April 18, 2001 First Session: Progress and Remaining Challenges Contents:
Session Chairs: Eduardo Doryan, Vice President, Human Development, World Bank, and Richard Anane, Minister of State, Ministry of Health, Ghana
Call to Order: Eduardo Doryan
Aims for the Meeting: David Alnwick, Project Manager, Roll Back Malaria
Welcome and Address by World Bank President, James D. Wolfensohn
Address by UNICEF Deputy Executive Director, Andre Roberfroid
Accomplishments to Date, WHO Director-General, Gro Harlem Brundtland
Questions and Answers PROCEEDINGS MR. DORYAN: Good morning, everyone. Please be seated. Your Excellencies, ladies and gentlemen, on behalf of the Roll Back Malaria Partnership, I warmly welcome all of you to this, the Fourth Global Partnership Meeting to Roll Back Malaria. As a founding partner, the World Bank is pleased to host this meeting three years after the inception of the Partnership and exactly one year after the African Summit on Roll Back Malaria that was held in Abuja, Nigeria, and which I had the privilege to attend. The goal of Roll Back Malaria is to halve the death toll of malaria-affected persons, young and old, from productive laborers to mothers and children living in the poorest communities of the world, by the year 2010. To achieve this goal, RBM has made a commitment to work together with a wide range of partners across different sectors. In testament to this commitment, I am pleased to see here that the Partnership is very well represented today. We are joined here by delegations from at least 21 malaria-affected countries from around the world and 51 organizations representing multilateral and bilateral agencies, NGOs, the private sector, industry, research institutions, foundations, and the media. I would like to extend now a very warm welcome to the Director-General of the World Health Organization, Dr. Gro Harlem Brundtland; to the Deputy Executive Director of UNICEF, Andre Roberfroid; and, indeed, to President James D. Wolfensohn from the World Bank. I would also like to acknowledge my co-chair for this morning's session, His Excellency Richard Anane, the Minister of State of Ghana of the Ministry of Health, who will chair the second part of the plenary session. And now it is my privilege to introduce David Alnwick, who in January, just a few months ago, assumed the position of Project Manager for Roll Back Malaria. So, David, you have the floor. MR. ALNWICK: Thank you very much, Mr. Doryan, Your Excellencies, ladies and gentlemen. It falls to me to say a few words of introduction for what we hope to achieve with this meeting over the next two days. I think the overall goal of the meeting is to recommit ourselves. In a way, this is a third birthday party. We're three years into a dynamic global partnership. And I think we want to look at how far we've got and to look at what more can we do to speed up the goals which we have agreed to and the efforts which we have agreed to make to tackle malaria. Just a reminder about where we've come from. The idea of a partnership was born in Geneva in 1998 to bring together global stakeholders in malaria control, to work in a concerted action, to work together. And this first meeting consolidated a joint vision of Roll Back Malaria and the idea that, to be effective in tackling malaria, there needed to be a social movement created. This could not just be a vertical top-down health intervention. The people involved in the problem, the people affected by the problem had to be involved. The second global partners meeting took place in Harare, Zimbabwe, in 1999. Here we proceeded to agree on the principles and content of Roll Back Malaria, clarified approaches of health system strengthening and malaria control, to see the two going arm in arm. And I think that this meeting consolidated the idea of Roll Back Malaria as a movement which also embraced the pre-existing enthusiasm and commitment to tackle malaria in Africa, bringing everything together. The third global partners meeting in Geneva just a year ago reached agreement on some of the technical principles of the importance of new technologies and ways of moving those forward. There was an endorsement of the overall Roll Back Malaria work plan, and interagency work plans were developed based on the comparative advantages of the founding UN partner agencies and the World Bank and embracing other partners, including the private sector. And there as a consensus to build country partnerships as the foundation for Roll Back Malaria action, an agreement that certain things could be done globally and should be done globally, but the essence of the movement had to depend on strong country partnerships. Just a very quick note at this point on recent developments. The Secretariat, in collaboration with Roll Back Malaria, global partners and country partners, has been supporting a process of country situation analyses. National consensus on the best strategies to roll back malaria have been developed, and functioning country partnerships have started to evolve. Later on we will give you a few more specific details of what's been going on. But almost all countries with a malaria problem, where malaria is endemic, have embraced this process of broadening participation in malaria control beyond a narrow health sector response, important as it is, to involve other national partners and, indeed global partners. Exciting new products--and we'll go into details about these later--have been catalyzed and are starting to be developed on the drug field, on the insecticide-treated net area. And there has been support for consensus on agreements on technical interventions and outcomes and on ways of monitoring impact. Strategies have been developed to start to take interventions to scale. We need to do more of this. There has been good development on incorporating a focus on malaria within a concern for strengthening sectorwide approaches in health, not to see these two things as conflicting alternatives, but to see the two as both being objectives of the same thing, of a strong health system which can also effectively tackle malaria. And we have made some progress in linking debt relief and poverty reduction strategies to action to roll back malaria at the country level. We need to do more on this. We are in the process, I think, of reviewing the roles and the functioning of Roll Back Malaria partnerships, and it's one of the things we want to do during this meeting. What has worked? What has worked well? What has worked less well? What do we need to do to accelerate action? And we want to hear country perspectives on how the global partnership has been supporting country action, and we have, in fact, commissioned a number of reviews which will be available for discussion and distribution; from about 15 countries, more detailed analyses have been done. Well, I think the main objective of this partners meeting is to remind us all that whilst we have started to make progress, I believe, in rolling back malaria, an enormous amount of work needs to be done, to remind us all that malaria continues to be a major development challenge. We