In July 1998, Gro Harlem Brundtland took over as the new head of the World Health Organization (WHO) in Geneva. The former Norwegian Prime Minister, who also became known around the world as chairwoman of the Brundtland Commission,set out to reform WHO and to establish new directions for its work. In a speech at the World Bank, she develops some of her thoughts on the future of WHO health policies.

Health and other aspects of development are inseparable. We cannot define the agenda for economic progress without thinking about people's health. And we cannot hope for better health ­ particularly for the poor ­ without recognising the importance of economic development.

The world enters the next century with hope, but also with uncertainty. Remarkable gains in health, rapid economic growth and unprecedented scientific advance ­ all legacies of the 20th century ­ could lead us to a 21th century that marks a new era of human progress.

I believe that the target of halving the number of people living in absolute poverty by the year 2015 ­ the overarching goal of international development ­ is attainable. But it will require that we focus on the things that really matter.

So let us look now at health itself. If the international community can agree on how the agenda for world health is framed, the more effective and influential that agenda will be. I believe that there is a growing consensus on where we should be heading. Let me highlight four messages that will appear in this year's World Health Report:

• First and foremost, there is a need to greatly reduce the burden of excess mortality suffered by the poor. This will require major shifts in the way that governments all over the world use their resources. It will mean focusing on diseases, like tuberculosis, which disproportionately affect the poor. It will mean focusing on groups in the population which are more vulnerable to poverty. It will mean focusing on diseases such as malaria and HIV/AIDS which we know limit economic development. And it will mean focusing on interventions that we know can achieve the greatest possible health gain, within prevailing resource limits.

Reducing the burden of disease suffered by poor people is not just a call to governments. To make real inroads into absolute poverty will mean harnessing the energies and resources of the private sector and civil society as well.

Need for targets

We also need to be clear about what the world should be aiming to achieve and the resources needed to achieve our goals. We believe there is a good case for negotiating a limited number of national and international targets ­ as a means of mobilising resources, concentrating international attention on the most important problems, and ensuring proper monitoring of progress and achievement.

• Second, there is a need to counter potential threats to health. These threats arise from many sources: from economic crisis, from unhealthy and unsafe environments and from risky behaviours. Tobacco addiction is one of the most important. But there are many others.

  Addressing the broader determinants of ill health provides a focus for working beyond the boundaries of the traditional health sector ­ a part of the development agenda that has been neglected for far too long.

  Pursuing more healthy national and international public policies is a particular challenge to the international community ­ not just in terms of what needs to be done, but also how. Concerted action across governments to achieve human development objectives is still a very elusive goal in many parts of the world.
  

• Thirdly, there is a need to develop more effective health systems. In too many countries, health systems are ill-equipped to cope with present demands, let alone those they will face in the future. In this regard, I was struck by a point recently made by World Bank President James Wolfensohn when writing about the prerequisites for sustainabl growth.

  He said that "too often in the past, we have gone after the 'easy targets', saying we would attack the more difficult (often institutional) issues later on. By contrast, good business strategy attempts to identify bottlenecks ­ the hard-to-solve problems that are impediments to success ­ and it begins by attacking these first."

  The institutional issues which limit health sector performance are a case in point. We have to start thinking about the difficult issues ­ such as pay and incentives in the public sector, unregulated private sector growth, and the politics of priority setting. Ignore these, or leave them till later, and we will almost certainly fail in our endeavours to improve people's health.

  Health sector reform is underway in many parts of the world. The often conflicting pressures on reforming governments are many. We have to recognise this. But in framing an agenda for international health ­ we must at least be clear about the desirable characteristics of health systems.

  Of course they should deliver better health outcomes. But we should also be concerned that they reduce health inequalities. They should enhance responsiveness to people's legitimate expectations. They should use resources as efficiently as possible. They should enhance fairness in the way they are financed. And they should protect people from major financial losses when they fall ill.
  

• Lastly, there is a need to expand the knowledge base that made the 20th century revolution in health possible. We need the tools and technologies that will ensure continued health gains into the 21st century.

  Governments of high income countries and research-based pharmaceutical companies continue to invest massively in research and development, oriented to the needs of the more affluent. Much of this investment benefits all humanity, but at least two critical gaps remain. 

