FORTY-SEYENTH WORLD HEALTH ASSEMBLY GENEVA, 2-12 MAY 1994

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1 WHA47/1994/REC/2 WORLD HEALTH ORGANIZATION O R G A N I S A T I O N M O N D I A L E D E L A S A N T É FORTY-SEYENTH WORLD HEALTH ASSEMBLY GENEVA, 2-12 MAY 1994 VERBATIM RECORDS OF PLENARY MEETINGS QUARANTE-SEPTIÈME ASSEMBLÉE MONDIALE DE LA SANTÉ G E N È V E, 2-12 M A I COMPTES RENDUS IN EXTENSO DES SÉANCES PLÉNIÈRES GENEVA G E N È V E 1994

2 WHA47/1994/REC/2 _WORLD HEALTH ORGANIZATION GENEVA, 2-12 MAY 1994 VERBATIM RECORDS OF PLENARY MEETINGS G E N È V E, 2-12 M A I GENEVA G E N È V E 1994 O R G A N I S A T I O N M O N D I A L E D E L A S A N T É FORTY-SEVENTH WORLD HEALTH ASSEMBLY QUARANTE'SEPTIÈME ASSEMBLÉE MONDIALE DE LA SANTÉ COMPTES RENDUS IN EXTENSO DES SÉANCES PLÉNIÈRES

3 PREFACE The Forty-seventh World Health Assembly was held at the Palais des Nations, Geneva, from 2 to 12 May 1994,in accordance with the decision of the Executive Board at its ninety-second session. Its proceedings are published in three volumes, containing, in addition to other relevant material: Resolutions and decisions, annexes and list of participants - document WHA47/1994/REC/1 Verbatim records of plenary meetings - document WHA47/1994/REC/2 Summary records of committees and committee reports - WHA47/1994/ REC/3 For a list of abbreviations used in WHO documentation, the officers of the Health Assembly and membership of its committees, the agenda and the list of documents for the session, see preliminary pages of document WHA47/1994/REC/1. In these verbatim records speeches delivered in Arabic, Chinese, English, French, Russian or Spanish are reproduced in the language used by the speaker; speeches delivered in other languages are given in the English or French interpretation. They include corrections received up to July 1994, the cut-off date announced in the provisional version, and are thus regarded as final. AVANT-PROPOS La Quarante-Septième Assemblée mondiale de la Santé s'est tenue au Palais des Nations à Genève du 2 au 12 mai 1994,conformément à la décision adoptée par le Conseil exécutif à sa quatre-vingtdouzième session. Ses actes sont publiés dans trois volumes contenant notamment : les résolutions et décisions, les annexes qui s'y rapportent -document WHA47/1994/REC/1, et la liste des participants les comptes rendus in extenso des séances plénières 一 document WHA47/1994/REC/2, les procès-verbaux et les rapports des commissions - document WHA47/ 1994/REC/3. On trouvera dans les pages préliminaires du document WHA47/1994/REC/1 une liste des abréviations employées dans la documentation de l'oms, Pordre du jour et la liste des documents de la session ainsi que la présidence et le secrétariat de l'assemblée de la Santé et la composition de ses commissions. Les présents comptes rendus in extenso reproduisent dans la langue utilisée par l'orateur les discours prononcés en anglais, arabe, chinois, espagnol, français ou russe, et dans leur interprétation anglaise ou française les discours prononcés dans d'autres langues. Ces comptes rendus comprennent les rectifications reçues jusqu'au début juillet 1994, date limite annoncée dans leur version provisoire, et sont donc considérés comme finals. - n i 一

4 ПРЕДИСЛОВИЕ Сорок седьмая сессия Всемирной ассамблеи здравоохранения проходила во Дворце Наций в Женеве со 2 по 12 мая 1994 года в соответствии с решением Исполнительного комитета, принятым на его Девяносто второй сессии. Материалы сессии публикуются в трех томах, которые, помимо прочих документов, содержат: Резолюции и решения, а также приложения и список участников - документ WHA47/1994/REC/1 Стенограммы пленарных заседаний - документ WHА47/1994/REC/2 Протоколы заседаний комитетов и доклады комитетов - WHА47/1994/REC/3 Перечень сокращений, используемых в документах ВОЗ, списки должностных лиц Ассамблеи здравоохранения и членов ее комитетов, повестка дня и перечень документов, подготовленных к сессии,содержатся на предшествующих основному содержанию страницах документа WHA47/1994/REC/1. В настоящих стенограммах выступления на английском, арабском, испанском, китайском, русском или французском языках воспроизводятся на том языке, на котором выступал оратор; выступления на других языках приводятся в соответствии с устным переводом на английский или французский язык. В тексты стенограмм включены исправления, полученные до июля 1994 г. - конечного срока, указанного в предварительном варианте, и, таким образом, они считаются окончательными. -iv -

5 INTRODUCCION La 47 a Asamblea Mundial de la Salud se celebró en el Palais des Nations, Ginebra, del 2 al 12 de mayo de 1994, de acuerdo con la decisión adoptada por el Consejo Ejecutivo en su 92 a reunión. Sus debates se publican en tres volúmenes que contienen, entre otras cosas, el material siguiente: Resoluciones y decisiones, anexos y lista de participantes: documento WHA47/1994/REC/1 Actas taquigráficas de las sesiones plenarias: documento WHA47/1994/REC/2 Actas resumidas e informes de las comisiones: documento WHA47/1994/ЫЕС/3 En las páginas preliminares del documento WHA47/1994/REC/1 figuran una lista de las siglas empleadas en la documentación de la OMS (incluidos estos volúmenes), la composición de la Mesa de la Asamblea y de sus comisiones, el orden del día, y la lista de documentos. En las presentes actas taquigráficas los discursos pronunciados en árabe, chino, español, francés, inglés, o ruso se reproducen en el idioma utilizado por el orador. De los pronunciados en otros idiomas se reproduce la interpretación al francés o al inglés. Las actas contienen las correcciones recibidas hasta julio de 1994,fecha límite anunciada en la versión provisional, y por consiguiente se consideran definitivas.

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7 序 言 根据执行委员会第九十二届会议的决定, 第四十七届世界卫生大会于 1994 年 5 月 2 至 12 日在日内瓦万国宫举行 会议记录分三卷出版, 除其它有关材料外, 其内 容包括 : 决议和决定, 附件及与会人员名单一文件 WHA47/1994/REC/1 全体会议逐字记录一文件 WHA47/1 卯 4/REC/2 各委员会摘要记录和报告一文件 WHA47/19g4/REC/3 卫生组织文件中使用的缩写清单 卫生大会的官员及其各委员会的组成 议程 及会议文件清单, 见文件 WHA47/1994/REC/1 先行页 阿拉伯文 中文 英文 法文 俄文和西班牙文发言的逐字记录, 用发言人使 用的语言刊载 ; 其它语言的发言用英文或法文译文刊载 这些记录只釆纳了 1994 年 7 月份以前收到的更正, 这是临时文本中宣布的截止日期, 因而它们是最后的文本 -vii -

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9 CONTENTS Page Preface iii VERBATIM RECORDS OF PLENARY MEETINGS First plenary meeting 1. Opening of the session 1 2. Address by the Director-General of the United Nations Office at Geneva 2 3. Address by the representative of the Conseil d'etat of the Republic and Canton of Geneva 3 4. Address by the President of the Forty-sixth World Health Assembly 4 5. Consideration of the situation of certain Member States falling under the purview of Article 7 of the Constitution: reactivation of the membership of South Africa 6 6. Appointment of the Committee on Credentials 7 7. Election of the Committee on Nominations 8 Second plenary meeting 1. First report of the Committee on Nominations 9 2. Consideration of the situation of certain Member States falling under the purview of Article 7 of the Constitution: reactivation of the membership of South Africa (continued) Second report of the Committee on Nominations 14 Third plenary meeting 1. Presidential address Adoption of the agenda and allocation of items to the main committees Announcement Review and approval of the reports of the Executive Board on its ninety-second and ninety-third sessions Review of the report of the Director-General on the work of WHO in Debate on the reports of the Executive Board on its ninety-second and ninety-third sessions and on the report of the Director-General on the work of WHO in Fourth plenary meeting 1. Announcement Debate on the reports of the Executive Board on its ninety-second and ninety-third sessions and on the report of the Director-General on the work of WHO in (continued) 44

10 233о2132Page Fifth plenary meeting 1. First report of the Committee on Credentials 2. Debate on the reports of the Executive Board on its ninety-second and ninety-third sessions and on the report of the Director-General on the work of WHO in (continued) Sixth plenary meeting 1. Address by the President of the International Olympic Committee 2. Debate on the reports of the Executive Board on its ninety-second and ninety-third sessions and on the report of the Director-General on the work of WHO in (continued) Seventh plenary meeting Debate on the reports of the Executive Board on its ninety-second and ninety-third sessions and on the report of the Director-General on the work of WHO in (continued) Eighth plenary meeting 1. Admission of new Members and Associate Members 2. Adwards Presentation of the Léon Bernard Foundation Prize Presentation of the Dr A. T. Shousha Foundation Prize Presentation of the Sasakawa Health Prize 3. Debate on the reports of the Executive Board on its ninety-second and ninety-third sessions and on the report of the Director-General on the work of WHO in (continued) Ninth plenary meeting Debate on the reports of the Executive Board on its ninety-second and ninety-third sessions and on the report of the Director-General on the work of WHO in (continued) Tenth plenary meeting 1. Twenty years of onchocerciasis control 2. Debate on the reports of the Executive Board on its ninety-second and ninety-third sessions and on the report of the Director-General on the work of WHO in (continued) Eleventh plenary meeting 1. Second report of the Committee on Credentials 2. First report of Committee A 3. Election of Members entitled to designate a person to serve on the Executive Board 4. Report by the General Chairman of the Technical Discussions Twelfth plenary meeting о6о о41. Announcements 2. First report of Committee В 3. Second report of Committee A -X -

11 Pages Thirteenth plenary meeting 1. Second report of Committee В 2. Third report of Committee A 3. Announcements Fourteenth plenary meeting 1. Acceptance of credentials submitted by Bolivia 2. Third report of Committee В 3. Fourth report of Committee A 4. Selection of the country or region in which the forty-eighth World Health Assembly will be held Fifteenth plenary meeting Closure of the session 238 Indexes (Names of speakers; countries and organizations) 245 -xi -

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13 TABLE DES MATIERES Pages Avant-propos iii Première séance plénière COMPTES RENDUS IN EXTENSO DES SEANCES PLENIERES 1. Ouverture de la session 1 2. Allocution du Directeur général de l'office des Nations Unies à Genève 2 3. Allocution du représentant du Conseil d'etat de la République et Canton de Genève 3 4. Allocution du Président de la Quarante-Sixième Assemblée mondiale de la Santé 4 5. Examen de la situation de certains Etats Membres tombant sous le coup de l'article 7 de la Constitution : reprise de la participation active de l'afrique du Sud 6 6. Constitution de la Commission de Vérification des Pouvoirs 7 7. Election de la Commission des Désignations 8 Deuxième séance plénière 1. Premier rapport de la Commission des Désignations 9 2. Examen de la situation de certains Etats Membres tombant sous le coup de l'article 7 de la Constitution : reprise de la participation active de l'afrique du Sud (suite) Deuxième rapport de la Commission des Désignations 14 Troisième séance plénière 1. Discours du Président de l'assemblée Adoption de l'ordre du jour et répartition des points entre les commissions principales Communication Examen et approbation des rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingt-treizième sessions Examen du rapport du Directeur général sur l'activité de l'oms en Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingttreizième sessions et sur le rapport du Directeur général sur l'activité de l'oms en Quatrième séance plénière 1. Communication Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingttreizième sessions et sur le rapport du Directeur général sur l'activité de l'oms en (suite) 44 Cinquième séance plénière 1. Premier rapport de la Commission de Vérification des Pouvoirs Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingttreizième sessions et sur le rapport du Directeur général sur l'activité de l'oms en (suite) 75 -xiii -

14 Pages Sixième séance plénière 1. Allocution du Président du Comité international olympique Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingttreizième sessions et sur le rapport du Directeur général sur l'activité de l'oms en (suite) 109 Septième séance plénière Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingttreizième sessions et sur le rapport du Directeur général sur l'activité de l'oms en (suite) 131 Huitième séance plénière 1. Admission de nouveaux Membres et Membres associés Distinctions 160 Remise du Prix de la Fondation Léon Bernard 160 Remise du Prix de la Fondation Dr A. T. Shousha 162 Remise du Prix Sasakawa pour la Santé Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingttreizième sessions et sur le rapport du Directeur général sur l'activité de l'oms en (suite) 168 Neuvième séance plénière Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingttreizième sessions et sur le rapport du Directeur général sur l'activité de l'oms en (suite) 181 Dixième séance plénière 1. Vingt ans de lutte contre l'onchocercose Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-douzième et quatre-vingttreizième sessions et sur le rapport du Directeur général sur l'activité de l'oms en (suite) 212 Onzième séance plénière Deuxième rapport de la Commission de Vérification des Pouvoirs 226 Premier rapport de la Commission A 227 Election de Membres habilités à désigner une personne devant faire partie du Conseil exécutif 227 Rapport du Président général des discussions techniques 227 Douzième séance pléniere 1. Communications Premier rapport de la Commission В Deuxième rapport de la Commission A 231 -xiv -

15 Pages Treizième séance pleniere Deuxième rapport de la Commission В Troisième rapport de la Commission A Communications Quatorzième séance pleniere 1. Acceptation des pouvoirs présentés par la Bolivie 2. Troisième rapport de la Commission В 3. Quatrième rapport de la Commission A 4. Choix du pays ou de la Région où se tiendra la Quarante-Huitième Assemblée mondiale de la Santé Quinzième séance plénière Clôture de la session 238 Index (noms des orateurs; pays et organisations) 245 -XV -

16 A47/VR/1 page 1 VERBATIM RECORDS OF PLENARY MEETINGS COMPTES RENDUS IN EXTENSO DES SEANCES PLENIERES FIRST PLENARY MEETING Monday, 2 May 1994, at 12h00 President: Mr С. ÔRTENDAHL (Sweden) PREMIERE SEANCE PLENIERE Lundi 2 mai 1994,12 heures Président: M. C. ÔRTENDAHL (Suède) 1. OPENING OF THE SESSION OUVERTURE DE LA SESSION The PRESIDENT: The Assembly is now called to order. Distinguished delegates, ladies and gentlemen, as President of the Forty-sixth World Health Assembly I have the honour to open the Forty-seventh World Health Assembly. I now have pleasure in welcoming, on behalf of the Assembly and the World Health Organization: his excellency Mr B. de Riedmatten, Permanent Representative of Switzerland to the International Organizations at Geneva; Mr Guy-Olivier Segond, Councillor of State, Chief of the Department of Social Action and Health of the Republic and Canton of Geneva, representing the Geneva authorities; Mr Hervé Burdet, Président du Grand Conseil; Mr Robert Hensler, Chancelier of the Republic and Canton of Geneva; Mr Vladimir Petrovsky, Director-General of the United Nations Office at Geneva, also representing the Secretary-General; Mr Pierre Keller, Vice-President of the International Committee of the Red Cross; the representatives of the United Nations specialized agencies, and the representatives of the various United Nations bodies; the delegates of Member States - and here I extend a special welcome to the observers from Nauru and Niue which have applied for membership of WHO. I am also, may I say personally and on behalf of the presidency, extremely pleased to see our colleagues from South Africa in their seat. I also welcome the observers of non-member States and the observer from Palestine; and the representatives of intergovernmental and nongovernmental organizations in official relations with WHO. I also welcome among us the representatives of the Executive Board.

17 A47/VR/1 page 2 2. ADDRESS BY THE DIRECTOR-GENERAL OF THE UNITED NATIONS OFFICE AT GENEVA ALLOCUTION DU DIRECTEUR GENERAL DE L'OFFICE DES NATIONS UNIES A GENEVE The PRESIDENT: I now give the floor to Mr Petrovsky, Director-General of the United Nations Office at Geneva. Mr PETROVSKY (Director-General of the United Nations Office at Geneva): Mr President, Mr Director-General, your excellencies, ladies and gentlemen, it is a great pleasure and privilege for me to address this distinguished Assembly of the World Health Organization and to convey to you the good wishes of the Secretary-General of the United Nations, Mr Boutros Boutros Ghali, for success in your efforts to advance the ideals of WHO. The radical changes which the world is now experiencing embrace a wide range of human activities and are in fact civilizational in nature. These changes have a direct and most significant impact for the United Nations and the organizations of its system. We all share the same symbol - the blue flag - but we also share the same purposes and principles as stated in the United Nations Charter. Today the unity of our system is of paramount importance. In this time of global change, the United Nations must act as a safety net, helping the international community to absorb the shocks of this transitional period and to solve its political, economic and social problems with maximum speed and efficiency. A great deal has been done to meet this challenge and to reorganize the institutions of the United Nations family, to ensure that the services which the system provides to governments are coherent and that each component draws on the other's resources and experience, rather than duplicating them, and that selectivity and coordination are carried out. The guidelines for these adaptations are outlined in the report of the United Nations Secretary-General and the Agenda for Peace and in his triad of peace, development and democracy, which reflects the essence of the current activities of the World Health Organization and which is in. fact the formula for survival of human kind in a time of transition. In the constellation of the United Nations bodies and organizations, the World Health Organization is one of the brightest stars. In recent years, WHO has been engaged in developing effective policy with regard to the humanitarian dimensions of the Agenda for Peace. The Organization's mandate is for peace through the protection and promotion of the health of all the people of the world. In formulating the response to humanitarian emergencies, it is essential that the organizations of the United Nations family and other institutional and nongovernmental organizations develop the ability to lead humanitarian action and protection of human rights with peace promotion in all its forms: preventive diplomacy, peace-making, peace-keeping and peace-building. It is most satisfying that WHO is in the forefront of this process. It is also significant that WHO has responded to more than 28 complex emergencies caused by war and civil strife. It is faced with the new challenges and risks in undertaking its humanitarian mandate in Bosnia and Herzegovina, and in other affected countries such as Croatia, The Former Yugoslav Republic of Macedonia, and Slovenia. In Africa 20 countries have benefited from the enhanced relief response and a number of emergency health projects have been implemented. WHO successfully meets challenges not only of substance but also of structure. The key feature of the WHO reorganization process to enable it to respond to global change is to update its health-for-all strategy to enforce the greater involvement of civil society alongside government. WHO advocacy for a new health partnership aims not only at strengthening interdependence among all sectors, communities and individuals, but also at sharing resources and responsibilities in the spirit of mutual respect and solidarity. This is not just a simple matter of health development, not just a question of delivering more health services, it is also a question of how to run the health system. It is now imperative to focus on these issues if we understand politically that our objective is to put the human being at the centre of development. The need to define the impact of social development on health and its interaction with the reduction of poverty, expansion of productive employment and social integration has become apparent during preparation for the forthcoming United Nations Conference on Population to be held in Cairo, the World Summit for Social Development in Copenhagen and the Fourth World Conference on Women in Beijing. These conferences will be the events that will launch the commemoration of the fiftieth anniversary of the United Nations. There is a certain symbolism to the dates, suggesting an attempt to make a break with the last fifty years of the United Nations during which the concept of security was defined in strictly political and military terms. Today we are faced with a situation where the security of the civilian population is being questioned, if it is not already in jeopardy.

18 A47/VR/1 page 3 A new concept of comprehensive security is beginning to emerge. It is no longer security of States achieved through the accumulation of armaments but security in all its aspects, including first of all security of the people and every human being. WHO has an opportunity to advance many ideas on human security through promotion, as Dr Hiroshi Nakajima has said, of general awareness that health is a way of life for individuals and communities, a way of thinking, of living and relating to others. In this respect, considerable progress has been made in improving coordination with the United Nations system regarding HIV and AIDS prevention, control and education. This year the WHO Executive Board adopted a comprehensive resolution on establishing a joint and cosponsored United Nations programme on this subject, with the participation of UNDP, UNESCO, UNFPA and UNICEF. A major effect of the endorsement of this programme by the current World Health Assembly could be mobilization of additional national and external resources for implementation of the global AIDS strategy. Particular attention needs to be devoted to the enhancement of coordination activities of the United Nations system in the field of preventive action and intensification of the struggle against malaria and diarrhoeal diseases, in particular cholera. In this respect it would be most helpful if the United Nations Economic and Social Council called for a substantial increase in multilateral resources to combat these scourges during its deliberations this year. It is clear now that cholera and malaria are especially lethal in poor societies. Their eradication, therefore, should contribute to the elimination of poverty itself. As a member of the ACC Inter-Agency Committee on Sustainable Development, WHO was assigned responsibility for implementation of the health chapter of Agenda 21. Collaboration between WHO, UNEP and ILO is specifically recommended in the International Programme on Chemical Safety as the nucleus for international cooperation in the field of protection of the human being. The WHO global strategy for health and environment has made it clear that governments and public must advance the central role of health in environmental development decision-making and foster partnerships between health and related sectors in this process. It is important that the activities of all organizations and entities involved be reoriented, revitalized and re-equipped to, carry out expanded functions in sustainable development. Ladies and gentlemen, all of us realize that health and development are extremely complex and difficult issues. Dealing with them demands fundamental political choices and a new partnership which must be constantly reaffirmed nationally, regionally and globally. What is now required from the international community at large is a demonstration of political will and ability to comply with a number of commitments. For my part, I can assure you that the United Nations secretariat, as the principal executive body of the United Nations, will continue to support the efforts of WHO and its Director- General. In conclusion, let me express my own best wishes for the success of the Forty-seventh World Health Assembly. I thank you for your kind attention. The PRESIDENT: Thank you, Mr Petrovsky. 3. ADDRESS BY THE REPRESENTATIVE OF THE CONSEIL D'ETAT OF THE REPUBLIC AND CANTON OF GENEVA ALLOCUTION DU REPRESENTANT DU CONSEIL D'ETAT DE LA REPUBLIQUE ET CANTON DE GENEVE The PRESIDENT: I now give the floor to Mr Guy-Olivier Segond to address the Assembly in the name of the federal, cantonal and municipal authorities of Switzerland. M. SEGOND (représentant du Conseil d'etat de la République et Canton de Genève): Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs les délégués, Excellences, Mesdames et Messieurs, à l'occasion de Fouverture de la Quarante-Septième Assemblée mondiale de la Santé, j'ai le plaisir et l'honneur de vous souhaiter, au nom des autorités fédérales, cantonales et municipales, la bienvenue à Genève et en Suisse.

19 A47/VR/1 page 4 Ces dernières années, Pactuaiité a montré, de façon spectaculaire, le fossé qui s'élargit, toujours plus vite, entre les pays riches et les pays pauvres : alors qu'en Afrique, plus de 2000 enfants meurent chaque jour du paludisme, en Europe, une femme - "la Vierge de Birmingham" - a recouru aux techniques de la procréation médicalement assistée pour avoir un enfant, sans faire Гашоиг avec un homme! Cette situation, paradoxale et scandaleuse, s'explique par les progrès de la médecine et par la manière dont ils sont gérés dans nos sociétés. En effet, au cours de ces cinquante dernières années, la médecine a fait des progrès formidables : après des millénaires d'impuissance, elle nous a donné le pouvoir de triompher de nombreuses maladies fatales, telles que la tuberculose, la syphilis ou la variole. Aujourd'hui, des transplantations d'organes sont possibles. Et les lois qui président à la formation de la vie sont découvertes. En offrant à l'homme la maîtrise de la reproduction, de l'hérédité et 一 peut-être - bientôt du système nerveux, la médecine touche l'être humain au plus profond de lui-même et interpelle la société tout entière. Ces percées scientifiques amènent à poser des questions importantes et graves : Qui est le père? Qui est la mère? Que peut-on faire sur l'homme? Que peut-on faire du corps humain? Jusqu'où la médecine peut-elle aller? Faut-il marquer des temps d'arrêt? Si oui, dans quels domaines? Toutes ces questions sont débattues, au sein des comités d'éthique, par des chercheurs, des médecins, des théologiens, des philosophes, des sociologues ou des juristes. Et l,opinion publique elle-même est de plus en plus sensibilisée. Tout ce travail est assurément nécessaire car, en évitant de provoquer un réflexe néoconservateur, il doit permettre aux citoyens de suivre, de comprendre et de maîtriser le progrès. Mais tout ce travail n'est pas suffisant. Il faut encore pouvoir répondre à d'autres questions. Par exemple, pourquoi la recherche, si active dans le domaine de la reproduction et de Phérédité, n'avance-t-elle pas plus rapidement dans la mise au point de vaccins contre le paludisme et les autres maladies tropicales qui, dans plus de cent pays, continuent à affaiblir, mutiler et tuer quotidiennement et en silence? La réponse vous est connue. La recherche n'aboutit pas parce que les vaccins - malgré le volume impressionnant de la demande mondiale - n'ont qu'un attrait mineur pour l'industrie : les gains sont faibles, les contrôles sont astreignants, et le marché se limite aux pays pauvres. N'oublions pas davantage la question de l'environnement; même si l'on n'en parle pas dans les milieux politiques traditionnels, le niveau de santé dépend très largement de la qualité de l'environnement et de la nature du développement. A l'échelle mondiale, le problème d'environnement et de santé le plus immédiat tient à rimportance des maladies et des décès prématurés provoqués par des pollutions de l'eau, de l'air, des sols et des aliments. Même le monde développé n'échappe pas à ces problèmes. Dans les pays occidentaux, des centaines de millions de personnes souffrent de maladies respiratoires causées par la pollution de l'air et le tabagisme,sont exposées à des dangers chimiques ou physiques inutiles, ou - même plus communément - sont tuées dans des accidents de la route. On le voit : les questions d'éthique ne se limitent pas, comme on le croit trop souvent, aux interrogations sur le progrès scientifique et médical. Elles sont à l'évidence beaucoup plus larges. C'est pourquoi elles ne doivent pas être réservées aux comités d'éthique qui ont généralement une vue limitée de leurs tâches. Ce sont tous les habitants d'un pays, tous les habitants de la planète qui doivent prendre conscience des choix qu'implique le progrès, réfléchir à leurs idéaux et à leurs priorités pour pouvoir décider ensemble de leur avenir et accéder au vrai désirable. Je félicite donc l'oms de se préoccuper de ces questions et je vous souhaite d'excellents travaux, consacrés à la seule cause qui importe : les progrès de la santé à travers le monde et pour tout le monde. The PRESIDENT: Thank you very much, Mr Guy-Olivier Segond. 4. ADDRESS BY THE PRESIDENT OF THE FORTY-SIXTH WORLD HEALTH ASSEMBLY ALLOCUTION DU PRESIDENT DE LA QUARANTE-SIXIEME ASSEMBLEE MONDIALE DE LA SANTE The PRESIDENT: Director-General, excellencies, distinguished delegates of Member States, ladies and gentlemen, the President of the World Health Assembly can on three occasions, express his or her mind on subjects related

20 A47/VR/1 page 5 to the proceedings of this Assembly. I had an opportunity to do so during last year's session and I do so now as a last undertaking in my present office, and I will be brief. To be able to serve in this capacity is indeed an honour and also a possibility to understand the complex machinery of world health development. The rotation principle in appointing officers to the presidency is important to underline the global character of this Organization. I am a European, elevated to this office through the European Region, representing thereby a part of the world that traditionally lives in prosperity and good health, favoured by huge resources. After Europe comes Africa to serve as President of the World Health Assembly - Africa, suffering from the colonial heritage, from war, poverty, disease, from racial conflicts, from social, cultural and religious cleavage. But the picture is getting less clear. Europe is no longer only a club of the very rich. When the iron curtain collapsed, we were free to see for ourselves the huge problems of underdevelopment in the field of health and health care in eastern Europe and in the newly independent States, and war and social and cultural conflicts as well as unemployment are now a part of the agenda in the European Region. Africa has shown dynamism, and resourcefulness as well. We have the privilege during this Assembly to say "Welcome back" to the representatives of South Africa, demonstrating hope for the future through the developments of recent months. And may I add personally that this is a particularly emotional moment, after so many years of withering hope to see South Africa take its rightful place here amidst us. There is a message for WHO in this turnover from a European President to an African President, to be regarded as a symbol of global change. So the question can be asked, are we now prepared to respond to that global change? During last year's World Health Assembly, this was the main agenda item. We elected the Director-General on the basis that it contributed to WHO's capacity to respond to global change. I think that we may have seen change starting. Still the question that we must ask ourselves is whether the speed and depth of change is enough. We know of the need for change and of the complexity of the process that brings change about. That is why it is so important that this Health Assembly takes over from the last one to follow up on every step taken and not taken, and the process of change must spread over the boundaries to other United Nations bodies in a way similar to what has been done on the subject of organization of the United Nations side on HIV and AIDS. Among the questions that we may address is the function of this Assembly. We meet every year for two weeks. The cost for Member States as well as for this Organization is high. Much energy is spent on preparing documents and plans, and to carry the burden of the formal proceedings. We may do well to observe during the coming two weeks if the price we pay for yearly meetings of the Health Assembly is right or if we could seriously reflect on reforming the Assembly - and not only other structures of WHO - to meet perhaps biennially, thereby conserving resources for the main task of working for world health. A third reflection from the presidency deals with the issue of health for those people who are not easily represented in the Health Assembly. Hunger, poverty and violence has prompted millions to seek refuge. In the international arena, we are familiar with the problems of traditional refugees protected by international conventions and we may generally find that the situation for legally accepted migrants is at least tolerable. But, in between, are the displaced persons - a major force in most continents, now also in Europe, suffering badly from their present status. Their status is less clear than that of other immigrants, and the fact that they are less than welcome by many countries tends to keep many of them on the road and a great many of them tend to stay there, on the road, no place to go and no place to go back to. The process of response to global change must face up also to this development. We should investigate, in Member countries and on a supernational level, the health situation of the displaced migrants, and we from WHO must advocate an understanding for the health situation of all those on the road, to create supportive environments for their health also. We need to identify and give a clear profile to these issues of health and human rights for the displaced. I would finally, dear colleagues, like to express my gratitude to you for giving me this unique opportunity, to the Director-General and his staff for all the ample support that they have given me, and I wish the incoming African President of the World Health Assembly "Welcome on board". Ladies and gentlemen, before the distinguished officials who have kindly attended the meeting of this Health Assembly leave us, I should like to thank them once again for having done us the honour of being present. I shall now suspend the meeting for a moment. Please remain in your seats, the meeting will resume in just a few moments.

21 A47/VR/1 page 6 5. CONSIDERATION OF THE SITUATION OF CERTAIN MEMBER STATES FALLING UNDER THE PURVIEW OF ARTICLE 7 OF THE CONSTITUTION: REACTIVATION OF THE MEMBERSHIP OF SOUTH AFRICA EXAMEN DE LA SITUATION DE CERTAINS ETATS MEMBRES TOMBANT SOUS LE COUP DE L'ARTICLE 7 DE LA CONSTITUTION: REPRISE DE LA PARTICIPATION ACTIVE DE L'AFRIQUE DU SUD The PRESIDENT: I give the floor, on a point of order, to the distinguished delegate of Zimbabwe. Dr STAMPS (Zimbabwe): Thank you, Mr President. As you referred in your valedictory to the happy events which have recently taken place in our Region, I would like to have an opportunity on behalf of the African group and especially in Zimbabwe's capacity as Chairman of the front-line States to introduce a resolution in order to restore full rights to the Republic of South Africa. This resolution is intended to be circulated to all Member States and I hope that it may be presented and adopted at the session starting at 16h30 this afternoon. J'espère que tous les Etats Membres de l'oms ici présents sont fermement décidés à restituer sans délai à un Etat Membre tous ses droits et avantages. Je vous remercie. The PRESIDENT: I now give the floor to the distinguished delegate of Zambia. Mr SATA (Zambia): Mr President, in supporting and seconding my colleague from Zimbabwe, I must express my disappointment at the way the Director-General's office and the Regional Director's office have handled this issue. It should not come from the floor. We feel that, as we congratulate South Africa, as we have all talked about it, this should have come from the office there, because the suspension came from there with the support of the Assembly. And I feel very strongly that my colleague's proposal is long overdue. Thank you. The PRESIDENT: I thank the distinguished delegate of Zambia, and I have been informed that the Legal Counsel would like to comment on that. Please, Mr Vignes. M. VIGNES (Conseiller juridique): Merci, Monsieur le Président. Je comprends fort bien les sentiments qui viennent d'être exprimés, mais il me semble qu'il faut dans des circonstances même exceptionnelles respecter les règles qui prévalent dans cette Assemblée : des résolutions de la nature de celle qui est soumise maintenant doivent être présentées par des Membres de l'organisation et non pas par le Secrétariat. Il est donc tout à fait normal que cette résolution soit présentée par une délégation et je crois comprendre d,ailleurs que c'était le sentiment qui avait été exprimé il y a quelque temps lorsque les groupes se sont réunis. Merci, Monsieur le Président. The PRESIDENT: Thank you Mr Vignes. I see at present no one asking for the floor. We have had in the presidency a short moment to reflect on the possibilities for handling the suggestion made by the distinguished delegate of Zimbabwe, and we think that it is most suitable to try to find a way that is as fast as possible to meet the requests of the African group. So we would like to suggest that we now distribute the proposed resolution from Zimbabwe and the African group among the delegates, and we do that just in two

22 A47/VR/1 page 7 languages. We will also find ways to waive the two days,rule and to waive the traditional referral of these matters to committees. I will now ask the Legal Counsel please to describe to us in technical detail how we can bend the rules on this very, very pleasant occasion. Please, Mr Vignes. M. VIGNES (Conseiller juridique): J'apprécie la demande adressée par le Président au Conseiller juridique pour voir comment on peut adapter un peu les règlements, ce que je vais faire très volontiers. L'événement que nous vivons est un événement tout à fait historique et tous les membres de cette Assemblée ainsi que le Directeur général lui-même ont conscience de son importance. C'est pourquoi il faut, et c'est le sentiment de tous, redonner à l'afrique du Sud la plénitude des privilèges attachés au droit de vote dont elle a été privée il y a trente ans. C'est pourquoi à circonstances exceptionnelles il faut trouver des solutions exceptionnelles. En effet, normalement, il aurait fallu que cette question soit examinée par la Commission В au titre du point 25 de l'ordre du jour provisoire; il aurait fallu également respecter la règle des deux jours avant que le projet de résolution qui vous est soumis puisse être discuté par la Commission mais, nonobstant, puisque c'est le désir de l'ensemble de cette Assemblée de trouver une solution, je vous suggérerais, Monsieur le Président, que l,on tranche cette question aujourd'hui même, lors de la séance plénière de cet après-midi, c'est-à-dire que l'assemblée décide de considérer dès maintenant en plénière le point 25 de l'ordre du jour et examine sous ce point la résolution qui vous est soumise. Nous avons reçu cette résolution il y a environ une heure et nous sommes en train de la distribuer. Je pense qu'il serait opportun que l'assemblée réunie en séance plénière l'examine après avoir procédé à la constitution de son nouveau bureau, c'est-à-dire après l'élection du nouveau président qui, je crois comprendre, sera choisi parmi les Etats Membres de la Région africaine. C'est la raison pour laquelle, Monsieur le Président, je vous soumets cette suggestion pour le cas où vous souhaiteriez la présenter à l'assemblée. The PRESIDENT: Thank you, Mr Vignes. If I may then summarize the suggestions to the World Health Assembly as to handling the matter of returning South Africa to its proper functions in WHO, they should then be the following. We have now distributed, or are distributing, the proposals from the African group, as presented by the distinguished delegate of Zimbabwe, in one language only though, and a translation into French will follow as soon as is technically possible. Secondly, I propose to you that you decide to waive the two days' rule so that we can decide on this matter as soon as is technically possible from that point of view. Thirdly, that we waive the traditional referral of this kind of matter to Committee B, and that we take it up directly in the plenary meeting. Finally, that the decision on this matter will be handled as the first official decision taken by the newly elected African President. That would then be the proposal of the presidency. Can that be accepted? I then understand that my suggestion has been carried by the World Health Assembly. 6. APPOINTMENT OF THE COMMITTEE ON CREDENTIALS CONSTITUTION DE LA COMMISSION DE VERIFICATION DES POUVOIRS The PRESIDENT: We now come to item 2 of the provisional agenda: "Appointment of the Committee on Credentials". The Assembly is required to appoint a Committee on Credentials in accordance with Rule 23 of the Rules of Procedure - and there will be no bending of these Rules, I assure you. In conformity with this Rule, I propose for your approval the following 12 Member States: Bulgaria, Canada, Chile, Côte d'ivoire, Namibia, Nepal, Netherlands, Portugal, Samoa, Seychelles, Tunisia, and United Arab Emirates. Are there any objections? I see none. The suggestion is carried. Subject to the decision of the General Committee, and in conformity with resolution WHA20.2, this Committee will meet on Tuesday, 3 May, in the afternoon.

23 A47/VR/1 page 8 7. ELECTION OF THE COMMITTEE ON NOMINATIONS ELECTION DE LA COMMISSION DES DESIGNATIONS The PRESIDENT: We now come to item 3 of the provisional agenda: "Election of the Committee on Nominations". This item is governed by Rule 24 of the Rules of Procedure of the Assembly, and, in accordance with this Rule, a list of 25 Member States has been drawn up, which I shall submit to the Assembly for its consideration. May I explain that, in compiling this list, the following distribution by Region has been applied: African Region, six members; Americas, five members; South East Asia, two members; Europe, five members; Eastern Mediterranean, four members; and Western Pacific, three members. I therefore propose to you the following Member States: Angola, Australia, Bangladesh, Barbados, Bolivia, Ecuador, Fiji, France, Iceland, Jordan, Kenya, Kyrgyzstan, Morocco, Mozambique, Myanmar, Oman, Pakistan, Panama, Philippines,Russian Federation, Senegal, Swaziland, United Kingdom of Great Britain and Northern Ireland, United Republic of Tanzania, and United States of America. Are there any observations, or additions to this list? I see none, therefore the decision is taken on the 25 members of the Committee of Nominations. As you know, Rule 25 of the Rules of Procedure, which defines the mandate of the Committee of Nominations, also states that proposals of the Committee on Nominations shall be forthwith communicated to the Health Assembly. The Committee on Nominations will meet at 13hl5. The next plenary meeting will be held this afternoon at 16h30. The meeting is now adjourned. The meeting rose at 12h50. La séance est levée à 12h50.