must not let it fall from the agenda. There are other major issues on the health agenda, but malaria remains important, a major impediment to development. And I think the overall purpose of this meeting is to ask how can the global partnership, the global movement, work with malaria-affected countries and their partners to mobilize more action which goes beyond the classic malaria control program, beyond the public health sector, and perhaps beyond the public sector in general. How can we strengthen viable partnerships to include all potential actors and players in order to make a rapid and sustained difference to malaria? That I think is the challenge before us for these two days. Thank you very much. [Applause.] MR. ALNWICK: It falls to me, Mr. Doryan, I think, just to say a few words about a video. We decided it would be interesting to launch the meeting with a short video film. Many of us, many of you are tackling malaria every day and are probably very, very familiar with the challenges. Others of you and others of us, unfortunately, perhaps, spend too much time in offices and perhaps have been a little bit away from the field. We thought, with your permission, it would be useful for all of us to see a few images of the reality of malaria. You heard that I took over the job of Project Manager of the Secretariat just three months ago, and it fell to me to help make this short video. We started with ambitions of going to four or five countries in different continents. When we saw the budget and the time scale, we lowered our ambitions. We went to one country, which was very accommodating, very hospitable, and the images are all from Tanzania. This does not mean to say that Tanzania is the only country which is tackling malaria. Many countries are. But please, just bear in mind we got some images for you from Tanzania which I hope will set the scene, I think in many ways so typical of what's going on in Africa. The video is a little bit of a conversation piece. Look at the images carefully. There are some images of very good things happening. There are some images of things which you may well wonder what are these things going on. And I think we will discuss some of these points later on. There is no script. For those of you who understand Swahili, you'll get a few hints about what's going on. There's no script and few subtitles. A very short video, Mr. Doryan, just five minutes to introduce the reality of malaria in the African situation. Thank you very much. [Videotape shown.] [Applause.] MR. DORYAN: I think both the words of Mr. Alnwick but especially the human face of malaria that we saw are a good start for our meeting. As host of this year's Global Partnership Meeting, I would like to invite President James D. Wolfensohn to share with us his perspective on the Partnership and where we stand today. Jim? MR. WOLFENSOHN: Well, Mr. Doryan, Mr. Minister, distinguished colleagues on the panel, particularly Dr. Brundtland, Your Excellencies, ladies and gentlemen. We are very happy to have the opportunity of hosting this fourth meeting of the Roll Back Malaria campaign. I am particularly proud that we have all of you here with us and representatives of our partner organizations in UNDP and UNICEF and, indeed, so many of you who have made a tremendous contribution to this Roll Back Malaria campaign. As Mr. Alnwick said, today is an opportunity for us not just to reflect on the progress that we've made in the last several years, but most particularly to talk about the action phase, to move from the discussions of the Partnership to implementation, and to learn from each other what we are doing and what we have been doing, and, more significantly, what we can do in terms of this really dramatic development and human problem. Over 3,000 people are dying every day, mainly children, and with economic costs that in Africa alone are estimated at $12 billion a year, we have a problem that is not only immense in human scale, but immense also as a development challenge. It is said to set back GDP in African countries that are affected by more than 1 percent per annum, and this in a continent which is struggling to build the levels of GDP growth so that we can attack the questions of poverty. This is a large and important issue. Indeed, at the meeting of the African leaders which was held, at which you, President Rawlings, made a very stirring speech, this recognition of the crucial importance of this campaign was made evident. And, in fact, the representation at that meeting was such that we were given confidence that African leadership was very much behind the approach that we're taking. Now, what is it that is significant about this work? It's clear that it's not just the money, though money is important. We ourselves in the institution have now got about $450 million out in various forms of anti-malaria programs in 46 countries over 56 projects. But we're ready to roll out additional funding, mainly IDA funding, for this work, really at the call of you, your Ministers, and for those that are Health Ministers, your Finance Ministers, whom not doubt you can influence in this effort. But we also recognize that even if we get the monetary resources which can come not just from us but with Jeff Sachs' help, all the grants that he's going to organize from around the world from all the people that he knows who are ready to give you money, if we can link the grants, the lending, and the funding in whatever form it comes, we know very well that that alone is not sufficient. The fight against malaria is not just a program to try and deal with the mosquitoes or the bed nets or the drugs that are required. That is, of course, important. The medical aspects, the focus on the disease, and prevention is crucial. But it has to go beyond that in two very important respects. First of all, it has to be national in scope. It has to be rolled out on more than a project basis. The numbers are too great to think in terms of a project here and a project there. We simply have to deal with this, as we do in so many other development issues, with programs that are replicable, that are communal and that are owned, and that can be rolled out on a broad scale. All of us could take a small area and deal with the question of malaria by delivering nets, by dealing with the problems of getting drugs, and giving a focus, and we could make an area safe. And that's a project which works and makes you feel terrific. And we tend to do that a lot in the Bank in all our work. But with the population growth anticipated to go from over 600 million to 1.1 billion in the next 25 years in Africa alone, with 2 billion more people in the next 25 years going into the developing countries, many of which are affected by malaria, projects alone are not sufficient. We have to come up with programs that are communal, where there's education, where it's known, and where we can engage all sectors of society, not just medical officers. And it starts with the planning of public works, the dealing with water. With every single project that we're engaged in, one needs to think in terms of the