution to WHO's normative activities, for example, elaboration of risk assessment documents prepared by the International Programme on Chemical Safety, and the ongoing work in connection with good manufacturing practices for pharmaceutical products. Regarding relations with the International Society ofHematology, the Board decided to maintain the Society in official relations with WHO for a period of one year in order to draw up a plan for collaboration. In the absence of reports on collaboration, the Board decided to defer for one year review of relations with the International Federation of Red Cross and Red Crescent Societies, International Medical Society of Paraplegia, International Academy of Legal Medicine, Network of Community-Oriented Educational Institutions for Health Sciences, World Organization of Family Doctors and the International College of Surgeons. It requested the Director-General to inform nongovernmental organizations ofthe importance of maintaining timely communications. With regard to the follow-up to decision EB99(17) concerning relations with four other nongovemmental organizations, the Board noted with regret that it had not been possible to agree on plans for collaboration with the International Federation of Physical Medicine and Rehabilitation, the World Federation of Parasitologists, and the World Veterans Federation. It decided to defer consideration of the maintenance of these organizations in official relations with WHO for one year. It requested that a report on the results of efforts to draw up plans for collaboration should be submitted to the Board at its I 03rd session. It also found that there was every reason to expect that relations with the International Society for Human and Animal Mycology would be revitalized through implementation of the agreed plan for collaboration, and therefore decided to maintain the Society in official relations with WH0. 1 Decision: The Executive Board thanked the Director-General for his report. 2 It requested the DirectorGeneral to initiate a consultation process, including a meeting with nongovernmental organizations and any other interested parties on the matter of official relations between WHO and nongovernmental organizations whose main area of competence lies outside the health and related fields, and to encourage increased informal contacts with such organizations. It further requested that a report on the outcome of the consultation process and informal contacts, if any, should be prepared for the consideration of the Board. The Board took note of the revised United Nations Economic and Social Council resolution 1996/31 on "Consultative relationship between the United Nations and non-governmental organizations". 3
10. METHOD OF WORK OF THE HEALTH ASSEMBLY: Item 19 of the Agenda (Resolution WHA50.32; Document EB101/34) Dr LARIVIERE (alternate to Mr Juneau) welcomed the availability of governing body documents on the Internet via the WHO home page, but questioned the two-week delay between the date of dispatch by mail and their appearance on the Internet. While countries without access to the Internet might be at a disadvantage, countries far away from Geneva, such as Canada, were at a disadvantage where ordinary mail was concerned. Canada would request the Director-General not to send by mail any printed documents that were available via the Internet. If other countries did the same there would be an appreciable saving which could benefit priority programmes such as malaria.
1 2
Decision EB101(15). Document EBIOl/33. Decision EB10l(l6).
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Dr LOPEZ BENiTEZ agreed; any savings were welcome in whatever field. He suggested that in countries without the appropriate technology, WHO country offices might assist ministries of health to gain access to WHO information via the Internet. Dr ZAHRAN (alternate to Professor Sallam) warned that sending out documents only via the Internet could have the effect of punishing countries which did not have the new technology. The poorer countries, which were unable to pay their contributions and therefore did not enjoy full rights of membership, might then also be deprived of their documents. Professor PICO (alternate to Dr Mazza) agreed with Dr Lariviere; it was important to improve both efficiency and the quality of the material provided for meetings; it was also important that documents be received in time for study by technical specialists in the countries. Use of electronic means was to be encouraged. However, the Secretariat should determine the access of each Member State to the Internet to ensure that none was overlooked, and countries should be informed when documents were available on the Internet. Dr MOREL, supported by Dr AL-MOUSA WI, said that regular mail should not yet be replaced by electronic mail; all documents should be distributed by both methods. The availability of documents on the Internet might lead to savings since fewer copies of the printed material would be needed. The CHAIRMAN said he took it that the Board wished to note the Director-General's report and to commend the initiative to make documents available on the Internet.
It was so decided.
11.