24 A47/VR/2 page 9 SECOND PLENARY MEETING Monday, 2 May 1994,at 16h30 President: Mr C. ÔRTENDAHL (Sweden) later: Mr В. K. TEMANE (Botswana) DEUXIEME SEANCE PLENIERE Lundi 2 mai 1994,16h30 Président: M. С. ÔRTENDAHL (Suède) puis: M. В. K. TEMANE (Botswana) 1. FIRST REPORT OF THE COMMITTEE ON NOMINATIONS 1 PREMIER RAPPORT DE LA COMMISSION DES DESIGNATIONS 1 The PRESIDENT: The Assembly is called to order. The first item on our agenda this afternoon is the consideration of the first report of the Committee on Nominations, contained in document A47/39. I invite the Chairman of the Committee on Nominations, Mr Diop, to kindly come to the rostrum and read this report. M. DIOP (Président de la Commission des Désignations): Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs, la Commission des Désignations, composée de délégués des Etats Membres suivants : Angola, Australie, Bangladesh, Barbade, Bolivie, Equateur, Etats-Unis d'amérique, Fédération de Russie, Fidji, France, Islande, Jordanie, Kenya, Kirghizistan, Maroc, Mozambique, Myanmar, Oman, Pakistan, Panama, Philippines, République-Unie de Tanzanie, Royaume-Uni de Grande-Bretagne et d'irlande du Nord, Sénégal et Swaziland, s'est réunie le 2 mai 1994 sous la présidence de M. Assane Diop, du Sénégal, élu Président de cette Commission. Conformément aux dispositions de l'article 25 du Règlement intérieur de l'assemblée de la Santé et à la pratique de rotation régionale suivie de longue date par l'assemblée à cet égard, la Commission a décidé de proposer la désignation de M. В. K. Temane, du Botswana, pour le poste de président de la Quarante-Septième Assemblée mondiale de la Santé. Je vous remercie, Monsieur le Président. Election of the President Election du président de l'assemblée The PRESIDENT: Are there any observations? In the absence of any observations, and as it appears that there are no other proposals, it will not be necessary to proceed to a vote since only one candidate has been put forward. In accordance with Rule 80 of the Rules of Procedure, I therefore suggest that the Assembly approves the nomination submitted by the Committee and elects its President by acclamation. (Applause /Applaudissements) 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

25 A47/VR/2 page 10 Mr B.K. Temane, Minister of Health of Botswana, is thereby elected President of the Forty-seventh World Health Assembly and I invite him to take his seat on the rostrum. Mr B.K. TEMANE (Botswana) took the presidential chair. M. B.K. TEMANE (Botswana) prend place au fauteuil présidentiel The PRESIDENT: Your excellencies, honourable ministers, ambassadors, delegates, Mr Director-General, I would like to thank this august Assembly for their trust in electing me as the President of the Forty-seventh World Health Assembly. Taking this opportunity, I would like to egress my appreciation to Mr Claes OrtendaM, my predecessor, for his contribution to the last Health Assembly. I shall deliver the customary address tomorrow and we will now continue with our work. 2. CONSIDERATION OF THE SITUATION OF CERTAIN MEMBER STATES FALLING UNDER THE PURVIEW OF ARTICLE 7 OF THE CONSTITUTION: REACTIVATION OF THE MEMBERSHIP OF SOUTH AFRICA (continued) EXAMEN DE LA SITUATION DE CERTAINS ETATS MEMBRES TOMBANT SOUS LE COUP DE L'ARTICLE 7 DE LA CONSTITUTION: REPRISE DE LA PARTICIPATION ACTIVE DE L'AFRIQUE DU SUD (suite) The PRESIDENT: As my first duty, :t is with pleasure that I request this Assembly to consider the draft resolution on the rights and privileges of South Africa, and I call for comments. I recognize the delegate of Zimbabwe. Dr STAMPS (Zimbabwe): Thank you Mr President, and may we take this opportunity of expressing our undiluted pleasure at your appointment as President for this session of the World Health Assembly. Max Theiler was a Nobel Prize winner. He should be very happy today. He discovered the viral nature of yellow fever at a time when it was fairly certain as far as scientific knowledge went that it was caused by a spirochete and he made possible the elimination of yellow fever in large areas of Africa and other parts of the world. As a result of the vaccine he developed we can live safely in many parts which were uninhabitable before. He was born in Pretoria, in South Africa, 95 years ago this month. Thirty years ago this month, in 1964,this Assembly deprived the Republic of South Africa of effective participatory rights because of the horrendous aberration of apartheid and its forcible silencing of the needs of the majority of its people. The effects of this perverse doctrine hampered, distorted and subverted the development of the whole of the sub-saharan African region, not least the country which I have the honour to represent. Zimbabwe's lost 20 years are still having their severe repercussions both in terms of recurrent expenditures and developmental handicap. As a member of the front-line States we helped forge the peaceful weapon of economic pressure against the unjust regime. As Chairman of the front-line States this year it has fauen to Zimbabwe to present this proposal which I hope all will celebrate in the affirmative and, for those of us whose religion allows, in alcohol later. This is a day for Africa. So often we hear and see the events in our continent which cause pain. Today we welcome back into our family the nation which has such great potential in our region to satisfy the economic developmental and health needs of all its people. From this point we believe that Africa as a whole has a brighter future, a greater solidarity and a unity of purpose in health which we were unable to realize before. I should also express my pleasant surprise that a Nordic European President of the Health Assembly, not noted for lack of sense of responsibility, has been kind enough to flex the Rules of Procedure sufficiently to allow us, as the representative of the African Region, to propose this resolution. As of 15h30 today, 59.2% of the votes counted in the first-ever democratic election in South Africa have accrued to the African National Council. This is an important fact since it is our sincere hope that as a result a new Minister of Health for South Africa can very soon be appointed and welcomed here at this Assembly, and participate fully in our deliberations. I therefore propose the following resolution for the consideration of the whole Assembly, on behalf of my country, my continent, Africa, and indeed the whole of the peoples of the world:

26 A47/VR/2 page 11 The Forty-seventh World Health Assembly, Noting the democratic elections which took place in South Africa from 26 to 29 April 1994 with a view to the installation of a Government of National Unity to represent the whole population of South Africa; Noting further the coming into force of a new Constitution in South Africa on 27 April 1994 which now governs governmental actions on all levels; Considering the desire of South Africa to participate henceforth in the activities of the World Health Organization and its Assembly and thereby to fulfil its obligations and assume its rights in accordance with the Constitution of the World Health Organization; 1. RESCINDS resolution WHA17.50; and 2. DECIDES that all rights and privileges associated with full membership of the World Health Organization be granted with immediate effect to South Africa at the Forty-seventh World Health Assembly. I commend this resolution to this session. Thank you. The PRESIDENT: I thank the honourable delegate of Zimbabwe, and I now recognize the delegate of Nigeria. Dr TAFIDA (Nigeria): Mr President, honourable mmisters, ladies and gentlemen, I would like to begin by congratulating the newly elected President of the Forty-seventh World Hëalth Assembly. I would also like to take this opportunity to thank the outgoing President, who has done his work very well and also has magnanimously a^-eed to bend the Rules of Procedure of this august Assembly so as to allow us to debate this all-important issue of allowing South Africa to resume its seat in the community of nations in this august Assembly. The history of the democratic struggle by the people of South Africa is no doubt well known to the world at large and in particular to the rest of the African continent. To achieve this democratic process Africa, and especially South Africa itself, has suffered a great loss of life and property. Unfortunate as it has been, today we are happy that South African people with the support of democratic forces managed to succeed in dismantling that abominable inhuman apartheid system. Africa's struggle for political freedom has now been concluded with a democratically elected system now being put in place in South Africa. This is indeed a very happy moment for the world, Africa and the South African people themselves. In the field of health most of the South African people, because of the apartheid system, were unable to enjoy a productive life. The health system was fragmented, which caused untold misery to the majority of the people of that country. In that regard the international community has a human obligation and duty to provide the South African people with all the much-needed assistance to enable them to accelerate the achievement of health for all by the year Indeed, a lot of this help will be required in the restructuring of the health system and in providing easy access to the needed health care and services for the majority who hitherto were denied these services. We in Africa welcome South Africa to the family of nations and hope they will be encouraged and given support to contribute to their fight against diseases that plague the continent. We are by duty bound therefore on behalf of the African countries to endorse the resuscitation of South Africa's voting rights, and firmly support the resolution on South Africa as proposed by the honourable chief delegate of Zimbabwe. TTiank you very much, Mr President. The PRESIDENT: I thank the delegate of Nigeria, and I recognize the delegate of Samoa. Mr SALA Vaimili II (Samoa): First I wish to congratulate you, Mr President. I am from a tiny little island in the region of the Western Pacific and no matter how small or how big our nations are, we come here from different backgrounds, different social economic standing, different languages, different colour, different religions, but our coming together today and for so many years in the past is for one purpose: to improve health for

27 A47/VR/2 page 12 all and the health of the world and our people. Mr President, we have a saying in Samoa which really means that all the policies and constitutions should be bent for a very valuable decision which we therefore wish to endorse and to which we give our full support; I hope this Assembly will give its full endorsement immediately to the resolution proposed by our colleague from Zimbabwe. Ibis is another sign of solidarity in our Health Assembly. Thank you. The PRESIDENT: I thank the delegate of Samoa. I now recognize the delegate of Egypt. Dr EL MAKHZANGI (Egypt): : ( 产 ) - J J I LsiJ I <s^>w4aj I. «_ " jj ^ Ц. ^S-j I ^ I I 丄 ^JI *<i J ó 力 jj I âла J I ^ f- I J j jj 1 L;»^ ^Sst^o JAClc Ju9^ o LeO I ^ jv I j ^cjl o! t dljv^o j^w^^jl La^^-. ^jji t js^i i ójl^^ji dujajuî 'i^olsj '(LL^J dljkii jîua ) I I JJ-AJ ^^JLSKJ I JjSJ jb I á^j jj) g o T- L;» ^JLA^l- LO^JÍ ^^ j á L^4 ^ y*^ ^JJLC <JlaC5 i 1 JlA j^ojü Лз^ D U>J LaJ I <SOv4aJ I <ltijâjcû LG-LÛ-R^ÂC J^JLC 4 产丄 Jl J^aiJl ^ т Д ^ 丨 ^ 丨山乂 /^^:^ ^ ^^ 丨 JiJ g, L*/! ci.l.i * 丄.._ t I qhw -LHJI 'à\^lcuji ^з ^Sb Lu*il*4/ L-^-.I Ô^^S Lj. ^JLc. «îlia ols I^A^JJI " з Lsd**/ ЦД^ JS\ ^J djt^ J ûj LAJ I ^J '<LO*WMA.) I Ji LIUJ I I Y^ The PRESIDENT: Thank you. Are there any further observations? I see none. Therefore, having listened to the observations and comments, especially on the resolution on the rights and privileges of South Africa as moved by Zimbabwe, seconded by Nigeria and others, I take this opportunity to invite the Assembly to adopt the resolution on the rights and privileges of South Africa. In the absence of any objections, the resolution is adopted. (Applause /Applaudissements) I recognize the delegate of South Africa. Dr MGIJIMA (South Africa): I thank you for the opportunity to address this meeting. Mr President, may I at the outset take the opportunity to congratulate you on the assumption of the presidency of this Assembly. South Africa pledges its full support to you in the execution of your important task. It is a remarkable coincidence that an African today presides over the proceedings that restore South Africa's full rights and privileges in the Health Assembly. Mr President, the opportunity to reassume all our rights in this august body is a momentous one for two reasons. First, South Africa is poised to celebrate the results of its first fully democratic elections. These elections have been dubbed a victory for peace and they epitomize the fulfilment of the ideals of all those South Africans who have struggled for a non-racial democracy. Secondly, the April 1994 elections have finally laid apartheid to rest. A free, non-racial, representative and democratically elected government of national unity is about to be installed. These events explain the presence of the South African delegation to participate in this Forty-seventh World Health Assembly and offer me the singular honour of addressing you on behalf of our country and people. The demise of apartheid and the electoral process have been marked by a spirit of reconciliation which has surpassed all expectations. Signalling a new beginning, South Africans in their millions stood in endless queues across colour lines determined to register their stamp of approval for the emerging democracy. Neither bombs, nor bullets, nor administrative

28 A47/VR/2 page 13 lapses could deter them. They were all united in their conviction of the importance of steering the country in a new direction. The pressing challenge for all of us in South Africa now becomes the need to sustain and harness that enthusiasm. There is a clear consensus in our country that the first step in this direction is that of laying a solid foundation for addressing the socioeconomic expectations of the hitherto deprived communities. As we South Africans embrace our freedom and embark on the arduous road of nation-building, we are inspired by the knowledge that Member States of this august body, which has sustained us through difficult times in the past, will be with us again in the future. We thank you for your principal support in our struggle for democracy. We shall draw strength from that support and undertake to ensure a solid contribution to the development of effective global action in the World Health Organization's programmes. By a remarkable coincidence, the World Health Assembly provides the first opportunity for South Africa's incoming government of national unity to resume its full participation in an international organization. What more fitting opportunity than the Assembly of a body dedicated to the health and welfare of the world's peoples? We recall with pride that South Africa was one of the first signatories to the Constitution of WHO, on 7 August The World Health Assembly declared its rejection of apartheid in 1964,taking away South Africa's right to vote through passing resolution WHA South Africa subsequently suspended its participation whilst remaining a Member. Since 1966 the South African Government has not participated in the Health Assembly. However, WHO's determination for justice in South Africa ensured growing cooperation with the liberation movements and the people of southern Africa at large. Today, the South African delegation, which again takes up its seat, does so with the blessing of the country's transitional Executive Council. This is a body which since December 1993 has had the task of levelling the political playing-field as well as endorsing major policy decisions. The delegation has also been endorsed by the National Health Forum, a body comprising a wide variety of role-players in the health sector, bound by a common vision of constructing a better health system for all South Africans. Common threads which will underpin future policy have emerged within and amongst the organizations represented in the National Health Forum. There is agreement that the underlying philosophy of our new health system must be the primary health care approach which WHO advocated and endorsed at the historic Alma-Ata conference. The concrete application of this approach is not going to be without difficulty, especially given the reality of the severe resource constraints and the historical inequities of our recent past. We are, therefore, requesting the international community to continue to provide material and technical support in the reconstruction of our social services, so that equitable health care can be provided to all our people. We have in the meantime produced a national health plan as a guideline to the reconstruction and development of a new national health system in our country. Finally, Mr President, allow me to extend a word of gratitude to the women and men of the entire world who stood by us in our struggle against apartheid and racial discrimination in South Africa. Our gratitude also goes to the World Health Organization and the Director-General, Dr Nakajima, the Regional Director for Africa, Dr Monekosso, and his office at large, for their unwavering support for the health of our people. In the past three years, Dr Monekosso personally intervened in the formation of the National Health Forum inside our country. He also helped by giving technical support to the planning process for a new national health system. Lately, he has facilitated the arrangement of South Africa's entry into the activities of WHO and its African Region. A special word of gratitude goes to the front-line States, which have until recently borne the brunt during our march to freedom. We thank you all. The PRESIDENT: I thank the delegate of South Africa.

29 A47/VR/2 page SECOND REPORT OF THE COMMITTEE ON NOMINATIONS 1 DEUXIEME RAPPORT DE LA COMMISSION DES DESIGNATIONS 1 The PRESIDENT: I now invite the Assembly to consider the second report of the Committee on Nominations. I ask the Chairman of the Committee on Nominations, Mr Diop, to read the second report of the Committee, contained in document A47/40. M. DIOP (Président de la Commission des Désignations): Je vous remercie, Monsieur le Président. Monsieur le Directeur général, Mesdames et Messieurs, au cours de sa première séance tenue le 2 mai 1994,la Commission des Désignations a décidé de proposer à l'assemblée de la Santé, conformément à l'article 25 du Règlement intérieur de 1,Assemblée,les désignations suivantes : Vice-Présidents de l'assemblée : Dr A. L. Pico (Argentine), Dr A. Abdel Fattah El Makhzangi (Egypte), Dr B. Voljc (Slovénie), Dr A. Ourairat (Thaïlande),Professeur V. Rajpho (République démocratique populaire lao). Commission A : Président - Dr N. K. Rai (Indonésie). Commission В : Président - Dr M. S. E. Asaad (Arabie Saoudite). En ce qui concerne les postes de membres du Bureau à pourvoir par voie d'élection, conformément à l'article 31 du Règlement intérieur de l'assemblée, la Commission a décidé de proposer les délégués des dix-sept pays suivants : Bahreïn, Burkina Faso, Cap-Vert, Chine, Cuba, Etats-Unis d'amérique, Fédération de Russie, France, Gabon, Guatemala, Guinée, Iran (République islamique d,),israël, Japon, Nigéria, Royaume-Uni de Grande-Bretagne et d'irlande du Nord, et Venezuela. Election of the five Vice-Presidents Election des cinq vice-présidents de l'assemblée The PRESIDENT: Thank you, Mr Diop. I now invite the Assembly to pronounce in order on the nominations proposed for its decision. We shall begin with the election of the five Vice-Presidents of the Health Assembly. Are there any comments or observations? I see none and I therefore propose that the Assembly declare the five Vice-Presidents elected by acclamation. (Applause /Applaudissements) The PRESIDENT: I shall now determine by lot the order in which the Vice-Presidents shall be requested to serve should the President not be available to act between sessions. The results are as follows, and the Vice-Presidents will act in the following order: the first will be Professor V. Rajpho of the Lao People's Democratic Republic; the second, Dr A. Abdel Fattah El Makhzangi of Egypt; the third, Dr A. Ourairat of Thailand; the fourth, Dr В. Voljí of Slovenia, and the fifth. Dr A.L. Pico of Argentina. I now request the five Vice-Presidents to come to the rostrum and take their places there. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

30 A47/VR/2 page 15 Election of the Chairmen of the main committees Election des présidents des commissions principales The PRESIDENT: We now come to the election of the Chairman of Committee A. Are there any comments on the proposals of the Committee on Nominations? There being no comments, I invite the Assembly to declare Dr N.K. Rai (Indonesia) elected Chairman of Committee A by acclamation. (Applause /Applaudissements) The PRESIDENT: We shall now proceed to elect the Chairman of Committee B. Are there any comments? There being no objections, I invite the Assembly to declare Dr M.S.E. Asaad (Saudi Arabia) elected Chairman of Committee В by acclamation. (Applause /Applaudissements) Establishment of the General Committee Constitution du Bureau de l'assemblée The PRESIDENT: In accordance with Rule 31 of the Rules of Procedure, the Committee on Nominations has proposed the names of 17 countries the delegates of which, added to the officers just elected, would constitute the General Committee of the Assembly. These proposals provide for an equitable geographical distribution of the General Committee. If there are no observations, I declare those 17 countries elected. Thank you. Before adjourning this plenary meeting I would remind you that the General Committee of the Assembly will be meeting immediately in Room VII. The members of the General Committee are the President and the Vice-Presidents of the Assembly, the Chairmen of the main committees, and the delegates of the 17 countries you have just elected, and whose names I shall now repeat: Bahrain, Burkina Faso, Cape Verde, China, Cuba, France, Gabon, Guatemala, Guinea, Iran (Islamic Republic of), Israel, Japan, Nigeria, Russian Federation, United Kingdom of Great Britain and Northern Ireland, United States of America, Venezuela. The next plenary meeting will be held tomorrow at 9h00. The meeting is now adjourned. The meeting rose at 17h20. La séance est levée à 17h20.

31 A47/VR/2 page 16 THIRD PLENARY MEETING Tuesday, 3 May 1994,at 9h00 President: Mr В. K. TEMANE (Botswana) TROISIEME SEANCE PLENIERE Mardi 3 mai 1994,9 heures Président: M. В. К. TEMANE (Botswana) 1. PRESIDENTIAL ADDRESS DISCOURS DU PRESIDENT DE L'ASSEMBLEE The PRESIDENT: Your excellencies, honourable ministers, ambassadors, distinguished delegates, Mr Director-General, colleagues and friends, it is indeed a great honour for me to be elected President of the Forty-seventh World Health Assembly. I am confident that with your cooperation and the effective assistance of the secretariat we, the elected officers of the Health Assembly, shall steer its work impartially and effectively so that your ambitions of contributing to world health through the effective performance of WHO can be realized. As we approach the end of our century it is becoming clearer that world health is indeed undergoing a major transition. On one hand, deficiency diseases and infectious diseases are still highly prevalent, and the HIV pandemic continues to make ravages, particularly in Africa and Asia. Tuberculosis, once believed to be under control in developed countries, has now become a scourge in both developed and developing countries. On the other hand, cancer has become a major cause of death in poor as well as in rich countries, while mortality rates from cardiovascular diseases are rising in many developing countries. In other words, many countries and geographic regions are undergoing both demographic and epidemiological transition, so that differences in the patterns of health and disease between developed and developing countries are becoming less distinct than they were 20 or 30 years ago. Noncommunicable disorders have become major causes of disability and death in most countries of the world. Unforeseen health problems are emerging as a consequence of new and changing economic situations, rapid industrialization and damage to the environment. The situation is further complicated by sporadic bursts of conflict which precipitate sudden and sharp deteriorations in socioeconomic conditions, including health. Migratory movements resulting from such crises often distort the labour markets of other countries, generating in turn other tensions and conflicts. We therefore obtain a composite picture where health status and health services are the resultant factors of several forces - political, demographic, economic, sociocultural, environmental, etc. Indeed, the past decade has seen rapid and often unpredictable changes in the global political situation, world socioeconomic conditions and the environment, as well as democratic, demographic and epidemiological transition. For example, rapid aging of the population and changes in lifestyle and the environment account for the increasing prevalence of cancer, cardiovascular diseases, diabetes, accidents, suicide, dementias and other chronic conditions. The double burden in developing countries of communicable diseases and diseases of affluence is being aggravated by the spread of the AIDS pandemic, and the resurgence of such ancient scourges as malaria, tuberculosis and cholera. Many of these health problems transcend national boundaries, calling for global solutions. One of the priority issues continues to be demographic growth. The world population is expected to reach six thousand million by the end of the century, and to exceed seven thousand million ten years later. The age structure of the world population is changing rapidly, and the older population is growing faster in developing than in developed countries. Attempts to check the overall rate of population increase have not so far had satisfactory results, although in several instances good progress has been made.

32 A47/VR/2 page 17 The finite nature of natural resources, indiscriminate storage of industrial waste leading to pollution, the greenhouse effect - all these are well-publicized examples of global problems which transcend national boundaries. On a related front, energy use is linked with the process of industrialization and technology development. Politicians and the industrial community face various technical and ethical issues which can hardly be avoided. In addition to health hazards resulting from individual behaviour - for example, smoking and alcohol abuse - thousands of environmental contaminants are being encountered, particularly in occupational settings. With regard to food supply and nutrition, two major dimensions come into play. First, at the individual level, education and behaviour play an important role. Second, at the socioeconomic level, issues of accessibility to food, its production and distribution, legislation, marketing and food control need to be addressed. This complex panorama should not distract us from addressing very concretely the priority issues which the international health community has resolved to face, notwithstanding the very limited resources available. We know, for example, that education and income are critical determinants of health. Economic and educational policies for poverty alleviation and for the most vulnerable groups are therefore essential to the improvement of health conditions. Such policies should promote equity and growth together. They should invest more in female education and promote the rights and status of women. The effects of these policies are likely to induce the poor to spend any additional income in ways that enhance their health improving their diet, obtaining safe water, and upgrading sanitation and housing. Health policies should plan the allocation of public resources so as to maximize health benefits. Highly cost-effective public health measures are well known. They include, for example, immunization, health education and AIDS prevention, school-based services, information services for family planning and nutrition, and programmes to reduce tobacco and alcohol consumption. The Expanded Programme on Immunization needs to reach more children, especially in poor households, with a gradual transformation into EPI-Plus", comprising, in addition to the six current vaccines,those for hepatitis В and yellow fever, plus vitamin A and iodine supplementation. Another critical area for government intervention is the provision of inexpensive yet effective treatment for school-age children suffering from schistosomiasis and other parasitic diseases. Governments should also encourage healthier behaviour by providing information on the benefits of breast-feeding and on how to improve children's diets. Measures to control the use of tobacco, alcohol and other addictive substances, using legislation as well as media and education, would reduce the burden of heart and lung diseases, cancer and injuries. Unless smoking behaviour changes within 30 years, premature deaths due to tobacco in developing countries will exceed the expected deaths from AIDS, tuberculosis and complications of childbirth combined. On the other hand, measures are needed to promote a healthier environment, especially for the poor, who are facing higher health risks due to poor sanitation, insufficient and unsafe water supplies, poor personal and food hygiene, indoor pollution and inferior housing. All these measures are consistent with the 1978 Alma-Ata Conference. I am pleased to indicate that Г attended the Alma-Ata Conference in 1978 and I had the occasion to attend the commemoration of the fifteenth anniversary of the Alma-Ata Declaration in It is quite evident that while some countries have made great strides towards the attainment of health for all, the progress made by most developing countries, especially in Africa, is not enough to give them cause for optimism that by the year 2000 they will attain acceptable levels of health. The goal of health for all was given special amplification, you may recall, at the 1990 World Summit for Children. Some 150 countries are now committed to improving the health of children and women in very concrete ways. Specific goals include the reduction of child mortality by one-third by the year 2000, reduction of maternal mortality rates by half, eradication of poliomyelitis, and major reductions in the morbidity and mortality resulting from several other diseases. Commitments to specific improvements in education, nutrition, water supply and sanitation were also made. These commitments underscore the political framework of health agendas. One could go on listing the catalogue of actions which have been identified to promote health and reduce the burden of disease and disability. There is, however, a sine qua non, a precondition for success, and that is a strong, unwavering political will. Without political will and determination, all policies, strategies and plans could easily fade into the realm of academic speculation. I will conclude by saying a few words about cooperation. Working together applies to disciplines, to sectors and to nations - for cooperation could and should be interdisciplinary, intersectoral and international. Cooperation is the best antidote to confrontation which eventually leads to conflicts, armed or otherwise. Interdisciplinary cooperation leads to the blossoming of knowledge. Intersectoral cooperation is the key to harmonious development. International cooperation is the way for a better world. The quest for health could also be an avenue for peace where people of good will work together and build their

33 A47/VR/2 page 18 common future. We have seen, on more than one occasion, how productive cooperation could be, and how destructive confrontation usually turns out to be. Ladies and gentlemen, the southern African region in which my country is situated has been witnessing events of great historical importance. The Republic of South Africa has at last become a democracy after more than 300 years of institutionalized racism that culminated in the infamous system of apartheid, under which the country was ruled from To other States in southern Africa, the changes taking place in South Africa are of great interest because, this being the most economically advanced country in the sub-continent and possibly in sub-saharan Africa, changes there will affect other economies in the region to a large extent. We are therefore looking forward to working together with the Republic of South Africa in various international organizations, including the World Health Organization, for the benefit of mankind in the sub-continent, as well as in the entire continent of Africa. I very much hope that the Forty-seventh World Health Assembly will promote a fruitful dialogue that will advance the solution of health and developmental problems and that it will lead to stronger cooperation between disciplines, between sectors and between our Member States. (Applause j Applaudissements) 2. ADOPTION OF THE AGENDA AND ALLOCATION OF ITEMS TO THE MAIN COMMITTEES ADOPTION DE L'ORDRE DU JOUR ET REPARTITION DES POINTS ENTRE LES COMMISSIONS PRINCIPALES The PRESIDENT: The first item to be considered this morning is item 8 of the provisional agenda, "Adoption of the agenda and allocation of items to the main committees", which was examined by the General Committee at its first meeting yesterday evening. The General Committee examined the provisional agenda for the Forty-seventh World Health Assembly (document A47/1), as prepared by the Executive Board and sent to all Member States. The General Committee recommended that the agenda contained in document A47/1 be adopted with the following changes: deletion of item 27,"Supplementary budget for (if any)"; and deletion of the words, "if any" at the end of item 11, since the item has to be considered by this Assembly. The General Committee also recommended that item 31 be expanded to include consideration of collaboration with other intergovernmental organizations, and that accordingly the title be amended to read: "Collaboration within the United Nations system and with other intergovernmental organizations". Does the Assembly agree with these recommendations? There being no comments or observations, it is so decided. The General Committee also decided that item 11, "Admission of new Members and Associate Members", will be taken up at 14h30, on Thursday, 5 May in plenary. The applications for membership received from Niue and from Nauru will be considered under this item. Allocation of items to the main committees: the provisional agenda of the Assembly was prepared by the Executive Board in such a way as to indicate a proposed allocation of items to Committees A and В on the basis of the terms of reference of the main committees. The General Committee has recommended that the items appearing on the agenda of the plenary which have not yet been disposed of be dealt with in plenary. As to the items appearing under the two main committees in the provisional agenda, they should be allocated as shown in document A47/1. It is understood that later in the session it may become necessary to transfer items from one committee to the other, depending on each main committee's workload. You will recall that yesterday we restored the rights and privileges of South Africa; this also comes under agenda item 25,which is allocated to Committee B. I take it that the Assembly agrees with this recommendation. There being no comments or observations, it is so decided. The Assembly has now adopted its agenda. A revision of document A47/1 will be issued and distributed tomorrow. I now move to the programme of work. For the remainder of this morning, in accordance with the decision of the General Committee, the plenary will hear the introductions to the reviews of the Executive Board reports and of the Director-General report, items 9 and 10,followed by the debate on these items. Committee A will meet as soon as the debate on items 9 and 10 has started in plenary. In the afternoon there will be a plenary meeting and Committee A will continue to meet concurrently with the plenary. The Committee on Credentials will also meet in the afternoon at 14h30. The programme of work for tomorrow, Wednesday, and for Thursday, Friday and Saturday will be as follows: on Wednesday, 4 May, in the

34 A47/VR/2 page 19 morning, the plenary will consider the first report of the Committee on Credentials and thereafter continue the debate on items 9 and 10. Committee A will meet as soon as the debate is resumed in plenary. In the afternoon the plenary will start with a special event when the President of the International Olympic Committee will make a statement. The plenary will then continue with the debate on items 9 and 10 and Committee В will meet as soon as the debate is resumed in plenary. Consideration of items 11 and 14 will move to Thursday, 5 May and Friday, 6 May, respectively. On Thursday, 5 May, in the morning the plenary will continue with the debate on items 9 and 10; simultaneously, the Technical Discussions will commence. In the afternoon, item 11,"Admission of new Members and Associate Members", will be taken up in plenary followed by item 13 "Awards", with its sub-items, and then the debate on items 9 and 10 will continue. When the debate is resumed in plenary, Committee A will meet. At 17h00 the plenary will adjourn to allow the General Committee to meet to draw up the list for the annual election of Members entitled to designate a person to serve on the Executive Board and to review the programme of work for the following week. On Friday, 6 May, in the morning, the debate on items 9 and 10 will continue in plenary concurrently with the Technical Discussions. In the afternoon the plenary will consider item 14, "Twenty years of onchocerciasis control", after which it will continue with the debate on items 9 and 10. When this debate is resumed, Committee В will meet. On Saturday, 7 May, in the morning, Committee A will meet concurrently with the Technical Discussions. The Chairman of the Technical Discussions will report to the Assembly in plenary on Monday, 9 May, in the morning. I would briefly like to draw your attention to the special event foreseen for Tuesday, 10 May, when Her Majesty the Queen of Sweden will address the Assembly at 12 noon. Does the Assembly agree with my proposals concerning the programme of work of the Assembly for this week? It is so decided. I would also like to remind the few delegates who have not yet submitted their credentials that they should hand them over to the secretariat of the Committee on Credentials before 14h30 today. 3, ANNOUNCEMENT COMMUNICATION The PRESIDENT: I now wish to make an important announcement concerning the annual election of Members entitled to designate a person to serve on the Executive Board. Rule 101 of the Rules of Procedure reads: At the commencement of each regular session of the Health Assembly the President shall request Members desirous of putting forward suggestions regarding the annual election of those Members to be entitled to designate a person to serve on the Board to place their suggestions before the General Committee. Such suggestions shall reach the Chairman of the General Committee not later than forty-eight hours after the President has made the announcement in accordance with this Rule. I therefore invite delegates wishing to put forward suggestions concerning these elections to submit them to the assistant to the secretary of the Assembly not later than Thursday morning, 5 May, at lohoo, in order to enable the General Committee to meet the same day at 17Ы0 to draw up its recommendations to the Assembly regarding these elections. 4. REVIEW AND APPROVAL OF THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY- SECOND AND NINETY-THIRD SESSIONS EXAMEN ET APPROBATION DES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE- VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS The PRESIDENT: We shall now pass on to item 9 of the agenda, "Review and approval of the reports of the Executive Board on its ninety-second and ninety-third sessions". Before giving the floor to the representative of the Executive Board, I should like to explain briefly the role of the Executive Board representatives at the Health Assembly and of the Board itself, in order to avoid any uncertainty on the part of some delegates on this matter.

35 A47/VR/2 page 20 The Executive Board has an important role to play in the affairs of the Health Assembly. This is quite in keeping with WHO's Constitution, according to which the Board has to give effect to the decisions and policies of the Health Assembly, to act as its executive organ and to advise the Health Assembly on questions referred to it. The Board is also called upon to submit proposals on its own initiative. The Board therefore appoints four members to represent it at the World Health Assembly. The role of the Executive Board representatives is to convey to the Health Assembly, on behalf of the Board, the main issues raised during the discussions and the flavour of the Board's discussions during its consideration of the items which need to be brought to the attention of the Health Assembly, and to explain the rationale and nature of any recommendations made by the Executive Board for the Assembly's consideration. During the debate in the Health Assembly on these items, the Executive Board representatives are all also expected to respond to any points raised whenever they feel that a clarification of the position taken by the Board is required. Statements by the Executive Board representatives, speaking as members of the Board appointed to represent its views, are therefore to be distinguished from statements of delegates expressing the views of their governments. I now have the pleasure of giving the floor to the representative of the Executive Board, Professor Chatty, Chairman of the Board. Professor CHATTY (representative of the Executive Board): :(^JuJuCJI ^ U J I Ji^)) ^k^jl jy Jux^ j 匕 il t dolcji Q cjju^ji m>_ Jl t^ju»j^i^ji t ^LsJI ^Juül juwoji «^j.m-tsjj 1,_ :* Ü ^ i ^ J L ^^Jl '^L- {^Jl s?-^^ 1 c r ^ 1 oujjuo ^ 0'\ ^Ju^JI ^JUuJU ^r^-i ^ 'i^ijo^ji ÜiJ V ^ JjJU ^ ^ J 匕史 е- o^l ^ ^^LJl ^ 一 I ^ ^ / i^^jl ^ ^ 為 丨丄 o ^ ^ ^ {,SLJ\ J^Jt ^ü^, jjuí^^ Л 1 ^Jl МП1 S. J o J ^ ^JJI j-uji puji JAJJI ^Jr^^.V/l : dfr^jj ' J^jl ^Is. ' A^UJI 4-uJUJI i^-ji ^jji. ) I vil» LOJlíJ I ^jji IЭ UojV I ^ < 匕. л LeJ I,t g 1 С Л ^Jn r J 1 ) ' JJL5.W0 'LU>4a6> JiLiu» ^O A-.U^JI 4 j. A^KACJL» ^ ^-jj! 4 lijli djjb J-JL^ U l ^I^JI^ V^JLkJI Л J^M J^Ji ^ ^ ^ o' 1 LT-W^1 " И ^ ^UJI J^JL. ^! ^jji,л ^!yj\ ог^з 丨 ^^ ujkic^ju ^L^JI 办 " ^JLc Ju^JI U ^ '^ЯяЛ ^p yi Ui ^.ib^ji^ 1:^1. Г,Л ^ ^. J ^ a J ' àlstk: J\ '«LuJUJI '«U^JI C 0 ^ ^ ni^uji l^ji JÍUlJI ^ 分 О.-л/^оНз cijjvjj^io ^ JJif J^L^cc 产 UJ1 J o j J I O ^ i O 1 f^ 1 1_, 二,L, '<Lj^<JI ^JUJlhJI ^^ul^ojj J-oaJI "á^y^o ciuíji SS^ lou j^^ji düi^ ^..-^aj 1 Cr vji^j-k ) LAJI Js '«LUJUJI ЪКЛОЛ 1 ^. jl^ji '«L^JLkûJI Cl/U I jjs-^l^ Cl/LwO^Jl ^ujjb q I < j^ol païl _з ^ Jl-. I ^л!^! JuuJt ' г^о^о ^Lf^ay, ^ I j^jsz fji^ (jl ^U^JI i^j d S j j^jujü ' ijliji 力 JJÍ ^Jt jjuji IÓA 1 ^.Jsz U^^b ^ 满 U/l ) ^Г ^oi^/^liji 广 ^ l^r ^ j_l J^JJI 己 l^f 己 ^ ^ ) -yj..-"' JAAJI I^JL-Í-Í^JI ^^JU-^JI (_SJI ci-lj^ji ^ /ÍV ' LijJI. Lg^. JuJuc. ÍV Ujjií

36 A47/VR/3 page 21 ^^JkJ '.LUc^l fau! fuji ^jujj ^ ^ J l ^^Jl o^ico ^Ij 1 l/ívj. ^ ÍV J! ) Ш 己 ^ ^ L a j! ^ j ^ J i I ^ À^wiL^JI 4-uJLsü! ^JL^JI yujl 1^JU Ш! C L^ c i ^ p l gl^luji ju 3! ^ c^ f^- 11 u 0^ 1 ^ cl^^ji c^ f 1 -^1 为 ^^ jrfj^ Uzi^u)^ ^JJUJLZJI ^JL>UJI fukcl ' ULAJuJI GÇL^JI Lw ci^lj! Jè J 力..lío f Li^ LJL> 尸 I 只 jsz jas Jl>I ^JL>uüI jjâj^ ^J! 'ÂJsu 二 91 '«LUÎLJI & 1 -\-L-lI ^^ I ^j^ucji ; ^jícji. d^cji lo^jklo J 丄, 一 ;:J I C^LJT ^^CJL^UJI ^jb,(., 1 ^ Lux-ИЛ^ ЪчллЛ-. ^-UicoJ i j\ Jbjj ; J 己Як? 1 о.ji) á^uíujl ^J J-ol^u^. '«L^L^j^I UV1 j, jl^iül ^J óa^uji I^UjVI ou^i Ik^jL ^UJI Ш 1 c^ljl ^ l^^j M^o 太 L^/^bJI ^ '«Lui-Ji^l u-^hajl ^ 一 jj 1 j!lj\ ^J ллл ^s. 'ÁJ^^oJI ' J L>J 1 jtíj^ jjá-j 1 Je»--. J Ub^ 1 jlst^o^ jj I <L q Ul^ IJI Jb ^-L-^J 1 丄o 二工 I ^. I JuuJ i ' j^wxaji Jui-Z; djl> qs ^JL>j^Jk^ ;, <)L>J 1 ^vu JUlWI *<LI ^улл д-ujlíü! JUlL^I^ glujjj UUJI qs. J_oL ^ jiá 二 ) 1. J 丄! *<LJ^JJI «L^^j ^js. jj>3\^ JJJaJI ó\ d^aû-z ' jl JI «LjuJjbJl ^js L»_fi>jl>I Js ^JL>uJ! juúic! ^JLsJU d_-j^ jj I duojájuoj 1 ^A>JL>vo ^^ < Í S I лl<iu>j! ^js ^ jls-oj! j^t Js^K} I I ^joj^hmj I ^ LÍ^J I ^^IÁJ! I^AO^HJ I 1 J JL ^juímoc^j j^t JÀl^ ^ri^^^ I jilj I J^J Ls«oJ I <LOJ JuúJ 1 ) ; 丄 J1 DJI-^^JI ^Э АЛЛСЛ 太 ^ÜJL JJLJL J-^LÍLUJ} 丄 ^JLC U/LWL J^ V/ÍV d-5hjuuûj I A^a^ I jljuu/^ I wv-^jüú."/ l.^ d.ojâ^lo.) I J I Js^t Lvco I ^x*-l>u>j 1 J "Ó JLJOJ I LU/J LÛ-OJ I J^WXJO) ^yüj^j ^js LO-A JL>I j\js JLÛIIC ULAJ I ^ LI-» <UxJ JuüJ d^vsjusj I d-csk.w! ^ll-u/v 1 ^S^ ^J JL-MAJ I j^ü ^js ^ ^ 1 dj>w4oj 1 <LOJd-LoJ du^j*)! JuvtiJ 1 Cl» L=OJuü 1 fi^^u LslaJ I <l2hjju>j I I ^iiu/v! ^js I Jk^ ^ U ^^JL>woJ 1 j^s L aj I ^ <x^j ju<xjj ('LSj^^Si! ) Í^JjJI p 1 J 'ioiho ^Ll-. \ j\jb JUO^I^. <cjl>l )áju 山 jji fjy>. Cl/^U^ A^a^Jl CI.LJ3 3I3ÍJI J p 1 J JLaiCuwL '«ÜJLÍCUJI ^-.jlscjl Lá^l LJU ^JUuJI l>ls>\^, 1jj^1 f'j^ o' jljüú jj^ûj 1 ^^JÜJi '<L>UJ 1 'Â^oJ! clmíjlo ^ Ïi5uiu> diuo^-. 产 1 Jl^JI ^^JLc f- U ij 1 ) ci;l; r/-.;:;.) 1 OJJÛJI doillo «í JOK^UÜ I ^ai I IJ J^-J AA!L«二.pj 1 <Lu/! J JJ 1 ^ Líbj I ^--JloJ I ^jui JLSLOJ I 方 ^CÜ 1 ^JàjJ I Лл^^ l^.^ij, HjjJl ^э ^Jj-Jl djji^ )j^l/ 々 yl;jl ^-cluji 3^-rJI <L=óliuJ <SpJ^jb d-.udjzjlcji ^J^iiii Lc^-j»^ tij^üjo, ^WO j-* p Luáj! ^ ij 1 js ^ i ^^JLsvoJ! 1 :1 力 dj J <uj JuJ I d-juíi-ojl J-ú-íÜ! isyi^o l g. "v^pi 1 tw>u> ^ij d o U I 二OJ I ^-AJJ *<5<J JOU> ^VO I 尸 ^JO! 少 Я!! ' C L»LF ^OAO ^J I JL> DJUOJ ^.D.LV.O-11 产 ÁJI 1 ул 1 JJlLJ!^ 1 «L^jLuü 1 j^s. ^ JL>JI " 丄 : \ ^Lxi-V JL^^Vl j-ou 1 jia ^ЛА-L^oJ I Jb \ ^ 1气气 ) 气气 Û '<J^JLL) ^WO LÍ j^j I! y^o ^- jj j L^m/ ci» I jjù^s'i 1 д-л-» Lie 己 L a - 1 ^jol yc^si Ju»Ju>Jl ^jji I dji 1

