Address by Dr Poonam Khetrapal Singh, Regional Director, WHO South-East Asia Region, at the University of Maldives

05 March 2014, Male', Republic of Maldives

Hon’ble Dean, distinguished Chairs of the Faculties, Ladies and Gentlemen.

Firstly I would like to thank the Government of the Republic of Maldives for giving me the opportunity of being here in your beautiful country. Secondly, I would like to thank the Hon’ble Dean of the University of Maldives for giving me this opportunity to give a brief talk on current global and regional health priorities and the role WHO is playing to address these priorities.

Maldives is one of the eleven Member States of WHO South-East Asia Region. Although the Region has eleven countries, it is home to more than 1.7 billion people, which is more than a quarter of the entire world’s population. And if you consider diseases of public health importance, almost 40% of the burden of those diseases is borne by the South-East Asia Region alone.

Starting from 2000 WHO regularly published the most comprehensive estimates of global disease burden using DALY or the disability-adjusted life years as a measure of the burden of each of those diseases. Since then, the global disease burden estimates have been regularly updated. The latest update for the year 2011 shows that there has been virtually no change in the top five diseases or conditions of public health importance in the last one decade, which includes: infectious diseases (including respiratory infections), cardiovascular diseases, injuries, neonatal conditions, and cancers.

It is important to bear in mind that most countries in our Region are still struggling with the prevention and control of communicable diseases. At the same time, they are faced with the growing burden of noncommunicable diseases which are rapidly escalating in almost all countries, placing tremendous pressure on their national health systems.

Just to illustrate, let me give you some figures; of the estimated 5 million new cases of TB, 3.5 million occur in our Region. What is more worrying is that of an estimated 90 000 cases of incidence of multi-drug resistant TB or MDR-TB, a mere 10 000 are enrolled for treatment; and of the approximately 3.4 million new infections with HIV, anywhere from 160 000 to 360 000 arise in the South-East Asia Region. But more importantly, the burden of noncommunicable diseases is increasing rapidly. For example, of the estimated 346 million people with diabetes in 2010, it is estimated that 71 million are in the SEA Region alone; of the 8.2 million deaths from cancers worldwide, 1.2 million have occurred in this Region alone. Likewise, of the estimated 7.9 million deaths from noncommunicable diseases worldwide, 55% take place in the countries of our Region. From these you can see how important the WHO’s South-East Asia Region is to the overall public health concerns of the world.

Ladies and Gentlemen, I must hasten to add that this Region has also seen many achievements too; leprosy is considered eliminated at the national level, although we still have relatively large number of cases in the Region. Maldives has been malaria-free for many years and yaws has been eliminated from India. There have been no cases of polio due to wild polio virus in the Region for more than three years and the Region is on track for polio-free certification – a truly remarkable public health achievement. Although we still have work to do, particularly for MDG 4 and 5, overall, the countries of our Region have made notable progress towards the Millennium Development Goals.

Given the above situation, you will ask what is WHO doing about it. WHO’s core mandate is to formulate evidence-based policy, set standards and norms and provide technical support to countries with a focus on capacity-building. WHO also has the mandate to monitor disease trends, and that is what the estimate for the global burden of disease is all about. For every disease or condition of public health importance, WHO brings together the best of global expertise to shape preventive and promotive policies and strategic frameworks which are discussed at great length with Member States at the World Health Assembly before they become guidelines for Member States. WHO provides technical support to Member States – both from within its own core staff strength as well as by mobilizing the best of technical expertise worldwide – to guide and shape national health policies and strategic framework, to prevent and control these diseases or conditions of importance to public health.

It is just a month since I took over as the Regional Director for the WHO South-East Asia Region. I am not totally new to WHO and the public health concerns of the Member States, as I have worked for a decade at the highest policy levels in WHO, first at its Headquarters in Geneva and, later, in the South-East Asia Regional Office itself. Therefore, for me, it is both an honour as well as a challenge to return now as the Regional Director. My vision for WHO’s role is to remain a strong partner to Member States and to contribute to joint efforts in improving health and well-being of the population of this Region. To do the above I intend to implement this mandate through four focused strategic directions:

  • addressing the persisting, emerging epidemiological and demographic challenges
  • promoting universal health coverage (UHC) and building robust health systems
  • strengthening emergency risk management for sustainable development
  • articulating a strong voice in the global health agenda.

Let me expand and share my views with you on these four strategic directions. The first strategic direction is: addressing the persisting and emerging epidemiological and demographic challenges. The Region is on track to be certified polio-free later this month. This success must now be replicated for other public health challenges, including the elimination of other vaccine-preventable diseases such as measles. Likewise, to build on the achievements of the TB programme, the menace of drug resistance and coinfections which looms large must be addressed. In addition, there are emerging pathogens and disease outbreaks such as the avian influenza H7N9 outbreak in China, which threatens to spread beyond the Chinese borders, and the Middle-East respiratory syndrome coronavirus (MERS-CoV) infection, which is also an emerging global threat. Fortunately, WHO has already in place the International Health Regulations, or IHR, which Member States are currently in the process of implementing. Once IHR is well in place, each country will be capable of following the standards, procedures and protocols within it that automatically stimulate specific actions when an emergency alert is sounded for a public health event of international concern.