HEALTH-FOR-ALL POLICY FOR THE TWENTY-FIRST CENTURY: Item 8 of the Agenda (continued from the twelfth meeting)
The CHAIRMAN drew attention to a draft resolution on the health-for-all policy for the twenty-first century and the annexed World Health Declaration which had been introduced at the twelfth meeting Dr CALMAN proposed several nonsubstantive amendments to the proposed declaration that were intended to improve the wording. He suggested that the first sentence of article 11 should read "We recognize that the improvement of the health and well-being of people is the ultimate aim of social and economic development", and that the fourth sentence of that article should read "We emphasize the importance of reducing social and economic inequities in improving the health of the whole population". He proposed that the first sentence of article Ill should be amended by replacing the wording following "good quality" with "and within affordable limits, and that are sustainable for the future". The third sentence in that article might be improved by inserting "continue to" before "develop health systems", since many countries had been developing health systems for some time. Dr ZAHRAN (alternate to Professor Sallam) supported those amendments and proposed further that the third and fourth sentences of article 11 should be reversed and that "Therefore" should be inserted at the beginning of the former. Professor PICO (alternate to Dr Mazza) supported the proposed amendments.
The resolution, as amended, was adopted. 1
1
Resolution EBIOI.R22.
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12.
IMPLEMENTATION OF RESOLUTIONS AND DECISIONS (REPORTS BY THE DIRECTOR-GENERAL): Item 9 of the Agenda (continued)
Section IV. Prevention of violence (Resolution WHA50.19) (continued from the twelfth meeting) The CHAIRMAN recalled that, during discussions on the item at the ninth and twelfth meetings, a draft resolution on concerted public health action on anti-personnel mines sponsored by Dr Alvik, Dr Blewett, Dr Hembe, Mr Juneau, Dr L6pez Benitez, Dr More! and Dr Stamps had been introduced and a number of amendments had been proposed. He suggested that the Board should confine further comments to the draft resolution, as amended. It was so agreed.
Dr LOPEZ BENITEZ suggested that the new paragraph 5 of the resolution recommended for adoption by the Health Assembly proposed earlier by Dr Zahran should be amended to read: URGES the international community and countries concerned to contribute to efforts under way to facilitate the clearance of anti-personnel mines in order to prevent injuries and deaths of civilians. The CHAIRMAN observed that while most of the amendments proposed earlier had not given rise to any difficulties, agreement had not yet been reached on paragraph 5 of the recommended resolution. He suggested that the Board should either decide on the initial proposal by Dr Zahran, or on the proposal just made by Dr L6pez Benitez. Dr SANOU IRA said that in her view the Board should consider the second proposal, since no consensus had been reach on the first, and to return to it would be in effect to take a step backwards. Dr ZAHRAN (alternate to Professor Sallam) suggested that in order to expedite proceedings the Board should again take up the proposal he had made at the ninth meeting in respect of paragraph 5, which had received a large measure of support. To take account of concerns expressed, he suggested that the wording should be amended to read: URGES governments that have planted mines in the territories of other countries to provide the latter with the required maps and identification of the minefields they planted, and to cooperate in minefield clearance in the countries concerned. The last phrase of the text just proposed by Dr L6pez Benitez, reading" ... in order to prevent injuries and deaths of civilians" would then be added. There would seem to be general agreement on the need for governments which had planted landmines to cooperate in locating and clearing them, and he hoped that the draft resolution could be adopted without a vote. Dr CALMAN supported the version proposed by Dr L6pez Benitez, and hoped that consensus could be reached on it. Mr SILBERBERG (alternate to Mr Voigtlander) said he fully recognized the public health impact of the recommended resolution under discussion, and would like to see it adopted. However, the version of paragraph 5 proposed by Dr Zahran raised difficult problems of international law, and it was still his view that WHO was not the appropriate body to discuss such problems. He preferred the version proposed by Dr L6pez Benitez, which offered a way out of the difficulty. Dr VAN ETTEN supported that view. The CHAIRMAN invited the Board to vote by show of hands on the proposal just made by Dr Zahran for paragraph 5 of the recommended resolution.