37 A47/VR/2 page 22 1 ÂA LxJâJuJî J^ Lg^jL2u>3 ' I^Jl J r/_ _(.JI jjl^!j!jà ^^J^uJI Ju^l^ J >J ci.uî^vl ^ çjâ-^ji ^^UJI ^Jl c/ 1 fbj! ^JuJ! ^Jl j\ (J-La^. Lo-J ^JL>uJ! d_lc 一 j^l ^jji 彡 己 1^:.. Л ^Jxl сl«jji jjlc wij I ^oju ^ЛЛ Ij^-jü I I J-A^uuy^! P Ijc I 己 ^ ao^ôji IЛЛ A-Rw- ^ js>c1k4ju &Jj! ^j-jaj I f..' I. ^рмэул^ ^JL^JL) ^^.cecji^ '«LccoUJI Ô^jJI ^J dj! jj! Ó^I^I \jjlq ^jj! d^cji J^> c ^ '«L^A-JI ^C^-ÛJ '«L^Lio ^Jbj 'LuxJb)li '<L JL *<L) s LcuJI ^Лд ^icl Ul^ 气气 Û 方 L^/^JIÎJI ^ ^ Ш 1 J^c ^ 一 1 J^UI Cl. l^luji ^ d i ^ J l, d^jji "V ^ J-^JL, ^ L ^ ^/^V^ ^ ^iu) Cl^ I. JJ ^ jri^^ (J-^ ^ l The PRESIDENT: \ Jx^J^ 力 Thank you, Professor Chatty, for your excellent statement. I should like to take this opportunity of paying tribute to the work of the Executive Board and, in particular, to express our appreciation and our warm thanks to the outgoing members who have contributed very actively to the work of the Board. 5. REVIEW OF THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN EXAMEN DU RAPPORT DU DIRECTEUR GENERAL SUR L'ACTIVITE DE L'OMS EN The PRESIDENT: I now give the floor to Dr Nakajima, Director-General, so that he may present, under item 10 of the agenda, his report on the work of WHO in The DIRECTOR-GENERAL: Mr President, excellencies, honourable delegates, ladies and gentlemen, one year ago I began to reform the management of WHO as you requested. The process is moving forward. It has to be steady, ensuring the participation of all. And, by 1995, I hope that reform will be harmonized at all levels of the Organization. WHO will then be better able to face the priority issues of health development in its Member States. Under most items on its agenda, the Forty-seventh World Health Assembly will be introduced to the many dimensions of the reform process. For reform, as all of us realize, is not just about structures. WHO has two major constitutional functions: the direction of international health work, with a responsibility for both advocacy and coordination; and the unique obligation of carrying out technical cooperation in the field of health with its Member States. Reform, therefore, means both improving our structures and redirecting our choices and priorities to better respond to the needs of our Member States. Reform is about improving WHO's capability to act and react more swiftly and effectively in the face of new health challenges and changing international and local environments. Within WHO, I have focused on developing collective management and strengthening communication and information throughout our global network. I established a Global Policy Council within which I meet regularly with the Regional Directors, the Assistant Directors-General and the Director of the International Agency for Research on Cancer. Together we review health trends and issues and update WHO's policies and strategies. With a membership representing all six WHO regions and headquarters at senior level, a Management Development Committee ensures technical coordination and follow-up. Collective management in WHO further extends to six development teams which are now looking into the following priority areas for reform: WHO policy and mission; WHO programme development and

38 A47/VR/2 page 23 management; WHO information systems; WHO information and public relations; WHO country offices; and WHO personnel policy. Already, some major programmes have been restructured, merged or streamlined, to foster intersectoral approaches and speedy action. Information and communication are crucial for decision-making and action. To support managerial reform and ensure the effective monitoring of health trends and health-for-all strategies, a comprehensive WHO management information system will be established. Furthermore, starting in 1995, as recommended by the Executive Board, WHO will publish an annual report on the health status of the world. The report will help to put WHO's work in perspective, assess its impact on health, and review priorities. I am convinced that it will also strengthen WHO's advocacy for health development, document the need to integrate health into other areas of government policy, and reinforce WHO's urgent call for national health system reforms. The Ninth General Programme of Work, which the Assembly will consider at this session, must be seen within the general spirit of reform. It will serve as a framework and a tool for global and national heath development during the period As such, it must accommodate both integrated, horizontal health interventions and vertical, disease-specific programmes. It must provide practical guidelines for immediate priorities while retaining enough flexibility to make room for future, as yet unidentified, health needs. In attempting to reconcile such contradictory demands and ensure a common purpose, the Ninth General Programme of Work proposes ten goals which are basically aspirations and measurable aims. It also spells out operational targets against which WHO and its Member States can measure the outcomes of their health interventions. These are realistic targets which we can achieve if we mobilize our efforts and resources. Priorities for health action differ from country to country and from region to region. So does the pace of change. Thus budget allocation, which is a balancing act between resources, needs and priorities, must allow sufficient flexibility for different regional and local programme priorities while preserving transparency and accountability. In January 1994,the Executive Board experimented with in-depth group reviews of selected WHO programmes. Tlie Board also decided to establish an Administration, Budget and Finance Committee and to transform its Programme Committee into a Programme Development Committee, entrusted with monitoring WHO's managerial and structural reform and ensuring that it enhances technical cooperation. All these mechanisms wül assist us in adjusting programme priorities and budget allocations to meet evolving health needs. They will also help us intensify our dialogue and partnership with our Member States. The Ninth General Programme of Work reaffirms WHO's commitment to our common goal of health for all. The definition of health given by the WHO Constitution is essentially dynamic. Any public health achievement or technological breakthrough sets a new baseline to be improved upon. Yet in many countries today, much remains to be done to meet even the most basic health needs. I have repeatedly expressed my vision of health as a continuous and inclusive development process, involving all countries and all individuals and communities. And I have reiterated WHO's commitment to national health development in support of world peace and development, whatever the political and economic environment. WHO's involvement in emergency relief operations and humanitarian assistance exemplifies this commitment to health, development, peace, and international cooperation. This involvement is of long standing and a constitutional obligation. Because of its traditional working relations with Member States, WHO is familiar with national and local health staff and situations. It can readily provide specific back-up through its technical programmes, as in the case of drug production and supply through its Action Programme on Essential Drugs. WHO's support also covers preparedness and logistics, and includes the training of health personnel among refugees and displaced persons. Altogether, demands on WHO for humanitarian assistance have increased. In spite of our financial limitations, we have been active in many countries and areas such as Afghanistan, Cambodia, Somalia, Liberia, Mozambique, the former Yugoslavia, the occupied Arab territories including Palestine, and more recently Rwanda. WHO works closely with local experts and institutions to ensure the provision of essential medical supplies and health care, particularly in countries affected by sanctions. WHO has expressed its serious concern over the adverse consequences which sanctions are having on the health of entire populations, both in the countries concerned and in neighbouring areas. While coordinating our activities with the United Nations system and international nongovernmental organizations, WHO always looks beyond the emergency period. Against fragmentation, WHO consistently strives to promote the sustainable and harmonious development of comprehensive health services based

39 A47/VR/2 page 24 on primary health care for all peoples nationwide, as we do today, for example, in Gaza, Jericho and other parts of the occupied Arab territories including Palestine. For all people to enjoy healthy and peaceful lives, hunger and poverty must be eradicated. Here, our priorities for action start with children. A significant worldwide decrease in infant mortality has already been recorded. From 163 deaths per 1000 live births in 1950 it has fallen to 65 in In 70 countries, with a total population of 3000 million, there are less than 50 deaths per 1000 live births. Because 1994 is the International Year of the Family, I wish to highlight the importance of the combined work of our technical programmes for family health, immunization and nutrition. By their intersectoral activities, they successfully promote not just the survival but also the healthy and happy growth of children. The health of women is also a high priority and a critical factor in family health and national development. Recently, the WHO Global Commission on Women's Health met in Geneva to take stock both of achievements and needs, and to prepare a consolidated plan of action to be considered by the Fourth World Conference on Women in Beijing in Sustainable development requires the prevention and control of major diseases such as malaria, tuberculosis and 1JTV/AIDS, which are destroying the most precious resources countries have, namely their peoples. Health action and development are closely dependent on demographic and socioeconomic factors. This has been demonstrated by the adverse consequences that structural adjustment has often had on the health sector, and by the negative impact of recent devaluations in Africa, especially on the availability of pharmaceuticals and other medical supplies. In our common fight against HIV/AIDS advocacy is essential. WHO will keep stressing the need for public policies which are consistent with, and actively support, health policies. WHO continues to support and cosponsor important international conferences such as the Conference on AIDS in Africa, held in Marrakesh. At the Summit of the Organization of African Unity, which will meet in June in Tunis, the heads of State have chosen to put "AIDS and the child in Africa" on their agenda. The next International Conference on AIDS will be held this August in Yokohama. It will be a major milestone in our annual policy and technical updates on HIV/AIDS. We have entered a new era where the dimension of caring for the people infected with HIV is receiving much greater attention. We must now ensure that this dimension is properly integrated into all health policies and services. Our tuberculosis programme has gathered momentum and is placing renewed emphasis on advocacy, policy and strategy development. Work continues on the development of new diagnostic tools and, in particular, drugs which can be used against multi-drug-resistant strains and hopefully a new tuberculosis vaccine. Major epidemics such as cholera, as well as malaria and other parasitic diseases still confront us with difficult situations. But recent advances in the development of drugs and vaccines are encouraging. The eradication of dracunculiasis (guinea-worm disease) is nearly achieved, although its certification will continue up to the year WHO is shortly to announce the establishment of a special global programme for leprosy elimination to enable us to step up our efforts in this last and decisive stage of our fight against this centuries-old scourge. The Forty-seventh World Health Assembly will celebrate the twentieth anniversary of a programme of which we are all particularly proud, the Onchocerciasis Control Programme. Having successfully carried out its control operations in West Africa, the programme has reached the final stage of "devolution". About 25 million hectares of land are now available for safe resettlement, and many among the previously affected populations have returned to their villages and farms. The sponsoring agencies and the international community are now able to turn their attention to sustainable development in these "oncho-freed" areas. Synergy and intersectoral cooperation are necessary to achieve health for all as an indispensable part of economic and social development. This is true not only in times of economic and financial constraints but at all times, because health itself is multidimensional. Thus, another major thrust of my leadership has been to set up new health partnerships. I have constantly looked for opportunities to create new alliances, to expand collaboration with other agencies and nongovernmental organizations and to enable the public and the private sectors to work together. This has always been, and remains, an important part of my vision of health and international cooperation. Our efforts to develop interagency and intersectoral partnerships are bearing fruit. A proposal is on the table, which has general support, for setting up a joint and cosponsored United Nations programme on HIV/AIDS. The programme will be administered and implemented by WHO and coordinated at country level by the United Nations resident coordinator, with strong technical support from the WHO country office. This ground-breaking initiative highlights our determination to enhance complementarity of action to meet the health needs of nations.

40 A47/VR/2 page 25 I have moved along the same lines to propose joint action in the field of immunization and vaccines. Negotiation is well advanced with UNICEF, UNFPA, the World Bank and the Rockefeller Foundation. An agreement should soon be concluded on a cosponsored programme, with WHO as the lead agency. With this in view, I am restructuring WHO,s programmes, merging the Expanded Programme on Immunization together with the Children's Vaccine Initiative and other vaccine-related units and activities. I want to strengthen our cooperation with all our partners, including nongovernmental organizations, because I want to make sure that, as of the year 2000,we save the three million children under five years of age whom it is in our power to save every year provided we have the resources. I also want to make sure that by the year 2000 we have eradicated poliomyelitis and that no child will ever again suffer the severe disabilities caused by this disease. And this is feasible provided we put into it the necessary political will and resources which many heads of State have already committed. Sound management of the environment is essential to protect and improve the health of present and future generations and, indeed, to ensure that there is a future left for them. On this issue again, and as a follow-up to the Rio "Earth Summit" and its Agenda 21,WHO has worked very had to promote joint programming and complementarity of action with other agencies. It has done so for example with its many partners within the International Programme on Chemical Safety and has pushed for the establishment of an intergovernmental forum. At the International Conference on Chemical Safety, held last week in Stockholm, at the invitation of the Government of Sweden and cosponsored by WHO with ILO and UNEP, we offered to act as secretariat to the forum. Soon, therefore, we shall be able to tackle environmental health issues in greater depth, achieving synergy to promote sustainable development. This leads me to the matter of our collaborating centres. These centres make up a vast and unique global network of expertise which we must use more effectively. Thus, as we enlarge our approach to health, we might bring them into intersectoral ventures rather than restricting our collaboration with them to specific diseases and health issues. Health for all to promote peace and sustainable development, through synergy and complementarity of action - this has been my vision of international cooperation and the basis of my leadership of the World Health Organization. Health issues, however, and consequently health action are becoming ever more complex as they are influenced by many factors external to health. New lifestyles and changing life-cycles have emerged which bring new health problems. These include a worldwide increase in the prevalence of noncommunicable diseases such as cancer, cardiovascular diseases and diabetes. There are new and expanding demands on the health sector because of a longer life expectancy which we would like to make as disability-free as possible. Poverty, migration and growing unemployment also have specific medical and psychosocial consequences which we must face and help to alleviate. Substance abuse has become a worldwide concern, together with the violence and behavioural problems it entails, and drug abuse is a threat to the lives and health of our youth especially. Global change requires us to rethink our fundamental understanding of human life, and of societies and civilizations, reasserting that human beings, as a species, are unique. We all have a common biological susceptibility to human-specific diseases such as AIDS, and we all share a capacity for mutual respect and solidarity. In the field of health, our sense of moral responsibility is expressed in our concern for biomedical ethics. Two important items on your agenda are related to health and ethics: infant and young child nutrition; and WHO ethical criteria for medicinal drug promotion. Your discussions on these two items will help shed light on important issues of ethics, enriching the current global debate with your different cultural views and approaches. For some time now, WHO has been developing its orientation with respect to biomedical ethics. Recently, I sent a questionnaire to all Secretariat staff at headquarters and the regions to elicit their preliminary comments and suggestions, both as concerned citizens of many countries and as people with experience in the Organization. The responses show a majority favouring the definition of minimum criteria and codes of good practice, and the spread of information and public debate as the best options for WHO to support Member States in this area. Equity of access to health care scores highest among the individual ethical issues of concern to WHO staff. It is followed by genetic technology, experimentation on human subjects, euthanasia and medical research. I shall soon extend the consultation process to all Member States and request their participation in drawing up a more systematic and technical catalogue of the ethical issues related to health and the priorities they would wish WHO to take up. Human reproductive health is an important example of WHO's involvement and responsibilities. At the United Nations Conference on Population to be held in Cairo in September 1994,WHO intends to table the issues of the definition of and actions for reproductive health including safe motherhood and other

41 A47/VR/2 page 26 health-related population matters. We will aim at a definition which includes access to reproductive health services, informed choice, and clearly defined rights and responsibilities. Access to health services is a matter not only of human rights but of ethics in general, and of individual and community responsibility. As they reassess their activities, all WHO programmes will give more emphasis to these issues, including in the fields of research, health promotion and education, human resources development and the collection and dissemination of information. Once again, I want to emphasize that health cannot be assessed and quantified as just any commodity. It would be foolish for us to ignore the impact of escalating health costs on public expenditure. The economic crisis, increased unemployment and the general aging of the world's population raise the question of the long-term sustainability of health services and their financing by a proportionally shrinking labour force. Yet the choices involved in health care policies go far beyond economic and managerial decisions. Implicitly, they involve our vision of the mutual relations and responsibilities of the State, the individual and the community. We should realize that at both the national and the international levels, our definition of health, of human life and of society, and our priorities will be read in our budget policies. And, for the time being, WHO's regular budget remains limited to zero growth in real terms and there is therefore greater need to focus on priorities. The 1946 WHO Constitution and the 1978 Declaration of Alma-Ata continue to express our unchanging goals for world health. Yet today we face new health problems and unsolved ones in a world environment which is increasingly unpredictable and seems irrational. Together, we must envision a new model for the solution of health problems, a model which is responsive to today's political and economic realities and which can help us shape new societies and civilizations. In a turbulent world, such a model must give rise to unified action throughout a reformed WHO structure and in our collaboration with Member States, with nongovernmental organizations and with all peoples - in a spirit of solidarity and shared responsibilities. With a new partnership for the development of human health, I remain optimistic that together we shall achieve our goal of health for all by the year My staff and I pledge to do everything in our power and concentrate all our efforts and energy on attaining this mighty objective. The PRESIDENT: Thank you, Dr Nakajima, for your eloquent and constructive words. 6. DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-SECOND AND NINETY-THIRD SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR GENERAL SUR L'ACTIVITE DE L'OMS EN The PRESIDENT: The debate on items 9 and 10 is now open. As you know, Committee A now begins its work in Room XVIII. I would recall that, in accordance with resolution WHA26.1, delegations wishing to take part in the debate on the reports of the Director-General and the Executive Board should concentrate on matters related to those reports, thus providing guidance which may assist the Organization in the determination of its policy; and delegations wishing to report on salient aspects of their health activities may make such reports in writing for inclusion in the record, as provided in resolution WHA20.2. I would also call the delegates' attention to paragraph 2(1) of resolution EB71.R3, in which the Executive Board stressed the desirability of having the debate focus especially on issues or topics deemed to be of particular importance. ТЪе delegates addressing the plenary at the Forty-seventh World Health Assembly are invited to give special attention to ethics and health. Delegations wishing to participate in the debate are requested, if they have not done so already, to announce their intention to do so, together with the name of the speaker and the language in which the speech is to be delivered, to the protocol officers on the podium. Should a delegate wish to submit - in order to save time - a prepared statement for inclusion in the verbatim records or whenever a written text exists of a speech which a delegate intends to deliver, copies should also be handed to the protocol officers in order to facilitate the interpretation and transcription of the proceedings. Delegates will speak from the rostrum. In order to save time, whenever

42 A47/VR/2 page 27 one delegate is invited to come to the rostrum to make a statement, the next delegate on the list of speakers will also be called to the rostrum, where he or she will sit until his or her time to speak has come. In order to remind speakers of the desirability of keeping their address to not more than 10 minutes, a system of lighting has been installed, the green light will change to amber on the ninth minute and finally to red on the tenth minute. Before giving the floor to the first speaker on my list, I wish to inform the Assembly that the General Committee has confirmed that the list of speakers should be strictly adhered to, and that inscriptions should be handed to the protocol officers. The list of speakers will be published in the Journal. I would remind those delegates who have to leave Geneva and are not able to deliver their speech before they leave that they can ask for their text to be published in the records of the Assembly. I now call to the rostrum the first two speakers on my list, the delegates of Slovenia and Egypt, in that order. I invite them to the rostrum: Slovenia and Egypt. I now give the floor to the delegate of Slovenia. Slovenia, you have the floor. Dr VOUC (Slovenia): Mr President, on behalf of the delegation of the Republic of Slovenia, I congratulate you and your country on your appointment as President of this year's Assembly. I support your aim to contribute to the formation of useful conclusions from this year's meeting. Mr President, health for all also provides a common ethical responsibility on a global level, which includes us all, irrespective of the environment to which we belong. It is not ethical to arrange the aims of health care policies in one's own country successfully while at the same time remaining uninterested in the same aims in a neighbouring or any other country. Health, life and quality of life are not restricted to just local or individual aims, but are global values, equally close to all nations. It is especially worth stressing the values of health and quality of life in regions where a large number of violent deaths occur. Since I come from a country which lies in close proximity to a region torn apart by violent death on a massive scale, allow me to illustrate the actuality of classical ethical responsibility in this connection. Violent death such as murder, suicide, fatal accident and abortion appear to different extents in all societies. They represent a negation of human rights to life and health, shorten life expectancy, cause a great loss of working years, family tragedies and a large number of orphans. Regions affected by war, wherever they are, represent septic foci of violence and lawlessness which can expand into general septicaemia. In all war-torn regions the right to life is more concerned with political and less with humanitarian rights, since many people are penalized by death only because of their nationality or religion. Data show that violent death appears more frequently in those societies with more limited means for providing for political, social and spiritual needs. So the relation between natural and violent death represents an interesting indicator of the quality of life in individual societies. Since the number of violent deaths in the world is not falling, I mention them in particular as an example of the global ethical responsibility of health care policies. I raise the question of ethical responsibility, health care organizations and health care policies in all forms. If we were to react to violent death as we do to the appearance of a dangerous infectious disease, the response of international society would be much more resounding. Violent death is not of course the only example of an ethical dilemma of this kind. There are many cases in which differences in seriousness and resolution of health problems throughout the world are known to us, but we do not regard them personally, since they are limited to a different environment. The concept of health is also associated with an ethical responsibility, which encompasses all countries, large and small, developed and undeveloped, rich and poor, to the same extent. Health for all reminds us to reconsider how we define the ethical responsibility for health care policies: if health is linked to the quality of life, then the ethical responsibilities for health and health care policies extend even into other social fields and other environments. WHO, with its strategy of health for all, has created an environment where health care policies include moral questions of the world. It is our common responsibility to incorporate them in all spheres of health policy. Dr EL MAKHZANGI (Egypt): :( 严 ) 一丨 rbjj 丨 ^aji ci,làisùilji ^jici'lw ^jli ^J jwx^oji CLls^JI З^ЦО! Л ^-Ic Loy> ^^Jl I C 1 js^jl jikj UoLS ^As 0 \ ^ 0)

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45 A47/VR/2 page 30 Ms SHALALA (United States of America): Mr President, Dr Nakajima, fellow delegates, ladies and gentlemen, it is an honour to address this distinguished Assembly of world health leaders. Dr Nakajima, I thank you for your warm welcome to my first World Health Assembly. Minister Temane, I would like to congratulate you on your well-deserved election as President of the Forty-seventh World Health Assembly, and for your eloquent address. I also wish to add the joy and welcome of the United States delegation to our sisters and brothers from South Africa. We celebrate South Africa's rebirth as a non-racial democracy. I bring you all greetings and words of support from the President of the United States. Looking out at this grand Assembly, I cannot help but be humbled by the infinite diversity of our earth - this tiny village in the universe. As we close out the twentieth century, we are beginning to witness a profound shift in global consciousness. From the Middle East to South Africa, from Bosnia to Rwanda, the whole world seems caught up in a whirlwind of change. Some of it is full of hope and wonder. And some of it is tragic and painful. In the midst of these massive changes, the United States is proud to stand with all of you in a vigorous and untiring effort to promote the health and well-being, and basic human rights of all people on our fragile planet. Because what we are really standing up for is the future of our world. The future of our world is a family in Asia, whose drinking-water has been purified for the first time, allowing their children to grow up strong and healthy. The future of our world is a two-year-old girl in Latin America who has just been immunized against polio thanks to the efforts of her government and the help of WHO. The future of our world is a classroom of students in Africa, where sex education is being taught to prevent the spread of HIV/AIDS and other sexually transmitted diseases. All of us gathered here recognize that health care is a human right. In my country, President Clinton has undertaken a bold initiative to secure health care for all Americans. And for the world he has put health care and population issues in the forefront of our development assistance policies and programmes. We are all gathered here today to reaffirm the commitment of the global community to prevent the spread of AIDS and other sexually transmitted diseases, to protect the world's children, and to empower women to live full and healthy lives, free of discrimination. The United States is investing more than US$ 2000 million a year in the fight against AIDS. We have made a major new commitment to AIDS prevention, while enhancing our investment in biomedical research. And we are stepping up our cooperation efforts with WHO and other Member States in the worldwide search for a vaccine to prevent HIV infection, in the development of new drugs for AIDS treatment, and in the development of woman-controlled methods that will protect against HIV and bacterial sexually transmitted diseases. We are especially concerned that, by the year 2000,more than half of all new HIV sufferers will be women and their children. We must do more to empower women to control their sexual and reproductive lives. And we must do more to enable men to take responsibility for their own fertility and the health and well-being of their partners and children. It is deplorable that over maternal deaths still occur each year. All of us need to work harder to ensure that prenatal, delivery, and postpartum care are available to all women. We also must ensure the right of women and men to be informed and to have access to safe, effective, affordable, and acceptable methods of fertility regulation of their choice. Too many of the deaths, injuries, and ill health suffered by women are caused by complications from unsafe abortions. During the week, this Assembly will consider a resolution on maternal and child health and family planning. My delegation supports the strongest possible resolution to facilitate rapid progress in reducing the unnecessary tragedy of maternal mortality and morbidity. As health ministers, we all know that access to quality reproductive health care will enhance the physical, mental, and social well-being of all our citizens. It will strengthen families. We also know that various social conditions undermine the health of women and girls. Gender discrimination blocks that access to health care. Gender-based violence is epidemic across the world. And girls and women endure some practices that are harmful and must be stopped. Among these practices is female genital mutilation, which tens of millions of girls and young women have suffered. The United States joins with other WHO Members in deploring this painful and dangerous practice. And we strongly urge the Director-General to accelerate his support and cooperation with Member States to implement measures that will bring this and other harmful practices against women and girls to an end. WHO has a pivotal role to play, and it is time to act decisively. In many health areas, the world looks to WHO for decisive leadership, and that requires effective, on-going management, and an ethos of continuous improvement. Just as the United States is streamlining government as part of our response to change under President Clinton's leadership, so must WHO continue efforts to manage resources effectively. This is too important to the health of the world to neglect.

46 A47/VR/2 page 31 And so, in closing, let me say that in this year - the International Year of the Family - we share a special responsibility to improve the conditions and uplift the spirits of families in all their forms in every country. We must answer the call of UNICEF's State of the world's children report, and recommit ourselves to the goals of the World Summit for Children to protect the youngest and most vulnerable among us. We must work together to immunize all infants and children. We must join hands to protect children from the ravages of war and abuse. We must create economic security and educational opportunities for each and every person on this planet. As world health leaders, we know that behind every statistic, behind every tragedy, behind every crisis, there is the face of a human being in distress. Our job is to make sure that these faces are not invisible - to reach out across the borders and differences that would divide us, with compassion and concern for all. To paraphrase the great American novelist, Ralph Ellison,"The world is woven of many strands. Our fate is to become one, and yet many." Interdependence is the great lesson we take into the twenty-first century. Our vision is health, empowerment, and human rights for all. M. LAHURE (Luxembourg): Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs les délégués, Mesdames, Messieurs, permettez-moi, Monsieur le Président, de vous exprimer à vous et aux membres de votre bureau les plus sincères félicitations de la délégation luxembourgeoise pour votre élection. Je vous souhaite beaucoup de succès dans votre mission et j'espère que cette Quarante-Septième Assemblée mondiale de la Santé nous permettra de discuter des problèmes qui préoccupent nos peuples et notre Organisation dans un climat de confiance et de parfaite sérénité. Et des problèmes, il en subsiste plus que nous ne pourrons en résoudre dans les prochains jours et les prochaines années, comme le démontre si bien le rapport biennal sur l'activité de l'oms en ,que notre Directeur général nous présente de façon claire et synthétique, ce dont je tiens à le remercier. Après six périodes biennales consécutives de croissance zéro du budget, et compte tenu de la dégradation de la situation économique et sanitaire de nombreux Etats Membres, il est évident que la mission d'améliorer la santé qui incombe à ceux qui dirigent notre Organisation au niveau central aussi bien qu'au niveau régional devient de plus en plus ardue. L'adaptation de l'oms aux changements économiques, politiques, sociaux et autres survenus dans le monde, selon les recommandations du rapport spécial présenté par le Commissaire aux Comptes en 1993 et la résolution WHA46.21 portant sur ce rapport, a tout juste été amorcée et devra être poursuivie avec détermination dans les années à venir; elle nécessite une réforme fondamentale des modalités d'exécution de l'action de l,oms, réforme qui devra être concrétisée dans le cadre du neuvième programme général de travail, dont un projet est soumis pour approbation à cette Assemblée. Je ne puis que souscrire aux principes généraux énoncés au chapitre 3 du document présenté sur ce sujet, et notamment à la nécessité d'établir des priorités et de procéder à une évaluation rigoureuse et continue du programme, afin d'optimiser la mobilisation et la répartition des ressources. Il est clair cependant que même si on réussit à planifier le mieux possible les travaux et même si on ne se limite qu'aux actions absolument prioritaires, il faut disposer des ressources nécessaires pour les mettre en oeuvre. C'est pourquoi nous sommes très préoccupés de Pexistence d'un déficit de cent millions de dollars pour la période biennale , et nous lançons un appel à tous les Etats Membres redevables d'arriérés de contributions pour qu'ils les règlent le plus rapidement possible afin de ne pas compromettre encore davantage le déroulement des programmes approuvés par l,assemblée de la Santé. En examinant le rapport du Directeur général pour la période , nous constatons que des efforts importants ont été réalisés en faveur de la santé pour tous et de Pégalité en matière de santé. Nous avons appris avec grande satisfaction que des progrès considérables ont pu être accomplis dans la voie de réradication de la poliomyélite, de rélimination de la lèpre et de l,éradication de la dracunculose. Vendredi prochain nous aurons d'ailleurs le plaisir de participer aux célébrations du vingtième anniversaire du programme de lutte contre ronchocercose en Afrique de FOuest, et à cette occasion nous aurons ГЬоппеиг d'intervenir au nom de la communauté des donateurs de ce programme, qui peut déjà être considéré comme un des succès de notre Organisation. Nous sommes en revanche très préoccupés par la stagnation, voire la diminution, des taux de couverture vaccinale et nous saluons toutes les initiatives que prend l'oms pour développer et promouvoir des vaccins efficaces et stables, simples à administrer et accessibles à ceux qui en ont le plus besoin. Nous réaffirmons notre soutien au programme élargi de vaccination et à Finitiative pour les vaccins de l'enfance qui est coparrainée par l'unicef, le PNUD, la Banque mondiale et la Fondation Rockefeller, et dont le secrétariat est assuré par notre Organisation.

47 A47/VR/2 page 32 La progression inexorable de la pandémie d'infection à VIH/SIDA dans le monde nous oblige à redoubler d'efforts contre ce fléau qui affecte maintenant des régions qui ont longtemps été épargnées. Cette évolution montre que nous devons absolument unir et coordonner nos actions dans le cadre d'un programme commun coparrainé des Nations Unies sur le VIH et le SIDA qui devrait permettre de mieux intégrer les idées et les approches des diverses institutions des Nations Unies dans cette lutte à mener d'urgence pour ralentir l,extension de la maladie. La tuberculose est une autre maladie grave qui est en progression au plan mondial et, pour la première fois depuis plusieurs décennies, son incidence augmente aussi dans certains pays d'europe et d'amérique du Nord. Cette maladie, contre laquelle nous disposons de moyens de lutte efficaces, est aujourd'hui dans le monde la principale cause de mortalité due à un agent infectieux unique et elle est à 1,origine de plus d'un quart des décès évitables chez l'adulte. Nous ne pouvons donc que souscrire à la nouvelle initiative de l'oms pour lutter contre la tuberculose et espérer qu'elle trouvera le soutien nécessaire auprès de tous les pays et des organisations concernées. Au plan national, je suis heureux de pouvoir dire que le Luxembourg s'est maintenant engagé formellement dans la voie de la santé pour tous, fondée essentiellement sur les soins de santé primaires. Certes, les orientations choisies par le passé dans le domaine de la santé ont été éclairées par les principes de ce mouvement, mais nous ne disposions pas d'un outil stratégique formel. Nous venons de combler cette lacune par la publication d'un livre blanc sur la santé pour tous, dont le but est de définir pour les années à venir les domaines d'action prioritaires en matière de prévention et de promotion de la santé, de fixer des objectifs clairs et des buts précis et chiffrés et de proposer des stratégies pour les atteindre. Nous avons soumis une première version de ce livre blanc à un large débat public, débat qui a accueilli favorablement et confirmé l'approche choisie. Je suis heureux de dire que cette nouvelle stratégie de la santé pour tous repose exactement sur les orientations exposées dans le projet de neuvième programme général de travail soumis à cette Assemblée, à savoir une approche intégrée et multisectorielle, l'assurance d'un accès équitable aux services de santé, la promotion de la santé et la prévention des maladies accessibles à des mesures efficaces. Nous mettrons tout en oeuvre pour atteindre les buts fixés et améliorer ainsi la santé et le bien-être de notre population. Au cours de la dernière année, le Ministère de la Santé a entrepris plusieurs actions dans un autre domaine cher à l'oms : le soutien et la promotion de l'allaitement au sein. Les directives européennes concernant la commercialisation des préparations pour nourrissons ont été traduites en un règlement grandducal daté du 20 novembre 1993; une commission spéciale a veillé ce que ce règlement se rapproche le plus possible du Code de i'oms. Conjointement avec UNICEF-Luxembourg, mon Ministère a organisé un séminaire de sensibilisation à l'initiative des hôpitaux "amis des bébés" au Luxembourg, auquel toutes les maternités luxembourgeoises sauf une étaient représentées. Un coordinateur national pour la promotion de l'allaitement maternel a été nommé et un programme d'action spécifique débutera sous peu. Dans cette optique, il est évident que le Luxembourg est disposé à soutenir toute résolution de l'oms qui vise à encourager cet objectif. Si mon Gouvernement fait des efforts constants pour promouvoir la santé et le bien-être des Luxembourgeois, il n'oublie cependant pas qu'il est de son devoir de contribuer autant que possible au développement et à la promotion de la santé d'autres peuples moins nantis. Depuis 1985, Faugmentation des crédits à la coopération au développement est substantielle et, en date du 31 juillet 1991, le Conseil de Gouvernement a confirmé l'objectif d'atteindre en 1995 un taux de 0,35 % pour le rapport entre Faide publique au développement et le produit national brut. Ce rapport est à considérer comme un objectif intermédiaire étant donné que, vers la fin de ce siècle, le Luxembourg entend atteindre 0,7 % de son produit national brut. L'orientation sectorielle de l'aide reflète l'intérêt particulier de la coopération luxembourgeoise pour des projets dans le domaine de la santé. En dehors de sa contribution au budget annuel de l'oms, mon pays a versé des fonds en 1993 à cinq programmes spéciaux, versements qui seront maintenus, voire augmentés en Nous aimerions ainsi exprimer à notre Organisation notre plein soutien dans sa mission sur laquelle se base notre espoir d'arriver un jour à faire de la santé de tous les citoyens de ce monde un droit acquis. Mr OUCHI (Japan): Mr President, Mr Director-General, honourable delegates, ladies and gentlemen, on behalf of the Government of Japan, I have the privilege to outline Japan's basic thinking on world health and on efforts to protect and improve it.