malarial impact. And we have to scale our projects in terms of communities so that there is a recognition on the part of communities that they are educated to the issues of malaria, that they know how to deal with them, and that they simply will not accept as a fact of life that 3,000 people die per day, mainly kids under five years old. This is not a necessity. It is a fact, but it's something that we must join together to fight against. And there the partnership that we have to build is not an uncommon partnership. It's a partnership first and foremost with governments. Governments must give this the priority that it needs and deserves. And it needs to be more than a health priority. It needs to be a priority which is embedded in government policy at all levels and is perceived, as is growing in terms of Africa in the case of AIDS, which is maybe more visible in some ways today, in terms of the public media, that this is a killer of a million people a year and a costly aspect of the loss of jobs, the loss of efficiency, the loss of GDP, and the loss of human contentment and human happiness. That is where we have to place this issue, so governments have their role. But governments alone can't do it. It has to be done with nongovernmental organizations, with civil society in its broadest forms, and with church groups, who have played such an important role in terms of health delivery systems and which need to be embraced in a more coordinated manner, voluntarily, than perhaps has been true up to now. We have been dealing with the faith-based organizations and with civil society in many of the countries in Africa, and most notably, I'm happy to say, in Tanzania, where we recently had a meeting with faith-based groups on this subject. So we're ready to reach out to all aspects of civil society and also to the private sector. For the private sector, it is not just a charity. It's self-interest. You need to keep the families healthy. You need to create an environment in which the lost jobs are diminished and where you have a healthy society in which you can operate. It's good business as well as good societal behavior. And what we need to do and what we're going to learn from each other in the course of these next few days is to learn of the initiatives that have been taken to see how from each other in the presentations that will be made we can understand what are the types of programs that work, that can be replicated, that can be owned and can be developed in scale. Keep in mind the replicability and scale and ownership. We're not interested in the programs that can solve the problems of 1,000 well-placed, well-financed families. When I say I'm not interested, I am interested but it's not the issue that we're facing today. You can deal with 1,000 families if they've got enough money and you've got a wall around them and you stop the mosquitoes and you have bed nets. The more significant thing is how to deal with the sort of people that we saw in this short feature that we've had before us today. We need to engage academia, and we need to engage the drug companies and the vaccine companies, and we need to give a focus to this war in which we're engaged. This is like, if I may say so, so many of the problematic wars and conflicts in Africa. They do not get the appropriate attention in the press. They do not get the sense of priority. They do not get the impetus that they deserve, as though life is cheaper and human suffering is less because it's in Africa and poorer countries. Suffering is the same in whatever family and in whatever economic strata. And we have today the responsibility and the opportunity to lift the level of awareness and to create the momentum and build on that momentum, because this is truly a fight, it is truly a war. We have to work with governments on taxes and tariffs. We have to work on it in terms of priorities. We have to look at the debt relief issues which were already mentioned by Mr. Alnwick and in which I believe we've already made significant progress. And we need, in fact, to use today as another starting point, no longer for analysis but for implementation. I want to say to you that, so far as the Bank is concerned, we're ready for that challenge. We're anxious to be part of it. We respect greatly the leadership of Dr. Brundtland and WHO and those that are setting the course for us. We're anxious to be a good partner, and we welcome you to this meeting. Thank you very much. [Applause.] MR. DORYAN: Thank you, Mr. Wolfensohn. Another partner organization is UNICEF, so I would like to go to the podium Mr. Andre Roberfroid, the Deputy Executive Director of that organization. Welcome. MR. ROBERFROID: Since the Roll Back Malaria initiative was launched in October 1998 by WHO, UNDP, the World Bank, and UNICEF, it has become a dynamic global movement. RBM has effectively mobilized resources and built effective partnerships with governments, donors, NGOs, and the private sector to work with communities to reduce the burden of malaria. Just one year ago, on April 25th, African heads of state and government, in their first-ever meeting on malaria, adopted the Abuja Declaration and Plan of Action, which was later adopted by the OAU and signed by all heads of state in Africa. Ambitious but feasible targets were adopted to reduce malaria-related mortality and morbidity throughout the continent. In July 2000, the G-8 launched the Infectious Disease Initiative, with special emphasis on malaria, HIV/AIDS, TB, and other childhood diseases. At this meeting, and at the December meeting in Okinawa, the G-8 strongly endorsed the global RBM goals and the Abuja Plan of Action. The group also pledged significant financial support. The RBM movement is indeed of particular importance to an organization like UNICEF, because infectious diseases, most notably HIV/AIDS, malaria, TB, threaten to wipe out the tremendous gains made in reducing infant and child mortality over the past 20 years. Nearly 70 percent of those who die from infectious diseases are children. Five infectious diseases cause over 50 percent of deaths among children under the age of five in the world's poorest countries. Malaria kills, as you know, at least 1 million people every year, the vast majority of them children. Every 40 seconds, a child dies from malaria. Every year, between 300 and 500 million in developing countries suffer acute episodes of malaria. Of the more than 1 million people who die of malaria-related causes each year, 90 percent are in Africa. Malaria is also a major cause of anemia during pregnancy and in young children, a cause of miscarriage and low birth weight among newborns. It is the leading cause of school absenteeism and poor concentration of students. Therefore, that's why UNICEF has identified malaria as one of the greatest obstacles to ensuring the rights of children. For the past few decades, the fight against malaria in Africa has been carried out using presumptive treatment to chloroquine. Yet, as you know, malaria parasites have developed resistance to chloroquine and other commonly used drugs. A breakthrough came with the