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The proposal by Dr Zahran was adopted by 15 votes to 6, with 7 abstentions. Professor PICO (alternate to Or Mazza) explained that he had abstained because, although he was in agreement with the spirit of the proposal, he did not think WHO was the proper body to deal with such issues. Or CALMAN said he regretted that consensus had not been reached, and that a vote had had to be taken. While he agreed that the matter was best discussed in other forums, he fully supported the principle behind the draft resolution. The CHAIRMAN, in the absence of any objections, took it that the Board was willing to adopt the other amendments proposed earlier.
It was so decided. The resolution, as amended, was adopted. 1 Or VAN ETTEN and Or CALMAN indicated they would have abstained if a formal vote had been taken on the draft resolution as a whole with the new paragraph 5. Mr SILBERBERG (alternate to Mr Voigtllinder) said he had not requested a formal vote on the amended resolution since he fully supported its public health provisions. However, that should not be interpreted as support for paragraph 5, which dealt with a difficult problem of international law which WHO was not the appropriate body to discuss. He entered a reservation in respect of paragraph 5. Or SANOU IRA regretted that it had not been possible to find a formula which suited everyone.
Section VII. Revised drug strategy (Resolution WHA49.14) (continued from the ninth meeting) The CHAIRMAN drew the attention of the Board to a draft resolution proposed by Or Alvik, Or Kariburyo, Or Morel, Or Mulwa, Mr Ngedup, Professor Sallam and Or Stamps reading: The Executive Board, RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution: The Fifty-first World Health Assembly, Recalling resolutions WHA39.27, WHA41.16, WHA43.20, WHA45.27, WHA47.12, WHA47.13, WHA47.16, WHA47.17, and WHA49.14; Having considered the report of the Director-General on the revised drug strategy; 2 Noting the activities of WHO to further the implementation of the revised drug strategy, in particular through support to the development and implementation of national drug policies; the strategy to review and assess the effectiveness of the WHO Ethical Criteria for Medicinal Drug Promotion; the flow of market information; guidelines for drug donations; and model drug information; Recognizing with satisfaction the progress made, and approving WHO's comprehensive response to current and new challenges in the pharmaceutical sector; Commending the strong leadership shown by WHO in promoting the essential drugs concept and national drug policies, which are contributing to the rational use of resources in the pharmaceutical sector and to improved health care;
1 2
Resolution EB10l.R23. Document EB 10 Ill 0 Chapter VII.
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EXECUTIVE BOARD, 101st SESSION
Noting with satisfaction that a number of Member States have adopted guidelines for drug donations that were based on the interagency guidelines issued by WHO, but concerned that inappropriate drug donations, such as donations of expired, mislabelled, inessential products, continue to be common; Concerned about the situation in which one third of the world's population has no guaranteed access to essential drugs, in which new world trade agreements may have a negative impact on local manufacturing capacity and the access to and prices of pharmaceuticals in developing countries, and in which poor quality pharmaceutical raw materials and finished products continue to move in international trade; Concerned also that drugs continue to be irrationally used by prescribers, dispensers and the general public, and because unethical promotion in developed and developing countries and a lack of access to independent, scientifically validated drug information contribute to such abuses, I. URGES Member States: (I) to reaffirm their commitment to develop, implement and monitor national drug policies to ensure equitable access to essential drugs; (2) to ensure that public health rather than commercial interests have primacy in pharmaceutical and health policies and to review their options under the Agreement on Trade Related Aspects of Intellectual Property Rights to safeguard access to essential drugs; (3) to establish and enforce regulations that ensure good uniform quality assurance standards for all pharmaceutical materials and products manufactured in, imported to, exported from, or in transit through their countries; (4) to enact and enforce legislation or regulations in accordance with the principles of the WHO Ethical Criteria for Medicinal Drug Promotion, and to monitor drug promotion in collaboration with interested parties; (5) to develop or maintain national guidelines governing drug donations that are compatible with the interagency guidelines issued by WHO and to work with all interested parties to promote adherence to such guidelines; (6) to promote the rational use of drugs through the provision of independent, up-to-date and comparative drug information, and to integrate the rational use of drugs and information about commercial marketing strategies into training for health practitioners at all levels; (7) to promote and support consumer education on the rational use of drugs and its inclusion into school curricula; (8) to evaluate progress regularly, making use of indicators developed by WHO or other suitable mechanisms; (9) to continue their funding and material support for the revised drug strategy especially by the provision of extrabudgetary resources to WHO; REQUESTS the Director-General: (I) to support Member States in their efforts to develop and implement policies and programmes that achieve the objectives of the revised drug strategy, including the development of tools, guidelines and methodologies for evaluation and monitoring; (2) to adopt a comprehensive strategy to implement the WHO Ethical Criteria for Medicinal Drug Promotion and to continue to review its effectiveness with all interested parties; (3) to extend the guidelines incorporated in the WHO Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce to cover pharmaceutical starting materials; develop and disseminate uniform guidelines on the regulatory control, export, import and transit conditions of pharmaceutical products; and develop standards of practice for entities involved in international trade in pharmaceuticals and pharmaceutical raw materials; (4) to strengthen and expand the provision of independent information on market prices of raw materials of assured quality for production of essential drugs;
2.