48 A47/VR/2 page 33 Mr President, I would like first to offer you my earnest congratulations on your appointment as President of the Forty-seventh World Health Assembly. My delegation is confident that your outstanding leadership will ensure that this Assembly is a most successful one. Mr President, we are approaching the year 2000; however, the world is confronted by political, social and economic change never before experienced. It is not too much to say that we are now facing historic change. We are aware that the Cold War really is over, but we are coming to realize that the threat of another tragic situation may be just beginning. Regional, racial and religious conflicts in former Yugoslavia, Somalia and elsewhere have had a devastating impact on people's health, and the least developed countries are still suffering from starvation, unemployment and so on. The gap between the rich and the poor is widening rather than narrowing. At the samé time, we have to pay great attention to serious issues affecting the disease structure and the health situation in the world. These include rapid population growth, rapid urbanization, aggravation of the health gaps between the developed and least developed countries, global-scale environmental destruction, and mass migration of refugees in areas afflicted by natural or manmade disasters. Health problems and related issues are not confined to any particular country, nor can they be totally resolved by health professionals. On the contrary, many of them are strongly expected to be better or more properly dealt with through international and regional cooperation. Over four decades have passed since our World Health Organization was established. Looking back at these years, WHO has tackled many different projects aimed at protecting the life and health of mankind, and in doing so has accomplished their respective goals. I am convinced that WHO, as the only United Nations specialized agency in the health field, can and will fulfil its leadership role in the health sector, and that it will address these issues in collaboration with the United Nations system and other organizations. Since the end of the Second World War, my country has steadily developed important health policy initiatives, such as programmes to control communicable diseases and improve maternal and child health. As a result, we have been able to obtain standards of health that are among the highest in the world. We need to plan and work from now on to make it possible for our society to be a bright and active one in which all citizens, young and old, can lead meaningful and fulfilling lives and enjoy health and peace of mind. For this purpose, we have placed the highest priority on developing an integrated health and welfare infrastructure for the elderly. We desire to contribute to the improvement of world health by sharing the technical know-how and experience accumulated during our own health development. To this end, we would like to take this opportunity to state our readiness to provide meaningful assistance for WHO's work and to promote the strategy of health for all. We are contributing actively to the work of WHO through technical assistance, and we send Japanese experts to expert meetings hosted by WHO. We have enhanced our collaboration and cooperation with WHO through WHO collaborating centres. One notable example of our international collaboration can be seen in the Tenth International Conference on AIDS, which will be sponsored by WHO in Yokohama, Japan, in August. We should like to refer to several WHO initiatives which we consider important to world health. WHO has taken action for its structural reform in response to global change. We are pleased to recognize that much progress towards the full implementation of such reform has been made. We expect WHO to continue to tackle the implementation of the relevant recommendations with dispatch and vigour. In the implementation of the programme, WHO has launched important initiatives, such as the Children's Vaccine Initiative, the joint and cosponsored United Nations programme on HIV/AIDS, and active participation in environment and health issues raised by the Member States of the United Nations on environment and development. We highly commend WHO's responsiveness to these priority matters. In particular, we welcome and support further efforts to enhance WHO's initiative in preventing communicable disease through the establishment of the Global Programme for Vaccines, last March. With regard to the joint and cosponsored United Nations programme on HIV/AIDS, the United Nations organizations concerned are jointly striving to fight the HIV/AIDS pandemic through a more unified programme. I do hope that WHO will provide the necessary leadership and that it will continue to play a central role in coordinating the efforts of all partners in the battle against HIV/AIDS. People across the world have attached greater importance to humanitarian assistance in the health field because of the increase in the frequency and seriousness of recent natural and man-made disasters and other emergency situations, which have had tragic consequences in all parts of the globe. We are proud of WHO's efforts to be increasingly involved in the area of humanitarian assistance and we would like to intensify our support to these efforts by WHO. Finally, WHO has been going forward under the direction of the Director-General, Dr Nakajima. We strongly endorse his productive action in addressing various health issues, and expect that WHO's

49 A47/VR/2 page 34 response to global change will be an ongoing process that will significantly contribute to the advancement of world health. As we approach the beginning of the twenty-first century, WHO is about to launch its Ninth General Programme of Work in order to move closer to the accomplishment of our noble goal of health for all. Now is the time for us to unite under WHO's banner and to make every effort to substantially improve the health of all human beings. Mr President, I would like to close this address by ensuring you of the commitment of the Government of Japan to contribute to making constructive efforts to fulfil its noble mission by providing all possible assistance to WHO. Mr Sang-Мок SUH (Republic of Korea): Mr President, Director-General, distinguished delegates, on behalf of the delegation of the Republic of Korea, I would like to extend my sincere congratulations to Mr Temane of Botswana on his election to the presidency of this World Health Assembly. In addition, I would like to express my thanks to Dr Nakajima and the Secretariat and staff of the World Health Organization for their excellent preparatory work for this meeting. Warmest congratulations are also due to the prize-winners, whose contributions to the cause of health are greatly to be admired. It is always a pleasure at this time to acknowledge the work of WHO for the improvement of the health of mankind. A half-century has passed since WHO was established and there have been great achievements worldwide in the field of health during this period. Today, with 187 Member States participating in WHO's work, we can face the future with renewed faith in the success of our cooperative endeavours. With the great changes taking place in the world society and the end of political confrontations and discord, we can hope for an era of true harmony and cooperation in the health, environmental and economic fields. At this momentous time, WHO has an even more important role to play in our future. WHO's contribution has been extremely important, for example, in the control of poliomyelitis, leprosy and parasites, and in establishing global cooperation in meeting new challenges such as AIDS. The Organization's role is also becoming more and more important in environmental control, with the rapid and serious changes in the earth,s environment. It is important to look back on the achievements of the past, but we must now consider how we should move forward. In a few years we will enter the twenty-first century and we need to examine carefully what WHO should be doing in this new era. It is therefore timely and appropriate that the subject of health and ethics is being considered as one of the new challenges, for this is indeed a subject of pressing importance for the well-being of mankind. Questions relating to health and ethics are becoming increasingly important these days with the need to ensure that all people enjoy equity in health care without social or economic discrimination. The rapid increase in medical technology and changes in lifestyles affecting health also present ethical challenges. There are a number of important current issues in health and ethics which face the world. We must take care, for example, that the introduction of new medical technology does not overwhelm us and we must ensure the proper evaluation of newly developed medicines, equipment and medical techniques before they are utilized in our already expensive health services. Research on human subjects, genetic engineering, organ transplant, new technology to prolong human life and the question of brain death are just a few of the issues which many of us are concerned about today. In addition,we must be prepared to consider the various needs of countries with different social and cultural backgrounds. WHO has been very effective in assisting nations to become aware of such issues and their implications. The Organization has also been successful in helping Member States to develop appropriate policies regarding ethics and health. Through its meetings and publications, for example, WHO has made available useful guidelines on specific questions of health-related ethics. International cooperation of this kind will be of even greater value in the future, as rapidly developing technology and advances in medical science present further ethical dilemmas to the countries of the world. Further work must be done to keep ahead of technological developments so that we are prepared to cope with their ethical implications. We should remember that human health is not only a question of medical technology. We need to assist countries, especially the developing nations, to adopt appropriate ethical guidelines suitable for their own special situations. More can be done by developed nations in exchanging ideas and in helping other countries benefit from the research and studies carried out in health ethics. With the rapid development of medial science and technology, health ethical issues will become more serious. This may hinder the advancement of equity, social justice, and human rights. Whether we

50 A47/VR/2 page 35 successfully meet these new challenges and create a better world to live in depends on the noble efforts of each and every one of you, the distinguished delegates here today. As a part of these efforts, I,on behalf of the delegates from the Republic of Korea, would like to make the following proposals. First, there should be a greater international exchange of information on health ethics as a step towards reducing the gap between the developing and developed countries in the utilization of modern medical technology. We must ensure that the benefits of advanced medical technology are truly shared by all people and not limited to the rich nations. More attention should be given to North-South cooperation as well as to the mobilization of private contributions from nongovernmental organizations at the national and international levels. WHO has an important part to play in helping to ensure that the ethical aspects of investments in health are duly considered in the development of national health policies. The Republic of Korea is fully prepared to share its knowledge on health and social welfare policies and its experience in socioeconomic development with all countries. Secondly, WHO, governments and health policy-makers must all keep up with the progress made in the development of new medical technologies that have ethical implications. They must also consider how these developments will affect the welfare of those for whom we provide health care. At the same time, health care consumers must be kept informed of medical developments so that they can make reasonable, considered choices when ethical issues arise. Consumer protection groups should be supported and ethical review committees, both in hospitals and in the public health field, should be encouraged to play their part. The media should also help by providing adequate coverage of new discoveries and their possible consequences for health and welfare. Thirdly, all countries, under the leadership of WHO, should strengthen their capacity for undertaking appropriate research in health ethics^ and WHO should continue to help establish internationally acceptable ethical and technical standards in the medical field. I have no doubt that the deliberations at this World Health Assembly will help to clarify many issues in health and ethics for the participating countries. I look forward to a very stimulating and constructive debate. Finally, Mr President, I would like to assure you that the Republic of Korea will continue to support fully WHO and the participating States in international cooperative efforts to achieve health for all by the year Ms d,ancona (Netherlands): Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, in the first place, I would like to extend my congratulations to you, Mr President, on your election and to the members of the Bureau, and I wish you all success with your important tasks. It is a great honour for me to address this distinguished Assembly on behalf of the Netherlands Government for the first time. However, as we have general elections today in the Netherlands, you will understand that I can only briefly enjoy the pleasure of participating in the work of this Assembly. Since the last Health Assembly, once again important changes have taken place in the world. Real chances for peace have been emerging in different parts of the world, such as the progress achieved in the Middle East peace process, in particular, between Israel and the Palestine Liberation Organization. We sincerely hope that the dialogue will result in a lasting peace. In South Africa the successful elections represent a major step towards the creation of a peaceful multi-ethnic society. We are glad that, as a consequence, South Africa returned yesterday to the WHO family. Unfortunately, in other places of the world, we are faced with continued tragedies, of which Rwanda and Bosnia are but two examples. These conflicts negatively affect the lives and the physical and mental health of all the people involved. Humanitarian assistance to the population afflicted by natural and man-made disasters must remain a relatively small task of WHO. However, in our opinion, WHO, among other United Nations bodies, especially has a clear role to play in peace building, by laying the foundations for global sustainable development. Another role for WHO lies in the phase of rehabilitation, when generally the whole health care system needs to be rebuilt. The effectiveness of operations in all these fields would increase tremendously, if forces are combined within the whole international community. The detrimental effect of war and conflicts on health is most obvious. Apart from the health problems in war-torn areas, the health situation of the population in recently pacified countries is also often worrying. However, the same is true for a great number of countries in the world. WHO has repeatedly pointed to the inequities in health between and within countries. The differences between developing and industrialized countries are still significant. In particular, the least developed countries have not really benefited from the great progress made during the past decades.

51 A47/VR/2 page 36 However, even within countries, there are vast differences in the health status of the population. The latter applies to both developing and industrialized countries. As was indicated in the recently published World development report 1993: investing in health, health is a prerequisite for economic development and vice versa. In this report, the crucial importance of health for a society is clearly recognized. The development of health cannot be seen apart from social changes within and between countries. Health and development are clearly interrelated. Economic development, education, poverty alleviation, environmental policy and agricultural activities at e all key factors influencing the health status of individuals and the population in general. The relation between health and development proves to be stronger in the case of women. Therefore, national policies should be more focused towards improving the health status of women. These persisting differences need worldwide attention, for governments can play a major role in changing the causes which lie at the root of these inequalities. National policy change may result in drastic health care reform and may also mean that the public health approach should be incorporated into overall policies as an integrated policy component. I call upon my colleagues in the Health Assembly to advocate, at the national and international level, the need for an intersectoral approach to health. Until now, the responsibility of other policy sectors for health has, in general, been insufficiently recognized. To be fully equipped for this major task, the implementation of the process of reform is a precondition for the success of WHO. WHO must not lose track of its original mandate as a technical and standard-setting organization. In this respect, the Netherlands are failing to receive the clear guidance of WHO in the setting of priorities, although we recognize that making choices is not an easy task. The Netherlands are convinced, nevertheless, that priority setting is essential to the future of WHO in the coming century. With respect to the type of programmes, the Netherlands would very much like to see a more integrated approach. When programmes are isolated activities, instead of reflecting coherence, this will undoubtedly lead to duplication of efforts and may even result in activities aimed at conflicting objectives. Needless to say, this is an inefficient method of work. The same applies to the apparent lack of synergy in the Organization between headquarters and the regional offices. Both should have their own qualities and tasks, which are complementary to each other. This would also lead to the improvement of the credibility of WHO and would add to the effectiveness in doing what needs to be done. More efficiency could also be achieved by closer cooperation and collaboration with other international and United Nations organizations. In Europe, a process of rapprochement is taking place between WHO's Regional Office for Europe, the European Union and the Council of Europe. We cannot stress enough the importance of combining forces. On the global level, a good example of interagency cooperation is the establishment of a joint and cosponsored United Nations programme on HIV/AIDS. We sincerely hope that all the possible cosponsors involved, including the World Bank, will eventually decide to participate in this new programme. The last theme I would like to discuss is the importance of ethics and health. We are convinced that WHO should play a leading role in the field of human rights in health and ethical questions in medicine. Although ethical questions have become more obvious with the development of new health technology, ethics He at the root of normal day-to-day medical practice. The respect of human rights is essential for the doctor-patient relationship. It is a prerequisite for the success of treatment. A positive and encouraging example of what can be achieved in this field is the adoption of a declaration on the promotion of patients' rights in Europe at the WHO European consultation on the rights of patients, held in Amsterdam, last March. This declaration contains a wide range of possible strategies for health professionals, health care institutions, patient organizations, governments and international organizations based on the principles of the rights of patients in Europe. These principles will be widely distributed. Hopefully, this declaration will be worth following. It deserves follow-up by WHO. Dr SHANKARANAND (India): Mr President, Director-General Dr Nakajima, distinguished delegates, ladies and gentlemen, my heartiest congratulations to you, Mr President, on your election as President of the Forty-seventh World Health Assembly. I also convey my felicitations to the Vice-Presidents and chairpersons of the Committees on their elections. I and my delegation are immensely pleased to extend our hearty congratulations to South Africa under the leadership of its great leader, Nelson Mandela. The South African people have waited and striven hard for this moment. At this hour, we gratefully remember the Father of our Nation, Mahatma Gandhi, who 100 years ago,as a young lawyer, was knocked down from the train and humiliated

52 A47/VR/2 page 37 because of colour and racial prejudice. It resulted in the germination of the seed of freedom in the hearts of South Africans, as the culmination of which we now see a South Africa free from apartheid. And today we welcome with jubilation and honour South Africa into our world health family and pay tribute to its leaders. We are meeting at a crucial moment in the history of mankind. It is just seven summers until we shall be stepping into the next millennium. The world is witnessing unprecedented turmoil, shaking the foundations of the political, economic and social structures. Massive reorganization of human society is taking place, and the barriers that kept different societies apart are breaking down. The long and continued world economic crisis has led to growing unemployment, continued inflation, recession and the collapse of the development process in many countries, and it has further aggravated the political and economic situation. The Cold War has ended, but regional and intercountry conflicts have continued and have led to the exodus of large populations, mentally and physically shattered, to areas of relative safety. In addition, many developing countries are witnessing a silent migration of people from the rural countryside to urban centres in search of a better life, only to face new disappointments and problems. In spite of the immense knowledge available to mankind through technological innovations and the ability to improve health and human development, millions have remained undernourished and are denied their immediate needs for food, clothing, shelter, medical care and education. The obvious result is poverty and ill health. Distortions in the development of the world economy have brought about a queer situation of over-abundance, on the one side, and deprivation, on the other. In the absence of adequate food, safe drinking-water, proper sanitation, primary health care and minimum education for the poor and the needy, health development will be a mere dream. Among the important changes in the global scenario, there have been significant achievements and also avoidable failures. Life expectancy has continued to increase and infant mortality continues to decline. The control of several communicable diseases has demonstrated our ability to surmount serious health hazards that appeared intractable until recently. The level of morbidity and mortality, particularly infant mortality, continues to be high in many developing countries. The progress in health status worldwide has widened the between the rich and the poor nations. Althou alaria continues to be a problem, with increasing insecticide and drug resistance, special strategies are being devised to bring down the morbidity and mortality due to malaria. The leprosy eradication programme has made remarkable progress in our country, and is poised for a quantum leap that will eliminate the disease as a major public health problem by the year A revised tuberculosis control programme has been formulated with a view to tackling this disease, which is posing a fresh threat with the spread of AIDS. The pandemic of AIDS is continuing its silent march, and we in our country are not sparing any efforts towards its control by introducing preventive measures through a strong information, education and communication approach, while at the same time encouraging various research efforts in an attempt to find a cure for this dreaded disease. 1 The emergence of HIV and AIDS has baffled all because of its tragic and unknown proportions. The fearful toll from AIDS in developing countries might nullify the result of decades of hard labour in achieving a reduction in mortality. The need of the hour is to remind ourselves that prevention is better than cure. The adage has become all the more important and relevant today as AIDS has no cure and prevention is the only solution. In any case, preventive and promotive health care are definitely more costeffective than curative health care. Tberefore, we have to lay more emphasis on preventive and promotive health care. Increased industrialization and urbanization are bringing in their wake new types of health problems, some of which are related to the new lifestyles. Deaths, injuries and illnesses due to vehicular accidents, emissions of pollutants, despoliation of the environment, increases in tobacco and alcohol consumption, and drug abuse, as well as cardiovascular diseases, cancer and diabetes, are matters of grave concern to health managers and need to be tackled on a war footing. Timely control of these through community action, education and promoting a moral code would help in mitigating suffering, especially of those living in the rural areas and urban slums in the developing countries. The escalating costs of health care and the non-availability of drugs to combat some diseases should make us turn to the untapped wealth of traditional medicine. Many of the Member countries have a vast reservoir of this heritage. Fortunately, in India, we have a long tradition of Ayurveda, Siddha, Unani and homeopathy based on herbal medicines, and the drugless therapies of Yoga and nature cure. India has rich resources of trained traditional medical practitioners in these systems of medicine and also high-quality standardized herbal remedies. Therefore, to encourage the use of locally available, safe and cost-effective therapy, we need to exploit this resource fully, and may be rewarded by solutions to intractable health problems.

53 A47/VR/2 page 38 But the fact remains that no amount of resources - external or internal - would suffice to meet the challenges before us unless we succeed in quickly arresting the growth of our population. The rate at which our large population is increasing eats away almost the entire fruits of our developmental efforts. Therefore, in order to bring about a meaningful and sustained improvement in the quality of life of our people, it is necessary to put an immediate brake on the ever increasing rate of growth of our population, and thereby break the link between overpopulation and poverty. Today, the need of the hour is also to keep up efforts consistently to control and eliminate the communicable diseases. There must be no room for complacency, and there should be no reason for despondency or the curable and preventable diseases of the poor may be aggravated. There has to be a three-pronged approach while improving the health status of the people in developing countries, firstly, to foster an economic environment that enables people to improve their own health; secondly, to reallocate government investment from specialized care in tertiary health care facilities to programmes of primary health care that would help the poor most; and thirdly, to facilitate and properly coordinate private sector involvement in health care. We appreciate the steps taken by the Director-General for establishing a Global Policy Council under his chairmanship for restating the mission of WHO in the light of changes in the world. However, it is necessary to ensure that the basic structure of WHO is not disturbed. The existing system of health management at the regional level should be further strengthened in order to achieve the cherished goal of health for all. The global economic crisis has hit the economies of the developing countries, resulting in substantial cuts in health budgets, the disintegration of rural health services, and shortages of drugs and medical equipment. While developing countries have been forced to effect large cuts in public expenditure, particularly in the social sectors, the arms race continues to escalate. Billions of dollars are being spent to produce newer generations of weapons of mass destruction capable of annihilating all traces of life on earth. The annual global military expenditure is around a trillion dollars. If only a small percentage of this wasteful and destructive expenditure could be diverted to health needs, the lives of millions of people could be healthier and happier. The global economic recession and the escalation of the arms race make it appear that our cherished aim of health for all may remain nothing more than a pious intention. Let not posterity accuse us of having failed or faltered in our attempts to provide health for all. Mr President, I would like to conclude by quoting our leader, the late Mrs Indira Gandhi; "We are here because we do believe that minds and attitudes can and must be changed and that injustice and suffering can and must be diminished. Our world is small; it has room for all of us. But it has room for all of us to live together and to improve the quality of the lives of the people in peace and harmony". Mme VEIL (France): Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs les délégués, Mesdames et Messieurs, je suis très honorée de m'adresser, au nom de la France, aux délégations du monde entier réunies ici, et je voudrais, Monsieur le Président, vous féliciter d'avoir été élu pour conduire les travaux de la Quarante-Septième Assemblée mondiale de la Santé. Je tiens aussi à assurer M. le Dr Nakajima de mon profond attachement à rinstitution qu'il dirige et de mon entier soutien à son action en faveur de la santé. L'époque que nous vivons est marquée par un accroissement de la misère et de la faim dans certains pays, notamment en Afrique, et par la recrudescence des conflits armés, accompagnés d'effroyables massacres parmi les populations civiles qui tentent d'y échapper par la fuite. L'exode des réfugiés et personnes déplacées, ainsi que la perte des ressources agricoles anéantissent des économies déjà très menacées, avec des conséquences désastreuses pour la santé. Dans ce contexte, des millions de personnes ne peuvent survivre que grâce à l'aide des organisations internationales : le HCR, l'unicef, et plus particulièrement l'oms. Il est donc plus que jamais indispensable de souligner le rôle que votre institution doit jouer afin d'imposer une prise en compte prioritaire des problèmes de santé. Droit auquel chacun aspire, pour soimême et pour ses proches, la santé devrait être reconnue par tous les Etats comme une préoccupation majeure, ne serait-ce que parce qu'elle est une condition essentielle du développement, notamment à travers les efforts entrepris vis-à-vis des femmes et des enfants. A l'heure où dans les pays riches le rythme de la croissance des dépenses de santé n'est plus financièrement supportable pour les économies et risque de compromettre d'autres avancées sociales tout aussi importantes, voire plus importantes, les pays en développement les plus pauvres ne peuvent même

54 A47/VR/2 page 39 pas, en raison de la diminution de leur produit national brut et d'une réduction drastique des crédits affectés à la santé, garantir le minimum de soins de santé primaires. Il reste donc bien du chemin à parcourir pour réaliser Pespoir de la santé pour tous, formulé à Alma-Ata en 1978 et réaffirmé ici même dix ans plus tard. Nous assistons aujourd'hui à la résurgence de maladies, comme la diphtérie ou le choléra, que l,on croyait en voie d'éradication. Plus grave encore, partout, le retour de la tuberculose tue à l'aube du XXI e siècle près de trois millions de personnes chaque année, frappant davantage les adultes que toute autre maladie infectieuse. La permanence du paludisme, qui frappe plus de 500 millions d'hommes et de femmes dans le monde, mais surtout l'irruption du fléau du SIDA, véritable peste des temps modernes, remettent en cause toutes les stratégies établies et les espoirs qu'elles avaient engendrés. Pourtant, le propos de la France, par ma voix, n'est pas.de céder au pessimisme. Je souhaite bien au contraire rappeler que notre lucidité à tous, ici rassemblés, est le préalable absolu à une mobilisation accrue de la communauté internationale, qui doit se traduire par un effort collectif sans précédent et davantage de solidarité entre les peuples du monde. Je fais, pour ma part, confiance à l'oms pour relever ces défis. Je me réjouis en effet particulièrement, Monsieur le Directeur général, que malgré cette situation dramatique pour des millions d'êtres humains, votre Organisation intègre le champ des préoccupations éthiques dans ses programmes. C'est à l'oms de rappeler que la santé des hommes impose des règles absolues, notamment éthiques, que nul ne doit pouvoir enfreindre. Comme vous l'avez si bien souligné dans de récentes déclarations, face aux problèmes que pose révolution de la médecine et des techniques médicales, face aux problèmes que pose la santé en général, il est urgent de "placer les gens devant leurs responsabilités et donner leur place aux différentes valeurs". Plus que jamais, la mission de votre Organisation est nécessaire pour dépasser les égoïsmes nationaux, bousculer les tabous hérités de l'histoire. Sa culture et son histoire ont fait de l'oms le garant d'une approche tout à la fois humaniste et réaliste du vaste champ de la santé publique, et le chef de file naturel de cette mobilisation. Afin d'y parvenir, l'oms dispose de la volonté et des capacités nécessaires pour assumer les lourdes responsabilités qui ne cessent de s'accroître et touchent très directement à l,avenir de l,humanité. Je sais que tous ici vous êtes bien conscients qu'à de nouveaux défis doivent correspondre de nouvelles approches, mieux à même de fédérer et de coordonner l'effort de tous. C'est contre le SIDA 一 le défi le plus cruel auquel nous soyons aujourd'hui collectivement confrontés - que l'organisation mondiale de la Santé a conçu avec d'autres organismes des Nations Unies un programme coparrainé de lutte. La France, qui figure parmi les pays développés les plus touchés par cette pandémie, a plaidé dès le début pour une telle approche et la soutient natureuement. Elle se félicite du rôle imparti à FOMS dans ce nouveau programme. Alors que nos ressources sont nécessairement limitées, il est essentiel d'établir des priorités et d'optimiser autant qu'il est possible les ressources disponibles. Pour ce combat, le maximum doit être fait, mais il convient de le faire sans délai car le temps presse. L'Afrique connaît déjà une situation extrêmement préoccupante; la pandémie progresse partout en Asie et en Amérique latine. C'est aujourd'hui qu'il faut produire un effort prioritaire si nous voulons arrêter le SIDA quand il en est encore temps. C,est dans ce contexte que la France a proposé, en étroite coordination avec l'oms, une initiative visant à renforcer la mobilisation de tous, particulièrement des responsables politiques, comptables des grands équilibres sociaux et économiques, dans la perspective d'une coopération accrue entre pays développés et pays en développement. A l'invitation du Premier Ministre français, un sommet des plus hautes autorités politiques, du Nord comme du Sud, devrait se tenir le 1 er décembre prochain afin de marquer notre détermination et de s'engager concrètement sur la base de priorités communes. Auparavant, les 17 et 18 juin, j'aurai le plaisir de recevoir à Paris plusieurs d'entre vous pour une réunion de travail qui se propose, au terme d'une vaste confrontation des points de vue et des expériences, de nous accorder sur les principaux objectifs à assigner à cette mobilisation. Diverses réunions préparatoires ont eu lieu ces derniers mois. Elles ont permis d'ores et déjà de dégager un consensus, dont je me réjouis, autour des principes qui doivent guider notre action, et d'esquisser les priorités susceptibles d'inspirer notre coopération. Ce sera l'occasion d'approfondir encore la question de la coordination entre les bailleurs de fonds bilatéraux, entre ceux-ci et le futur programme coparrainé d'une part, et les organisations non gouvernementales d'autre part; ce sera aussi l'occasion d'étudier les possibilités d'aider les pays bénéficiaires à coordonner l'aide internationale, dans le cadre des programmes nationaux de lutte contre le SIDA. Par cette initiative, annoncée par ma voix à la Conférence de Marrakech (Maroc), en novembre dernier, et qui s'est enrichie des réflexions de plusieurs de ses partenaires jusqu'à faire l'objet, aujourd'hui, d'un large consensus, la France aspire à susciter une solidarité renouvelée à l'égard des pays les plus démunis, qui sont aussi trop souvent - il faut le dire - les pays les plus touchés par la pandémie.

55 A47/VR/2 page 40 La santé, dans un monde où les interdépendances n'ont cessé de croître, le progrès des sciences et des communications aidant, est Faffaire de tous. La responsabilité première de ceux qui sont en charge de l'intérêt public est de ne négliger aucun effort pour combattre les fléaux qui le mettent en péril et qui, en menaçant chacun de nous, menacent l'humanité tout entière. Je suis certaine que ce message, dans le droit-fil de l'humanisme qui inspire depuis si longtemps l'action de l'oms, saura trouver dans cette Assemblée l'écho qu'il est en droit d'attendre. Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs, je formule pour vos travaux, pour nos travaux, les meilleurs voeux de succès et je vous remercie de votre attention. Dr OURAIRAT (Thaüand): Mr President, Mr Director-General, excellencies, distinguished delegates, ladies and gentlemen, allow me to join this august body in extending our congratulations to you, Mr President, and the four vicepresidents, excluding myself, for your election to this office. We, in Thailand, extend our warm and proud congratulations on the great success of our friends in South Africa. This is not just the joy of the South African people, but also a bright hope for mankind all over the world. We would also like to express our appreciation of the achievements made by Dr Nakajima, his Assistant Directors-General and the WHO staff in working with Member States to bring better health to our friends in all parts of this rapidly changing world. Increasingly, we learn that we all have to work harder and faster if we do not want to be left behind by all the other developments happening in the world today. In Thailand, what seems to be frequently referred to by our colleagues in other countries may be the impressive economic growth, but I am certain that we, as social developers, all know extremely well that the faster the economy grows, the harder the work of the social sector, of which health is an integral part, has become. In our attempt to bring better health either at the individual level or at the population level, what we need to do is to carefully re-examine our traditional beliefs and values along with our decisionmaking process. Changes are needed in our health care system. We see proposals about health care reform being discussed and introduced everywhere. Looking at our friends in the developed world and then back to our own country, I am quite certain that this urge for reform has not happened purely because we are afraid that it will become unaffordable unless we do something about it now. For even in Thailand, where economic growth seems to be on the increase, there is still a need for reform. This is not out of pure economic necessity, but is a lot more to do with our new thinking, our moral and ethical reorientation towards health. I am quite sure that public health policy-makers wanting to introduce changes face very difficult controversies and dilemmas as they challenge the traditional ethical values held by different stakeholders in health care systems. In traditional medical practice, we do our best to save lives, regardless of how much money we put in, so long as we have the technologies available. Failing to do that could be seen as unethical conduct. In reality, we could not afford to save an individual at any cost, and this is the issue we are all familiar with as policy-makers. Conventional business practices see advertising and marketing as essential parts of successful business, whereas in health we are concerned to ensure that people's health will not be compromised by such practices. Thus there may be conflicting ethical standards as between the health and other sectors. Most strategies for prevention and health promotion limit individual freedom or make certain behaviours subject to punitive measures. For those of us who are for individual rights, this is undoubtedly a hard decision. More complicated is how we would deal with the highly sophisticated but costly technology that may be made available only to those who can afford to pay. It is impossible for any government to make them available to all citizens in the country. Will it then be considered unethical if policy-makers leave all these to the market forces and individual ability to pay? Issues raised by technologies dealing with life and death create even more controversies in policy decisions. Even with life-creating technology such as in vitro fertilization, there are still hard decisions to be made. For developing countries, this may seem quite a remote issue, but we will have to deal with it sooner than we anticipate. We see state-of-the-art technology available in one part of the world, and certain groups in the developing countries immediately demand similar technology. Some of these demands might be easily met, but some may need a more thorough consideration. Mr President, we are all now living in a world much smaller than it was even half a century ago. What is important for us as a world community is to be aware of our proximity to one another. What is happening in the developed part of the world can undoubtedly cause ethical dilemmas for policy-makers in the developing world, where resources are far more limited.

56 A47/VR/2 page 41 Consideration of the ethical issues facing policy-makers in health cannot be complete without reference to the problems regarding the prevention and control of HIV infection. Preventive programmes on HIV infection have created a lot of controversies among health personnel. Advocating condom use to prevent heterosexual transmission is like advocating safe prostitution, or safe promiscuity. Although we know very well that such issues as prostitution or promiscuity are not within the health sector mandate, it goes against the grain to have to advocate safety for such behaviour. The same applies to the advocacy of the use of clean needles and syringes among intravenous drug users to reduce the HIV infection risk. Testing for HIV infection poses another dilemma. Do we adhere to the principles of voluntary testing only, or shoijd we make it compulsory for all sex workers to be tested to prevent the spread of the virus? Are we then protecting the customers at the expense of the sex workers? Are we again ensuring safe prostitution and therefore indirectly advocating such behaviour? Each country has to make its own decisions based on its own sociocultural values and ethical standards, which are relative rather than absolute. In health policy decisions, one aspect is always favoured over the other. The benefits of the public are put before those of the individual. The needy groups are put before the better-off. Prevention is preferred to cure. The cost-benefit ratio is valued more highly than benefit at any cost. These are the principles of any rational policy decision-making. Unfortunately, in the real world, things are never black or white. Stakeholders also have different sets of values in regard to health. They have different values about how much government should interfere or regulate their behaviour. They have different expectations and values with respect to state-of-the-art technology. They differ on how much they should do to take care of their own health, or on whether it should be left mainly to the health professionals and hopefully miraculous technology. Even though ethics and values may vary from one country to another, we can definitely learn from one another. Even though it may not be easy to reach consensus at the global level, I wish we could work together more closely as a global community to reorient and reconcile different values among various stakeholders. For us in the same geographical region, with a comparable sociocultural background, it would be even more important that we seek to find ways of working together. It is essential for the better-off countries to offer help and render support to those countries in greater need of better health. In an increasingly smaller world, such as we are living in right now, ethical considerations in health policies should not be limited to any one country's boundary, but should also be applied to others, especially to neighbouring countries. As good Buddhists, we in Thailand realize that the way to good health and happiness is through sharing and helping. As we achieve success in certain aspects, we must share our solutions with our neighbours. I am sure that all distinguished delegates agree with me that caring for others and working for the vast majority are indeed the values held by all of us in any part of the world. Towards this end, I can assure you, Mr President, that Thailand stands ready and willing to join hands with WHO and Member countries for the tasks ahead. M. MENDO (Portugal) (interprétation du portugais) : 1 Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs les délégués, Mesdames et Messieurs, j'aimerais commencer mon intervention en vous félicitant très sincèrement, Monsieur le Président, pour votre élection. J'adresse également mes félicitations à tous les autres membres du bureau et je tiens à exprimer ma conviction que vos travaux auront beaucoup de succès. La profession médicale est peut-être la première au monde qui s'est imposée à elle-même des normes éthiques de conduite. Depuis plus de deux mille ans, le serment d,hippocrate est accepté en tant que charte des devoirs et de la conduite morale du médecin et utilisé comme référence pour les codes de conduite modernes des autres professionnels de la santé. Depuis toujours, la faculté de pouvoir influencer la santé et la maladie, la vie et la mort, a effrayé les gens et placé ceux qui en avaient le pouvoir au rang de demi-dieux, de saints, de démons ou de magiciens légendaires. Afin d'apaiser les peurs et d'accroître la confiance dans le médecin, indispensable au succès de la médecine individualisée, le serment d'hippocrate cherche à assurer aux individus que le médecin est un ami, qu'il est discret et soucieux du seul bien-être de son malade, qu'il ne profitera jamais de son pouvoir ni n'en tirera d'avantages personnels et qu'il ne transmettra jamais son savoir à des personnes incapables d'observer les mêmes règles de conduite. Le serment d'hippocrate demeure, dans sa simplicité et sa brièveté, le document profane le plus influent sur le comportement du médecin. Toutefois, établi pour un exercice individuel de la profession au temps où 1 Conformément à l'article 89 du Règlement intérieur.

57 A47/VR/2 page 42 la médecine était uniquement une relation entre un être souffrant et quelqu'un à qui cet être demandait de l'aide, ce serment ne mentionnait pas la dimension sociale aujourd'hui exigée du professionnel de la santé et de l'homme moderne. La croissance considérable de la connaissance des sciences médicale et biologique, la révolution technologique que nous continuons à vivre, la fin de la pratique isolée des professions de santé, la mondialisation des communications, des problèmes sociaux et des préoccupations écologiques ont créé le besoin toujours plus manifeste d'une très forte composante sociale dans notre éthique de conduite. Je dois, en tant qu'être humain, être pleinement conscient que "l'autre" est ma limite et que ma souveraineté finit où la sienne commence, mais que sans lui je ne serais rien, que sa souveraineté m'est indispensable car la vie est une société. Même si individuellement une conduite éthique qui ne concerne que ma relation avec l'autre de mon seul point de vue est admissible, comme Га si bien défini M. Stirne dans "L'Unique et sa Propriété 11, il n'est plus possible de penser à l'éthique sans tenir compte des problèmes soulevés par les conduites collectives, par les situations réelles de pauvreté intolérables, par les guerres, les famines et les misères du monde, ce qui nous amène à affirmer qu'il est indispensable d'introduire une dimension sociale universelle dans nos codes d'éthique, lesquels doivent non seulement tenir compte de "l'autre" comme une limite et un partenaire, mais aussi considérer la ville,la communauté, la nature, les peuples, la planète comme bénéficiaires ou victimes de nos comportements. En d'autres termes, la solidarité doit être l'une des dimensions les plus prônées et privilégiées de l'éthique de conduite; solidarité qui s'exprime historiquement au moyen du soutien aux intérêts du groupe, du pays, de Fethnie, de la "race", solidarité que de nos jours nous nous devons de rendre universelle et qu'il nous faut mettre au service des grandes causes humanitaires. C'est à ce stade qu'intervient la politique, car les gouvernements peuvent et doivent contribuer à universaliser les comportements solidaires. La vie moderne est si exigeante, les périodes d'apprentissage, d'activité et de formation professionnels, les engagements, les devoirs et les obligations sont si importants, que, même s'il le souhaite, le citoyen dispose de peu de temps pour mettre son savoir et sa capacité au service d'un grand objectif social. Il appartient aux gouvernements de permettre aux individus d'exprimer plus largement leur attachement aux valeurs de la solidarité sans que leur vie professionnelle ou familiale puisse en pâtir. Ceci est essentiel en ce qui concerne l'éthique et la santé, thème qui nous rassemble aujourd'hui et sur lequel nous devons non seulement réfléchir mais aussi faire des suggestions. En approfondissant ce sujet, nous sommes amenés à tirer deux conclusions. Premièrement, si, comme Га dit Jean Bernard, la bioéthique est "une rigueur double, la rigueur glaciale de la science et la rigueur rigide de la morale", c'est avec cette double rigueur que nous devons relever les défis et faire face aux dangers de la technologie du futur et au problème moral de la solidarité humaine. Deuxièmement, la solidarité est la composante sur laquelle les gouvernements peuvent le mieux agir indirectement, en assurant aux citoyens qui la pratiquent la sauvegarde de tous leurs droits individuels. C'est pour cette raison que le Gouvernement portugais, de concert avec les organisations compétentes, a décidé que les professionnels de la santé volontaires pour des actions de solidarité entreprises par des organisations non gouvernementales ainsi que pour des missions de coopération menées par l'etat ne seraient pas pénalisés à leur retour et pourraient garder leur emploi et leur salaire, et que la durée de leur mission de coopération serait prise en compte lors de rétablissement des primes d'ancienneté, de la retraite, de la formation professionnelle et de la promotion. De cette façon, nous espérons stimuler l'esprit de solidarité des professionnels et accroître considérablement le nombre des actions de solidarité que nous menons dans le monde, y compris dans les pays africains lusophones auxquels nous sommes attachés par un passé commun séculaire et un avenir d'amitié. Pour terminer, Monsieur le Président, permettez-moi de formuler mes voeux les meilleurs pour le succès des travaux de cette Quarante-Septième Assemblée mondiale de la Santé. The PRESIDENT: I thank the delegate of Portugal, who was the last speaker this morning. Before adjourning, I would like to remind the Assembly that briefings will be held during the lunch break on the tuberculosis epidemic and on WHO's follow-up on the United Nations Conference on Environment and Development. The tuberculosis briefing will be held in Room XVI, and the briefing on the United Nations Conference on Environment and Development will be held in Room XXII. The

58 A47/VR/2 page 43 briefings begin at 13h00 and are scheduled to last for one hour. There will be interpretation into English and French. The proceedings will now adjourn, and resume at 14h30. The meeting rose at 12h30. La séance est levée à 12h30.