introduction of insecticide-treated bed nets which have been shown to reduce malaria mortality by as much as 25 percent. But in most countries, the use of bed nets is under 10 percent, and the retreatment rate of mosquito nets with insecticides is less than 15 percent. Malaria chemoprophylaxis during pregnancy has also been promoted for years, but its impact is limited by low compliance and increasing resistance to chloroquine. At the same time, as it will be explained in more detail in the next sessions, new and highly cost-effective technologies are now available. First, long-lasting nets in which insecticides are incorporated into the net fiber at the factory can continue to kill and repel mosquitoes even after more than 20 washings. WHO is in the process of testing this technology, and the nets will become commercially available at an affordable price this year. Second, new anti-malarial drugs are highly effective in treating severe episodes such as cerebral malaria in young children. A recent meeting convened by RBM has recommended that all countries that need to change first-line anti-malaria treatment because of resistance use combination treatments. Third, intermittent presumptive therapy against malaria during pregnancy has been shown t be effective in reducing the incidence of low birth weight in newborns. The challenge is how to implement such programs nationally, going to scale. What stops us from ensuring that all children benefit from these technologies? One factor is that these technologies are considered to be expensive. Are we ready to accept the concept of poor medicine for poor people? But, indeed, at current prices, combination malaria drugs cost dollars rather than cents. The price of long-lasting insecticide-treated bed nets is double that of normal nets, $4 instead of $2. But the experience we have with the Global Alliance for Vaccines and Immunizations has shown that, through a major global initiative involving new partnership, more costly vaccines like hepatitis B can be made universally available and prices can be reduced considerably once demand increases. Colleagues, our goal here is to achieve a consensus on innovative and bold strategies. Many of these strategies are key to achieving the ambitious target adopted at the Abuja Summit. For example, first we must promote an accelerated endorsement of effective malaria drugs, including combination drugs in areas with chloroquine resistance, long-lasting insecticide-treated bed nets, and intermittent presumptive malaria treatment in pregnancy. Endorsement must come from governments and international partners. We certainly hope that these partners will commit to provide the financial and technical support required on a sustained basis to ensure access for all children and women to cost-effective interventions. Second, we must work to further develop international and local partnerships. GAVI is a model of positive partnership with the pharmaceutical industry and major private donors. Public-private partnerships in rolling back malaria have been initiated in several countries, for example, the proposal by Exxon Mobil to support RBM activities in Nigeria, Cameroon, Equatorial Guinea, Chad, and Angola. This will be undertaken mostly through the government and NGOs. In Western Kenya, private companies involved in irrigation schemes are providing free nets to company workers and their families and are making malaria treatment available in local communities. Similar schemes are being implemented in Angola and Nigeria. At the local level, experience has shown that community-based strategies that actively involve the poor are more cost-effective and sustainable in reducing the impact of infectious diseases in the poor. Bamako Initiative programs in Mali, Benin, Guinea, Kenya, Zambia, and many other African and Asian countries have created a solid basis for sustainable community-based programs. The creation of a revolving fund has ensured that essential drugs and bed nets are available to communities at affordable prices. Third, there must be sustained financial support by national and donor governments to implement RBM strategies. Long-term commitments are required in order to strengthen health systems and to ensure that capacity-building efforts at national, district, and community levels are accelerated in order to efficiently absorb increased funding. At the global level, the creation of a global health fund currently being discussed by RBM partners and other major donors provides an opportunity for additional and sustained funding for RBM. At the national level, health sector reform provides a major challenge to RBM efforts in the context of basket funding and decentralization. Countries like Mali, Ghana, and Uganda are demonstrating that RBM and health sector reform can be mutually reinforcing. Taxes and tariffs on mosquito nets and insecticides have already been eliminated in several countries, including Tanzania, Uganda, Zambia, Cote d'Ivoire, and Nigeria. And more countries are in the process of doing so. The challenge is to ensure that this saving is passed onto the consumers in the form of reduced price of mosquito nets, particularly for poor families living in rural areas. Fourth, we have the responsibility to commit to a more equitable distribution of resources if we wish to alleviate poverty and the burden of diseases like malaria among the poor and most vulnerable, especially children. Childhood is the most crucial time for breaking the cycle of poverty by providing education, health care, and other means for increasing productivity. The importance of a good and healthy start in life for reducing poverty constitutes an additional reason for supporting the Abuja targets, which focus on pregnant women and young children. The G-8 HIPC Initiative and the evolving PRSPs provide interesting opportunities to assure equitable resource distribution. For example, in Cameroon, the Ministry of Finance has allocated $3 million of HIPC funds for bed nets. In Mali and several countries, HIPC is used to increase salaries of health staff whose scarcity in rural areas has become a major constraint to the performance of the health system and the implementation of RBM. The development of PRSPs in the least developed countries provides a unique opportunity to place RBM at the heart of poverty reduction strategies. Finally, we should continue to support research to develop effective anti-malaria drugs and vaccines that can be delivered through existing systems. Experience has shown, however, that once the conditions are met, there is an important remaining challenge: to develop effective mechanisms to transfer knowledge, commodities, services, and funds to families and communities, especially to the poorest, with inadequate access to the formal health system. This is where UNICEF is ready to support you. Being a field-based agency, our strength is in our country program and country offices. In 161 countries, our professional health staff are working with government, private sector, and nongovernmental agencies to help establish stronger partnerships and newer ways of cooperating