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(5) to continue the development and dissemination, also using electronic media such as the Internet, of independent information on pharmaceutical product safety and instances of counterfeit drugs or medicines, on drug selection and on rational prescribing; (6) to assist Member States to analyse the pharmaceutical and public health implications of agreements overseen by the World Trade Organization and to develop appropriate policies and regulatory measures; (7) to review and update the revised drug strategy to reflect current and continued challenges in the pharmaceutical sector and the principles articulated in the renewed healthfor-all policy; (8) to report comprehensively to the Fifty-third World Health Assembly on progress achieved and problems encountered in the implementation and renewal of WHO's revised drug strategy, with recommendations for action. Or VAN ETTEN and Professor PICO (alternate to Or Mazza) asked for their names to be added to the list of sponsors.
The resolution was adopted. 1 Section IX. Ethical, scientific and social implications of cloning in human health (Resolution WHA50.37) (continued from the tenth meeting) The CHAIRMAN drew the attention of the Board to a draft resolution proposed by the Rapporteurs which read: The Executive Board, Having considered chapter IX on Ethical, scientific and social implications of cloning in human health in the Director-General's report on implementation of resolutions and decisions, 2 and the information document on the same subject,3 RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution: The Fifty-first World Health Assembly, Recalling resolution WHA50.37 on cloning in human reproduction; Noting the general consensus reached at the national and international levels since the Fiftieth World Health Assembly regarding human cloning for reproductive purposes; Noting in particular UNESCO's Universal Declaration on the Human Genome and Human Rights and the Council of Europe's Additional Protocol to the Convention on Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine, which deal with the prohibition of cloning human beings; Considering that the currently available information from animal studies involving cloning through somatic cell nuclear transfer indicates that this would be an unsafe procedure for reproductive purposes in the human; Recognizing that developments in cloning and other genetic procedures have unprecedented ethical implications and raise serious matters for concern in terms of safety of the individual and subsequent generations of human beings, 1. REAFFIRMS that cloning by means of somatic cell nuclear transfer for the replication of human individuals is both ethically and biomedically unacceptable and contrary to human dignity and integrity;
1 2
Resolution EBIOI.R24. Document EBIOI/10. Document EBIOI/INF.DOC./3.
3
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EXECUTIVE BOARD, 101st SESSION
2. URGES Member States to take appropriate steps to prevent cloning for the purpose of replicating human individuals; 3. REQUESTS the Director-General: (1) to establish a study group with the aim of developing guidelines relating to the use of cloning procedures for non-reproductive purposes; (2) to continue to monitor, assess and clarify, in consultation with other international organizations, national governments and professional and scientific bodies, the ethical, scientific and social implications of the use of cloning procedures in human health; (3) to ensure that Member States are kept informed of developments in this area in order to facilitate decisions on national regulatory frameworks; (4) to report to the 103rd session of the Executive Board and Fifty-second World Health Assembly on actions taken by the Organization in this field.