59 A47/VR/2 page 44 FOURTH PLENARY MEETING Tuesday, 3 May 1994,at 14h30 President: Mr В. K. TEMANE (Botswana) QUATWEME SEANCE PLENIERE Mardi 3 mai 1994,14h30 Président: M. В. К. TEMANE (Botswana) 1. ANNOUNCEMENT COMMUNICATION The PRESIDENT: The Assembly is called to order. Before we resume the debate on items 9 and 10, I wish to inform the Assembly that one of the Vice-Presidents, Dr A. Abdel Fattah El Makhzangi of Egypt, has had to leave Geneva. I would suggest, if the Assembly agrees, that he be replaced by Dr M. Zahran of the same delegation. Are there any objections to this suggestion? I see none; the proposal is therefore accepted. 2. DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-SECOND AND NINETY-THIRD SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR GENERAL SUR L'ACTIVITE DE L'OMS EN (suite) The PRESIDENT: We shall now proceed to the debate on items 9 and 10. The first speaker on my list is the delegate of China. 孙隆椿 ( 中国 ) Mr Sun Longchun (China) 尊敬的主席先生, 尊敬的中岛宏总干事, 尊敬的各位代表, 女士们, 先生们 : 我荣幸地代表中国代表团在本届卫生大会上发言 首先, 请允许我对塔曼先生和其他五位先生当选为本届卫生大会主席和副主席表示热烈祝贺, 预祝他们工作取得成功 中国代表团高度评价总干事中岛宏博士所 作的 年工作报告, 对世界卫生组织在总干事领

60 A47/VR/2 page 45 导下, 在促进世界和平与发展 保护和增进人类健康以及自身的改革方面所取得的成就表示热烈祝贺 近年来, 全球政治 社会和经济形势发生了巨大变化 我们高兴地看到, 为适应变化的环境和新挑战, 世界卫生组织理事机构和秘书处一道开始了对政策 管理和組织机构的改革, 强化了对全球卫生行动的指导, 改进了信息资源利用及卫生技术规划的制定和执行 对此, 中国代表团给子高度赞赏, 并希望这种改革深入 持夂地进行下去, 以造福于全球人民的健康 中国代表团非常关注 人人享有卫生保健 政策的修订工作 我们认为根据全球社会经济发展的不同情况, 对 2000 年应达到的特定目标, 各项具体指标和所需资源进行系统客观的分析 评价是十分必要的, 借此, 将决定如何进一步调整目标和制定新的战略或替代战略 我们希望卫生组织根据不同国家和地区初级卫生保健的实际形势和需求, 不断修订与完善相关的战略和政策, 并使社会各方面共同分担资源和责任 必要时, 可召开国际会议, 进行专门研讨 过去一年, 世界卫生组织与各成员国的技术合作是成功而有效的, 在消灭脊灰 麻风以及其它疾病的规划活动方面, 通过各方努力, 获得了较显著的成果 从大量的卫生实践中, 我们看到疾病模式和卫生问题正在发生变化, 与不健康的生活方式有关的心脑血管病 癌症等慢性非传染病正在增加, 在改善医疗丑生服务的同时, 我们更加认识到社会需要多部门广泛参与的卫生行动, 健康教育和卫生促进应成为公共卫生的主要措施, 卫生组织应加強研究这一领域的前景 策略与方法, 以便对各成员国进行有效的指导 我们十分重视中岛宏总干事提出的新的伙伴关系的看法 当今卫生发展要求我们与社会各个领域 各个方面建立牢固的伙伴关系, 共同承担起卫生发展的责任

61 A47/VR/2 page 46 恭管世界 i 生组织由于经济困难, 对技术合作规划进行了较大的调整, 但总部 地区办事处及各国家代表处千方百计克服困难, 不断改进规划和预算管理, 保证了重点领域工作的进展 但是, 我们仍然关注卫生组织面临的经济困难形势, 我们希望各成员国认真履行按期缴纳会费的义务, 呼吁发达国家和捐助机构加强对卫生发展的投入 各方面对 :e 生组织秘书处改进财务状况的努力应给子更多的帮助和支持 我们也高兴地看到卫生组织秘书处为改进人事管理, 在招聘职员中既重视人员素质又公平使用地域和性别标准等方面所做的努力 由于社会 政治 经济等复杂因素, 发达国家和较不发达国家之间贫富和卫生服务状况的差距在扩大, 一些国家由于战乱 灾害 贫穷, 卫生设施受到破坏, 我们对此深表关注 我们希望世界卫生组织进一步加强对最困难的国家的支持和帮助, 在紧急救援和人道主义行动中发挥更积极的作用 主席先生, 改革与发展是当今世界的两大主题 当前中国的改革开放和现代化建设事业进入了重要阶殺, 杜会主义市场经济的建立为我国卫生发展和改革提出了新课题我们将继续坚持 顸防为主, 依靠科技进步, 动员全社会参与, 中西医并重, 为人民健康服务 的卫生工作方钎, 逐步深化卫生工作改革 几年来, 根据社会对卫生服务需求的变化, 我们主动拓宽卫生服务领域 为减少浪费, 克服弊端, 医疗保险制度改革已纳入社会保障制度总体改革规划, 并巳开始试点 为保证人民防病治病的基本需求和合理用药, 从 1982 年开始, 开展了国家基本药物目录的制订工作, 在年初完成了中成药及抗感染等 1 1 类化学药品的遴选与审定 中国有三分之二以上的人口在农村, 我国政府十分重视农村卫生工作并将其确定为卫生工作的三大战略重点之

62 A47/VR/2 page 47 一 目前在我国实施的 2000 年人人享有卫生保健 的规划目标正在从试点阶段过渡到普及阶段, 对城市初级卫生保健的评价指标体系也正在制定之中, 这些必将使中国卫生工作的整体水平走上一个新台阶 过去一年, 中国还在疾病防治方面取得了重要进展 为响应世界卫生组织西太区确定的到 1995 年消灭脊髓灰质炎的目标, 中国釆取了以強化免疫和加強监测为重点的策略 去年 12 月 5 日和今年 1 月 5 日开展了全国強化免疫曰活动, 对全国约 1 亿 4 岁以下儿童加服两次脊灰疫苗, 此次活动规模在历史上是空前的 此外, 我们要力争在 1995 年实现以乡为单位计划免疫接种率达到 8 5 % 我们还制定了全国消除新生儿破伤风行动计划, 并进行了孕期和育龄期妇女的破伤风疫苗接种工作 世界卫生组轵等联合国机构 许多国家政府及非政府组织积极参与和支持了我国各项重要卫生行动, 为我国卫生事业发展发挥了促进作用 借此机会, 我代表中国政府表示衷心的感谢 中国政府正在积极筹备将子 1995 年在北京召幵的第四次世界妇女大会, 我们相信此次大会必将进一步推动妇女 儿童事业的发展 中国是一个人口众多的发展中国家, 经济基础还比较薄弱, 各地卫生状况有一定差异, 到本世纪末, 要实现我们所确定的各项卫生目标, 任务仍十分艰巨 我们一方面要坚持巳经确定的卫生工作方针, 继续深化改革, 促进卫生事业的发展, 另一方面, 我们也希望继续与世界卫生组织等国际组织保持良好合作, 积极履行应承担的国际义务, 增进与成员国之间的互助合作与技术交流, 为促进全人类健康事业的发展做出贡献 谢谢大家

63 A47/VR/2 page 48 ПРОФ. НЕЧАЕВ ЭЛ. (РОССИЙСКАЯ ФЕДЕРАЦИЯ) Professor NECHAEV Е.А. (Russian Federation) Уважаемые г-н Председатель, г-н Накадзима, уважаемые министры, дамы и господа! Разрешите прежде всего поздравить Председателя Ассамблеи и его заместителей с избранием на эти ответственные должности. Мы с интересом заслушали доклад о большой работе, проделанной Исполкомом на его Девяносто второй и Девяносто третьей сессиях. Рекомендации сессии Исполкома в адрес нашей Ассамблеи отличаются четкостью и реалистичностью, они значительно облегчают работу данной сессии. В целом доклад Председателя Исполкома свидетельствует о растущей роли этого уставного органа в деятельности ВОЗ. Из отчета Генерального директора о работе Организации за истекшее двухлетие мне хотелось бы подчеркнуть, что она проходила в сложной обстановке экономической нестабильности и локальных вооруженных конфликтов в ряде районов мира. Отчет свидетельствует о том, что Генеральным директором были приняты все необходимые меры для того,чтобы свести к минимуму негативное влияние растущих финансовых трудностей и возможно полнее осуществить двухгодичную программу в этих условиях. На утверждение нашей Ассамблеи предлагаются некоторые меры, необходимые для стабилизации финансового положения ВОЗ на будущее. Я имею в виду увеличение в два с лишним раза размеров Фонда оборотных средств. В условиях огромной задолженности по взносам нельзя не согласиться с подобной вынужденной мерой. Россия обязуется продолжить погашение задолженности по обязательным взносам в бюджет Всемирной организации. Как показывает двухгодичный отчет, деятельность нашей Организации продолжает вносить существенный вклад в охрану и укрепление здоровья мира, оздоровление окружающей среды. В целом работа ВОЗ, безусловно, должна быть оценена положительно. Особо следует отметить возрастающую роль ВОЗ в операциях по оказанию помощи пострадавшим в различных чрезвычайных ситуациях в мире. Мы высоко оцениваем ту поддержку, которую оказывают ВОЗ, Европейское сообщество, ЮНИСЕФ и международные неправительственные организации реформам здравоохранения нашей страны. Проведенная в 1992 г. вторая оценка хода выполнения Глобальной стратегии достижения здоровья для всех позволила вновь убедиться в правильности выбранных основных задач и подходов к их решению, показала масштабность достигнутых результатов и одновременно высветила некоторые негативные моменты и новые проблемы. Результаты мониторинга свидетельствуют о необходимости дальнейшего усиления межсекторального сотрудничества и интегрированного подхода к проблемам охраны здоровья населения, достижения оптимального баланса централизации и децентрализации управленческих функций. В истекшее двухлетие значительный прогресс достигнут в деле ликвидации некоторых из наиболее распространенных и опасных заболеваний, таких как полиомиелит и лепра. В то же время внушает тревогу некоторое снижение уровня иммунизации детей на первом году их жизни по сравнению с 1990 г. Высока заболеваемость малярией, туберкулезом. Мы с особым беспокойством констатируем рост заболеваемости в нашей стране дифтерией, корью, коклюшем, острыми кишечными инфекциями, венерическими болезнями, туберкулезом. Предпринимаемые энергичные усилия по совершенствованию системы санитарно-эпидемиологического надзора, развитию мощности медицинской промышленности по производству биологических препаратов и санитарному просвещению населения вселяют уверенность в скором изменении ситуации к лучшему. Мы приветствуем неослабевающее внимание Организации к развитию научных исследований в области медицины и здравоохранения, в том числе существенный рост количества научных сотрудничающих центров ВОЗ по сравнению с 1991 г., где по-прежнему лидирующее положение занимает Европейский регион. Своевременным и важным представляется начало проведения глобального обзора и оценки сотрудничающих центров. В деятельности Всемирной организации здравоохранения в области укрепления и развития медицинских научных исследований и подготовки кадров здравоохранения

64 A47/VR/2 page 49 проблемы организации здравоохранения заслуженно занимают все более значительное место. Нам импонирует, что 70% учебных стипендий, выделенных ВОЗ в отчетный период, предназначались для подготовки персонала по проблемам организации служб здравоохранения и управления ими. И это не случайно. Значение организационных вопросов и их актуальность непрерывно увеличиваются в условиях обилия проблем, ограниченности выделяемых на здравоохранение финансовых ресурсов, необходимости поиска их наиболее эффективного и рационального использования. Важнейшей отличительной чертой нашего времени является реформирование здравоохранения в большинстве стран мира. Этот процесс не обошел и ВОЗ, которая на глобальные изменения в мире отвечает дальнейшим совершенствованием своей работы. Я имею в виду проводимые меры по реорганизации планирования и бюджетирования деятельности Организации, повышению эффективности расходования финансов. Эта идея прослеживается и в предложенной на утверждение нашей Ассамблее Девятой общей программе работы Организации. При всей лаконичности она осталась достаточно содержательной, нашлось в ней место и для этических проблем, которым Генеральный директор просил уделить в ходе общей дискуссии особое внимание. Велико значение этих проблем в лечебной и профилактической работе, особенно в борьбе с такими заболеваниями, как психические расстройства, СПИД, трансплантации органов и тканей и в проведении исследований на людях. В последнее время все большее признание получает значение этических проблем в организации здравоохранения. С нашей точки зрения, в широком плане важнейшая этическая проблема организации здравоохранения - это обеспечение общей доступности к квалифицированной медико-санитарной помощи. Прежде всего над решением этой проблемы мы упорно работаем совместно с ВОЗ, осуществляя великую идею достижения здоровья для всех. Реформируя российское здравоохранение, мы стремимся сохранить в нем все лучшее из достигнутого ранее. Одной из наших задач является, в частности, возрождение на качественно новом уровне принципов земской медицины, славных традиций земских врачей - высокоэрудированных специалистов широкого профиля, носителей высокой культуры и этических ценностей. На этой основе, с учетом богатого национального опыта российской медицины основательно готовим и расширяем контингент семейных врачей, врачей общей практики. В стране стремительно развивается система медицинского страхования, практически на 3/4 территорий обязательное медицинское страхование уже стало реальным элементом системы лечебной помощи населению. Президентом России Б.Н. Ельциным в обращении к Парламенту и народу страны поставлена задача уже в текущем году обеспечить охват всего населения обязательным медицинским страхованием. В проведении своих реформ мы опираемся на опыт и рекомендации Всемирном организации здравоохранения. Наше многолетнее сотрудничество с этой Организацией всегда было плодотворно и эффективно. И таковым, надеюсь, оно будет и впредь. Благодарю за внимание. Mr KÓNBERG (Sweden): Mr President, Mr Director-General, distinguished delegates, all major world trends - political, economic and cultural - have a profound impact on health. International health development can only be seen in its context, and health for all can only be achieved by concerted action all through the United Nations system and the international health community. Recent evaluations of the health-for-all strategy confirm that inequities persist in health status, and in access to health care and service, between continents and countries, as well as between groups within countries. The disadvantaged are children, particularly girls, women and displaced persons. The most important issues of this Health Assembly concern the leadership role of WHO in international health. WHO has to reform its leadership role to bring about harmonious health strategies in the international health community as a whole. This requires both the defining of specific objectives and the creation of common means of implementation of health action. A recent example which may lead the

65 A47/VR/2 page 50 way is the proposal to establish a truly global joint and cosponsored United Nations programme on AIDS. Last year's Health Assembly concentrated its reform ambitions along the lines of the Working Group on the WHO Response to Global Change. An important set of recommendations concerns the methods for closer coordination of budgetary and extrabudgetary programmes. As extrabudgetary funding now surpasses the regular budget in volume, the survival of WHO as an entity governed by all its Member States depends on the alignment of the extrabudgetary-financed programmes within the overall policies of the regular WHO programmes. The proposals regarding these matters may provide a possibility to increase the efficiency of the Organization by clear priorities, concentration of efforts, and better use of available resources through coordination. But we may not rely only on a more unified economic system. We need to create a unified organizational status of WHO. WHO globally, regionally and locally suffers from not being able to act as one organization. The achievements of global change so far are not conclusive and final. We have still a long way to go. This year, 1994, we have an opportunity to address the status and health of women and children, at the International Conference on Population and Development to be held in Cairo in September. We believe that WHO, through its global health mandate, is particularly called upon to argue for a substantial conceptual change concerning sexual and reproductive health. Sweden, in our preparations for the Cairo conference, believes that sexual health and reproductive health need to be addressed in a broad sense, including both health and "unhealth", men and women, young and old. Reproductive rights are central in a new strategy for human development and social and gender equity. The best established of these rights is the right to decide when not to have a child, that is, the right to safe and effective contraceptive methods. Women who are not able to avoid abortion should have access to safe and legal medical support and services. Women's health has long been a non-priority issue worldwide. Women's health - as we see it - goes beyond maternity and reproductive problems and should be acted upon all through the life cycle of women. The Health Assembly in 1992 stron^y focused on the issue of women's health, demanding the establishment of a Global Commission. Important control stations on development are the United Nations Conference on Population in 1994 and the Fourth World Conference on Women in Beijing in We have precious little time to register achievement in the area before the Beijing meeting. And we now need the strong backing of the Director-General and the Secretariat as well as the support of Member countries, to live up to the expectations of the 1992 Assembly. I hope that the work of this Assembly will actively guide WHO,s contribution to the Cairo conference, the Beijing conference and the agenda for action on women's health, foreseen by the Health Assembly in An endorsement by this Assembly of the concept of sexual and reproductive health would constitute such a contribution 難 and a very important message to the conferences. I would like to refer to the recent meeting of the Preparatory Committee for the Cairo conference, which requests reviews of the roles, responsibilities,mandates and comparative advantages of the bodies of the United Nations system addressing population and development. WHO will naturally play an important role in these reviews and in subsequent decisions. We are all aware of the harmful consequences of substance abuse. Young people in particular suffer badly from drugs in my country as in almost all developed countries. And in some developing countries as well. We have, in my own country, sought solutions in a strict policy aiming at a drug-free society. We have not succeeded. But we have come quite a distance. We have no chance to achieve our goal without true cross-boundary cooperation. If the habit finds an island to survive on, it serves as a centre for redistribution of drug addiction also to countries which have been moderately successful in pursuing a strict non-use policy. And such islands will emerge, wherever we fail to make it understood and legally clear that the use of drugs is not only harmful but disastrous. That is why we need solidarity and cooperation and many new initiatives, to make the fight against drug abuse, particularly in the young population, a major undertaking in all afflicted societies and organizations concerned. I am therefore grateful for the initiative taken by WHO and a group of private interested parties to form a foundation to fight drug abuse among the young of this world's population. I will not disclose any of the announcements that will be made in the special ceremony next week by Her Majesty the Queen of Sweden, but generally lend my total support to this project. Mr President, Sweden believes in a strong WHO. We need it because we regard health as an undertaking that can only be understood in a global context. I recognize the efforts of this Organization, and I take this opportunity to congratulate the Director-General and the Secretariat on the results achieved.

66 A47/VR/2 page 51 El Sr. MASSAD (Chüe): Señor Presidente, excelentísimos señores, distinguidos delegados, señoras y señores: Hoy, Chile tiene un sistema de salud mixto, en el cual el sector que es de responsabilidad del Estado tiene la obligación asistencial directa sobre tres cuartas partes de la población. El sector privado, estructurado a través de la creación de las instituciones de salud provisional, provee el seguro de salud para la cuarta parte restante. Esta última incluye en general los sectores de mayores ingresos de la población. El Estado juega también un papel normativo en el campo de la salud, y busca una complementación de ambos sectores que permita el pleno acceso de todas las personas a la salud, como lo consagra la Constitución chilena. El Gobierno del Presidente Eduardo Frei, el segundo Gobierno desde que se recupera la tradición democrática chilena, reitera con energía la decisión de fortalecer las tareas públicas en salud para dar cuenta de los problemas emergentes y del permanente riesgo de aparición de las patologías particulares del subdesarrollo. En los últimos años de este siglo, Chile se encuentra empeñado en poner en marcha reformas eficaces que modernicen el Estado, introduzcan incentivos vinculados al desempeño y sirvan prioritariamente a los sectores más desposeídos de la población. Chile ha logrado indicadores biomédicos de muy buen nivel, aun si se los compara con países de mayor ingreso que el nuestro. Sin embargo, esos indicadores, que reflejan la situación del promedio de la población chilena, ocultan grandes diferencias vinculadas a los niveles de ingreso y riqueza. Por ejemplo, mientras la mortalidad infantil ha descendido a un 14,2 por 1000 nacidos vivos, es posible encontrar comunas relativamente más ricas y mejor dotadas en que dicho indicador muestra niveles menores al 7 por 1000,mientras que también es posible encontrar un número de comunas pobres en que esa cifra supera el 40 por En lo grueso, las políticas del pasado han tenido éxito, pero se quedó atrás el componente de equidad. Introducir mayor equidad en las políticas de salud es uno de los grandes desafíos que enfrentamos hacia el futuro, y el primer principio básico de nuestras políticas. Lograr equidad exige acercar cada vez más las decisiones a las personas para reflejar sus verdaderas necesidades y preferencias. Por eso, un segundo principio fundamental de las políticas es la progresiva descentralización en la toma de decisiones, en el marco de una política general que oriente los planes y programas específicos de salud. En última instancia son las personas las que han de juzgar el éxito de las políticas y exigir rendición de cuentas por sus resultados. Esto se logra mediante la participación, tercer principio fundamental de nuestras políticas. La participación permite, a la vez, que la gente pueda ejercer presión para lograr la equidad, y su materialización requiere necesariamente una progresiva descentralización en la toma de decisiones. Estos tres principios, equidad, descentralización y participación, definen el contenido de nuestras políticas en el campo de la salud, y la eficiencia que se busca en la ejecución de las tareas de salud tiene como objetivo fortalecer la aplicación de tales principios. Así, esperamos introducir compromisos de gestión en todas las unidades del sistema público de salud, y asignar los recursos en función no sólo de las necesidades, sino también de la capacidad para satisfacerlas con el mejor uso posible de recursos, manteniendo y mejorando la calidad de la atención prestada. Las tareas en materia de políticas de salud se han hecho más complejas por la transición epidemiológica y demográfica en la que se encuentra nuestro país. Hoy tenemos condiciones ambientales y humanas asociadas al subdesarrollo junto con causas de enfermar y morir más parecidas a un país desarrollado. Las principales causas de muerte, y que explican más del 70% de ellas, son enfermedades cardiovasculares, tumores, accidentes y violencias, y enfermedades del aparato respiratorio. Se han denunciado en el país 910 portadores y 582 enfermos de SIDA; no se han detectado casos de cólera ni de sarampión en el transcurso de este año. Además, el envejecimiento poblacional, unido a patologías emergentes como el embarazo de adolescentes, la drogadicción y los accidentes mortales o invalidantes en gente joven, ubican a nuestro país en una situación de transición demográfica y epidemiológica. Las patologías están cada vez más vinculadas a las conductas, lo que obliga a enfrentar los problemas de salud del futuro como una tarea mucho más amplia de información y educación que lo hecho hasta ahora. Esta es una razón adicional para buscar la activa participación de la comunidad en las tareas de la salud. Las nuevas características epidemiológicas y demográficas, así como el progreso tecnológico, hacen necesario reestudiar las necesidades de recursos humanos y de infraestructura en el campo de la salud, así como promover instancias de capacitación permanente y condiciones de trabajo apropiadas a todos quienes se desempeñan en estas tareas en el sector público. Esta será una preocupación destacada del Gobierno en los próximos años. Ambos factores, transición epidemiológica y progreso técnico, plantean hoy también nuevos desafíos en la bioética. La instalación en Chile del Programa Regional de Bioética, de la Organización Panamericana de la Salud, que ha contado con el decidido apoyo de nuestro Gobierno, hará importantes aportes a la discusión y la formulación de criterios para enfrentar tales desafíos.

67 A47/VR/2 page 52 También plantea desafíos nuevos el cuidado del medio ambiente, ligado indisolublemente a la salud y a la calidad de vida. El Gobierno de Chile, a través de distintos programas de educación y prevención y por medio de diversos organismos públicos que se preocupan de estos temas, se encamina a una solución integral de los problemas ambientales, con la colaboración del sector privado. Estas tareas se realizan en el marco de una Ley de Bases del Medio Ambiente, recientemente promulgada. La próxima Conferencia Mundial en la Cumbre sobre el Desarrollo Social, que se llevará a cabo en Copenhague en 1995 por iniciativa de nuestro país, examinará la relación entre la salud y el desarrollo social, así como sus interacciones con los temas de pobreza, integración social y empleo. En este contexto la salud debe considerarse como un capital, y el gasto en salud como una inversión especialmente ligada a las posibilidades de progreso de los más pobres. Para éstos, la salud es realmente, su único capital. Reconocemos así los conceptos de la Constitución de la Organización Mundial de la Salud, que señala que la salud se encontrará siempre en una relación recíproca y simbiótica con toda una serie de factores económicos, culturales, psicosociales, ambientales, biomédicos y éticos, los que forman parte integrante del más amplio proceso de desarrollo social. Permítanme usar esta oportunidad para agradecer ante ustedes toda la cooperación internacional que Chile ha recibido tanto de instituciones multilaterales como de gobiernos amigos. Quiero agradecer también, en nombre del Gobierno de Chile, la labor desempeñada por el Director General de la Organización, Dr. Hiroshi Nakajima, su dedicación y su preocupación por la salud de las mujeres, hombres, niños y ancianos de este planeta, que es la gran responsabilidad nuestra. Chile, como importante exportador de frutas, vinos y otros alimentos elaborados, celebra la intención del Director General de que la OMS desempeñe una función más importante como coautora del Codex Alimentarius. Esta norma, que se ha visto reforzada con la reciente firma de los acuerdos del GATT, garantiza que los alimentos producidos en conformidad con ella sean inocuos, nutritivos, y ofrezcan la protección sanitaria adecuada. Normas más estrictas, por lo tanto, pueden ser obstáculos no arancelarios al comercio que debieran ajustarse a los nuevos compromisos en el GATT. Del mismo modo, quiero manifestar nuestro compromiso con la Organización Mundial de la Salud en todas las tareas que emprendan en favor de la salud, la paz y la convivencia universal. También apoyamos la posición conjunta de los países del Grupo Andino, que será expuesta por el Sr. Ministro de Salud del Ecuador. Termino expresando la satisfacción del Gobierno y pueblo de hile por la reincorporación de la República de Sudáfrica como Miembro Pleno de la Organización Mundial de la Salud después de la celebración de elecciones libres y democráticas que pusieron término definitivo al injusto e inhumano régimen del apartheid. Dr JÁVOR (Hungary): Mr President, Mr Director-General, respected ministers, delegates, colleagues, first of all, I congratulate the President and the Vice-Presidents for their election and wish every success to this World Health Assembly. I deem it a great honour to be able to address the Health Assembly, and speak of questions and problems of global, regional and national importance. I come from a part of the world where health services are undergoing fundamental transformation. In the international forums, we regularly speak of our problems, experiences and results. We are deeply convinced that sharing of experience can contribute essentially to improving the health status of the world's population. In our country, as well as in other countries of central and eastern Europe, due to the low level of GDP, it is impossible to devote reasonable resources to the health services. So, when preparing our reforms, an ethical dilemma was very forcefully raised: to what extent shall we be able to ensure equity in health and free access to health services? The study of research conducted on this subject all over the world shows that there is no country on the globe which could afford to finance everything that is already medically possible. Our health policy is built on a number of social contracts expressing solidarity between young and old, healthy and sick, rich and poor. In our view, it should be a basic ethical principle that none of the social groups should monopolize resources and provisions and that these should be targeted at those who are in greatest need. When resources are limited and needs are growing, the basic principles of solidarity and targeting should be accompanied by measures resulting in a more cost-effective use of available resources. We deem it to be extremely important that general ethical rules of health care should be in the province of bodies representing the health professions, which are self-organized and built on the principle of guilds. Establishing, maintaining and enforcing ethical rules cannot be considered as a State task. These aspects were carefully examined and reflected upon by our Government and Parliament when, one month

68 A47/VR/2 page 53 ago, acts on the Chamber of Physicians and the Chamber of Pharmacists were passed. At present, regional chambers are being set up, and - according to the plans - Hungarian medical doctors and pharmacists will elect the leaders and governing bodies of the two national chambers during the second half of this year. Through these measures and processes, a forceful partner is being created for State health policy, and political aspects can only be asserted through continuous consultation and mediation with legally established bodies of professionals. This way, health policy can be built on consensus, which undoubtedly serves the interest of all partners: providers, financers and users. At the same time, through these measures, providers are encouraged and forced to independently formulate rules of ethical behaviour, and ensure their enforcement, without State intervention. In our opinion, these are the guarantees on which general ethics should be built all over the world. Another dimension of ethics - solidarity - is of regional and global character. It is impossible not to see the gaps that exist between health status and the health care services in. developed countries and in developing ones. These gaps exist within Europe, and they are even more evident on a global level. In the summer of 1990,WHO headquarters together with the Regional Office for Europe initiated and launched a programme in Europe, the EUROHEALTH programme, which is a health programme to close the gap for the countries of central and eastern Europe. Since that time, the European Union, the Council of Europe, the World Bank and several other intergovernmental and nongovernmental organizations and countries have joined the initiative and are actively taking part in its realization. This continent-wide solidarity is a beautiful example of ethical behaviour, and the manifestation of the conviction that we are individuals, representatives of the same and single human race, and we do have the same rights for health and health care. Under the present economic and political conditions of the world, it is impossible to realize these rights uniformly, but efforts should be made. This kind of global solidarity is a traditional and highly appreciated policy of WHO, which should be carried on in the future as well. In view of the extreme importance as well as the deeply human character of these activities, we cannot fail to mention that in the implementation of these programmes, we very often experience parallel activities and superfluous actions and travel, often of high technical cost that stem the flow of valuable financial resources to governments and health services and, in the final analysis, to the people in need in the recipient countries. From this forum, as well, may I ask and urge each official and staff member of the World Health Organization to show an example of ethical behaviour, to critically monitor and evaluate the effectiveness and results of the programmes, and to use all means to achieve the fullest possible implementation of original aims and plans. May I take this opportunity to call your attention to the fact that recipient countries constantly give expression to their wishes to be provided with less technical assistance and more operating resources. It is natural, as well, that the recipient countries should make accounting and the monitoring of implementation possible. I would like to suggest that a strategy be elaborated to reshape the role and activities of the WHO staff in these programmes, making use of modern communication and informatics technologies, and by a more efficient operation of staff make programmes more vivid. Filling the European gap can serve as a model and, in my view, the experiences gained through the successful cooperation of countries and a number of organizations in Europe could be effectively used in trying to handle global health problems. I am afraid, f Europe is unable quickly and effectively to settle its own health problems, especially to eliminate the huge differences that exist, effectiveness on a global level in this respect seems to be even more uncertain. From this perspective as well, I feel it to be of the utmost importance to create a European health strategy, with the participation and collaboration of all organizations and institutions present and concerned in the region, regarding them all as equal partners, and having the final aim of serving the whole continent and, as part of it, Member States of the different organizations. Ladies and gentlemen, may I underline here the word "serving" Member States. To realize that, new working methods, new management techniques are necessary, and I am convinced that conditions for that are much more favourable now than they ever were during the last decades. Hungary greatly appreciates the support it has been receiving from the large family of the World Health Organization during the last four years. We have done our best to participate actively in preparing and implementing these programmes. We took part in elaborating the EUROHEALTH programme, we have introduced overall health reforms, for the realization of which we gained the support of a number of intergovernmental and nongovernmental organizations, as well as of individual countries -1 am afraid time is too short to name them one by one here. In my view, these experiences, this kind of working method can essentially contribute to effectively promote the improvement of health status and health care. We are ready any time to present these experiences on a regional or global level.

69 A47/VR/2 page 54 Professor ZOCHOWSKI (Poland): Mr President, Mr Director-General, distinguished delegates, I am extremely glad that I have the opportunity to address you in the name of the Polish Government today, because 3 May is Polish National Day. First I would like to congratulate you, Mr President, and the Vice-Presidents, for your election to the highest posts in our Assembly. I wish you every success in carrying out all the tasks that will enable our Assembly to take important decisions. I would like also to congratulate Dr Nakajima on his report and his thoughtful approach to the reform of our Organization. We see the proposed changes as a necessary response to the rapid economic and social transformations observed in different regions and countries. Let me take as a basis for sharing our views with you the process of transition toward a free-market economy, which is taking place in Poland. As in other countries, the health services are currently undergoing major changes. There is strong pressure for the introduction of health care insurance systems and for privatization. Internal market mechanisms are being introduced at the primary health care level, with the free choice of physicians and linking of salary to amount and quality of work. All these changes require a substantial change of the management philosophy and practices. They call for the transfer to Poland of various experiences and training methods from other countries. However, significant cultural, social differences and traditions preclude an automatic adoption of the ready-made methods and solutions brought by foreign consultants without adapting them to local conditions. Moreover, our experiences show that quite often experts from foreign countries have considerable difficulty in understanding and correctly judging the conditions and process of change. No wonder the effectiveness of their hard work often is comparatively low and is not very useful for our real needs. On the other hand, one of our greatest concerns is the health conditions of our society. There is a negative trend in such health indicators as mortality due to cardiovascular diseases, traffic accidents and oncological diseases, mainly lung cancer. It stems mainly from a spread of unhealthy lifestyles, high consumption of tobacco or improper nutritional habits. The implementation of the national programme of health, which is based on the philosophy and principles of health for all, adjusted to Polish priorities, is one of our most important tasks. There is a unique opportunity for countries in transition to move toward more imaginative health development. Such development should be based on the best experiences from Europe and from States elsewhere. It should focus on redesigning health systems in line with health-for-all policies, tailored to the different needs of each country. Therefore we strongly support opinions that the World Health Organization should act as a top-level consultant agency in health. It should provide impartial expert advice on key issues related to investment in health, and organization and financing of health services. Sober evaluation of real needs and extent of changes by WHO experts of high prestige is more convincing than evaluation by the national experts. This could be of great help to health care managers. We also welcome with great interest the stress placed on promotion and protection of health contained in the Ninth General Programme of Work. I have to say that for years we have been advocating the role of WHO as a health information centre for the Member States, due to its unique position. We therefore welcome the Director-General's statement that stress will be placed on its coordination function in collecting, generating and transferring valid information on health matters. We consider it as one of the most important tasks which will build up the image of the Organization. We are also in agreement with every effort aimed at better use of available WHO resources. This calls for better coordination between different programmes to avoid overlapping and a piecemeal approach in the stage of their implementation at national level. The structural reorganization of WHO should facilitate cross-sectoral collaboration between different programme areas and organization of target-oriented activities. The proposal for bringing together the Expanded Programme on Immunization, the vaccine development programme and the Children's Vaccine Initiative will help to make the work of WHO more productive, and therefore receives our support. We also agree that the fast development of biomedical technology creates many controversies not only in such areas as medically-assisted human reproduction or gene therapy, but also with regard to scarce resources for health. It brings up such important questions as accessibility of health care, rationing of more sophisticated medical procedures, and rights of both individuals and communities. We therefore welcome the proposal for active involvement of WHO in the field of human rights and biomedical ethics. I would like to inform you that an interdisciplinary centre of patients' rights, bioethics and medical law has been established in Warsaw. This centre will organize in November this year a conference for teachers of bioethics from central and eastern Europe. The centre is counting on close cooperation with WHO in this area.

70 A47/VR/2 page 55 In conclusion, I wish to stress that the Polish delegation fully supports the draft of the Ninth General Programme of Work and also the proposals presented by the Director-General for programmatic changes in the work of the Organization - on the road towards the twenty-first century and a better future. Mr HAMADE (Lebanon): : (^LiJ) JL^JI J Iw. ^J I j)- 厶 I i ó J Luü I ^ CLi I,-..,1 - I i jsj 1 ^Sb^oj i ^ LsU! 太 Juül J Ul-u/ i^jau^i j} I à AJI V ^ J 1 l^j чг 11 "^ 一 力 必 丄 " 一 / 1 с/ 1 ^ 一 ^ JUJLHÂJ 1 I ^JAJ^ J A-UÜ L$IJ 1 AJXAQJ \ DUOJAJUIJ ^ LAJ 1 方 JUÜÍ JL;*^^ 1 ^J I ^ D-» I ^JU 二 :G J^ JJ I P LÁC I ^ F- LU/^ J P^LO^JU «Ü JLS^ 产 G * DJ JSUV^LOJ I JJTK-J 1 ^ J^Ù ^A-JUV ^-Û-JUV 1 ^ JLOJ I ^ 1 ^ Ал-. t^uj I d-uü LsiJ î d^kaoj 1 ^J I d^. J^aJ! ^ I (^JAJ-A^l^i I ÜLjI-CU»! I ^o wi^j-o Lg-g,^^ ^ I Ljj^u-» ^llj I А га.л ) LAJ 1 dowsioj I d^xjajuo Cl» У^^И^о <3l5 J^lS- ^^-LoJ I jlcl</ jls^ ^^JLc L<S ^-j! jjlji^ 0.о г/.1яу 1 ^ ^ 1 ^Js '<LJUIJJ1 ^ '<L^>L>-aJ1 ^ âj^^ji ^jji cjllljcji dljjj ^ A-J^' ip^ 业 js, 产 ^ о ^ а А з ^ I JUJJ!^ ^jlulxi^j! ^u-l>woj 1 PLÁCI) ^л^ 丄力 d^js-iojlj ^L«-JI JLOJ! Juct^JI л L. '.oj ^ Lii I JsUv^lXûJI I ^ J^ÂJ ^-ЛЭ I I J ^-O JuoJ!^ Ai^^ciu^J 1 J^ jj 1 ^JJÜ dujis) JsUx/^lloJ 1! ^-u/^jlufrl jm I ^ I Júie^i cixilàj 1 ^9_wxJ 1 ^-«-«jjlûj! L*i-»-L)! ^^o v 1 Ls-Û-» cl*jl> ^^iij I «Uo^^JI ^-o JL=KJ I L) JL-/ l^ojb Lu/^ LJ Lo Llo^^xJ ^j^j^xjíjü! ^JLff ^ UaJÜ 1 O^" 2 *" { jy^ ^ ^ j ^ia LiôJ 1 <i jjb ^s JloJ 1 ^ 1»5l J I j ij I ^o ^ л L^ LaJ I IJJ JoV LaS ^jb 1 ^ ^ g 4 )-? Lio ^JU Ô j J^ZUÛ^ dj^vo^co á^jjsums ci» Lu/j Lo-o f 1 js> ^JM <s-> j Lo л LJ L^-âJ I ^ O^^WOAJ I LjlJU 1 CSJSIIÍ^AJ I ^ ^ j^i I i9*^1 ^j!b ^o Д-cff \ ^ L**AJ! j^j 1 J^* ^jo^oj*^ I 1JL^» Ll-»-^^ i C l / Lsül LJ5 Llllli V A - J L - S.! ^-U/*^ I J-uJsC ^Jl yujij jyül ^ 山 Uj JJU ^ 乙 U l ^ ^Jl ^JLJI 0 U J 0I d^aâj 1 duj Ju) v91 JlA i L-» ^jji^j t <1l-Ii1jk.o-)!! j I ^o,j-o LSJ! 1 à! ^ov 1 Cl^ 1 j I jj D-"-»I ^^AOIJ^M L5U</ L^-JCO^ <S V. 少 G_ Ü CLCÂ 1 J LO ^J^J 己 A/^JU ^JÜ 1 J-^^LLJ I D-^UJ LAJ I L^C Ló^ I ^-Ifi IwJLc joilo I ój> L ^o Lo J^j I jf Jl.) 1 ^ ^JJâJ! 3 у. ; я, ) 1 ^o Lsiü <l-lllr>wo-) I á^yhs. ^jj! ç^jsuu-ld JjJ ^ I ^JU JU JL4 U1J 1 ^JU ^ l^^ji ó JLA^ 1 4-uxJ LAJ I dj>ws<aj I ^J^^-CM-O ^ J Lû-» ^llj I dubj о UujJ d-owvaj I Ijili ^js ulw Ju>j 1 jj-cs Î^uujSjJ 1 I I ^O J^ÍLÍIÍJ 1 ^CJL^USJ I J <I J I ^O JOV I J ^JU ^IJJ I ^ Д-USJ LAJ I 1 <LOJÀ-LO UJI ^yj! Cl^J^J l.g :.;.QgЯо^ '«Lxj^LoJl ^^JsC ajl^i LJikjuJl3 'Á-JLo-яЛ ^IsVl Д-^Э LoJ <Laj JusJJ 产 LaJI ^«.J^jJ 1 i^j L^Cj LsO^ J dlj A-ceJ 1-aJ I Cl->1 ^- jjj l g L^Il^ 1 ^ J^j v^i^^ji^ J ) J ^ O J^-^ ^jas. J-Jj Lu;.Jul j-wlji ^LsJI J^aJ! ^ol:^ U) d i l i lg 丄. 1 U L. ^^oji ^ Ь) С. jlbvl I JlA jux^uji^ J^Â-uJl,- ->""«L^^ *<Luv5 V r Д 1! jjlo ^O dt-^skaoj I I jj-oj>wo ^-C^J I ^J^ LsJlJ L-» ^J-^OJILLQ J-OU ( V j I l ^-L-" l-lli 1 j L^KJ 1jf 产 Uâj Ig :л " JWXJÍCIO Cl^Ux: dj t CL^^J^ ^Э ^ ojî djllao ç-o^ Jsux^uJl J^K-J I ^ j - î J I JiLiuw iua^wûjl A-^b^Jl ^ol JsJL^ Á-Jj^Í AJJ^AJI lo^bul ^JL-^JI 山 ^plcji '<jju1 '<LL>^o ójj-coji a^jlji Loi jjl 1 jujji L^jl i^jaji^js! ^ Juu*v SkltS-1 ^ Aja^ZJ» ^ JJ I I 1 ^j-^ 1 Ijul^ d jil ujj I ÂJj 1^-oJ 1 ^J I

71 A47/VR/2 page 56 j^j IJu^JsCj Ij^Jl^J: U^iJaJI JL^o t ^ti 产 U J^JL^W 己 : 丨 J d^aji " J J1 I^ÍJlú^ 1 ^ l OO-W J Ll_J Sks. <Jc> 1 d_9^ j]o ^J! LC4/ ^J LS Lo ^^Jc jji_/ Ll-J A^Jâ-lûJ I L U clu^ jj\ c^lj^ ^ iiiv^ J^>L JI о. - :. I ^JLc jjs>^iji j-o JiJaJI jlx/âo LJbü 11 ^JJl ^UJJI ^ ^ ^ 4 UJb.^ItVl 11A ^ UJU Ъ^Лк^Л.,:U c^vuji yiil 山 ci; ^JLcJ I 己уЬул ^js Li-J ^- -..-Уя о 11 J^ j-o ^ LsûiJL;- I, g,! Lü 产! I jjb jh j J L> i... : A-^JaJ 1 ^^ ûj I <i-ct/j Lo-o J L^o Lll^ Ij^-lSÜ^ Iji-» juíz I L<v-o á^asj 1! J*^ 1 ^ <V.g (j^o Л^а-Ц I Cl/jJñ 1! ^ Cl^ LMSLÂJ I vjl/sjo-1 己 Ц»^ f I ^nj^m ^^-ùlloj i ^ j I ^ ^j-ic ^ Ualltw^xJ I DJI \^ L^LIO^ LU-^Ъ J U ^ ÓJUI LIA ^^VJI J-oj>wo '«Lx-JLJ! 一 j ^ c l i Ji jji ysb JjLf ^S^Ua/ ^JI U 1 ^л L^Juo ^j^-jj^ 1 1 Llo duvi. LsJ I LJb A-uü L«J! v-àjoji ^Lw/ ^Ul! jy^i d^oji ^o 产 UJ1 JLLJi ^o ç >> or^ 产. j U ^ u J i îj^ji ^ «a^ il o^vb j^1 i^h o:'^"'^ л! LE D-ГКЛО-/ I LLR< L O ^ JJ! LUM^^OJ 1 L^VIÂI^ ")!! ^JL^ LÁ-OJ! i 丄 J! p L^J ^ j o 1 JoJl^IJ L» ^J LaJ I ^^sji * ^ i ^ I I ^c <L-coJ Le ^^llj^ Lji ux^- IjJ J Lio L-bfL- j31 o^jb Ó J3 JJI 亡 L^ju^ ci» Iw^JuC Y> 1 ^^J1 ^J^j I I Lixsü I ^э ^J I! ^^ 丄 jj I Ji-^XAJ I ^J l-5ïj! ^^ J-í ^ [ J^i ^vmuxj I l g яdwco-) L«J I do^cj 1 <3uü Ju) j! à^ Lcwi^ duo l^-j I.1 ^-«.oj^.l 1 ó J LíCcuJ \ ^ LAJ I ^ ллси) 1 Dr WONG (Singapore): On behalf of the Government of Singapore, I extend to the President, Vice-Presidents and elected officers of the Forty-seventh World Health Assembly our heartiest congratulations on your election to your high offices. I would also like to congratulate the Director-General on the very well presented and comprehensive report on the work of WHO and efforts made to achieve health for all by the year The Health Assembly resolution on "Health for all by the year 2000" in 1977 and the Declaration of Alma-Ata in 1978,called for international commitment in involving the community in the design and delivery of health care interventions. In 1992, the United Nations Conference on Environment and Development again emphasized community participation in safeguarding the natural environment. Another delegate spoke this morning about high ethical principles, inside the chamber; outside, the exhibits deal mainly with grass-roots community action. I do not see them as separate, unrelated issues; in fact, involving the community in policy decisions affecting its own health is certainly a matter of high principle, quite apart from the question of effectiveness. Iberefore I would like to share a little of my country's experience in community action to promote health. Today, the health status of Singaporeans is comparable to that in many developed countries such as the United States of America, United Kingdom, Australia and Japan, and like them we are beginning to see a change in the pattern of diseases. Currently, cardiovascular diseases and cancers alone account for 60% of the total deaths in Singapore. Diabetes is also on the rise. Diseases such as these have multiple causes or risk factors such as unhealthy diets, low physical activity, obesity, smoking, high blood pressure and high blood cholesterol. With changes in the pattern of diseases from essentially communicable to lifestyle-related diseases, improving the health status of Singaporeans has to change from the traditional public health approach, i.e. from health care providers to the population, to one which involves more community participation. Hence, from 1984 onwards, new approaches have been used which include greater intersectoral coordination, collaboration with the mass media, community participation, and empowerment of the people with knowledge and skills so that they can actively participate in "bottom-up" planning and take action themselves. There is a strong rationale for this change in approach. First, an educated community, with a high literacy rate, sets the platform for more community involvement. Singaporeans in general have begun to be more conscious of their role in health care matters. Moreover, many of the risk factors begin in childhood, and are often value-laden, culturally and ethnically defined. The "private" nature of these