  One concerns research and development relevant to the infectious diseases that overwhelmingly afflict the poor. The other concerns the systematic generation of an information base that countries can use in shaping the future of their own health systems. I now want to turn to my second theme: what are the implications of this agenda for those of us who work in organizations concerned with international development?

  First of all, we have to be clear that countries must remain in control of their own development. National ownership of the development process ­ in health or any other sector ­ is essential. We can articulate priorities on the basis of sound evidence. But we cannot prescribe. We can assist in building capacity to set national goals and objectives. But we need to take care that the way we work does not undermine the need for governments to determine their own spending strategies.

Joined-up approach

I have touched on the need for concerted action across governments to tackle the broader determinants of ill health. But we also need a more "joined-up" approach within the international development community. Within individual agencies ­ so that themes such as poverty reduction drive the work of all parts of the organization ­ and do not become the preserve of special departments. And, even more, we need a "joined-up" approach between agencies.

As you know WHO is an active participant in helping to shape the UNDAF process. But co-ordination needs to extend beyond the UN and beyond the health sector alone. It is in this context that we warmly welcome ideas such as the Comprehensive Development Framework that has been proposed by Jim Wolfensohn.

In the field of health, we have learnt our lessons. We know there is a limit to what can be achieved through isolated projects. We have seen too many pilots that never went to scale ­ remaining as islands of excellence in an under-resourced sea. We hear from our Member States about health projects that failed because insufficient attention was paid to the institutional and political environment in which they were implemented.
For these reasons, agencies, development banks and governments are coming to realise the disadvantages of traditional development projects. They recognise, as we do in WHO, that sectoral approaches offer a way of supporting health development in ways that strengthen national ownership and help to build sustainable national systems.

The Comprehensive Development Framework takes sector-wide thinking an important stage further ­ in a way that makes the links between the overall economy, the structure of government, and the many facets of human development more explicit.

I have heard people say that this kind of framework represents nothing more than good development practice. Indeed, the same has been said about sector-wide programmes. And in many ways these statements are true. But I believe there is much to be gained by being explicit and systematic about good practice. We hope that the proposed framework will be influential in gaining the attention of both governments and development agencies ­ and acting as a focus for rethinking and renegotiating development policy and practice.

We sense that the thinking behind a more comprehensive approach to development still has some way to go. Beyond the ideal, we need to think through what will happen in practice, particularly we need to ensure a proper focus on human development outcomes. We also need to be clear about what we mean by success ­ particularly in piloting the approach in selected countries ­ but also in the longer term.

I would now like to turn to my third theme: change within WHO itself.

WHO is the lead agency in international health. But even in its own field, we have to recognise that the global agenda is too broad for one agency alone. We need to be realistic, and to define how WHO, as a single UN agency, can contribute most effectively.

Reform and renewal within WHO

Over recent months, we have embarked on a far-reaching process of renewal and reform.

Our first objective was to reorganise work at headquarters in a way which properly reflects the nature of our business. Subsequently, we took the first steps to align the budget with the new organizational structure, reallocating resources to match our new priorities. The process of rolling out these changes to regional and country offices is now underway.

Many of you will be familiar with the changes in Geneva. Work is grouped under nine clusters, and 35 departments have taken the place of 52 previously separate programmes. The structure is flatter and we have introduced a more transparent system of corporate management, led by the Cabinet. Whilst many of the reforms are now complete, much still remains to be done: to introduce greater staff mobility, to move further with gender parity, and to further reduce our administrative costs.

We have also recognised the need to define common strategic themes which will underpin the work of the whole Organization. Our work in this area is still evolving, but I would like to share with you our thinking to date.

Some have said that the policy of Health for All should remain the guiding concept for WHO. I do not disagree. Health for All enshrines values such as equity, which will continue to be central to our work. But we need something more.

We need a corporate strategy which acknowledges not just the ideal of Health for All, but the path by which this ideal can be achieved. Since many of the world's population are excluded from health care, and since health outcomes are inequitably distributed ­ we need to be clear about what needs to be done.

In addition, we need a corporate strategy which defines the role of WHO as an individual organization. This will help us in framing our overall objectives ­ against which our performance can be judged by others. We must beware of confusing the performance of WHO, with the performance of our Member States.

We believe that four related themes should guide our work. The first two concern where we focus our efforts. The second two concern how we work.