for the benefit of children. We do have a supply and logistic operation which has been chosen by GAVI to support the procurement of hundreds of millions of dollars of new vaccines over the next five years. UNICEF has also established a special supply unit in Pretoria. Using competitive bidding, we are helping to procure millions of dollars' worth of mosquito nets and insecticides each year for several countries in Africa. The average price of nets has been lowered from over $5 to below $3. The nets are obtained mostly from African suppliers and are delivered in just about a month. UNICEF programs in safe motherhood and prevention of mother-to-child transmission of HIV, which we are supporting in many countries, are powerful vehicles for preventing malaria in pregnant women. One such method is to provide a free treated bed net to each pregnant woman in countries where malaria is endemic. Finally, UNICEF has years of experience in supporting communication activities to change the behavior of families in the areas of health care. This is an important factor in improving the acceptance and compliance of malaria treatments, malaria prevention in pregnancy, and systematic use of treated bed nets. Ladies and gentlemen, this coming September, 11 years after the historic World Summit for Children, leaders from around the global will gather once again at a special session of the General Assembly to rededicate themselves to the rights of children. UNICEF is determined to make the fight against malaria one of the prominent themes of this special session. And, in conclusion, on behalf of UNICEF, I'd like to pledge here today that we will make our network of experienced, country-based staff and our financial supply and monitoring system available to support the expanded Roll Back Malaria efforts worldwide. Thank you very much. [Applause.] MR. DORYAN: Thanks. The World Health Organization houses the Roll Back Malaria Secretariat and plays a critical role in catalyzing country-level partnerships, as well as provides technical leadership to the Partnership. Dr. Gro Brundtland will update us on the accomplishments to date on this very vibrant Partnership. MS. GRO BRUNDTLAND: Thank you very much, and dear colleagues at the panel, Excellencies, ladies and gentlemen, I'm very pleased to be with you here today to focus on the challenge of rolling back malaria as a key for global health action. And let me start by reflecting on the changing context within which we are all working. There is increasing recognition by key decisionmakers, whether in government, in private sector, or in civil society, that healthy communities and societies are vital for the future development of nations and our planet. Simply put, investing in health used to be seen more as a luxury to follow investing in energy, in transport, or in defense. Now the health of a society is seen as one of the first prerequisites for the development of its people. Taken together, the facts tell us that differences in people's life expectancy and well-being are one of the most vivid signs of the divisions in our world. They are also one of the main causes of this divide. Today, the role of people's health in contributing to their development has a central place in global debate. When we talk about economic development of the poorest countries, improvements in health stand out as a key prerequisite to progress. When we talk about global trade development of the poorest countries, then we cannot ignore issues of access to life-saving medicines and technology at affordable prices. When we talk about human security in our modern world, the global spread of disease, such as malaria, tuberculosis, and HIV/AIDS, form an important threat. When we talk about the frontiers of technology and science, advances with potential impacts on health are dominating the scene. When we talk about the environment, we worry about the consequences for our health of unsafe food and lifestyles, of pollution, and of global warming. This growing recognition of the importance of the health of societies and communities has led to a greater focus on global health issues. Now, I believe there are two reasons: the first is the growing realization of our common vulnerability to disease in a globalized world; the second, the growing body of evidence linking ill health and the slow progress of economic development. We know that communicable diseases, particularly HIV/AIDS, TB, and malaria, are themselves major causes of poverty. The success or failure of our collective response to these threats is critical. It holds the key to the economic and physical security, not just of individuals and communities, but of nations and continents. Last year, we set up the WHO Commission on Macroeconomics and Health, chaired by Jeffrey Sachs. This will provide solid evidence for future action based on sound economic analysis. The Commission has already assembled some powerful data. Quite simply, the devastating effect of ill health on the economic prospects of the world's poor community has been underestimated, massively so. Africa's GDP would be far greater than it is today if malaria had been tackled through political resolve 30 years ago when effective control measures first became available. There is no way the poorest countries will be able to achieve sustained economic development until we manage to stop the devastation caused by HIV/AIDS, malaria, TB, and other childhood and maternal-related illnesses that also lead to and cause poverty. For these countries, health is the first and most important investment. Of course, this does not mean that we should hold off investment in industries, infrastructure, or education until these countries are less affected by ill health. It means that without new investment in health, many of the other efforts are unlikely to be effective or sustainable. The key to driving back illnesses that cause poverty is straightforward: invest more and invest it well. WHO estimates that no country can offer an effective basic health care to its population without spending at least $60 or so per person per year on health. Yet most countries that suffer from widespread malaria, HIV/AIDS, and other infectious diseases have less than $15 per person per year to spend on health. I recently heard the Minister of Health from Malawi describing how changes in the value of the local currency have reduced planned government spending on drugs this year from $1.25 to just 75 cents per head. Now, how much more is needed? In order to reach agreed targets for malaria, TB, and HIV/AIDS, additional annual investments of $5 to $10 billion per year for at least 15 years are called for. If that sounds a lot, it equals 0.4 percent of the combined GDP of the industrialized nations, the same nations which have pledged to spend 0.7 percent of their GDP on development assistance but in recent years have reduced it to an average of less than 0.2 percent. I am confident that finance will become available, though under quite tight conditions. That is why I have encouraged WHO staff and colleagues within other UN agencies to think ahead. Last