72 A47/VR/2 page 57 practices, particularly lifestyle-related issues such as diet, means that any behaviour change should best be made as close as possible to the homes and workplaces of those affected. This is the philosophy of the Government of Singapore. It took the lead with clear policy statements on the role of individuals and community action towards health. The first major programme which adopted a community approach was launched in A national health campaign committee was set up, and targeted educational activities at major diseases. Over the years our approach has evolved to be more community-oriented, i.e., from a disease-based approach we have moved towards helping to change personal and group behaviour. Voluntary organizations as well as the commercial sector routinely provide sponsorship and active participation, while health education activities are ongoing. These are brought to a focus in our annual campaigns marked by intensive publicity, mass media education as well as large scale activities. This approach is taken not only for promoting healthy lifestyles but also for smoking education, AIDS education and others. Of great significance in the history of health promotion in Singapore was the launch of a 10-year national healthy lifestyle programme by the Prime Minister in April This programme is steered by a coordinating committee comprising representatives from government ministries, the national trade union body, the employers,federation, community and voluntary organizations and professional bodies. These organizations plan and implement their own educational activities to help achieve the long-term goal of the programme. A central unit in the Ministry of Health keeps track of all programmes and helps to direct support where necessary. The unit also ensures coordination of public policies so that they do not conflict as regards health. In 1993, the focus of education moved to exercise. Again the Prime Minister launched the campaign by leading mass exercise organized simultaneously in various sports stadia with live TV telecast. Apart from mass education and mass events, special programmes have been designed to reach out to specific target groups, particularly those at risk. You may be interested to hear that we are now facing a particular problem created by rising affluence and our changing lifestyles. There is a high level of obesity among schoolchildren. In 1992, 13% of primary and 15% of secondary-school children were found to be obese compared to only 9% ten years ago. The Ministry of Education has devised a special programme, called the "Trim and Fit" scheme, to address this. The scheme provides a motivational framework to encourage schools to reduce obesity and improve physical fitness of the student population. It also provides incentives for students to keep physically fit. At school, a significant amount of curriculum time has been allocated to the teaching of health education, from primary to pre-university level, in the syllabuses for science, home economics and physical education. Another area where we concentrate efforts on educating the public is at workplaces; management and unions are involved in the planning and implementation of health promotion programmes. In this connection I am very pleased to note that a training course organized with the support of WHO was conducted in 1993 for workplace health-promotion facilitators. Due to the good response, another programme is planned for the later part of this year. Whereas in the earlier years persuasion and incentives were needed to encourage acceptance of health promotion programmes, it is now very evident that the climate has altered significantly. Schools, workplaces, community organizations and groups are now initiating their own programmes, and when assistance is sought from the Ministry there is shared decision-making. Other major programmes such as the national smoking control programme, the AIDS education programme, cancer education and mental health education programmes also involve community action and participation. In the fight against AIDS, emphasis is placed on public education; the Ministry of Health organizes AIDS education programmes with organizations such as educational institutions, rehabilitation centres for drug addicts and homes for delinquents. The Department of Sexually Transmitted Diseases has an ongoing programme which screens commercial sex workers for HIV and educates and trains them on how to protect against AIDS using the condom. Action for AIDS, a voluntary organization independently organizes community outreach programmes including accessing those at risk who would otherwise be less amenable to programmes run by the Government. For the cancer education programme, we involve the Singapore Cancer Society, and special attention is paid to self-help groups, including women's groups, for example, for women after a mastectomy, stoma care and so on. To monitor the progress of health promotion activities, periodic review and evaluation are conducted. So far as healthy lifestyles are concerned, survey results show that we are beginning to see significant improvements in the control of risk factors; for example, the prevalence of hypertension and the total cholesterol level of Singaporeans as well as the proportion with total cholesterol above the desirable limit have declined; however, smoking rates have risen slightly in the last two years or so, and this is an area

73 A47/VR/2 page 58 where we need to work harder. Quick population surveys following campaigns show a high rate (80% to 90%) of the people are aware of our campaign activities and messages. In conclusion, our experience shows that education and information disseminated continuously raise health knowledge and help to create a "pro-health" social climate in the country which favours the use of community approaches. A political leadership which is strongly committed to health promotion and spearheads and oversees the national effort is an important factor in strengthening community action towards the adoption of healthy behaviour. As the patterns of diseases and risk factors are similar in many countries, our experience may prove useful to others. Through our newly established WHO Collaborating Centre on Health Education and Health Promotion, we wiu be able to share more information on our programmes with others who are interested. Mr President, these are some programmes which Singapore has implemented to achieve the vision of health for all by the year To conclude, I would like to assure you and the Director-General that Singapore will work in close cooperation with WHO as we have always done in the past. Dr MARANDI (Islamic Republic of Iran): In the name of God, the compassionate, the merciful. Excellencies, Mr President, Mr Director-General, honourable delegates, dear colleagues, ladies and gentlemen, I would like to begin by extending my warmest congratulations to the President and Vice-Presidents on their election, and my sincere appreciation to the Director-General for his comprehensive report. I hope that this Assembly will be of much benefit in promoting health for all. We are approaching the end of the twentieth century, and have committed ourselves to providing health for all in our countries by the year We have made great progress in improving people's health status in the last decade. Vaccine-preventable diseases have declined by introducing activities in the Expanded Programme on Immunization, and the annual death toll of the under-fives has been significantly reduced. Also the implementation of oral rehydration therapy and the acute respiratory infections control programme have further diminished the mortality rate of children. Although the health indicators are optimistic, the statistics among countries have wide variations. Many countries still lie on the critical side of these figures and large populations of the developing world live under undesirable health conditions. Major problems, such as rapid and rampant population growth and poverty, still threaten the least developed and developing countries. Developed countries also face cultural decadence, environmental pollution and economic crises. Diseases such as AIDS and its related consequences, addiction, disregard for religion and moral values, unemployment and the problem of street children are burdening people worldwide, be they from developed or developing countries. More than at any other time, resolving these problems requires the full cooperation of all nations, and countries sharing common concerns must work more closely. Here, the role played by WHO is of vital importance. In the Constitution of the Islamic Republic of Iran, based on the commandments and teachings of the holy religion of Islam, as well as the Iranian culture, health and well-being are considered the basic, indisputable right of all Iranians. The priority of health is very evident in the five-year socioeconomic development plans. To this end, the establishment of an organized health care system has been a priority from the outset. This has led to one of the most efficient primary health care systems in the world, particularly in the rural areas, as recognized by international health authorities. In the second five-year socioeconomic development plan, due to be brought into effect at the beginning of next year, it has been estimated that the primary health care system now covering 70% of the rural and approximately 100% of the urban population will attain full coverage. Along with the development of the health network, we have recently begun enhancing the provision of health services in the urban areas of large cities, with local women serving as health volunteers. Community participation and social mobilization in health services have been of major interest in recent times. We used over volunteers in the national poliomyelitis immunization day, held on 15 April On this day, about nine million children under five were vaccinated nationwide, regardless of their immunization history. The second round is to be held on 12 May 1994, the goal being poliomyelitis eradication. In addition, we are at the stage of controlling measles and eliminating neonatal tetanus, with over 95% vaccination coverage for all children under one. All vaccines for the expanded programme on immunization are produced in the Islamic Republic of Iran and a plan has been devised to supply regional countries with our surplus vaccines, after assuring our self-sufficiency. The programme for improving nutrition for vulnerable groups like mothers and children is of much concern, and the Islamic Republic of Iran is one of the forerunners in promoting breast-feeding. The last survey taken in 1991 indicated that 66% of mothers breast-feed their children up to the age of one. The national lactation management centre is among the most active centres in the Region.

74 A47/VR/2 page 59 ""Notwithstanding that our country still has a high population growth rate, this rate has been lowered from 3.2% at the beginning of the first five-year development plan to 2.3% at its close by the implementation of the family planning programme as well as the population policy. The Government's political support and the full backing of the religious centres have been instrumental in the success of the programme. I must mention here that all contraceptive methods, excepting abortion, are practised in the Islamic Republic of Iran, and contraceptive services are free of charge. A public health insurance programme is under study by the Islamic Consultative Assembly, and a plan has been prepared to give nationwide coverage to all strata of people. As to medical education, we will be self-sufficient in the near future with regard to educating physicians, paramedical staff and specialists, through the integration of medical education into the Ministry of Health, and the expansion of the universities of medical sciences and health services in the provinces. University professors serve in scientific committees established to carry out health programmes in addition to teaching, and the nation's health network provides facilities for the medical students field training. Quality at the level of medical education towards community-oriented medical education is currently given emphasis. Ethical issues are of special importance in the health system as they are based on the holy religion of Islam. The teaching of medical ethics at medical schools is addressed at all educational levels. A medical ethics studies and research centre at the Ministry of Health and Medical Education is involved in carrying out education, research and planning as well as bringing health services in line with ethical codes. In January 1994,the health ministers of the Central Asian republics as well as Afghanistan, Turkey, Pakistan and Iran met in Teheran in the context of the Economic Cooperation Organization (ECO) to formulate a coordinated health care programme in that area. WHO and UNICEF participated in the discussions and we shall rely on their contributions in providing assistance to the ECO members. Finally, I cannot conclude without expressing my deep sense of outrage for the tragedy that prevails in Bosnia and Herzegovina. Here we see a major humanitarian situation where an entire Muslim nation has been left at the mercy of Serbian aggressions. Obviously WHO cannot help Muslims to defend themselves. They might have been deprived of the means to exercise their right to self-defence by the Security Council and it remains for the Security Council to correct their unjustified position. WHO can contribute, however, in the alleviation of the suffering of the Bosnian Muslims by taking a much more active role in providing assistance and care. Professor RIZZO NAUDI (Malta): Mr President, Mr Director-General, distinguished delegates, I would like to start by offering you, Mr President, and the Vice-Presidents my congratulations on your election to office, and to wish you every success in your work. I would also wish to thank the Director-General and the Chairman of the Executive Board for their reports, and have much pleasure in welcoming and supporting the applications of Niue and Nauru for membership of this Organization and offering my Government's congratulations and welcome to South Africa on resuming her rightful place among us. May I now comment on some of the points raised in the Director-General's report, and also respond to his request for reference to be made in this debate to the issue of ethics and health. In his rq^ort for the last biennium, the Director-General referred to the conclusion of the work of the Executive Board's working group on the WHO response to global change. The working group deserves our gratitude for a major undertaking competently accomplished, and for elaborating a set of recommendations to refocus the Organization's mission, strengthen its cohesion and improve its transparency, accountability, management structures and technical competence. However, the elaboration of recommendations will not, of itself, achieve the hoped-for objectives. Their success will depend upon a conscientious, determined and persistent process of implementation. I,therefore, welcome the initiatives the Director-General has already taken to give effect to some of the recommendations as a step in the right direction. Nevertheless, we must recognize that for the reforms to succeed, there needs to be the wholehearted commitment of the governing bodies, the Secretariat, the regional bodies, and the WHO country offices to work together and collaborate with each other, in a relationship of trust. Now, as never before, the world stands in need of a strong, purposeful and united Organization with a clear mission, coordinated action and unity of purpose. Without these, WHO will lose its influence and credibility to everyone's detriment. The Director-General's report is indeed an impressive record of an enormous number of activities undertaken, at times, under the most difficult and trying circumstances. The major thrusts of the

75 A47/VR/2 page 60 Organization's policy have on the whole been working well. The integrated approaches promoted by the Director-General are beginning to show good results and should be further developed. The slowing down of the momentum of the global immunization programme is, however, a matter of concern, as is the AIDS pandemic and the continuing deteriorating situation in the spread of tuberculosis, which is now the world's leading cause of death from a single infectious agent. We read of predictions of 30 million deaths from the disease and of 90 million new cases within this decade. The complicating factors of HIV, multi-drugresistance, poorly managed programmes, the difficulties of many poor countries in securing regular drug supplies, and the mass movements of refugees all add to the seriousness of the situation. What is most distressing of all, as the Director-General,s report points out, is that the main obstacle to tuberculosis control is not lack of medical knowledge but inadequate political will. Every effort must be made to accord higher priority to the programme, and I welcome the Director-General's proposal, which was agreed by the Executive Board, to establish a Special Account for Tuberculosis within the Voluntary Fund for Health Promotion. What the report shows is not only the efforts that have been made to meet both the old and new challenges but also the vast amount of work that still needs to be done. More and more demands are being made upon the Organization almost daily both at the global and the regional levels. In these circumstances, the imperative for a sharper prioritization of the Organization's programmes and activities on a continuous basis becomes all the more necessary in order for it to function efficiently within its budget and to retain its credibility. That said, the Director-General is absolutely right to point out that for the Organization to meet its existing and emerging priorities, the availability of resources is a basic prerequisite. We cannot expect the Organization to fulfil its mandated obligations and, at the same time, deprive it of the legitimate means to do so. We are on the threshold of achieving notable successes in controlling,eliminating, and even eradicating some of the worst scourges that have afflicted the human race for centuries. It would be unforgivable if we left the twentieth century with a legacy of unfulfilled promises. We must not go down the slippery slope of pushing back the goals we had set ourselves and upon which millions of the most vulnerable populations of the world had set their hopes. We must all make sacrifices, and those most advantaged must make the major sacrifices if health for all and all the lofty pronouncements of solidarity are to have any meaning beyond good intentions or strong rhetoric. We will soon be embarking upon the Ninth General Programme of Work, and whereas it is expedient that we should be preparing ourselves for the new challenges in a changing world, it is equally important not to lose sight of the unfinished business left over from previous general programmes of work. We have become good at addressing longer-term issues, but less good, perhaps, at dealing with matters of immediate concern. We have been too ready at times to espouse fashionable theories and abandon proven and tried solutions. We must make better use of the tools we already have. We need perhaps to go back to fundamentals. I was, therefore, pleased to note that the Director-General sees the Ninth General Programme of Work as outlining how WHO could increase its capability better to support countries in health development. Priority action, where necessary, must continue to be given to the establishment of effective health infrastructures based on primary health care. Not only have such structures not yet been universally established, but we are seeing health infrastructures breaking down in some countries. Effective health infrastructures are the key to the successful delivery of programmes. Without these the goal of health for all cannot be achieved or sustained. In his recent address to the Executive Board last January, the Director-General drew attention to the ethical challenges resulting from the dramatic developments in biomedical technology. These advances, have, indeed, prised open a door to a world of undreamed-of opportunities and, at the same time of the most serious implications. They raise complex social, ethical, legal and moral issues. This whole area is fast becoming one of the most perplexing issues which society is having and will continue to have to grapple with. WHO has a role to play in the unfolding scenario in facilitating reflection and exchanging experiences, but it must tread carefully on issues of bioethics and conflicts of value systems which touch upon the religious and philosophical convictions, the cultural values and the traditions of the diversity of its Members. These should be and must continue to be respected. The issue of ethics and health, however, goes beyond the bioethical dimension. As members of the European Region we take some pride in the fact that a specific target on health and ethics was introduced in the revised version of our common health policy and targets document, which provides a framework and particular approaches to decisions relating to the health of individuals, groups, and populations. Included among these are the important issues of ethics and health policy, of confidentiality and of the increasing complexity of ensuring equity in access to health services, the allocation of public funds, the rationing of resources, and the distribution of human and technical resources for health, to mention but a few. These are legitimate fields for WHO to continue to explore and on which to provide guidance.

76 A47/VR/2 page 61 May I now devote the last few minutes to highlighting one or two developments in our own health services. We have recently carried out a number of structural reforms in the organization and functioning of the Department of Health, improved the provision and delivery of health and personal social services, especially for the elderly, and have also started work on a health care information system whereby every Maltese citizen will have an integrated health record. All these activities, reforms and policy initiatives have provided the right opportunity for us to develop a coordinated health strategy, which will set clear objectives, clarify aims and responsibilities, and set a framework against which progress can be measured. We are grateful to the Regional Office for Europe and to the Department of Health of the United Kingdom for offering to assist us with this initiative. Standards of training for nurses and other health workers have continued to be upgraded. Through the Institute of Health Care of the University of Malta a range of courses has been devised and is being implemented at degree, diploma and certifícate levels, representing different levels of need in the health service and different academic abilities. These courses will also be made available to overseas candidates. A major programme of reform and modernization of our hospitals is at an advanced stage and will provide a wide range of high-quality diagnostic, curative and rehabilitative facilities. With the generous help of the Belgian Government, we have embarked upon the formulation of a national mental health policy and strategy to refocus mental health care towards a more caring and personalized service to clients and their families. The Belgian Government is also assisting our pharmaceutical section to develop a drug registration system for all pharmaceutical products manufactured locally or imported into Malta. I was pleased to note that steady progress is being made in the proportion of women in established offices in the Organization. My Government set up a secretariat for the equal status of women which, together with the Commission for the Achievement of Women, ensures that the Government's policy to secure the effective implementation of the principle of equality between men and women in every sphere of Maltese life is actively pursued. Women's representation on public bodies is increasing. The number of female students enrolled in the University of Malta is now over 45% of the student population. A directory of Maltese women giving information on their qualifications, skills, activities and experience in the various sectors has been compiled and periodically updated, and is made available to ministries and Government departments, local associations, organizations and trade unions. Finally, Mr President, allow me to conclude on two congratulatory notes. First, I would like to offer my delegation's congratulations to the worthy nominees for this year's various prestigious awards, and to say that we are particularly pleased at the recognition being given to Sir Donald Acheson for his immense contribution to the advancement of public health, and for his sterling work for this Organization, and I would also like to express our pleasure that WHO has re-established official relations with the World Medical Association. That this happy event has taken place at a time when the presidency of that Association is held by a Maltese compatriot makes this a doubly auspicious occasion for us. Mr IOANNIDES (Greece): Mr President, Mr Director-General, dear colleagues, honourable delegates, it is a great honour and a great pleasure for me to address this Assembly on behalf of the Greek Minister of Health and the European Union. First and foremost I would like to stress the extremely important and crucial role of this Assembly, as its main concern is the struggle for the healthiest possible life of mankind. As we all know, the World Health Organization during the past decades has made significant progress towards the implementation of certain health programmes, strategies and initiatives, even though new endemics and epidemics will demand even more from the implementation if people's needs are to be met. The biennial report of our Director-General, Dr Nakajima, for the period is an eloquent proof of what remains to be done in the field of health in our constantly changing world. Considerable work has been undertaken on every front, but it must be acknowledged that living conditions of the world population and access to health services are continuing to develop in an inequitable manner. Turning now to my role as representative of the Chairman of the Council of the European Union for health matters, it is a great pleasure for me to inform you today that since last November the entry into force of the Treaty on the European Union, has added a new dimension to European cooperation, that of public health. This will further strengthen existing cooperation between Member States. This new dimension is important not only for promoting health among populations of the Member States of the Union, but also for fostering relations between the European Union and other countries of the world, and also international organizations active in the public health field, in particular WHO.

77 A47/VR/2 page 62 As spelled out in Article 129 of the Treaty, close cooperation between Member States on health matters will be promoted and joint efforts will be made to combat major health scourges, such as cancer, cardiovascular diseases, AIDS and other transmissible diseases, and drug dependency. Community action in the field of public health will focus on encouraging cooperation between Member States, lending support to their actions, and promoting coordination of their policies and programmes. In practical terms this involves the establishment of networks, information exchange systems and joint actions in various areas. The Treaty also specifies that health protection requirements shall form a constituent part of the Union's other policies, such as the internal market, environment, agriculture, consumer protection, aid to development, etc. Furthermore, cooperation with the other countries of the world and international organizations will have to be developed and enhanced to make best use of the limited resources available for the health benefit of all inhabitants of our planet. The role of WHO is of course paramount in this context. Ministers of health of the European Union have been meeting regularly in the past, and a number of important decisions have been taken in the field of health. The European Parliament is closely associated in the discussions and shows keen interest in health issues. A profitable collaboration has been established between the different European institutions: the Council, the European Parliament, the Commission, the Economic and Social Committee, and the Regional Committee, which all have to contribute to the promotion and development of a public health policy in the Union. Within the Union, important ongoing programmes, in particular against cancer and AIDS, have already been established. In the Council of the European Union, ministers responsible for research are considering biomedical research as an important component in the framework research programme of the Union. Regarding cooperation with third countries, that is, countries that are not members of the Union, large programmes in support of health policies, health system reform and health promotion are already ongoing. Public health is mentioned specifically in a number of association, cooperation and partnership agreements concluded recently between the Union and countries of eastern Europe and the newly independent States. Moreover, Member States are taking steps towards a more coordinated approach in the support they give to developing countries. The Council is currently discussing resolutions on the policy of cooperation with developing countries in the field of health and especially of AIDS. These texts will define principles and general objectives for the interventions of the Union and of Member States. In the framework of humanitarian assistance, considerable medical and health support has been provided and is provided at present by the Union to a number of countries and populations in great need. Tmight conclude "this part on behalf of the presidency of the Union by referring to the initiatives and issues which the Greek presidency has at the moment on the agenda: prolongation of the programme "Europe against AIDS", to the end of 1995; adoption of an action plan to combat cancer for the period ; a resolution concerning the framework of action in the field of public health, which determines the priorities of actions; and a resolution concerning cardiovascular diseases, which is specifically an initiative of the Greek presidency. All these issues are being discussed at this moment and the final texts will be agreed upon in the near future. In the third part of my intervention, I would like to make a reference to Greece and its efforts to upgrade the system of public health and to develop conditions ensuring an equitable but also efficient, health system, with existing resources. In Greece, we enjoy one of the highest life expectancies in the world. Still, we have set high priority on the implementation of our national health system which we first started in 1983 and at this very moment we are in the process of bringing about major reforms in it. I could not leave the rostrum without mentioning some important points. Biomedical technology opens tremendous avenues for research. Indeed technological advances of the past forty years are said to have surpassed those of all prior human history. On the other hand, they raise far-reaching medical, ethical and legal issues, such as the cloning of cells of human embryos. Medical ethics is increasingly seen as an integral part of medical education curricula. Those ethics have a multiple and extended role in medical education: enriching understanding of the basic values of the profession. The appropriate model of science in medicine is no longer simply biomedical, but also social and psychosocial. Thus, medical education is necessary to extend and include prevention, public health, ethics, social sciences, health promotion, and human rights, elements which can usefully fit in with the management of an efficient and high-quality health care system. I should also like to make special reference to the central topic of the Technical Discussions at the Forty-seventh World Health Assembly, "Community action for health". It is a subject that implies a significant change in approach both for government and communities. No more appropriate subject could be found. The Greek delegation is awaiting the conclusions and recommendations that will come from these discussions.

78 A47/VR/2 page 63 Concluding my address to the Assembly I would emphasize that, if we are to keep pace with a rapidly changing world, international cooperation is required for the exchange of know-how in order to achieve higher standards of health for our populations in a more efficient way. At the same time we should take full advantage both of WHO policies, such as the health-for-all strategy, and its programmes. All of us want a high standard of health for all, not just for a few, to which all - and not just a few - should contribute. Human health is improving in part due to WHO active cooperation and efforts with Member States. But it seems to me that there are still many groups whose health status is relatively low, such as the elderly, children, disabled persons and women in many countries. Let me finish by stressing also the need for cooperation between States and this Organization. In this way we will all feel as one world family which works for one of the noblest purposes and missions, health for all people. For this mission I wish the best of success to all of you. Dr HEBRANG (Croatia): Mr President, honourable delegates, ladies and gentlemen, it is my pleasant duty to extend my most cordial congratulations and those of my delegation to the President elected to preside over this World Health Assembly, as well as to the chairmen elected to chair Committees A and B. The delegation of the Republic of Croatia is now for the second time attending the World Health Assembly, which is without doubt the most authoritative body in the field of health worldwide. The Republic of Croatia became independent and recognized worldwide in 1992,becoming at the same time a Member State of the United Nations and of WHO. The next point of my address is the fact that the Republic of Croatia since 1991,has been exposed to military aggression and to the war imposed on it by the Serbian aggressors. Now the circumstances in my country seem to be unique, being far away from the usual standards and stereotypes. Everything is undergoing serious and extended change, so that the agenda item of the Health Assembly, called "WHO response to global change", is fully appropriate to our experiences, processes and expectations for change in all public sectors in Croatia. Croatian "national change" has brought freedom to our country and now we are waiting for the process to be finished politically, not by war. We are trying to create an entirely new national health system, based on the experiences of other countries. In doing so, we are also using and implementing many useful guidelines, recommendations and experiences of WHO, trying to do it according to the principle not to adopt, but to adapt". The new health and health delivery system of the Republic of Croatia is aimed at the achievement of health-for-all goals for the Croatian people, namely achievement of physical, mental, social, intellectual, spiritual and ethical health. I would like to stress that the main points and main parts of our new health legislation relate to the accessibility,acceptability and affordability of health care, and of primary health care in particular, thus enabling all citizens of Croatia to have access to primary health care. In doing so, we have reaffirmed and are implementing the targets of the Global Strategy for Health for All by the Year 2000 as adopted by WHO at the global level, thus confirming the principles of social justice and equity, in terms of equal chances for everybody in utilizing health care. Through our new act on health insurance, as well as through other legislation, we have introduced a mechanism for collecting and allocating financial resources, bearing in mind the necessity of effectuating the declared principle of equity. Available financial resources in health services are collected through the health insurance scheme from very different, poorer or richer, communities and regions in Croatia. Through the above-mentioned principle of solidarity and mutuality, they are equalized at the country level. We intend to spread these principles also over the temporarily occupied territory of the Republic of Croatia. We have taken special care that basic health care is always and everywhere assured, together with ethical principles in particular. In doing so, we are implementing through our acts the main principles on patients,rights. Our country is facing now a great and specific ethical problem: providing health care for more than displaced persons and refugees from Bosnia and Herzegovina, temporarily placed in the Republic of Croatia; which means more than 11% of our entire population. In accordance with peace conferences and peace-making processes, many of these people are expecting to return to their destroyed, damaged and devastated homes, thus changing their status of displaced people or refugees to "returnees". When and if returning home, they will be accompanied, first of all, by priests, teachers and primary health care manpower. In the fruitful cooperation with the WHO Regional Office for Europe, mostly through the EUROHEALTH, Healthy Cities and Healthy Schools programmes, we are training primary health care teams to take responsibility for providing health care in devastated and economically destroyed parts of the Republic of Croatia.

79 A47/VR/2 page 64 I would like to mention some other ethical principles and issues that we have followed during our recent history. At the beginning of the aggression against Croatia in 1991,a health headquarters was established at the Ministry of Health, charged with taking care of a great number of injured and sick persons. The staff members of this health headquarters were trained in, among other subjects, implementing ethical principles and human rights in war conditions. The staff members, mainly consisting of primary and hospital physicians, became more familiar with international conventions and with the Geneva conventions in particular. The conventions were printed, reproduced and distributed broadly among health manpower, primarily to those acting at the frontline, in daily contact with the enemy. They were obliged to study the conventions and to implement them everywhere. We can verify and give evidence and testimonies that the treatment of our people, of refugees and of wounded enemies was equal in our hospitals and we are proud of it. Unfortunately, the enemy did not do the same and did not follow the above-mentioned ethical principles. The documentation of the enemy's behaviour is published in the brochure "Croatia: hospitals on target - a testimony". Seventeen Croatian hospitals or larger medical centres were either completely destroyed or seriously damaged, being a precise target for the enemy's artillery. It is one of our ethical duties and responsibilities now, in the post-war period, to find all missing persons, about 7000 of them, and to identify these victims, informing their families about their fate and providing them with a chance for human and dignified burial. I am aware of the fact that I have spoken about sad issues and happenings, but it is our reality. We are optimistic - the following period will be characterized by reconstruction and rehabilitation. I take this opportunity to extend our most sincere thanks and gratitude to all Member countries of WHO, to national, international, governmental and nongovernmental welfare organizations and agencies worldwide, which helped us and supported Croatia tremendously, especially in terms of providing medical drugs and supplies. In that respect I have to point out the professional and humanitarian role of the staff of the WHO Regional Office for Europe, which enabled us to minimize the consequences of that terrible war. I do hope that in 1995,at the Forty-eighth World Health Assembly, we will report about the successes in revival of our country and of our health services in particular. Expecting and forecasting it, I would like to recall two declarations of the United Nations (1992 and 1993) and a resolution of the WHO Regional Committee for Europe, declaring the need for help and assistance to be provided to the Republic of Croatia based on solidarity in reconstructing the country, destroyed in the war imposed on it, especially the reconstruction of our damaged and destroyed hospitals. It is an ethical issue, too. Dr MALHAS (Jordan): :(, 丨 )^^ ^ 补 ^UJ] U5 九 ^ b J I. Л ^ ^ u^ ^JijU 山 jji -U^M 山 jji ^ ^ J U 1 ^ M ол^ O 1 尸 У J^. ^ J l l^ji y w ^ ^ j.a.v: H ^JL^JI JLJ\ ^jkj 一 JL^ 一 1 一 0 > V^JI 彳一 ;L^oJUJI l^ji ;- " UUi>l тг ^^ ^v-uuji 4 бл c^ O^jn^^ 0 х J j ^ djljb h J^ U5 - ol^ji JiL^JI ^ ^ J Ç h U ^ Ç 太 ^Л. VJUJI ^ ^JU^J! ^SjJ ^ Ш.ï 力 Jl.JÜ. W W I A ^ J 丄 Ul ^ "loi^o JL^I ^ ^ JL ^-Ul fbji ^JuJ! ^jk^ Li. 方 ^Jl ^ f^^^ ii 产. V JU dl; Я, ^ cl j J 丨 ; ^JUJ 丨 cujji ^LJ ^ U5. LUI ^^JLJI 产 J l J^J 山 1 ч^ ч?^ f U J^-U. ' ^J! ^ ^ J-us J^J^J ^UU^VI a^j J-Ü-JI / 丨.u-JuJI ^ycji IJLÜJ og^ji liji ^ jsj J] fuji 太 o^jj jjujl U

80 A47/VR/2 page 65. ^ ^ O^îy^^S (^bji ' ^4, 0- >a.r. 8. Il JL. J^ W 丄 一允 ^ >3 (J ^ U ç^lj. ijl J^à ^ ^ JL 0'l ju^vl Lb уь dju J 匕 0I. J'iU^I J^^p ï^il^ji Si>UJI ^ p J I L^aU - ^Л 巧 I I^iU^I oíl^iji ^ ^UJI л,,.-,-л cl^u^ji f^j V ^ o- 1 ^ЛкЬ. '«Lbls 沖 i^ji ^ iiiuji aile I ' JS^Lo ^ykj d/ I Ü^^CAímJ I I ^ ^^UAJI) C^U^I^I J-O V L ^ U v 方.,'<L-LxJI L^lijJj ^ ^ ^. v ^ J i / 丨 ' jlo 二".'>1 /1 L^jJ ;Luc._,_JI l^ljji y i ) ^Jl ^UJ! Lb JUÜL l^jl^i ^ ^ 如 ^Jl l^u^io ^ c^li^iji dlbj ^ U l o ] з^чпз c^uojuji ju.jutji ^JuJll j-o ^l^iji dlb ai^ U^J^ Or^ 丨一 儿二 ik^lj! ^i^bvl 0is dji LtU^ V.,,,, 0" p ^ LgJU^I ^ Uju, 丨 > pu^ji ;UjUJI gls^i > J 1^ la^ > T 一处 1 么 c^ и л > ylvji ^^cucji.. u - ^ j e 1^ 1 ^ c^ 尸 r^j Ъ^ 1 山 1 Ji^ LJI /I a^siji J^aJI *^>JU> JiJC ' JjUCJI Lb y 严為 ^^!^ l^ji^ll Ji l^i L^-JI CLJUj il ci^^:^ U ^ U UUJ I dlb A-^CLmaJI J^JJI CLum^ ç-ew/3 ^iaj CL^ ^Ju^SU 己 ^ U i Ji L -.l j l 丄 U ^Я^ЛМ I^pJL diuo 3 ^ÂJI ^ ^Jl I jjfe 1 au» * jlji 3 GIJ^UJI ^ ^о^ял LgJUül ^o ^yao Jiu^ jl) US «d-u)lj1 ^ ' i 山 I d^a-. ü/4 l^ikc Ô^UI ' iui liui^ji Isb^JI^ ' jlwuji ^ b l ^JU U^i 0I. jl^jl djjb JiU dw^j ^ ^LJI cjl uji ^^клал ^^ Jl ^s jujvi I^waJI (J-JU> J A-U>UJi JJ-JI ^ f- li^j^í I ^ ^ЛчоЛ W"-...J ÓÜ^O JI^M * 二,1*4" 1 wxsj ij ty^'ác ^ I <i Lo ^Jubl y> 'i^iiji J^üJI j^ji '<L^LAJI J^aJI 已 li d-j^^cu) l^jloji J^ З-ôJI ejm^l '.wд-^л J^wül ^pjubly 'iuwo 'L,Uu>J Lui diul5b ç-ô LuJLJI 1^М ^з-âj' 山 ^ d^luji 山 Л Ó-J ^^ o^j ^ U^tí- 9^ dj 丄 Lui «ôjuji3 1 J 1 t^^sjj} ^a-cw 郎 с/ 丨 l^l^o ^J > c^luj /I c M ^ 1b ^JLs tci^uulji lg^ sju^ji ^joj-sj J^jJI а l,.g..""l d_u>lji J^aJ! J^L^ i^l 0 >k. ^Jl l^u^ji 山 Jl ' JLkJI çjuu, '^iji c^lllj! jji ⑷ ^L^, ^ d«uj UJ!3 '0^-JlLJ I J^wül I j I 'LULJI.^Jl jbsü Uju,^ I J ^ I j^lyjj ^JUJI IJl^J U^x; ^ U! j^j p13j /l f I ji U Ji *<Lu>LJI J^jJ! a-^üuaji J^jJI ^Lsiz :^-JL L a^olji {Jy^ ^ '<LcoLJl 山 jji J 3 JP ^ Üb^JuA^; ^.LwJl J-J j^soj ' -cct/l j J d-o^lcj!. J^s 'Â-ceLJi J^jJI {j l 7í^z ^ Í L^li jjlo^ "iibj^ji do^jvl p Lo-x/1 ^Jl j^gil ó Jrf lk}\ J^JJI ' ^-cajl dojuji ^ LlJJI ^ d-^livûji J^JJI

81 A47/VR/2 page 66 О) ^J 匕.' -ÍUOJI J^JJI ^ ^ IFCJI UJJL^ ^! ' =JLJI J^ J I ^ I ^JIBL ^ I^JJLC gwlji i-ju^) JLÜ^I ^ ^ ^ t S^JI 一 LJI yl^ji ^ J^jJI 丄 ^ ^ ^ h^ ^ 々冉 J\ ^ ^iu'l SU!,,..,, ^ g U U I Lb /I L^JI U dji ^ ^ Jl Z Jp \. V JI J ^ l ^ J^l JjUc Jj^JI LJb..wLJI JjjJI ^JL^I ci^ 0 加 jji oslji ;\ 11 U", 丨丄 JUJI ^ jucüo i^iul Lb J-oli Jl^JI ^ 01 一 J.A 11 ^ 丄 w j ïj^l cli^-^ji ' ^U <'á_ujuji.lx^ji -JuJLu, b^^j ^ЛА-^jJ I ЦАЧА/! J^Jù^ I Dr RADITAPOLE (Lesotho): Mr President, Honourable Ministers, distinguished delegates, ladies and gentlemen, let me start by congratulating you, Mr President, the Vice-Presidents and all other office-bearers upon your election. We thank you for giving your time to serve us in various ways during the duration of this Assembly and beyond. On behalf of the Lesotho delegation, I wish to thank the Director-General, and the Secretariat for the preparations they make each year which contribute to the fruitful and enjoyable time at the Assembly. The main task of the Organization in the recent past has been to manage, adapt and cope with change. From available reports it seems the Organization is coping and adjusting well. This is important because the alternative is organizational irrelevancy, atrophy and eventual death. There have been changes taking place in most of the Member States. However in some Member States, these changes have had negative effects on the health of the people, as well as creating unplanned demands on meagre national resources. It is for this reason that the World Health Organization has to remain strong and able to respond effectively, as well as provide the necessary leadership. We are pleased to note that the programme of work has succeeded in developing strategies that are not prescriptive, as planning in this changeable world has to be flexible and at best scenario-building. As we stand on the threshold of the next millennium, it is worthwhile to stand back and look at the recent past. In some of our countries life in the last decade has been characterized by a pervasive sense of being overwhelmed by intractable problems at home, while being bombarded at times with sympathetic criticism from some quarters. In the process we have found ourselves embracing all sorts of ill-conceived solutions recommended to us as necessary change, if only not to appear stubborn, arrogant or insensitive in the eyes of the prescribers. It is in such situations that flexibility, adaptation and scenario-building in managing change assume even greater importance. We note that the Executive Board has requested the Director-General to produce a world health status report. We hope that such a report will not become only of historical value. Hence we humbly suggest that the best use we can make of the report is for scenario planning for better health for all. We also suggest that the report should serve as an instrument and a basis for realignment of the programme of work of the Organization as well as the proposed rolling plans. Lastly, we suggest that the world health status report become a platform for measuring the deficit between the actual situation obtaining and the global health goals. For planning purposes it is also important to have estimates of resources which will move us towards these global health targets. As a way of integrating health and human development in public policies, we propose that the World Health Organization takes the lead to give effect to such policy orientation. We humbly suggest that the membership of the Global Policy Council, for instance, be revised to include independent members. As far as technical programmes are concerned, we are happy with the areas of emphasis and orientation. We will be making comments in the Committees as the specific items come up for discussion. It suffices to say here that we are pleased with the Organization's leadership in the area of the revised drug strategy. The Lesotho delegation hopes this Assembly will come up with a resolution on this important issue as a reaffirmation of our commitment. Coming closer home, the Lesotho delegation wishes to congratulate our brothers and sisters in South Africa for the successful elections which now put behind us the sad history of that beautiful country. The ANC victory is victory for all South Africans; it is victory for the Region; it is victory for the continent of Africa; and it is victory for all peace-loving peoples. We look forward to seeing South Africans take their rightful place in all the international and regional groupings. Their success should give all of us