Dr MOREL said that in his view paragraph 1 of the recommended resolution diluted the recommendations that lay behind resolution WHA50.37 by specifying a particular method of cloning. The paragraph might be read to mean that the replication of human individuals would be acceptable if other methods were used. Moreover, use of the word "biomedically" might indicate that the matter was simply technical which was not the case. He therefore proposed that the paragraph should be amended to read: REAFFIRMS that cloning for the replication of human individuals is ethically unacceptable and contrary to human dignity and integrity; He had recently read the comment by a scientist working in the field that in his country it was not ethics but the law that was followed; he therefore proposed that paragraph 2 should be amended by inserting "including legal and juridical measures", after "appropriate steps". Paragraph 3(1) should be amended to read: "to continue to monitor, assess and develop guidelines on the potential use of cloning procedures for non-reproductive purposes", and paragraph 3(2) should be replaced by: "to set up a panel of experts to prepare a declaration- or a statement of principles - on the new ethical issues arising from advances in genetics and their medical applications". Paragraph 3(3) should be amended by the insertion of "in coordination with other relevant national and international bodies" after "ensure". Finally, he proposed that the Board should take note of a preliminary statement on medical genetics produced by a WHO expert group which had met in December 1997. If possible, reference to that statement should be included in the preamble to the draft resolution. Professor PICO (alternate to Dr Mazza) expressed his support for the proposed amendments, but suggested that in paragraph 2 "prohibit" would be preferable to "prevent". Dr BLEWETT said the proposed amendments amounted to a substantial reconstruction of the draft resolution which raised a number of difficult points. In his view the proposed amendments were too complex to consider quickly and without seeing them in writing. Mr DEBRUS (alternate to Mr VoigtUinder) agreed, saying that the proposed amendment to paragraph 3(1) seemed to suggest that the use of cloning procedures for non-reproductive purposes was considered to be ethical, but in fact the guidelines procedure should be open from the outset, and the work of the panel of experts in that regard should not be anticipated. Mr JUNEAU said he agreed with most of the proposed amendments, in particular the change to paragraph I. It was important for WHO to continue to keep Member States abreast of developments around the world on a regular basis. Up to date information was essential to assist them in making appropriate legislative changes. With a little effort, the proposed amendments could be incorporated. Dr AL-MOUSA WI supported all the amendments proposed by Or More!.
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Dr MOREL said his proposed amendments could probably be improved from a linguistic point of view but what was certain was that paragraph 1 had to be changed. Dr CALMAN said he agreed with the amendments proposed to paragraphs 1 and 2, but those proposed in respect of paragraph 3 gave rise to difficulties and should perhaps be left for further debate at the Fifty-first World Health Assembly. Dr LOPEZ BENITEZ proposed that a panel of experts should draw up model legislation which could serve as a guideline for Member States when they came to make changes to their own national legislation. Mr DEBRUS (alternate to Mr Voigtlander) said that everyone agreed that it was essential for the Board to recommend a resolution on the subject to the Fifty-first World Health Assembly but the discussions had shown that it would be difficult to reach an immediate decision on such complex amendments. Given that there would be an opportunity to propose and discuss amendments at the Health Assembly, he suggested that the Board should adopt the draft resolution as originally proposed.
The CHAIRMAN invited the Board to vote on the amendments proposed by Dr More! in respect of paragraphs 1 and 2.
The amendments were adopted by 23 votes to 1, with no abstentions. The CHAIRMAN then invited the Board to vote on the draft resolution, as amended in respect of paragraphs 1 and 2, as a whole.
The resolution, as amended, was adopted by 24 votes to 1, with no abstentions. 1
13.
DISEASE PREVENTION AND CONTROL: Item 10 of the Agenda (resumed)
Emerging and other communicable diseases: antimicrobial resistance: Item 10.3 of the Agenda (continued from the twelfth meeting) The CHAIRMAN introduced a draft resolution on emerging and other communicable diseases proposed by the Rapporteurs reading: The Executive Board, Having considered the report of the Director-General on emerging and other communicable diseases: antimicrobial resistance, 2 RECOMMENDS to the Fifty-first World Health Assembly the adoption of the following resolution: The Fifty-first World Health Assembly, Having considered the report of the Director-General on emerging and other communicable diseases: antimicrobial resistance; Concerned about the rapid emergence and spread of human pathogens resistant to available antibiotics; Aware that antimicrobial resistance is increasingly hampering treatment of infectious diseases as a result either of totally ineffective currently available antibiotics or of the high cost of "new generation" agents;
1 2
Resolution EB10l.R25. Document EBlOl/13.