year, we asked ourselves how would our work change if we were to catalyze a massive effort to improve health. After a period of intense and focused work in all parts of the organization, we are now ready to respond to the challenges of scaling up, plan an unprecedented new push for health. We will face some great challenges. We will need to be disciplined in how we define our task. We must begin with a few central diseases and conditions: malaria, TB, HIV/AIDS, childhood diseases, and conditions that cause maternal and infant mortality. Gradually, but still quickly, as health systems are strengthened and capacity increases, we need to widen the task toward other health priorities such as the growing burden of non-communicable diseases and mental illness and the high level of injuries. We must ensure equity. It is the poorest who suffer most from disease, yet they are the hardest to reach. The middle classes in the cities, with their political clout, have always managed to skew health priorities toward their needs. We must ensure that health interventions are aimed at the poorest, whether they live in the slums of the cities or the rural outback. We need to focus on diseases, yet we cannot succeed unless we build up health systems. When we dramatically increase the spending and the funding, it will change the whole dynamic which has pitched those working in disease-specific or so-called vertical programs against those concerned with sectorwide approaches. These are not competitive agendas. We must do both. And we must make sure that both local authorities and international donors agree on the priorities. In short, we must focus on outcomes, not on structures, philosophies, or ideologies. If we can show measurable reduction in disease within a reasonable period of time, we continue. If not, the funding stops. This is a new and, for many, tough approach to public health. But like any investor, governments and the private foundations and companies which will invest in this new push for health must be able to see a return on their investment. It will mean new ways of working for health, locally, nationally, and internationally. We cannot expect there to be a single entity in control directing others with any kind of military precision. We cannot expect another smallpox eradication campaign. Instead, the work will be taken forward by a variety of groups--government, private or voluntary, faith-based or secular, international and local, campaigning on behalf of others or doing something themselves. This is where Roll Back Malaria is an example, bound by common values and a well-understood concept, with partners knowing what has to be done and how to do it. Roll Back Malaria is characterized by rapid, flexible, and decentralized decisionmaking in ways that hold different groups together so that they can make the best use of investments to ensure effective action. They have shown an ability to do this even in countries with underdeveloped public sectors and weak health systems. So, colleagues, Roll Back Malaria, as we have heard, was launched in October of 1998 by the partners, those present here today and UNDP, in response to calls from heads of state and government. A broad range of partners has joined the movement. I know that many who wanted to be with us here today could not be invited for space reasons. It is a sign that the Global Partnership is a healthy one. The movement has agreed to the goal of halving the global malaria burden by the year 2010. It can be achieved, although much hard work will be needed. We do not speak only of reducing deaths and episodes of illness; Rolling Back Malaria is also about reducing the economic burden to countries. We are all working in new ways to roll back malaria, but what we do is firmly based on what we have learned from past experience. Countries have taken on the hard work of doing analysis so that evidence-based solutions could be defined. They have changed their ways of working to include nontraditional partners such as nongovernmental organizations and for-profit companies, who can play a pivotal role in expanding countries' capacity to improve the delivery of goods and services. We are now in a position to sketch out our future work--one of the main objectives of this meeting. The concrete partnerships formed to roll back malaria are the backbone of the movement. Governments are working with a wide range of partners to develop evidence-based strategic plans and plans of action. They respond to country needs and potential. Eleven out of 40 country partnerships in Africa are now implementing the plans that have been jointly elaborated. These plans, developed around a national consensus by all Roll Back Malaria stakeholders, reflect an agreement on how best to scale up the national and local response to malaria. Partners at country level all pledged investments into these plans, thus sharing and endorsing the technical and institutional features of national strategies. There are budgetary gaps, and Global Partners are invited to help ensure that those plans do not fail. Countries seek support through bilateral development assistance, although were there a multilateral facility for supporting Roll Back Malaria action, the resources would certainly be well-used. This potential to support a country-developed effort is totally different from earlier top-down disease control blueprints. The move toward a multilateral facility means that Global Partners pool their technical capacity and resources. They can help to scale up the response through backing for existing country strategies. This is how Roll Back Malaria is an element of the new approach to international health that is starting to emerge--not project-based aid, but a large-scale international response to the expressed needs of countries and their people. It is built up from work with affected communities, with local organizations, with researchers, and with campaigners. We will undertake a global effort to find new cures for malaria as drug resistance increases. During the working group session, the Medicines for Malaria Venture will be able to talk about their exciting plans to develop a new antimalarial every five years; the TDR program participation in the Roll Back Malaria movement through working with the pharmaceutical industry to find ways of making combination drugs more accessible. The discussions last week in Norway should help us move forward on principles for increasing availability of patented medicines, including combination therapies, in low-income settings. Combination therapy is not only useful for treating individual patients. It also slows the development of drug resistance. Its action will also impact on malaria transmission. These additional public health benefits can be classed as "public good externalities." Reducing the transmission and infection through effective drugs and insecticide-treated materials has an impact on everybody. We cannot expect individual families to assume the total burden of paying for that public good. Indeed, if we were to leave the choice of an antimalarial drug policy to market forces