82 A47/VR/2 page 67 strength as well as hope that meaningful change is possible and that no obstacles, however large, can stand in the way of positive change. I wish to conclude by saying that health for all is no longer just a social objective. This perhaps is an opportunity for communities as well as political leadership to design new ways to motivate those who work for health improvement. Perhaps the Technical Discussions will offer us the opportunity to explore the way forward. We look to the World Health Organization for leadership in facing these challenges and opportunities. Mme MARLEAU (Canada): Monsieur le Président, Monsieur le Directeur général, honorables délégués, Mesdames et Messieurs, au cours des prochains jours, l'assemblée entreprendra Pexamen d'une question fort importante, celle de la réforme de rorganisation mondiale de la Santé. Ensuite, pendant les mois qui viennent, il incombera aux ministres de la santé et aux secrétaires d'etat à la santé de traduire en réalités le fruit des réflexions de cette semaine. Le Gouvernement canadien appuie la volonté de changement au sein de POMS. Depuis 1948, elle a dû composer avec une situation en constante évolution. Par exemple, les quarante-six dernières années ont vu nos connaissances médicales faire des progrès prodigieux, avec toutes les adaptations que cela suppose. De nouvelles crises ont émergé, d'anciens fléaux sont revenus nous hanter. A cause de ces changements rapides, le "leadership" exercé par FOMS a peut-être perdu de son éclat. II nous faut maintenant lui permettre d'être à nouveau à Favant-garde dans le domaine de la coopération socio-sanitaire. A nous de définir comment elle peut mieux servir tous ses Etats Membres. Le temps est venu d'examiner la vocation originale de FOMS et de diriger à nouveau ses efforts vers les secteurs dont Paction ne peut être coordonnée qu'à Féchelle internationale, par exemple la surveillance de certaines maladies, rharmonisation des réglementations relatives à la santé en vue de l'application commune de normes élevées, ainsi que la coordination et l'échange d'informations portant sur la recherche et la santé, particulièrement en ce qui concerne réradication et l'élimination de certaines maladies. Il y a manifestement bien d'autres sujets qu'il faudrait aborder, mais il serait long et inutile d'en dresser la liste. (The speaker continued in English.) (L'orateur poursuit en anglais.) WHO must focus on what it does well - and ensure that its collective, and limited, resources are used in response to our collective priorities. The fight against AIDS is one of those priorities. I believe leadership is a key to effective action in this area. That is why in Canada's view a cosponsored United Nations programme is the best way to ensure that the efforts of the entire United Nations system produce the best possible results. Canada is a strong supporter of international AIDS activities. We look forward to the next international AIDS Conference in Yokohama this August and to our hosting the 1996 Conference in Vancouver. My department will financially support the Conference and help communitybased and nongovernmental organizations from all over the world convey their messages and share thenexperiences. We will also provide free registration for 500 Canadians living with HIV/AIDS, and for 500 individuals from developing countries. My Government is also very concerned about children at risk, not just in Canada, but around the world. As one of the signatories of the United Nations Convention on the Rights of the Child, Canada has followed up its commitment with an action plan for children to support children and families in Canada and around the world. Through the international component of an initiative for children we call "Brighter Futures", Canada funds Canadian non-profit organizations to work with partners in developing countries on several projects. For example: to integrate disabled children in Latin America into their communities, to improve conditions for children in areas of armed conflict in the Middle East, and to assist street children in Canada and abroad. Let me now turn to the subject of ethics and health, which Dr Nakajima has proposed as the common theme for our statements in plenary. In Canada, we are actively addressing several major health issues with important ethical dimensions. I would note, in particular, the very difficult issues raised by new reproductive technology. A few months ago, after four years of work, the Royal Commission on New Reproductive Technologies submitted its report to the Government. The Commission was struck by the importance Canadians attach to having children,and therefore by the critical need to prevent infertility and to regulate practices designed to overcome infertility. It recommended first that immediate attention be given to specific health risks it had identified. Second, it recommended that certain current and potential

83 A47/VR/2 page 68 practices not Ъе permitted in Canada. These include: research involving human embryos and cloning, the creation of animal/human hybrids, or the transfer of human embryos to other species. Third, it suggested that a national body be established in law to regulate other practices. We are currently studying alternative control bodies and mechanisms to determine their ability to deal with existing and emerging issues related to reproductive technology. I also wish to speak not only about ethics and health, but also about equity and health, especially equity between women and men. One of our priorities is to make Canada's health system much more responsive to the particular needs of women. We need, for example, to ensure that clinical trials of drugs and other treatments no longer underrepresent women in their samples. There have been questions about the attention devoted to areas where women have special needs, such as osteoporosis, menopause, and breast cancer. I have made increased attention to breast cancer a personal priority, as I recently told the Canadian House of Commons. The Government of Canada will soon create a centre of excellence for women's health. The centre will help us to identify major health priorities for women, and allow us to create strategies to address them. We are determined to ensure that our vision for health will encompass everyone. That must include the poorest and iaost vulnerable. In Canada, we seek to ensure that all of our people have the same access to health services - without regard to ability to pay. Canadians take enormous pride in their health system - one that is universal, portable, comprehensive, accessible, and publicly administered. We believe the equity of our health system is the truest test of our ethical commitment. And we recognize that equity is not only a social value, nor is it confined within national borders. It is a vital element of development for all countries regardless of their level of development. Last year, the World development report 1993: investing in health put forward a cogent argument for a worldwide approach to health based on equity. The report challenged assumptions about health programmes in the developed and developing worlds. The challenge that this report posed is becoming familiar to Canadians as we work to improve and renew our own health system. We have to do this while the Federal Government and the provinces work together to address the same kinds of severe upward pressures on health costs faced by governments everywhere in the world. We will soon be launching a national forum on health to be chaired by the Prime Minister of Canada. This forum wül be an ongoing attempt to consolidate and act on an emerging consensus on what needs to be done. We will be seeking the views of users as well as providers. The health system is there to benefit everyone and, with everyone's commitment, we will make it the best system possible. I am confident that the health forum will reinforce what Canada is doing right, while identifying areas where efficiencies and improvements are possible. In closing, Mr President, I wish to reaffirm Canada's support for the reform that WHO has initiated, which must extend to its Member States. We all stand to benefit if the process continues to be carried out positively and effectively. In this regard, Canada sincerely welcomes the opportunity to work closely with WHO and with other governments, including our colleagues from South Africa, on issues of common concern. Mr KAUKIMOCE (Fiji): Mr President, honourable ministers, distinguished delegates, ladies and gentlemen, as the Minister for Health and leader of the delegation from the Republic of Fiji, I am honoured to have the opportunity to address the Forty-seventh World Health Assembly. I bring to you greetings from my Islands in the South Pacific, the Fiji Islands. May I, on behalf of my delegation take this opportunity to congratulate you, Mr President, and your country, on your election to the highest office of the Health Assembly. We wish you success in this Assembly. At this juncture, I would like, on behalf of the Government and people of Fiji, to record our gratitude to the Director-General, Dr Nakajima, for his work and leadership during the last year, and for the comprehensive report he presented this morning. We are also grateful to the Regional Director for the Western Pacific, Dr Han, for his part in servicing our Region so efficiently. Along with many other countries Fiji is in a state of transition as regards its major health problems. On the one hand, we continue to record a decline in the extremely dangerous infectious diseases of childhood (largely brought about by immunization, with WHO support), and a fall in other severe infections and communicable diseases such as tuberculosis and leprosy. On the other hand, we are now confronted by alarming increases in noncommunicable diseases such as diabetes, heart complaints and cancers. Unlike the "traditional" diseases, these tend to be lifelong or chronic, rather than short-term ailments, and the reduction of the problem lies as much with individual patients as with the health service. Again in common with many other countries, we in Fiji and the other small island nations in our Region look to WHO to provide advice, financial and other support as we tackle these health problems.

84 A47/VR/2 page 69 WHO financial support is valuable, although relatively small-scale, amounting to about 1% of our annual capital and recurrent government expenditure on health. We are pleased that WHO is continuing to serve our Region. WHO has provided and continues to provide strong and consistent support to a number of key health services, most notably in the areas of immunization and maternal and child health, and to our efforts to firmly implement that version of primary health care most suitable to our island State. WHO support has played an important role in seeding health initiatives which, once developed and seen to be useful, are taken on by the Government. In addition, WHO has made a significant input to the development of our human resources for health. WHO has also enabled us, and I am certain other countries, to feel in touch with a sympathetic world health community, with a very real, even if intangible, benefit for relatively isolated communities such as ours in Oceania and the Region. These are,to my mind, clear and indisputable advantages of our membership of WHO. Mr President, I offer some general comments based on our experience in Fiji on WHO programmes in our Region, and raise other general issues which could provoke both formal and informal discussion in the course of this Assembly. As this august Assembly has convened to do, I ask: how can we further improve the part played by WHO in helping us raise the health status of our people? First, I draw your attention to the management of the WHO budget. I was pleased to note how the proposed budget for the biennium is being designed to be "realistic" in relation to the funds likely to be available to WHO. I emphasize the word realistic. Recently my senior management team in Fiji, as would have happened in other countries, laboured to produce a sensible and balanced submission to WHO for the budget, going through fierce debates, eventually to achieve some consensus. Many of the other delegates here I am sure were involved in a similar process and I sincerely hope that in the coming biennium we can avoid the financial adjustments we had to go through in recent years. AIDS and HIV infections are not yet a serious problem in my country or in our part of the Region. However, all efforts are being made to prevent them from expanding, by continuing to strengthen surveillance systems, and education and information campaigns. It is, therefore, most important that financial support from the international community should not be disrupted but be sustained. We recognize the challenges faced by those managing the WHO budget and the backcloth of considerable uncertainty against which they must act. I hope, however, that they too recognize the effects on activities expecting funds of redirection of resources and timing of changes. Secondly, I welcome the initiatives in the current reforms, evaluation and other management processes, and the involvement of local country staff. There is general agreement that without proper monitoring and evaluation it is not possible to tell whether inputs are producing the health outputs (let alone the health outcomes) intended. We need not spend as much of our resources and time for processes, but rather use them for substantive issues. We will be working with our Regional Office on achieving higher quality and more appropriate information, and perhaps devising a means to overcome unnecessary administrative burdens. Thirdly, I must highlight the need for effective response by WHO offices. Devolution of authority and strengthening of country offices seems urgent. We must work together and enthusiastically to ensure that WHO officials are able to make decisions freely, and minimize frustration and embarrassment. For good health services management, we need to remove any delay and any uncertainty; these can be costly in terms both of local and WHO time. A related issue is that of the involvement of countries, and especially smaller countries, in the WHO strategic decision-making process. I realise that there is already a well-established system for this purpose, but is it really achieving its aim? Is the system itself satisfactory? Are Member States making full use of the system? In small Member nations, we can have a sense of being clients rather than an integral part of WHO, being both contributors and recipients of funds. Of course, we may not be making sufficient effort to involve ourselves in the current system for the strategic management of WHO and I am determined that we should do so in the future as an important step in the proper evolution of our relations with WHO. Fourthly, there is the relationship between WHO and other donors. Although WHO is not one of the larger donors in our health sector programmes, it plays an important role in providing valuable information and advice to other donors. Clearly, WHO needs to work in careful coordination with other donors and partners, and this is largely achieved at present through informal links. I believe that more formal channels of communication should be established, especially with the bilateral donors, to improve coordination, which should be vested in each country's ministry of health. I would like to close by saying that I am from the South Pacific and the points that I have raised are based on my own Fijian perspective, but if some or all of my concerns are shared by other delegates, I would hope that a healthy and open debate may ensue for the benefit of all. I trust that my remarks have been taken as a positive contribution for our development, as they have been intended to contribute to a

85 A47/VR/2 page 70 constructive and continuing debate on how WHO can grow ever more effective in meeting the needs of its Members. I would also close by expressing appreciation for the cooperation and support which Fiji has received from WHO, and by reaffirming in turn my country's clear support for WHO and for its future work. Mr President, I pray that the Lord will readily bless you all in your deliberations and wish you and the Forty-seventh World Health Assembly every success. The PRESIDENT: I thank the delegate of Fiji and I give the floor to the delegate of Samoa. I should indicate that I have received a special request from the delegate of Kazakhstan and I will respond to this request after Samoa's presentation. Mr SALA Vaimüi II (Samoa): Mr President, Vice-Presidents, Director-General Dr Nakajima, Regional Directors, fellow ministers from all over the world, dignitaries and guests, ladies and gentlemen, it gives me great pleasure to stand in front of you today on this occasion of the Forty-seventh World Health Assembly to bring to you greetings from the South Pacific island of Western Samoa. I am also glad to see a lot of familiar faces of my fellow ministers of health from all over the world. Although we come from different backgrounds, are of different socioeconomic standing, and have different languages, different colours and different religions, our coming together today and for so many years in the past is for one purpose. That purpose is to improve the health of our people and of the world to reach our global goal of health for all by the year 2000 and beyond. Let us not forget at this stage WHO developments in the field of curative and especially preventive aspects of health, by bringing under control some of the most dreaded diseases of the past decades, like tuberculosis, leprosy, or poliomyelitis. And I am pleased to inform this Assembly that our country, Western Samoa in the middle of the Pacific Ocean, is reaping the benefits of these programmes. Our country is one of many countries in the world suffering from diseases which are associated with changes of lifestyle brought about by industrialization and western influence. Our Ministry of Health is embarking on a major project which is focusing on the preventive aspects of these diseases, mainly obesity, high blood pressure, heart diseases and diabetes mellitus. Our country is a poor country and to carry out a programme of this scope, we need the total commitment of our health workers and also our people. But we also need resources, and we depend on the help of external donors and our major funding agencies for our health programmes in WHO. I look forward to the close working relationship between our country and WHO and I beg to seek more funds to enable our country to implement these programmes. For instance, I would request continuous funding for immunization of children. Mr President, may I draw your attention to a question that was in my mind this morning: "What are we doing here this week?" I believe all of us here have a full commitment to our respective countries and to our planet Earth to improve health matters. Just yesterday we waived some provisions of our Constitution to achieve full recognition for one of our WHO family members - South Africa. We welcome her back. This is a sign of WHO family solidarity. Today we pledge our full support to our colleagues from Niue and the Republic of Nauru, and endorse their application to become members of the WHO family. I wish to share with you two elements needed to achieve health solidarity: (1) we must have strong faith; (2) we must love all the people on our planet so as to obtain global health, harmony and peace. Before I resume my seat I would like to express, on behalf of our Government and people of Western Samoa, my thanks to the Director-General, Dr Nakajima, our Regional Director, Dr Han, our WHO Representative and all other committees and organizations that have assisted our country through the Ministry of Health. I know for sure that we cannot exist without your help and continuous support, that you have provided for many years in the past. The PRESIDENT: I thank the delegate of Samoa for the presentation and for observing the time-limit. I very much regret that because of an urgent appointment this evening, and because we did two things that we should not have done - that is the plenary started late this afternoon and most delegates spoke longer than they should have done - there is insufficient time to hear the delegate of Kazakhstan, who has to return to his country tonight. It was my intention to give his request sympathetic consideration. Nonetheless, I would

86 A47/VR/2 page 71 like to assure the honourable delegate of Kazakhstan that if he will hand his written statement to the Secretariat, it will be published in the verbatim record of our meeting. 1 Д-РДУЙСЕКЕЕВ (КАЗАХСТАН) Dr DUJSEKEEV (Kazakhstan) Г-н Председатель, уважаемый Генеральный директор, уважаемые члены президиума Ассамблеи, уважаемые делегаты, дамы и господа. Менее двух лет Казахстан является полноправным государством - членом Всемирной организации здравоохранения. Но даже за столь короткий период значительно усилилось влияние ВОЗ на развитие здравоохранения в республике. Пользуясь случаем, я хотел бы с этой высокой трибуны еще раз выразить искреннюю признательность Генеральному директору, д-ру Накадзиме, а также руководству ВОЗ за то, что теперь мы имеем возможность совместного обсуждения политики, стратегии, проблем здравоохранения на всех форумах Всемирной организации здравоохранения. В результате распада СССР Казахстан получил новые положительные возможности, но вместе с тем он столкнулся с большими трудностями в своем развитии. Кризис политического, экономического, социального, нравственного характера становится глубже. Не снижаются темпы инфляции. Не сбил их и переход на национальную валюту. Валовый внутренний продукт за январь - март этого года сократился на 30% по сравнению с тем же периодом прошлого года. За истекший год заработная плата выросла в 14,5 раза, а потребительская корзина -в 23 раза. В особенно сложной ситуации оказалось здравоохранение республики. Начало 1994 года продолжает характеризоваться крайне недостаточным финансированием, отсутствием фармацевтической и медицинской промышленности. Ухудшаются демографические и основные показатели здоровья. Девяносто третья сессия Исполкома предложила обратить особое внимание на тему "Этика, справедливость и здоровье". Любая политика, связанная со здоровьем, должна осуществляться в соответствии с этическими принципами и правами человека. Следуя этому, была принята новая европейская задача. Это пересмотренная тридцать восьмая задача по охране здоровья и этике. В настоящее время Казахстану также приходится выражать озабоченность по поводу увеличения числа групп населения, подвергающихся негативным психосоциальным ситуациям. Это безработица, миграция населения, недостаточная социальная поддержка, социальная изоляция, межнациональные конфликты. Все это проявления несправедливости, порождающие проблемы здравоохранения. Эти проблемы, являющиеся новыми для Казахстана, требуют особого подхода. Для разработки мероприятий по обслуживанию этих уязвленных групп населения нам придется также учитывать соответствующие статьи Всеобщей декларации прав человека, принятой Организацией Объединенных Наций, а также другие международные конвенции в области прав человека и этики. И здесь нам придется искать профессиональной поддержки со стороны ВОЗ. Казахстан приветствует решение Генерального директора о создании Целевой группы по политике в области здоровья и развития на период гг. (во исполнение резолюции WHA 4524). Основополагающий документ Целевой группы уделяет огромное внимание мерам политического характера, которые необходимо предпринять различным секторам для улучшения состояния здоровья большинства уязвимых групп населения. 1 The text that follows was submitted by the delegation of Kazakhstan for inclusion in the verbatim record in accordance with resolution WHA20.2

87 A47/VR/2 page 72 в Докладе Рабочей группы по действиям ВОЗ в ответ на глобальные изменения представлены 47 рекомендаций. Мы бы хотели пожелать ВОЗ скорейшего и успешного выполнения рекомендаций 2, 3 и 4 об обновлении политика ВОЗ, подразумевающих прямые консультации с государствами-членами. Доклад Генерального директора еще раз подтвердил, что туберкулез в настоящее время признается Всемирной организацией здравоохранения в качестве приоритетной проблемы. В докладе было подчеркнуто, что под угрозой дальнейшего ухудшения ситуации с туберкулезом находятся государства бывшего Советского Союза. К сожалению это так! Заболеваемость туберкулезом в Казахстане сохраняется на высоком уровне. Летальность в 1993 г. возросла на 19у29Ь. Хочется надеяться, что Всемирная организация здравоохранения поддержит нашу национальную программу по борьбе с туберкулезом. В Казахстане ВИЧ-инфекция и миграция населения пока не являются большой угрозой. Но ухудшение может всегда произойти, поскольку ВИЧинфекцию не остановить. ВОЗ правильно и своевременно оценила ситуацию, и Европейское бюро ВОЗ, следуя принципу легче предотвратить, чем лечить, учреждает в настоящее время пост для Казахстана и республик Центральной Азии для усиления деятельности по профилактике ВИЧ/СПИД. Казахстан не участвовал в обсуждении Восьмой общей программы работы, так как не является членом ВОЗ. Теперь же мы имеем такую возможность. Итак, какова же позиция Казахстана относительно представленного вниманию сессии проекта Девятой общей программы работы. Прежде всего, основные направления Девятой программы совпадают с политикой Казахстана. Из четырех направлений глобальной политики ВОЗ, особенно актуальной для Казахстана является укрепление и охрана здоровья. Казахстан полностью одобряет принятые ранее Огтавскую и Франкфурктскую Хартии по охране здоровья и окружающей среде. Мы заранее можем сказать, что и Вторая Европейская хельсинская хартия по окружающей среде, которая будет приняла в июне этого года, также будет близка нашим проблемам. Общая стратегия охраны здоровья населения Казахстана, конечно же включает вопросы оздоровления окружающей среды, т.к. нас тревожит сложная экологическая обстановка почти по всему Казахстану. Резко обострились заболевания, обусловленные экологическими и техногенными причинами. На Сорок шестой сессии Всемирной ассамблеи здравоохранения, а также на Европейской сорок третьей сессии Казахстан выступил с предложением о создании программы ВОЗ, направленной на уменьшение воздействия на здоровье населения последствий известного Семипалатинского ядерного полигона, который действовал в самом центре Казахстана на протяжении сорока лет. Также Казахстан поднимал вопрос об актуальности создания Программы ВОЗ по оздоровлению населения гибнущего Аральского моря, так как эта проблема из национальной давно переросла в общечеловеческую, глобальную. Я вновь обращаюсь к Ассамблее с тем же предложением. Еще не исполнилось и года со дня подписания Первого соглашения о сотрудничестве Казахстана и Всемирной организации здравоохранения (17 июня 1993 г.). Но республика уже ощущает на себе внимание со стороны Регионального офиса и штаб-квартиры. Программа ЕВРОЗДОЮВЬЕ - это уместный подход для решения целого рада актуальнейших проблем в новых независимых государствах. Реализация этой программы является крупной организационной и управленческой задачей ВОЗ. Понимаем, что особенно сложно приходится с распределением ресурсов, тос. эта проблема, которой отведен высокий приоритет, будет забирать около половины регулярного бюджета Регионального бюро.

88 A47/VR/6 page 73 Казахстан ожидает больших результатов от Программы ЕВЮЗДОЮВЬЕ, так как она охватывает самые актуальные сферы, являющиеся составными стратегиями политики "Здоровье для всех": -обеспечение качества служб здравоохранения -профилактика болезней -укрепление здоровья проблема окружающей среды и здоровья. Недавно созданный в Европейском бюро ВОЗ справочно-информационный центр - Клиарингхауз занялся обеспечением потребностей страны в вакцинах и лекарственных препаратах. ВОЗ за последний год усилила сотрудничество с Казахстаном. Заметное оживление произошло после создания в Казахстане бюро ВОЗ по связям, что тоже имеет большое значение для поддержания эффективных контактов между Казахстаном и Всемирной организацией здравоохранения, а также оказании помощи в развитии эффективного международного сотрудничества в области здравоохранения. В прошедшем году ВОЗ и ЮНИСЕФ провели в Алматы конференцию, посвященную 15-летию Декларации первичной медико-санитарной помощи. Были проанализированы достижения и определены меры, необходимые для дальнейшего прогресса в достижении цели здоровья для всех. В заключении, позвольте мне выразить искреннюю благодарность Генеральному директору д-ру Накадзиме, Региональному директору - д-ру Асваллу, представителям ЮНИСЕФ, ООН, Всемирного банка и других международных организаций за то понимание, с которым они относятся к проблемам Казахстана, за их поддержку и активную деятельность в улучшении здоровья народов нашей республики. Позвольте мне заверить Вас, что Казахстан всегда готов поддержать инициативы ВОЗ для достижения общей цели - здоровье для всех. The PRESIDENT: This concludes our work for today. We shall resume our meeting at 9h00 tomorrow morning. The first item will be to consider the report of the Committee on Credentials. Committee A will meet as soon as the general debate on items 9 and 10 is resumed in the plenary. I would also wish to mention that I am requesting my Vice-President, Professor Vannareth Rajpho, to replace me in the Chair tomorrow morning. I wish you a pleasant evening, and the meeting is adjourned. The meeting rose at 17h35, La séance est levée à 17h35.

89 A47/VR/5 page 74 FIFTH PLENARY MEETING Wednesday, 4 May 1994,at 9h00 Acting President: Professor V. RAJPHO (Lao People's Democratic Republic) CINQUIEME SEANCE PLENIERE Mercredi 4 mai 1994, 9 heures Président par intérim: Professeur V. RAJPHO (République démocratique populaire lao) 1. FIRST REPORT OF THE COMMITTEE ON CREDENTIALS 1 PREMIER RAPPORT DE LA COMMISSION DE VERIFICATION DES POUVOIRS 1 Le PRESIDENT par intérim : C'est un honneur et un plaisir pour moi de siéger à la présidence de la séance de ce matin. Je déclare la séance ouverte. La première question inscrite à notre programme de travail d'aujourd'hui est l'examen du premier rapport de la Commission de Vérification des Pouvoirs qui s'est réunie hier sous la présidence du Dr M. Hamdan (Emirats arabes unis). J'invite le Dr Shamlaye (Seychelles), Rapporteur de la Commission, à venir à la tribune donner lecture du rapport qui figure dans le document A47/43. Docteur Shamlaye, s'il vous plaît. Dr SHAMLAYE (Seychelles) (Rapporteur of the Committee on Credentials): Mr President, distinguished delegates, Director-General, it is my honour to read the first report of the Committee on Credentials. The Committee on Credentials met on 3 May Delegates of the following Member States were present: Bulgaria, Canada, Chile, Côte dlvoire, Namibia, Nepal, Netherlands, Portugal, Seychelles, Tunisia, United Arab Emirates. The Committee elected the following officers: Dr M. Hamdan (United Arab Emirates) - Chairman; Dr G. Loukou (Côte d'ivoire) - Vice-Chairman; Dr C. Shamlaye (Seychelles)- Rapporteur. The Committee examined the credentials delivered to the Director-General in accordance with Rule 22 of the Rules of Procedure of the World Health Assembly. The credentials of the delegates of the Member States shown in the Annex to document A47/43 were found to be in conformity with the Rules of Procedure; the Committee therefore proposes that the World Health Assembly should recognize their validity. Mr President, with your permission, I shall not read the list of Member States and I would refer distinguished delegates to the written version. 1 The Committee examined notifications from the Member States listed below, which, while indicating the names of the delegates concerned, could not be considered as constituting formal credentials in accordance with the provisions of the Rules of Procedure. The Committee recommends to the World Health Assembly that the delegates of these Member States be provisionally seated with all rights in the Assembly pending the arrival of their formal credentials: Afghanistan, Bolivia, Bosnia and Herzegovina, Djibouti, Georgia, Greece, Japan, Kyrgyzstan, Latvia, Malawi, Mauritius, Pakistan, Papua New Guinea, Republic of Moldova, Rwanda, Tajikistan, Vanuatu. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

90 A47/VR/6 page 75 Le PRESIDENT par intérim : Je remercie le Dr Shamlaye. Y a-t-il des observations? Je rappelle que les délégués doivent rester à leur place pour prendre la parole. Il semble que personne d'autre ne désire intervenir. Puis-je donc considérer que l'assemblée approuve le premier rapport de la Commission de Vérification des Pouvoirs, étant entendu que les déclarations faites à cet égard seront reproduites intégralement dans les comptes rendus in extenso de FAssemblée? Le premier rapport de la Commission de Vérification des Pouvoirs est donc approuvé. 2. DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-SECOND AND NINETY-THIRD SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR GENERAI SUR L'ACTIVITE DE L'OMS EN (suite) Le PRESIDENT par intérim : Passons maintenant au débat sur les points 9 et 10. Les deux premiers intervenants inscrits sur ma liste sont les délégués du Zimbabwe et de l'indonésie que j'invite à venir à la tribune. Je donne la parole au délégué du Zimbabwe. Dr STAMPS (Zimbabwe): Mr President, honourable ministers, delegates, Director-General, ladies and gentlemen, all governments are being challenged by the escalating costs of health care, and whether by crude measures of budgetary "capping" and the imposition of user fees, as in our region, or by the development of internal markets or the so-called "new public health", evasive action is being taken by the State finance authorities to stem the tide of need and demand in the provision of health care services. Where these controls are unsuccessful and the burden of health services becomes too heavy for the State, we in the developing world who are indebted to the Bretton Woods financial cartel dismiss our ministers of health. It gives breathing space to the "fiscus" and there are plenty of new faces to choose from. In the developed world, the democracies have a subtler and more sophisticated method of cost containment: the services decline and the voters dismiss the whole government. In either case, the problem for health is how to maintain, at least, our gains and perhaps add a little progress, without thereby "breaking the bank". Unfortunately, the devices developed so far simply do not work. People, identifying themselves as patients, want the best - while the State, like King Canute, is wishing to turn back the tide of increasing and uncontrolled demand for health services. In Zimbabwe, we adhere to the primary health care paradigm as established at Alma-Ata. Despite a decrease in real terms of the per capita expenditure on health services, we have been able to retain the gains achieved since Independence a short 14 years ago. Nonetheless, some stresses are showing. I have come here in the middle of a strike of junior doctors and other State health workers that arose precisely because they have seen their economic status rapidly decline during our economic reform programme, and at the same time agreed conditions of service have not been put into effect as a result of our economic downturn which was severely aggravated by the pan-regional drought of Similarly, for the first time since we embarked on the Universal Child Immunization programme we have seen an ominous reduction in vaccine coverage, brought about by economies forced upon us through lack of available transport and personnel, and the increase in the cost of vaccines at the very point in time when we are assuming responsibility for the cost of their procurement. Zimbabwe now pays for three of the vaccines, and in will purchase the requirements for one or possibly two more. Despite our success in family planning, the procurement of appropriate "inputs" still causes concern. As a result, illegal abortion is unacceptably high (at about per year) with the consequence that clandestine abortion is the second commonest cause of maternal mortality and morbidity - tragic because it is an almost totally preventable situation. HIV and AIDS are now reaping their grim harvest. Collecting comprehensive statistics in this arena is fraught with difficulty, and we estimate that probably one-third of actual cases are reported; but, as

91 A47/VR/7 page 76 projected from sentinel studies carried out earlier, deaths from HIV-related disease continue to rise, though at a lower rate than worst-scenario projections predicted, while tuberculosis is effectively exploiting the impaired immune status of HIV-infected children and adults to the extent that both case numbers and case fatality rates have dramatically escalated over the past half decade. In the environment which now prevails, these deaths challenge the credibility of the "preventive behavioural change" message because many will say, "I heeded your advice, and still I am dying of AIDS". Zimbabwe successfully contained a major epidemic of cholera last year, bringing it under control within three months and eliminating the disease in seven months. The feared resurgence did not occur, we believe, because of effective water and sanitation improvements and the clear health messages which were broadcast. Tropical dysentery, however, remains a problem especially in informal urban and periurban settlements has seen the publication of the third edition of the Essential Drug List for Zimbabwe (EDLIZ). The fact that this is used extensively is indicated by one edition I picked up at one of our hospitals. The success of the stratagem in containing drug costs and promoting rational prescribing was assessed by a national health research analysis in December 1993 which demonstrated, among other things, that on average over the past four years more than 92% of drugs were genetically prescribed, that the average number of items prescribed has significantly improved at the peripheral health institutions and that patient knowledge regarding drugs is at a very high level - 90% for the essential parameters and 75% as regards the indication for the drug being used - nationwide. Furthermore, it identified some weaknesses in distribution and labelling which need attention. This exercise has proven the value of essential national health research and surveillance, and is something which we have a firm belief in and commitment to. Joseph Stalin is recorded as saying: "One death is a tragedy, a thousand deaths is a statistic". Sadly this observation has been confirmed again very recently. One racing driver dies - the whole world mourns. An ex-president is buried - the flag remains at half-mast for 30 days; Rwandans die - it is a statistic on the international media. But even worse, the one million children who die in Africa every year are not even noticed. In this respect, the world stands indicted in the same condemnation which must be applied to Stalin. We have to bring before the world's conscience the uncaring attitudes of those who determine its monetary priorities, which result in such carnage. No longer should we, like dogs, be called upon to be grateful for the crumbs which fall from the rich man's table. We need to establish once and for all those irreducible health rights which all the children, all the people of the world should be guaranteed by the global community, whether or not the States to which they belong can afford to allocate resources therefor. We, too, celebrate the rehabilitation of South Africa to full enjoyment of her rights of membership. For us, especially in sub-saharan Africa, this is a cause for great celebration, and if you find us indulging a little in the legal drug of libation in its various forms you will not only forgive us, but hopefully join us. Finally, with the resumption of active membership of South Africa, we foresee significant health needs in this arena. In the light of this shift in the geopolitical balance in our region, WHO needs clearly to formulate the most effective and efficient way in which the Regional Office can discharge its considerably expanded role. In this regard, Zimbabwe stands ready and willing to provide such facilities as may be appropriate. Professor SUJUDI (Indonesia): Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, allow me, first of all and on behalf of my delegation, to congratulate the President, the Vice-Presidents, and the other members of the Bureau on their election to their respective posts. I am confident that under their wise and able guidance the Assembly will yield fruitful results. On behalf of the Government and people of Indonesia I would like to take this opportunity to joyously welcome the Republic of South Africa back in our fold. May I assure the distinguished delegate of South Africa of our full support to the Government and people of South Africa in their process of nation-building and national development. As we come closer to the year 2000 it is saddening to note that foreign assistance devoted to health development in developing countries is decreasing. This is further aggravated by political turmoil, misallocation of already scarce health resources and most recently by the formation of various economic markets. The World Bank in its World Development Report 1993: investing in health clearly describes these unfavourable situations and calls upon donor agencies to solve this problem through concerted efforts. Technical cooperation among developing countries alone seems to be inadequate. What is more important is government commitment towards health development aimed at improving health status, particularly of the poor.

92 A47/VR/5 page 77 Indonesia is fortunate in that health development has been integrated from the outset of the first long-term national development plan launched in We are now entering the second long-term national development plan, started just last month. Health development is gaining more impetus because the objective of national development is enhancement of the quality of life of the Indonesian people. Needless to say, health and education play a very important role in our efforts to improve the quality of life, as evidenced by their inclusion in two indexes, namely, the physical quality of life index and the human development index. During the first long-term national development plan, impressive achievements in health status were observed. Infant mortality rate dropped from 145 per 1000 live births in 1967 to 58 per 1000 live births in Life expectancy at birth increased from less than 45.7 years to 62.7 years in the same period. Protein-energy malnutrition in children measured using weight for age as the parameter was reduced from 18.9% in 1978 to 11.8% in Despite these heartening results, some problems deserve special attention such as iodine deficiency, anaemia due to iron deficiency in pregnant women and children, malaria, acute respiratory infections, tuberculosis and the most recent, AIDS. A National AIDS Committee chaired by the Coordinator Minister of Welfare has already been established and a presidential decree will soon come into force. During the last phase of the first long-term national development plan, the Ministry of Health implemented various innovative approaches. Thiese included the use of generic drugs, deregulation in the fields of pharmaceuticals and hospitals, recruitment of newly graduated physicians on a contractual basis, placement of midwives at the village level, decentralization of health efforts down to the district level and a health maintenance assurance scheme, the Indonesian version of a prepaid managed health care system. The use of generic drugs in government health facilities has made drugs more accessible and more affordable to the community at large. Their share of the total drug market at the present time is around 10%. Per capita spending on drugs in 1970 was US$ Recruitment of newly graduated physicians on a contractual basis is aimed at improving the distribution of physicians down to the most remote areas as well as improving the quality of care. Placement of midwives at the village level will improve child survival and safe motherhood. It is planned that by 1996 all villages, around non-city villages in number, will have a midwife. So far ( ) midwives have been deployed. The various deregulations in the field of pharmaceuticals are meant to slow down price increases. With deregulation in the field of hospital care, private companies and foreign investors are allowed to build and operate hospitals. If this policy works, the budget intended for construction of new hospitals could be shifted to primary health care which is used more by the poor; incorporation of hospitals or conversion into "unit swadanas n will improve its quality as well as its efficiency. Decentralization of health efforts to the district level coupled with integration of some project funds for basic health services through health centres will make health development more suitable to the people's needs. Health maintenance assurance schemes at the present moment cover about 12% of the population. They are mainly enjoyed by civil servants and their families, armed forces retirees and industrial workers. Special efforts, in the form of village health funds to cover rural communities, are now under way. These innovative approaches will be continued in the forthcoming decades. The most salient feature of health development in the next five-year development plan (Repelita VI) for will be its share in poverty alleviation. In general it can be said that health development is geared towards the needs of the poor. Communicable diseases control, nutrition improvement, provision of clean water and environmental sanitation are mostly needed by the poor. However, to s arpen the policy, a strategy on health sector financing will be undertaken. Government subsidies will be better targeted on the poor by using tarif differentiation/higher cost recovery coupled with the use of health cards for poor families,to enable them to obtain free health care. This is a temporary measure and will be withdrawn as soon as their welfare has improved as the result of income-generating activities promoted by 1 the Government. I will now touch upon the Technical Discussions at the present Assembly. The topic "Community action for health" is indeed well chosen. This is so because in most developing countries and developed countries alike, community action in health is indispensable. Government alone will not succeed; for instance in Indonesia the community including the private sector contributes 70% of the total health budget, leaving only 30% to the Government. Indonesia has a lot of experience in motivating the community to participate in health development. Of prime importance is the role of the Family Welfare Movement (PKK) in establishing managing and operating the so-called integrated health and family planning posts or Posyandus in villages. At the present time there are around Posyandus throughout the country, or on average four Posyandus per village.