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EXECUTIVE BOARD, 101st SESSION
Concerned about the extensive use of antibiotics in food production, which may further accelerate the development of such resistance, I. URGES Member States: (I) to encourage the development of sustainable systems to detect antimicrobial-resistant pathogens, thereby increasing the awareness of antimicrobial resistance, and to monitor volumes and patterns of use of antimicrobial agents and the impact of control measures; (2) to develop educational programmes for professional staff and the Jay public to encourage the appropriate and cost-effective use of antimicrobial agents; (3) to improve practices to prevent the spread of infection and thereby the spread of resistant pathogens, and to promote appropriate antibiotic use in health care facilities, in the community, and in food-animal production; (4) to develop measures to protect health workers from the hazards of resistant pathogens; (5) to develop measures to prohibit the dispensing of antimicrobials without the prescription of a qualified health care professional; (6) to strengthen legislation to counter the manufacture, sale and distribution of counterfeit antimicrobial agents and the sale of antibiotics in the informal market; (7) to take measures to encourage the prudent use of antimicrobials in food-animal production; REQUESTS the Director-General: (I) to support countries in their efforts to control antimicrobial resistance through the strengthening of laboratory capacity for the detection of resistant pathogens; (2) to assist in the development of sustainable national policies for rational antimicrobial use, not only in human medicine, but also in food-animal production; (3) to collaborate with those in public health, the pharmaceutical industry, universities and institutions concerned with research, laboratory testing, marketing, prescription and consumption of antimicrobial agents, in order to encourage sharing of knowledge and resources to combat antimicrobial resistance; (4) to devise means for the gathering and sharing of information between countries and regions on resistance in certain pathogens; (5) to develop information and education programmes for prescribers and users of antimicrobial agents; (6) to encourage promotion of research and development of new antimicrobial agents.
2.
The resolution was adopted.'
14.
PROVISIONAL AGENDA FOR AND DURATION OF THE FIFTY-FIRST WORLD HEALTH ASSEMBLY: Item 20 of the Agenda (Documents EB101/35 and EB101/INF.DOC./1)
Dr VAN ETTEN asked when more detailed information would be available on the programme for Thursday, I4 May, the fiftieth anniversary of WHO. The DEPUTY DIRECTOR-GENERAL ad interim said that full information would be made available once it was clear which Heads of State would be present.
1
Resolution EB10l.R26.
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Decision: The Executive Board approved the Director-General's proposals, as amended, for the provisional agenda of the Fifty-first World Health Assembly .1 Recalling its earlier decision2 that the Fiftyfirst World Health Assembly should be held in the Palais des Nations, Geneva, Switzerland and open on Monday, 11 May 1998 at 10:00, the Board decided that it should close no later than Saturday, 16 May 1998. 3
It was so agreed.
15.
DATE AND PLACE OF THE 102nd SESSION OF THE EXECUTIVE BOARD: Item 21 of the Agenda
Mr AITKEN (Assistant Director-General) suggested that the Board might wish to decide that its 102nd session should be held on Monday and Tuesday, 18 and 19 May 1998, at WHO headquarters. Dr CALMAN said that the 102nd session would be a particularly important session, coming at a time of transition, and it would be useful for Board members to be informed at that session of how the transition process was going. Decision: The Executive Board decided that its 102nd session should be convened on Monday, 18 May 1998, at WHO headquarters, Geneva, Switzerland, and should close no later than the following day, Tuesday, 19 May 1998. 4
16. CLOSURE OF THE SESSION: Item 22 of the Agenda After the customary exchange of courtesies, the CHAIRMAN declared the session closed.
The meeting rose at 19:35.
1 2
Documents EBlOl/35 and EBlOl/INF.DOC./1. Decision EB100(12). Decision EB 10 1(17). Decision EB101(18).
3 4