While our fight with communicable diseases continues unabated, the mounting epidemic of noncommunicable diseases is stretching health systems of all Member States. Currently, more than half of our burden of disease is caused by four major NCDs: diabetes, cardiovascular diseases, cancers, and respiratory diseases. It is estimated that in the Maldives about 70% of deaths are due to NCDs. More importantly, the risk factors such as tobacco use, imbalanced nutrition and inactivity are quite common.

I am fully aware of the fact that primary prevention of NCDs is difficult. Many of their root causes reside in non-health sectors whose policies have, very often, adverse health effects. The health sector, we know, has negligible influence in the shaping of such policies. Therefore, I intend to redouble my efforts to articulate the need for having “health in all policies” and making health central to development in all relevant sectors.

This takes me to the second strategic direction, which is advancing UHC and building robust health systems. Universal health coverage, or UHC, is the flagship WHO umbrella programme that aims to ensure that all people obtain the health services they need without suffering financial hardship when paying for them. This requires:

  • a strong, efficient, well-run health system
  • a system for financing health services
  • access to essential medicines and technologies
  • sufficient capacity of well-trained, motivated health workers.

There are three dimensions to UHC – access, affordability and quality. Therefore, UHC is a functioning health system that has a well-defined package of essential services of quality that are accessible and can be afforded by all people. In Maldives, you are fortunate that successive governments have been trying to build built a health system that ensures access to basic health services. The real challenge for you will be the affordability and sustainability of UHC, particularly as public health concerns shift from communicable to noncommunicable diseases and the long-term impact of chronic health conditions. This is particularly relevant to our Region which has the highest out-of-pocket spending and relatively low public investment in health. These are key causes of inequities in access to health care. With burgeoning NCDs coupled with an ageing population, health-care costs are bound to spiral upwards.

Ladies and Gentlemen, I would like to touch upon one particular aspect of UHC and its relevance to this country. The South-East Asia Region has a booming pharmaceutical industry with India leading, particularly in the production and export of generic drugs. And yet for many countries, particularly countries like the Maldives, access to essential medicines and vaccines remains a major concern. We will take a proactive role in helping our Member States by utilizing the flexibilities in international treaties as well as promoting and facilitating innovation and cost-effective procurement mechanisms, especially for countries that are in greatest need.

We all know that the WHO South-East Asia Region is extremely disaster-prone. Last year, our Region accounted for around 41% of global mortality from natural hazards. Every year, millions of people lose their lives, livelihood and their homes during natural calamities. During such events, the poor are the hardest hit and, therefore, suffer the most. Therefore, my third strategic direction is to strengthen emergency risk management to ensure sustainable development. We have developed excellent benchmarks for preparedness and response in emergencies, which have received global recognition. We need to promote new ways of augmenting national capacity and making disaster risk reduction an integral part of national sustainable development policy.

Finally, for the fourth strategic direction of articulating a global health agenda, it is important, in this era of interdependency and cooperation, to build and sustain alliances and partnerships. Such collaborations not only generate more resources, but also strengthen our influence to bring about positive change. While the solidarity of countries in the South-East Asia Region is respected widely, our voice in the global health agenda needs to become louder, so that we are not denied access to the global benefits that we rightfully deserve. This is possible only through stronger partnerships, both within and beyond the Region.

Now let me dwell on some of the changes in the world that we need to adapt to. WHO has never been a funding agency. However, scarce WHO resources were used in the past to provide cash-based support to countries. There was a time when this was necessary and, for some countries, it is still relevant in a limited way. But let me emphasize that WHO is not a donor agency; the resources of WHO come from the contributions of Member States. The assessed contributions are topped with what is generally referred to as voluntary contributions which are usually programme or project-specified funds entrusted to WHO by Member States or other funding agencies. The resources of WHO are intended for providing technical support required by Member States and not for defraying the cost of delivering health care services, which is rightfully the prerogative of their ministries of health. I may add that there are more donors out there today with far deeper pockets than WHO. Therefore, WHO is adapting to ensure that it has the capacity to provide leadership in health and relevant technical support to Member States. This understanding is essential in appreciating the relationship between WHO and its Member States.

Ladies and Gentlemen, I must say that this nation is a blessed one. The beautiful islands and atolls of this country epitomise the saying, “Small is beautiful”. Even your population is small and, therefore, manageable. Successive governments have built an impressive network of health infrastructure in all islands, ensuring equitable access to health care services by all people. And your present government is equally committed to improve the health of the people of this country. However, delivering health care services in all the remote islands of your country is a challenging task.

Being an island nation brings its own geophysical challenges of reaching people in remote islands; ensuring rapid referrals or, for that matter, timely distribution of essential supplies to the far-flung island health facilities. There is a serious shortage of well-trained and motivated human resources in Maldives which is expected to continue in the immediate future. Further, as the country moves towards more decentralization and popular governance, ensuring stable financing for critical services and essential public health investments will continue to pose difficulties which, if not consciously addressed, can threaten the achievements made thus far. However, I have the utmost confidence in the leadership of this nation, and in the collective strength and wisdom of its masses to adequately and appropriately address its needs. As WHO, we stand ready and committed to support the Government in its march towards a healthy and disease-free Maldives.