alone, which would strongly favor individual, short-term results in contrast to longer public health benefits, it is unlikely that the new combination antimalarial therapies would ever be applied on a wide scale. The large-scale introduction of combination therapies is clearly an area where innovative public-private partnerships will be key. We have also seen development in efforts to prevent people being bitten by malaria-carrying mosquitoes, as we have seen on the screen today. Five years ago, it was difficult to find a mosquito net in Africa for less than US$10. Appropriate insecticides were hard to find. Insecticide-treated nets for half that price and less are now available in many countries. The private sector has responded to the call of promoting these materials and has invested private capital into factories in many countries. Tanzania and Nigeria are two particular examples here. Last year, at the Summit in Abuja, the heads of state committed their governments to reducing or waiving taxes and tariffs on net material and insecticides used in public health. To date, the number of countries who made good their Abuja commitment is small. Don't misunderstand me--the abolishing of taxes and tariffs on nets is not the only measure to ensure the wider utilization of insecticide-treated materials. But the action that has been taken clearly indicates governments' commitments to bold actions to prevent malaria. The effort to roll back malaria is also an initiative for strengthening health systems. Effective action involves improving people's ability to access effective health care systems. This also means enabling more people to manage their health in the home. However, it is also our responsibility to make sure that shopkeepers and other private, informal practitioners have the skills to identify severe diseases for urgent referral to the formal health service. The millions of people around the world living in countries severely affected by conflict are often amongst the most vulnerable to malaria. Country partnerships in some of the worst-affected situations have identified their capacity and needs and are already beginning to scale up ground-level action. Some Roll Back Malaria country partnerships have significant participation of the private sector. Their motivation varies from country to country. Enlightened engagement by multinational corporations has resulted in plans going beyond the short-term self-interest of keeping a work force healthy by addressing health needs of whole communities. Two recent examples from Eastern Europe and Africa exemplify this approach. Action taken by these countries clearly indicates their governments' commitment to prevent malaria, and I hope that other countries will follow their example in the near future. Exxon Mobil has recently announced its commitment to country-level partnerships in a number of African countries, as we have just heard. They are working with the governments and with nongovernmental partners to build and maintain new health care facilities in underserved areas to better treat not only malaria but also a range of other diseases. INAI [ph] has continued its strong support to roll back malaria in Abidjan and expanded its health investments now into areas in Africa. The scale of this engagement and operation could, of course, still be significantly increased. So, colleagues, we have taken the time to take stock, to define strategies and principles, to establish partnerships, and to see what works. But it is now time also for more expanded action. The Global Partnership needs resources to support country action, to back its advocacy and communication work, to promote the development of health systems to roll back malaria, and to foster effective research and to measure outcomes. I hope that at this meeting, global Roll Back Malaria partners will consider ways to commit the resources and support for effective and speedy implementation of the agreed national strategies. Local partnerships are key and must take the lead, but they cannot do it alone. They need vital finance and infrastructure. And certainly, partners need the resources and the support necessary to develop new tools and to make those that exist accessible to all those who need them. Thank you very much. [Applause.] MR. DORYAN: Thank you very much, Dr. Brundtland. I think it is a clear overall picture of what we have to tackle in the near future. We have a few minutes for questions and answers, especially questions to the speakers. Given that in the next two days, there is going to be enough time to engage in discussions and listen to comments from the audience, we should stick at this point primarily or only to questions in order to make the next few minutes the most appropriate for the event. So could I please ask anybody, including members of the press, if they would like to ask questions. What we will do is entertain two or three questions and then allow the speakers to address them. And if you could please introduce yourselves--I cannot necessarily know all of you who are here, nor can I always see who is speaking, so please introduce yourselves. We do have microphones; there are a couple of people with microphones. So let's open it for a few minutes for questions and answers. Yes, I think there is a question from Mali. We're going to entertain two or three questions and then allow the speakers to respond. Go ahead, please. QUESTION [Interpreted from French; no interpretation at start of question]: --became rather visible in Africa because of the vector probably, maybe because of the economic weight, because of the influence it had on the economy. HIV/AIDS is also becoming visible. So I would like to raise the question today: Why not malaria? Why today is it not possible to imagine a program or subregional programs for the fight against malaria, and why can we not think about financing mechanisms for these subregional factors? If I take the example of Western Africa, ECOWAS has one specialized agency for health. I would like to know what could be the financing mechanisms of these specific agencies, these health agencies in these subregions, to make sure that beyond countries--because obviously, they do not all belong to certain initiatives--how can we have initiatives at the level of the subregions so that there may be exchanges among these countries in Africa, because sometimes they are isolated and are not able to be included. I think this is a very basic question, and we should find an answer so that we may progress a little bit faster. Thank you very much, and I apologize for having been so long. MR. DORYAN: Thank you very much. We'll take a couple more questions. Could you identify yourself, please? QUESTION: As you know, the Rotarians have been involved in a major way in the polio reduction campaign, and they remain focused on that until it is done. The question is what is your message--what questions are you asking of Rotarians in order to engage them in the fight against malaria on a worldwide scale? Thank you. MR. DORYAN: Thank you for being to-the-point. From Senegal, please. QUESTION: [Interpreted from