• We need to be more focused in helping to obtain better and more equitable health outcomes.
• We need to be more effective in supporting health sector development.
• We need to be more strategic in our work in and with countries.
• And we need to be more innovative in creating influential partnerships.The first strategic theme relates to the first component of the agenda for international health ­ reducing the excess burden of disease suffered by the poor.
• We are committed to reducing the burden of sickness and suffering resulting from communicable diseases. Roll Back Malaria is central to this approach. But we will also contribute as effectively as possible to combating the global epidemics of HIV/AIDS and TB and to completing the eradication of poliomyelitis.
• We need to step up our ability to deal with the rising toll of non-communicable disease.

Special attention will be given to cancer and cardio-vascular disease. The Tobacco Free Initiative is supporting and leading this approach.

• We will pay more attention to the delivery of high quality health care for children, adolescents and women.
• We will put the spotlight back on immunisation as one of the most cost-effective health interventions.
• We will continue to support countries in their quest for access to affordable and quality essential drugs.
• We will work to see that mental health ­ and particularly the neglected scourge of depression ­ be given the attention it deserves.
• We need to intensify our efforts to reduce the enormous burden of malnutrition, especially in children.
• We need to be better at responding to increasingly diverse kinds of emergencies and humanitarian crises.
• And we need to be able to deal more effectively with inter-sectoral issues ­ particularly the threats to health that result from environmental causes.

The second theme relates to health sector development.

WHO has always been strong at responding to specific requests. We are good at fielding highly qualified technical experts. But often individual experts tend to see the world through their own expert lenses. We are less good at helping senior decision makers deal with the big picture.

Regaining our place at the centre of the health sector development agenda is a challenge for the whole of WHO. And it is one of the reasons why I have launched the project under the title of Partnerships for Health Sector Development.

The project will be working to advance our strategic agenda on several fronts. It will work throughout the Organization to establish a health sector development perspective in all aspects of our work. It will also be concerned to help you develop a more strategic approach to work with countries. Certainly, the project will have a role in helping WHO to develop more influential partnerships.

WHO and its relations with member states

Thirdly, we need a more strategic approach to our work in and with countries. WHO is not a donor agency. Its prime resource is knowledge and people. In thinking about our relationships with Member States we need to think not just about what we spend but what we do.

We work for countries in two ways. We work in countries by establishing a direct presence in order to respond to national developmental needs. In this regard, it is essential that our in-country presence is adequate for the tasks we need to undertake.

We also work with the entire community of countries, collectively or in groups, helping them to mobilise their collective wisdom, knowledge and efforts in the production of norms and standards, sound evidence and surveillance data. These are all international public goods which benefit all.

Other agencies expect WHO to know about the health situation in countries. And not just in terms of indicators of health status. As we build our relationships with international financial institutions and other development partners ­ we need to be able to present not just information, but intelligence ­ a concise account of the key issues which are central to health sector development. We need to be able to do this, not just in exceptional circumstances, but as a regular part of our organizational performance.

Lastly, we need to forge more influential partnerships.

In approaching partnerships, we need to shift our strategic direction substantially. We need to move from our traditional approach ­ which too often has favoured our own small-scale projects ­ to one which gives more emphasis to strategic alliances. Alliances will allow us both to learn from and to influence the thinking and spending of other international actors.

Global partnership

WHO can lead more effectively when we link up with others, agree on a clear division of labour, and ground rules for conducting our relationships. The cabinet projects on Roll Back Malaria and the Tobacco Free Initiative will act as pathfinders for WHO ­ demonstrating how we can be more effective by taking a lead role in global partnerships.

We also need to stop seeing bilateral agencies purely as donors to WHO, and recognise them as influential partners in the development process.

Over the past few months we have devoted a great deal of energy to renewing relationships and forming stronger partnerships with several international bodies ­ with the IMF, the World Trade Organization, the Organization of African Unity, the European Union ­ and not least of course with our UN partners and the World Bank. We need to learn to rely not just on formal structures and framework agreements between organizations ­ but actively to develop informal alliances and coalitions. Our work on sector programmes has taught us this in many countries.

We need to work harder to understand each other's language and procedures. Health specialists cannot work without reference to development economists. Aid managers cannot work without reference to the views of health sector specialists. This idea is central in my own thinking that all the work of WHO should be concerned with health sector development in its broadest sense.