French; no interpretation at start of question]: Professor Oumar Faye, Minister of Senegal. More particularly in Senegal, we do know that this sector is a very large source of treatment. How can we make sure-- MR. DORYAN: Excuse me. Is there a problem with the translation? [Pause.] It has been resolved. Thank you. Go ahead, but be as short as possible. QUESTION: Shall I start again? I said that after independence, many countries adopted a pharmaceutical policy largely inspired from the former colony. And I said that this legislative mechanism did not take into account the concepts which are really based on populations' needs. It means that as far as pharmaceutical policies, they failed. They failed, first of all, because the populations have very low buying power, and this was made even worse by devaluation of the French CFA, but also because the social-cultural environment of the patients is also difficult, but also because of the lack of dynamism of the informal sector. This sector is growing very much in Africa, and it is a great source of treatment. I think the most productive approach and the most realistic approach would be to take into account these practices in the health policy. When we talk about the private sector, we do not very often talk about the informal sector. How can we make sure that this informal sector which today plays a very important role as far as treatment and care--how can we make sure that there is a synergy in the private sector and the structural sector? Thank you very much. MR. DORYAN: Thank you. We will entertain a final question, and then allow the speakers to respond. Is there a final question? [No response.] MR. DORYAN: Okay. Who would like to start? Dr. Brundtland? DR. BRUNDTLAND: Thank you. The first question was why are the subregions of the African countries not included in the process. In a way, I was thinking, we have made a lot of effort to really see that this Roll Back Malaria movement is country-based. Now, to support action between countries, both the total African and the global level are important, supporting the countries and having it work effectively. However, it is true that in the African context, both the SADCC, the ECOWAS, and other subregional entities are part of the picture, and the Regional Director from Africa came up and gave me a short note just confirming that in fact, we are in the process of trying to also stimulate the subregional units to be more actively engaged not only in Roll Back Malaria, but in health issues more broadly. So your point is well-taken, and it needs to be done. But basically also, your question is one of focusing and mobilizing more resources on public health efforts, both at the subregional and the country level and, of course, the regional efforts. Then, there was a question from Rotary--what will be my message in three months when I speak to the Rotarians? Well, I don't think my message will be changing fundamentally in those three months. I think I will be very strongly focused on doing the job which Rotary has been involved in on polio, as you said, because we cannot miss, as we are approaching a result which is worldwide but which still needs quite considerable efforts in a number of countries over some more years. But of course, there is a potential for the involvement of Rotarians as Rotarians, but also many of these people belong to companies which again can be part of a global effort in malaria and HIV/AIDS in really stimulating a broader attention to the key area of building up at least a basic health system that can reach not only the workers of the companies, but the villages, the communities, the families of which they are part. So I think my message will be that we can never solve global health problems by public actions alone and by government or intergovernmental efforts. Civil society, private, informal--which was the other question from Senegal--the informal sector--they are all not only part of the solution, but in fact they are all also responsible. Nobody can lean back and say this is something for somebody else to be dealing with, and since we pay taxes, if we do, somebody in the public sector has to be dealing with all of this. No, this is not going to be enough. So people will have to see ways of partnering and making the best of their comparative advantages to be able to add to the momentum of solving problems which are solvable and where the gaps are too great. So I think that's the first preparation for the speech to Rotary. Thank you. MR. DORYAN: Thank you very much. Mr. Wolfensohn? MR. WOLFENSOHN: I just simply support my leader, Dr. Brundtland. And you will be pleased to hear that I have not been asked to speak at Rotary, so I have no particular message for them at this moment. But on the subregionals and on dealing with the other sectors, I agree with my leader. MR. DORYAN: Thank you. Andre? MR. ROBERFROID [Interpreted from French]: Thank you. I would like to answer the Minister from Mali as to the question on support of subregional activities. I think that there are a number of initiatives which deserve to be explored, but I would like to inform you first of all that in the United Nations Secretariat, the Secretary-General has just sent a mission to Western Africa more particularly in order to study with our ECOWAS partners more specifically the possibility of an organized collaboration with regional institutions. I think that so far, these institutions were mainly concerned with economic, social, and monetary issues, and I think that initiatives such as Roll Back Malaria make it possible for them to choose a new activity area, and I think they will be happy to be responsible in this area. [In English]: On the Rotary and your collaboration on polio, you have shown one particular quality, I would say. It is that you are patient, and you stand to your commitment until the end. I think that if you decide to start to get involved in malaria, you should know that you are engaging yourselves for a long time also and that we will continue until the end. But as Dr. Brundtland said, don't jump before we finish the job on polio. I think that's the number one priority. [In French]: As far as the Senegal question is concerned, I think that the informal sector issues that you mentioned mean that we have to ponder over alliance possibilities. We have world and national alliances right now. And I think that the informal sector that you are talking about should make it possible to create local as well as community alliances. It is at this level that the informal partners that you mentioned will be able to do something. For example, in the area of distribution of mosquito nets, they may play a very significant role. Of course, they will have to have support, which we will have to create. But it will be necessary that communities as well as their management mechanisms be included. Thank you. MR. DORYAN: Thank you. I would like to thank the speakers for their encouraging words. We are going to have a 15-minute break now for coffee, and we'll be back at exactly 10:30. Thank you. |
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