93 A47/VR/5 page 78 The Government of Indonesia is very grateful and deeply honoured for the selection of Mrs Soepardjo Roestam as the Chairperson of the Technical Discussions. She is the Adviser to the Family Welfare Movement, and the recipient on its behalf of the Sasakawa Health Prize in She also participated in the 1992 Technical Discussions entitled "Women, health and development". I am confident that she will direct this year's Discussions very well. In this august gathering I would like also to remind all who are present here of our commitment to the eradication of poliomyelitis, the elimination of neonatal tetanus and control of measles as well as the elimination of leprosy by the year As I mentioned earlier, achievement of health for all by the year 2000 might be jeopardized if we do not act properly and quickly. Hopefully, the third monitoring of strategies for health for all by the year 2000 which is due soon could be used by WHO in assisting Member States to redirect their health development if it is deemed necessary. Finally, I would like to express my sincere and deep appreciation to the outgoing President of the World Health Assembly. My appreciation also goes to the Regional Director for South-East Asia, Dr U Ко Ко, for his invaluable support to Indonesia during his term of office. I hope that his successor Dr Uton Muchtar Rafei will provide similar support. Le PRESIDENT par intérim : Je remercie le délégué de l'indonésie. Je donne la parole au délégué de l'algérie qui va parler au nom de l'union du Maghreb arabe (Jamahiriya arabe libyenne,maroc, Mauritanie, Tunisie et Algérie). J'invite le délégué du Myanmar à venir à la tribune. Mr MADANY (Algeria): : ( ) ^ ^ л^ <L>vuaJ1 л ^LSTJI ^.JloJI :. 11 <«Çhv'-,-.') IJ LaJ 1 1 Л. я ay 口 Jl**«J1 ^ V; 4 ü^á^jl f- LÁC I ^ с t-д/^ J Luül i Л-caJLaJI л т..я. ау) Lcu^j 'i-cwlio^ Ó^UJI ^J-aJI JU^Î ^L. J^^-UJI^ oj)5;:.", a-u»ljí l^ju» IojJcuJI cl^w 0l,vL..)l tg 二 '«LxaoJI JÍUu^ d-^i^j! 卢 3 ЯЫ * ju> 乂丨 л.je л 6. ^JU j^o. gjjl ^ UjJI # 声 l^slá ^ ' LJ 山丨約 >il>> ^ U5 t! ал LicUr^l ^c d-^l^^i Ój^c^z L03 'L^y, ^^iji ^ U : 0 ] c^rí ^ О^З ^ij! ^^^Jl 一 ly hlji о- 11 чг 1^^.Lal: 二 1 ^J! C^Lca-V^JI ÓC UU I'<Sbu,L>wi3 ÔJlJU» LJLi-i'l 方 ^ U A L ^ Ô ^LíJl 方 JuJí, J, 1j/l i^o ^^OwoJI J^i^j! С Uxxl d, :""II3 ' jluji (^fs jjl ^Jbua/ H. ^iíúioji ^jrtj^ A UJ 广 ^ jsjl}] c^lt JLCL^ '<LUJL$J1 d^^jl '<ULiJ ^^ 少笮..'^ I l^-lotrv. '^^IlJIj Л, ау*. 1 \ ЛИ, 1::a 11 Cl» I-.^IÍ-uí-oJ! CL>! J JaI^JI ^J 1M-U 1JUJ1 ôlu>ji '«LJ1 yls> ^Haj! \лл 3 JiJ *<LuxJ Jl 办 一 1 ; 1 L, ' I^U^MJI U jf «Jus-S^L) J^AS- <v r «^ J^ó < L^-JUl Ji^l ЛЛС. ÓJlo JlJU) ^J^u U ^Jl L»^ j!b JJ? yu^^i Cijj c^ui>ji ^Jl 'ÜUVL, c^j jlki\ 3 J^=J! jlí^l íl^ ^ ljl^j «.jlofl, 'i^ji Ibi 0U jo-ji!jla ^ ÜL 产 0Ijl1JI l^a jju^ívi, djj) Í Lftj^Uo «.а4 ^ 'ij^s ^S i^kj, pjlji qi jjl i_jl l '"L^Jjl 己 ULkS. : -"U^J^s. ^.jiaji 3 f UiJI J6 j e l^l^'í/l c^lüjuji ^ io-xut ' JifL^Jt ^ (JUJI ^ jbuo ÏJlc ^ r)l\ loü^, J_,jJI Jíj^ 01 ^Jl Lia ' jlivl

94 A47/VR/5 page 79 JLo^l 3 Ljí ^jjl, ^o^lj. ' DUJ1 JiUuJI ^ LJ ^ ^ Mc A ^ o u 出 -^ >?Jb», fl 广 ^ ^ j ^^"Jl j U ^ I 0IjJ_J. 0 yl)l IJla ^ ^ J l ^ ::,.'.- -..Л ^LJL ijl^ u^j^b oj'y^' o' ^^ i> '^-"-jji ' Jkj^ d_, pyb JsUL; Ji_, p Jb^Jt ^aji ^UcJI ju=1 VI ^ i Ujla ^ ^ ç-^jj Lw L**/1 ci» «? If ^jjji s- 1 ju^i l «u^jji U^Jl^JI j-i^aji Jl^uJl ^JLÎ l^lji 0IjlLJI ^! " JbJu«Jt tll JI ^ JUC^L ^ И ^ Л uáji^jij «L^IjJL ^S ^LIJTJ IJla ^ (_ r Ic L^j^aJ.I JÍLÍlaJI i ÜojÜL. l^jln-oj í 4Ï Juj I 'iljo-^aji jl^aji i-í_j Li:^ J 力 :... 1,.! ^ ïj^ IsJíb Ij UUb.«i^JI o-o J^: J-I^-Jt Jij. L ^ y 1-1^1 Jlj^l I 丨 j I d^^ Lu/ Lo àjtyauj ájijb 丨 jj I I «J^IIû c^l^hol. _._«...^ Ig-.^IUJ 一 К SjUJI JiUuJI ^ i^ji be; ó^v 勺 I ^ ftisji J^'t ^ 'LuJUJIj "i^juji jl^ Ш Ul/l d^uki ci^jl l^o ;^I ^ fl U.IJL^I J 戶 ^ ' Jp^Jt a^il JU- ^ -ili J ^ bj]^ ^ ^J^v К vjijl (b^o Hj^JI Ji. j t.ïi^m ^-U «LáDI (^^If jju Ш fliji Jl^ JUi Ji-îb J^l^u. g I J U ^ I 0IJJL ^J ^r^^ оз 1^1 'Lr^J-" ^j^ji J U ^ I i^ji ^yj^c J^U ^ d 乂 j 3l zj\ jlil ^ IJla JU^M ^ dy.^oll ^jliji JL-JI 辟 JS bjb ^ I ^ y» L, H UUJIJS Jk^ LibUij! J^J. ^ J^.1 ^ ioiaíi^uj! c^l-jlilel ^JJI ^UciJI ^^Ji - ui 产 o^u^ju ^U- ^Ji ^UJI ^U^Jl ^ UUJlJI JikJI), 勺 I. U^k^ CUSJI ^ I^^ji -a^i 己..,-.o-. 11 'i^ju^ji j^u ^ 11 J ^ LJU ^aj tl^iji o ^ ^ JW-^" ' -ilu ^ U Ü 力 L 6.JUb^/l J^i ^s ^jli-a ^e^j^j Lcyby, л...:.,il. is-la- L a L JiJaJI^ pvl ci-ljj JuOj ^i^ji 'idilio» к) «i-juji -<LJ=>JI ^I^JI (O :^ L ^ jyi^ 山也 < Ï-w-JJJJI^ ' ^aji i^olül Цк pjj (Г) «Ljl jj! f^^ djuji.'^jiîl j^l;(1) ÍJL^JI '<L>JI<lo и 只 (о) 一 ^ ^ Ib^i.L^JI ^ 'ij^i o-o -. L ^! ^ Ü ST ers ^ 0JUJI J>> ' -wjuj! ' 5-míJI 01 ^^Jt - jièjj] ^ JiLíuJI.d^wJlj ^OeJL, ^Lá- ^jlku, ^j'li-u» ç-ôj lk:, JJI j^vl л<j 1 s^ J^O o'-v» j-^jj ju=l ^JÎ Uol ^U^J! Jiu^JI a^jji JUjc^VL, L»U L^ü 只 ^juji ^ 01 ^^ el^jju LJbJI ' j^jui ' С^ЛЛЛ, RT. ЫI CLJA^AJI) F ;, :J ^ÎL; ^J J. 1 ^JJUJI T ' U^JSU Lo Lollâ 1 jj^jlí dujjb I jj 1Л^л^мЛ JL J I U J I

95 A47/VR/5 page 80 *Lsü CL/1 jjus»vâjлliiôji^ JLo-я 二 以 *^ 1 ^L«L< «^^uxiji L»oJî JjjJI mroji^ ЬсГчлС^ I ЦГ>ЧЛДИ) 1 IWM4AJ 1 ^ CL^L J I ^ЛЛО Á^O L «ÁJT LBV^/ 1 «^ TX/ISÜ I LC^JJ 1 Í^JAJ^J JJ 1 JUMUJ 1 Lu**v^<kJ I J^Ü ^U ÜJJ^ Í^OIjc^lj^lo ^j/l L^mJI ^Ji ó?- ^jli-oji J^j ^ ^ I «N^yÂ-oJ I J^ü ^ I ^SJ^. лу^кл.о^ ó^o ÀJLSlû ^^Зчлси) I - 气./ * *»"«1 13 f ^O l-ij-> j^j^li Ü I FJLS «'â-j^^j! '<LJLJI «^LJÂJUJL J^.C,.<J 1 ^JLK^UJI 川 - vju^ímji J^jJI ci,! j jjlji ^JL O.O:; V; j j^jail. ^^^bji «^:L>Jli.^.ллаЛ -t>l jj! '«L^J^^ÍI c^l j L>uJI LJsLiu; j^^kj V^ I-ем/ Lu/! jjiix^t áj^ jj I j I ^J^l 己 LKaS jjí^} I J^Ü ^uu» ^s a^^wiaji.:tk Uo JlaJ^. 0 la_uji IJu» l^jlyg. :: o-,:.j Wr^b Ji-i ^Э cijpl 尸 V A:.'/:/1 «затхла-)! л oj^.а,л ci* L^ L ^^juxiv ^jj 1 I^J^ao^ JJJ js^ л:. 4 ij! i-^ii I ^JLc l^-lv Jl I Lo-o < I ^з j^ji I p 1 jj^ ójjs L> ^^JLc üjli J x J ^ J U w. 己 1 J Ls^oJI «LuJL«J 1 *..' : vjtj^1 ^-.U/ jci ^ ^lijl О^Л bb^sis A-.JL5JI J^ Д-^liJl 乙 Lô^ll ^^.U 己 ЯЬЛ *<5uu>J wilibî LuJUJî AA^JÎ.À 丄 ;AJ 浐 LAJI ^OAJI, "^ v^jlkjl «LâJ I <Uco 1 d^b^j LaJ! I A^KjAj^sy- ^Э M^gfLo I JsZ «-LiOj duj^tsb Laj>J! L^s^sur* Lji^b.^â'i t-^j-v-,dj^ü 己 L>ух**.' i л^лло Ljuo-. L^Â-iLo^ д.ол 11 二 д/< Is vsj t^u^sjj 1 ^ Ju***» IJJIЗ. JLLJ! IÓA ^JL CL/^^IJU 1-Я 1 JJ^ ^ '«IJLLI «Ш I d^j liu> áj, «J djb Lu> IS I a> c 1一.-«丄 I Ju»'LJ Auu^ jsj t Ó L*j>J rt-jtw^! I ^э ^jj^iuojl 产 g".4., J j 1 I jj^s fi.a ;,...ЛоM -LÁ/Í) jj! I^jJ dujij ^J 'iuûjliji ^ ^SJ üjl^'i «j^^^ji 4 :., 13 ' j^jji J^yb,11 ^juwl^ Mr THAN NYUNT (Myanmar): Mr President, Your Excellency Dr Hiroshi Nakajima, honourable delegates, ladies and gentlemen, it is indeed an honour for me to be here today at this auspicious World Health Assembly. I am grateful to the organizers of this all-important meeting for giving me the opportunity to феак on this occasion. On behalf of the Government of the Union of Myanmar, I would like sincerely to extend my warm congratulations to the President on his unanimous election. I am fully confident that under is able leadership the sessions of the Assembly will prove to be very productive and extremely beneficial to Member countries. It is noticed that because of the changing socioeconomic conditions and epidemiological scenarios all over the world, the modus operandi of the Organization must also be modified in order that it can be strong and healthy. In this context, it is very appropriate that the Director-General initiated a reform process, i.e., "the WHO response to global change". I am sure that this will lead to the Organization's becoming even more dynamic and responsive to the need. The Government of the Union of Myanmar would like to reaffirm its commitment to community action for health as a fundamental and essential component of health development. It is thus important that Member countries should identify new orientation in approaches and strategies for intensifying community action for health. No country will deny that involvement of the community to improve the overall health status of the nation is a sine qua non. The Government of the Union of Myanmar also endorses the fact that the strength of the nation lies within the country and in its people, and thus community action for health is essential not only in respect of health development but also broader social and economic development. It is in this context that Myanmar nationalstrategies and plans of action for achieving the goal of health for all have been formulated. It is generally agreed that nongovernmental organizations play a significant role in initiating and sustaining community action for health. Their uniqueness, creativity and willingness to work in remote and different locations give them greater credibility. Having envisaged the effective role that can be played by

96 A47/VR/5 page 81 these organizations, we all should give undivided attention and full support to their collaborative and synergistic nature. In the present era, it is seen that several organizations, be it United Nations or nongovernmental organizations, are involved in health care activities from different perspectives. It is high time that a mechanism is developed to coordinate the activities and interrelate the objectives and policies of those organizations if they happen to operate in a particular locality in order to achieve a synergistic and complementary effect for the beneficiaries. Thus, the activities carried out would be fruitful and more costeffective. Because of technological breakthroughs resulting from different forms of research, the health system has to deal with many new issues, including ethical issues. The degree of urgency, as well as the implications arising, vary from country to country. It is therefore urged that Member countries work together to arrive at a common understanding and solution. The emphasis in the formulation of the Ninth General Programme of Work is on support to countries and the international health community to reduce inequities in health, coupled with measures to tackle specific problems affecting health and health systems. This is highly appropriate, and the Government of the Union of Myanmar appreciates it very much. In this respect, Member countries should pay special attention to the policy orientations in order to provide the framework for WHO's work during The Ninth General Programme of Work will definitely maximize WHO's performance at national, regional and international levels. I am happy to convey the fact that Myanmar's current National Health Plan has already been drawn up, based on similar policy orientations. The capacity of many national health systems has been stretched to the limit because of increases in demands by the beneficiaries. Within the given limited resources, the only solution would be appropriate reallocation of financial, manpower and technical resources within the health sector. I am sure that the important aspects inherent in this will be given due attention by the Member countries of the Organization. The HIV/AIDS problem faces every Member country. The Government of the Union of Myanmar is sparing no effort to tackle and contain this problem by all possible means. The fight again HIV/AIDS has also been declared a matter for national concern. At this juncture, I would like to reiterate that this problem could not be solved by a country alone, especially in this age of easy and free movement of people. Member countries are called to fight this disease in an integrated and concerted manner under the flagship of WHO. This meeting provides a useful forum for us to explore various ways and means to improve the health status of the people based on the experience of Member countries. All of us must take this opportunity to the fullest extent possible. In conclusion, Mr President, may I once again thank the Director-General, Dr Hiroshi Nakajima, not only for his commendable contribution in leading the Organization in an effective manner but also for the achievement of â spirit of new partnership developed between WHO and its Member States, as well as among Member States. Finally, on behalf of the Government of the Union of Myanmar, I would like to state that under WHO's able leadership in the field of health we will work together in close collaboration with Member countries to achieve the goals of health for all. Dr CHRISTIE (Norway): Mr President, may I congratulate the President on his election as President of the Forty-seventh World Health Assembly. Permit me to take this opportunity to mention the close relationship which has existed for several years between Botswana and Norway. The cooperation between our two countries has resulted in improved health services for our people, mutual respect and understanding. Today we join the optimism expressed by Botswana and other African countries and congratulate South Africa on the free elections and the restoration of its membership in WHO. The signing of an autonomy accord between Israel and the Palestine Liberation Organization, scheduled to take place in Cairo this afternoon, is also an extremely positive piece of news. These developments in South Africa and the Middle East - two conflicts which have been on the agenda of the United Nations for more than 20 years - show that we must never lose hope in our efforts to find political solutions, even to long-standing conflicts. A sound and viable environment is vital for human health. It is therefore important to realize the responsibility of our generation to hand over a better environment to future generations. Health services can never cure the results of uncontrolled radiation from nuclear fallout. Nuclear disasters represent major environmental and health threats and they must be prevented. The Norwegian Government is firm in its commitment to improve environmental protection by securing nuclear safety. We recognize that a

97 A47/VR/5 page 82 commitment to nuclear safety requires national initiatives as well as international collaboration. Recent changes in Europe have created new and challenging opportunities in this field. Let me therefore use this opportunity to give you an example of promising regional cooperation on a range of issues including health and the environment. The Governments of the Russian Federation, Denmark, Finland, Iceland, Sweden, Norway, as well as the European Commission, have agreed to establish a council for the Barents region. This council will provide impetus to local and regional collaboration. The ministers of health from countries of the European Region, the WHO Regional Office and other agencies met in Norway a few weeks ago to discuss future collaboration in the Barents region. We agreed on a declaration which reiterates the commitment in the region to the WHO strategy for health for all. It addresses several important issues in the health area, such as improved mutual understanding and cooperation in the monitoring of health effects. We will also identify possible interventions to alleviate adverse effects of industrial pollution, of radioactive waste and of living and working in an arctic climate. We also agreed to support regional collaboration on health promotion and to improve health services. The development of better health services to benefit the indigenous people in this region is also an important aspect of our joint effort. We consider the Barents region initiative to be a good example of practical international collaboration to obtain concrete results and to solve environmental health problems. On this note we look forward to enhanced cooperation and involvement by WHO and its Member States in the field of environment and health. Last year my intervention in the Health Assembly addressed certain aspects of financial irregularities disclosed by the external auditor. It was reassuring to hear the Director-General declare at the Assembly last year that the slightest irregularities were unacceptable. Being aware of the measures implemented by the Director-General since last year's Assembly to rectify the situation to some extent, we look forward to further initiatives. The highest ethical standards in financial transactions are fundamental to provide the Organization with sufficient funding for its activities. In this connection permit me to address another point which we feel has not yet been quite sufficiently dealt with. This concerns the situation where Executive Board members enter into contract with the Secretariat. We do not consider this to be in accordance with good management practices. The members of the Board should refrain from entering into contracts with WHO, not only during their term of duty, but also for one year thereafter. I would like to draw your attention to the development of primary health care. It is promising to read last year's report from the World Bank, entitled World development report 1993: investing in health. The report focuses on primary health care as a means to better health, and an investment giving a sound return. These same points are made in WHO's regional EUROHEALTH programme. This programme puts emphasis on implementing new strategies of primary health care in central and eastern Europe, as well as in the newly-independent States. Providing health care to women is primary health care in practice. It is important to realize that a woman's health will directly influence the health of the child and of the whole family. The women's health should also be addressed for its own value, providing improved quality of life and increased well-being for all women. Norway will continue to support child-related programmes, safe motherhood, nutrition and reproductive health in WHO. In our opinion these are some of the areas in which WHO should focus its attention. Norway is worried about the increasing spread of tuberculosis and HIV/AIDS. We are aware that the spread of these diseases is interlinked. Tuberculosis has become "the big killer" of the two, claiming the lives of three million people every year. We believe that cooperation between these two programmes should be strengthened as it is of great importance that they reap the mutual benefits of the efforts made in fighting the disease. The HIV epidemic has grown dramatically since 1987 when the United Nations General Assembly recognized WHO as the lead agency in the fight against AIDS. The disease now dominates public health programmes in many countries, and it can no longer be perceived as only a health problem. It threatens socioeconomic development in many countries and societies. This has led other United Nations agencies to play more active roles in fighting the disease. The follow-up of World Health Assembly resolution WHA46.37 aiming at establishing a United Nations global programme on HIV/AIDS should lead to strengthened interagency efforts. Again I would like to underline the importance of developing clear mechanisms and procedures for coordination at country level. Also, I would like to emphasize that a new coordinated programme will not succeed unless there is genuine consensus and full participation from all sponsors. We should remind ourselves that a good drug strategy is necessary to fight tuberculosis. Clear governmental plans for controlling the tuberculostatic drugs from the production line to final consumption are the best guarantee to fight this disease. The failure to set up such national plans would open up further development of drug resistance and thus create major set-backs in the fight again tuberculosis. Through

98 A47/VR/5 page 83 the Action Programme on Essential Drugs and the ethical criteria for medicinal drug promotion, WHO has claimed a leading role in the global collaborative efforts to improve rational use of drugs. Safeguarding the quality of drug information in accordance with the ethical principles drawn up by WHO should be taken for granted as a basic policy in this respect. Finally, I would like to use this opportunity to mention one of WHO's success stories - the containment and dramatic reduction of dracunculiasis, also known as the guinea-worm disease. The number of new cases has been reduced by more than 80% in the past four years. Encouraged by these good results, we call upon the Secretariat to ensure adequate resources to provide total eradication of this grotesque, disfiguring disease. Norway is willing to give further support to attain this goal. If all Member countries could join forces in an effort towards achieving this goal, it would prove that WHO continues to play a major role in fighting serious diseases on the road towards health for all. Dr TAFIDA (Nigeria): Mr President, Director-General, distinguished ladies and gentlemen, I wish to express the heart-felt congratulations of the Nigerian delegation to the President of this august Assembly on his election. My congratulations also go to the Vice-Presidents and other elected officers. I should also like to congratulate our brothers in South Africa who have had all their rights and privileges restored. We in Nigeria do not claim a monopoly of the virtues of the primary health care approach, but it does have a special promise for us as a country with a dependent economy. Our fiscal commitment to social services has had to be curtailed over the last decade as a result of dwindling external earnings. And, while we have continued to appreciate the assistance provided by external partners, we have not deluded ourselves into believing that such assistance would continue indefinitely, or in the magnitude that meets our expectations. We have therefore accepted the challenge of mobilizing community support for our health development efforts. But even if government had all the resources to deliver our health care package to our millions of people, we would still need the community's affirmative action to ensure that priorities are rightly set, and that strategies do not only make the desired impact, but are sustainable - and we have such a virile and varied community in Nigeria: professional groups, nongovernmental organizations, village as well as community development associations, employers,groups, workers' unions, and special-interest bodies. While primary health care has provided auspicious contexts for mobilizing the community at the grassroots, it has been a daunting challenge, but one that we have bravely accepted, to carry the message of health to all members of the community. For greater efficiency, effectiveness and sustainability, the National Primary Health Care Development Agency was established by law in late The Agency took off mid-1993 and its presence is already being felt. However, although we attained a landmark of universal childhood immunization coverage of 80% in 1991, coverage has fallen sharply owing to economic and political setbacks whose effects we are now strenuously redressing, mainly through "increased awareness" campaigns and the development of local capacity for vaccine production. Nigeria recognizes the dangers posed by the AIDS/HIV pandemic. We have established a national AIDS control programme under the political direction of the National AIDS Committee chaired by the Minster of Health. We now have 102 health facilities in the country which have been provided with HIV screening equipment, with the assistance of WHO and the British Overseas Development Administration. In addition, some states of the Federation and private health institutions have installed screening equipment on their own. The national control of diarrhoeal diseases programme is operated along a three-phased strategy, including preventive interventions to reduce disease incidence, improved home treatment and improved health facility treatment. Much has been accomplished. Oral rehydration therapy (ORT) managers have been appointed in every state and trained in programme management. Over 6000 ORT units have been established and a majority of "care-takers" have been educated to understand the use of sugar-salt solution (SSS) in the home. Diarrhoea training units have been established in the four primary health care zones and in several medical college teaching hospitals. WHO training materials have been completely revised to conform to Nigeria's health policy, and a new three-day case-management course for first-level health workers has been devised. Over 2000 health workers, including more than 200 doctors, have been trained in the care of children with diarrhoea by national and state authorities alone. Thousands of others (over 3600) have been trained by other organizations. The problem of the shortage of ORS sachets is being addressed by the encouragement and establishment of local manufacturing companies. As we review the national programme periodically within the context of the primary health care programme we can take pride in our achievements, although much remains to be done.

99 A47/VR/5 page 84 In the sphere of nutrition, protein and energy malnutrition (РЕМ) and micronutrient deficiencies are widespread in Nigeria, a situation compounded by the incidence of iodine deficiency disorders and vitamin A deficiency. We are committed to universal iodization of salt by the year The short-term strategy involves the distribution of iodized oil capsules to all women of child-bearing age (15 to 45 years) in hyperendemic areas, while the prevalence of vitamin A deficiency is being assessed and mapped out in the country. The incidence of tuberculosis has increased with the advent of AIDS, and is being addressed under a joint national tuberculosis and leprosy control programme, which was established in 1988 and formally launched in Although tuberculosis poses the greater danger, it has so far attracted very little donor support compared with leprosy. We are committed to the control of the two diseases despite our limitations. We have another success story in the eradication of guinea-worm (dracunculiasis). A 90% decrease in the number of cases (from in 1988 to in 1993) has been achieved. Yet, only 37% of guinea-worm-endemic villages in the country now have potable water. My Ministry is working relentlessly with the Ministry of Water Resources and international donors to provide water in endemic villages even as we get on with vector control. We hope to have treated 80% of all ponds requiring treatment by the end of this year. In view of the need to handle the issue of drug administration and control with greater efficiency, this responsibility, which was previously handled by a department in the Ministry of Health, has now been devolved to a semiautonomous body, the National Agency for Food and Drugs Administration and Control (NAFDAC), set up in This Agency regulates and controls the import, export, manufacture, distribution and sale of drugs in Nigeria. However, policy issues and related matters remain under my Ministry. One of the macro-economic strategies for our health care delivery efforts is the female functional literacy project supported by the Peoples Bank of Nigeria through its innovative "Banking for Health" scheme, with inbuilt mechanisms for income generation among the poor female rural populace. Along with the Bamako Initiative, a community-based strategy to strengthen primary health care, and the proposed national health insurance scheme, we are thus striving to protect the health delivery system from the vagaries of the economy. In addition to the above-listed measures, my Ministry has developed an essential drugs programme with the assistance of the World Bank so that, together with the Bamako Initiative scheme, drugs are made available to the citizenry at affordable prices. For this purpose, a drug revolving fund system with cost recovery mechanisms has been put in place at federal, state and local government health institutions in Nigeria. In concluding, Mr President, 1 would like to take this opportunity to thank all those friendly nations and organizations who have helped us in diverse ways to carry out the various health activities in Nigeria. I also wish to appeal to those who have curtailed their assistance to us, or intend to do so, to please bear with us and continue with their assistance during these difficult times, considering their effects on the teeming masses of my country. Dr AL-SWAILAM (Saudi Arabia): : ('<Ljy^-JI ^ill^jl) ^J^J,-aJI <üluj! с/ 1 чи ^^^ da^l) hujî 4UJ1 太 Л о^ъ^ ч?^ 如 h U y ^jji ^Ь-о ^^Jl a^jj 1^ f^5^ 一一 UJ1 JU, C! 叫. 衡 -<UUJi ^Ül ^ o 1^1 一 '«LLJUJl ;Uol ^ JIjuJI^ J-J^l f^j о^ч^з Л u^b J^j^.^^Jl ^ ^ ^Sjlè ^JçkJI çij^i ^AJ! J3^3 М^Г-МП^ чн J^1 C^ fbji jtíj^ J^ Л ^JU ^^ÜJI US 山 aji ^ijb^ ^ '<ÜUJI ^ c^lo^uj^ C1.ÜUJI 己 U^M ⑶ 川 ) j c'ij^uj^ 山 ^ sribjl 3 v.r^1 ^ V U U & WLLJ >J1 叫 l^ui^jl, 山 Л Oi^ 1 '^ 1

100 y ^^^ cll^aji ^ ^ijj^laj! ^JuJI 只兵 U ^!^ci^l^ A47/VR/5 page 85 ójlj^ '«LJ^Vl '<L^>w^JI ^wol j^ij^ Lûjj^l f Lóf Л 山 jji ^JâA^ ' jlc l.. t j,.. jj ' JL; ^Jl ^bjl C^JI ci^l ^ U^l^ f^^c^icjl C^Ujl^ JU^^I д-.-'к^ ) I J5 LiuJ I ^o jujlíüj I ^J^CLLU dli^-o J'<5L> L«J I ^As. ci;^jâ^ «'i Lu>J I ci^ Ls»-s уь Jjxl 丄 J fjuj! ^ 力 ^c^c ^jls. digjjl^i LU ^ Ln5J. '«L^-Jlj vjllôjlj ^^ '«jjbjic t Lssj! 3rt r..o r/.l'4vlcluij^jji^ ci^ui^aj! ^ L/^Jl^ ci/lcl>w<j!^ j-sjuji ^sjll) duj^-o I jjb Liü^ "<L ^aoju5iji A wa JI J^bj-o ^J! ójj^ V, La^Vl ^ ' <>î О- 5 4 s ^ L^^/l ^ '<LxJ >JuJj ^-.jlic çjuaj 'LcoLJl 山 jji JJf rt-.j^j ^^Jb JiLiuj^ cijj^sujl J\J zj,\ ÓJL-З L03 «^JLeJI 山 Ü ^jodulo^l CI/^JL^O c^i JL yjja lai LaJ I d-ji J^^LW Lo^j)-*-;:'.-! 1 d-j jj-jûly ЦЛл-гО Д bol 1 d-s^-j djul: a-ujljji '(UW«AJ1 loilio jlbl LiJLc^ ^^jji ^pu ' lllj! LJ^^MJI У ^f^jl d,:ul *<LLx^J A^li^ Hi: 己己 : ^^cji ^-cu^ji J.OJB JI ^ djalqj d»i! ^Ju> ^ç-jx LA 1_*5l U> JUwJI^ ^ l^ l^j^o c^iai SXj^ ^^oj! ^э I ^-.U-Jl '«L^îj^JI '^jl^ji^ ' c!^ du^ji^ O 11 ci,lk>l;j._jl 3 c^u/jluji ^ ^,П 1 ; j.q^-. 1 Uj JJ^AJ^ Á^JÍMJ '^JLÍ^! j^w-cji 产 ) clll^>j1 ljjb 0 C \ loiliji '«Lux^J! 己 Ц^^ЛМ l J-;,<: LOUIAI ^О^л-Л Vf^1 ^- ид Láe ^-cû-iûlj l.«r «.o.r»> l-v.l.a^ Lo 1 j I ó j AlÂrx^ «Jlo^Lm/^ ^J LuaJ^/ î Л j Ls U> ^jjlc J IaJk-U л^о L> d_> l-lff ««J LíxJ I 'i^ji O 1 Ifr-'l ^ {W^ 'i^ji ^ UwUl U> üi jl^l. 'i-^-ji '^U^J!^ JUjI ^ ojlî.'á-j^i V JI ' ou^i 只 JiU ^ - ^líuji culbui ^J^ ' IjLJJj. ' - o k ^ J I ci,l,jl JI V.. 4 ". 11 J- 1 з U l ). V llll J! ^ ^iui ^ i.jj^^l, Lg^lo ^ üi^ ^UJl i^l jisi ^s ájji Од-w ^Saz l^aul ^LiuJi ^o о- 6j\j 3 f U Ji ^-U ^ ^ ^ jj î Vd^-xAcJ «^^i^skaoj ICL» Lô I ^-iwxalj JLÎL^JI U^j J^c ^ V^jJI i-u-jt c^uuiil ^ IJL^ ^L^HI U j3 O ^Ji düu^ jjbc^, Lo^i LU JUJI ^J ^J 'i^j! j-íuj Ig^JUj.i^U^lM ^ ^ Igj.JJL^. UAJl LbJ fjuji 0'\ 1 j f L*vjJ I ^ CLI^JUXJI UJUJI LcJLc олн^ " o^ 匕 1^ o 1, c^ 乂 Jlbl di y. 丄 <J1 ojbcji ^! u^ c^l^^ji ^ Ji 0 e \ ' ojliji I f < r. U i 'LuJL$J1 loüju) «LJáJuJl Ó j^j áo^lxji JLUJI Le Professeur MINCU (Roumanie): Monsieur le Président, Monsieur le Directeur général, chers collègues, Mesdames et Messieurs, c'est un grand honneur pour moi de féliciter chaleureusement M. Temane pour son élection en tant que Président de la Quarante-Septième Assemblée mondiale de la Santé, et de lui souhaiter plein succès dans l'accomplissement de cette haute responsabilité. Mes félicitations s'adressent également aux autres membres du bureau et j,ai la conviction que, sous leur direction, les travaux de l'assemblée vont se dérouler d'une

101 A47/VR/5 page 86 manière efficace et aboutir à des résultats bénéfiques pour nous tous. J'aimerais aussi remercier M. le Directeur général, le Dr Hiroshi Nakajima, et ses collaborateurs pour l'oeuvre remarquable accomplie par l'oms afin d'améliorer l'état de santé dans le monde. Je voudrais saluer la décision prise à l,unanimité par notre Assemblée visant à admettre en qualité de Membre de plein droit de rorganisation mondiale de la Santé l'afrique du Sud, qui vient d'organiser avec succès sa première élection démocratique. J'ai suivi avec grand intérêt le rapport présenté par le Directeur général sur l'activité de l'oms en Notre délégation apprécie hautement ce document qui reflète l'activité riche et complexe de l'organisation au service de tous les Etats Membres. Permettez-moi de vous informer que le Gouvernement de la Roumanie et le Bureau régional OMS de l'europe ont signé tout récemment un programme-cadre de coopération à moyen terme pour la période Ce document s'inspire des priorités de la réforme sanitaire en cours en Roumanie et reflète, en même temps, les stratégies de l'oms. Il offre ainsi le cadre de référence pour que l'organisation puisse contribuer aux efforts du Gouvernement roumain en vue de réaliser ses programmes de santé. Le nouveau système de santé que nous avons commencé à établir repose sur les principes suivants : développement des soins de santé primaires, décentralisation du système de santé, nouvelle modalité de financement des services de santé par l'introduction des assurances de santé, création d'un cadre national pour accréditer les fournisseurs des soins de santé, et mise en oeuvre d'un système mixte de services de santé publics et privés. L'approche soins de santé dans ce système sera fondée sur les prémisses suivantes : équité, solidarité des utilisateurs des services, libre choix du médecin par les patients et coopération entre les fournisseurs. Pendant la période de transition actuelle, qui s'avère complexe et difficile, nous avons besoin du soutien de l'organisation mondiale de la Santé, du Bureau régional et de tous les Etats Membres, avec lesquels nous avons déjà conclu de nombreux programmes de collaboration bilatérale. Nous comptons aussi sur l'appui financier offert par l'union européenne et par les pays du "Groupe 24". C'est avec satisfaction que nous constatons que l'ordre du jour de l'assemblée contient des sujets d'intérêt pour la santé publique de la Roumanie, par exemple la santé et le développement, la santé de la mère et de l'enfant, la planification familiale, l'éthique dans la promotion des médicaments, la lutte contre la tuberculose et le SIDA. Je saisis cette occasion pour exprimer la volonté de la Roumanie de participer, en coopération avec les autres Etats Membres, à la réalisation des programmes de l'oms dans ces domaines et pour déclarer qu'elle est disponible à cet égard. Mon pays pourrait mettre à la disposition de l'organisation des spécialistes roumains, dans le cadre de ses projets, organiser la formation de spécialistes, et contribuer à la conception et à la construction d'unités sanitaires et sociales dans d'autres pays. La Roumanie, qui observe strictement l'embargo imposé à la République fédérative de Yougoslavie (la Serbie et le Monténégro), est affectée, elle aussi, par les conséquences économiques graves qui en découlent, y compris dans le domaine de la protection de la santé. C'est pourquoi, nous apprécierons que, outre d'autres organismes internationaux, l'oms mette en oeuvre des programmes spéciaux d'assistance technique au bénéfice des pays les plus touchés par l'embargo. Je tiens à réitérer le fait que mon pays est prêt à participer aux actions qui seront décidées à cet effet par la communauté internationale en ce qui concerne la reconstruction après le conflit sur le territoire de Гех-Yougoslavie, y compris le réseau sanitaire de la zone à la réhabilitation duquel, j'en suis convaincu, l'oms apportera une contribution spécifique. Pour conclure, j'aimerais remercier M. le Dr Hiroshi Nakajima, Directeur général de l'organisation, tout comme le Bureau régional OMS de l'europe, pour Passistance offerte à la Roumanie, et j'exprime la conviction que cette excellente coopération se développera davantage. Mr YUSUF (Bangladesh): Mr President, Mr Director-General, your excellencies, distinguished delegates, ladies and gentlemen, this is a unique opportunity and great honour for me to be in the midst of the distinguished leaders in health development. Permit me to congratulate the President on his election to the high office which he so richly deserves. At the outset, let me congratulate South Africa on her re-entry as a Member of WHO. The democratic elections which took place in South Africa will go a long way towards bringing about peace and stability in Africa, in South Africa and in that region. Since her independence in 1971,Bangladesh has been making sustained endeavours to improve the quality and content of life of the people and has attained a considerable degree of success, despite resource constraints. Food production has almost doubled, life expectancy has increased by almost 30% and child mortality has decreased by 40%. Infrastructure has been set in place, new industries have flourished and

102 A47/VR/5 page 87 the people have reaffirmed their commitment to democracy. The Government of Bangladesh has been pursuing a consistent policy of health development that ensures provision of basic services to the entire population through primary health care, particularly to the people in rural areas, where health facilities were extremely poor from the outset. In the midst of myriad problems, the country's health care delivery system has been improving during the past decade. With the progress in decentral ation of the administrative system and the inception of the democratic system, tangible success has been achieved in health infrastructure development, production and deployment of manpower, appropriate attention to human resources development for health, and addressing the equity and the gender issues. I am delighted to draw your attention to two laudable achievements concerning the success of oral rehydration therapy and attaining high immunization coverage in the country. The national coverage with DPT-3 and OPV-3 for children under the age of one year and up to 23 months is 74% and 88% respectively. However, full immunization coverage of children under one year of age is 62%. BCG coverage is 96% for children under two years old and ТГ-2 coverage for mothers of child bearing age is 80%. Mothers are universally aware of the preparation and use of home-made oral rehydration salts. The infant mortality rate has been substantially reduced as a result of oral rehydration therapy and success in the expanded programme on immunization. We are in the process of achieving progressive success in the population control programme. The present contraceptive prevalence rate is about 45%. The total fertility rate is 4.0 and the population growth rate has fallen to 2.02% in The Government has been pursuing a community-based family planning service by organizing satellite clinics each month in the country, with a view to providing a family planning service within reach of the target mothers. All-out efforts are being made to curb the population problem and the boom. In order to achieve health for all by the year 2000 through primary health care, reorganization of the health care delivery system has taken place at different levels. The district hospitals are being strengthened in terms of expansion of service provisions and quality of care. The Thana (sub-district) health complexes are rendering curative, preventive and promotive health care services to the community. Health development committees headed by elected public representatives, including members of Parliament, have been formed and given overall responsibility for improving the health care system, both at sub-district and district level hospitals. A management committee is being formed to improve the overall management of hospitals providing tertiary care. It is envisaged that this will bring positive changes, particularly in community participation, intersectoral action, mobilization of local resources for health and developing a cost-sharing mechanism, in the course of our renewed efforts for health development in future. A need was felt to devolve more authority to the hospital, introduce local funds, and generate mechanisms to ensure more control by hospital administrators over planning, budgeting and spending. With these objectives in mind, the Government undertook a study on hospital organization and administration, with the assistance of WHO. It is expected that the first phase of implementation in line with the study will be launched soon. In view of the need for concerted endeavours towards development, we recently launched a programme: "Education for all by the year 2000 AD." Some of the major targets are the following: compulsory primary education; a food for education programme; increased enrolment in schools; free education up to class eight for girls; establishing new schools and promoting adult literacy through the informal education system. National and international nongovernmental organizations are also putting their heads together in this struggle to eradicate illiteracy throughout the country. Nascent concern about environmental population and health hazards were not left out of account. Bearing this in mind, in line with the instructions of our Prime Minister, a separate Ministry has been set up to look into the environmental issues. Under the fourth population and health project, with assistance from the World Bank and its co-financiers, we have launched the biggest health and family planning project in the country since Particular attention has been given to the maternal and child health programme. In Bangladesh the distribution of the static health facilities is in line with the administrative units. The lowest tier of the Government administrative unit is the Thana (sub-district). There are 460 in the country, in which we have 397 Thana (sub-district) health complexes (that is, hospitals), each with 31 beds including six beds for maternal and child health; they are adequately staffed with doctors, nurses and paramedics, including an organizational set-up of field personnel. At the union level, the static health facility is the family welfare centre. Out of the total of 4350 unions in the country, 2853 have such centres built to date.

103 A47/VR/5 page 88 Private sector involvement in health is another avenue that is fostering progressive positive changes in the country's health system. Recently, quite a number of hospitals with specialized health care facilities have been set up by philanthropic individuals or organizations. There are at present five private medical colleges in the country. A number of deficiencies still exist, impeding effective implementation of the health-for-all strategies throughout the country. The Government is aware of these weaknesses and has initiated efforts to overcome them. There have been improvements in many respects, but there is tremendous scope for further improvement and positive changes in the managerial process, so as to ensure more effective implementation of the health-for-all strategies. This requires not only mobilization of internal resources but also increased external support and international cooperation. The priority tasks ahead are the following: curbing the rapid population growth, mobilization and utilization of internal resources in a more equitable manner, in line with the priority needs and aspirations of the people in general, creating a congenial political environment and stability based on a democratic consensus, ensuring people's participation in government efforts, strengthening intercountry cooperation and partnership in development, and improving the planning and managerial system. With the introduction of its national drug policy, Bangladesh made substantial gains in increased local drug production, improved quality assurance and easy availabiliy of essential drugs at a cheaper price, even at the rural level. In order to obtain full benefits from the national drug policy, Bangladesh is in favour of the implementation of the WHO recommendation for monitoring of the WHO ethical criteria by the prescribers and pharmaceutical companies; it also supports the development of capacity-building at the While I am speaking here, thousands of our people are suffering from a severe cyclone which struck yesterday, on 3 May 1994,at a speed of 250 km per hour. The detailed damage and death toll are yet to be known. At this point, I would like to recall the decision of the Conference of Ministers of Health of the South-East Asia Region to set up a WHO-sponsored emergency preparedness and response centre in Dhaka for Asia and the Pacific. The Director-General of WHO was present at that meeting. I would request the Director-General and the donor community to extend their full support and cooperation in order to set up the centre in Dhaka at the earliest possible time. Dr ADAMS (Australia): Mr President, 1994 is the year when, to quote this morning's Herald Tribune, the Republic of South Africa shed the moral outrage of apartheid. We wish to record our great pleasure in being able to welcome the representatives of the new South Africa to this Assembly. When we met in this hall in May last year this Organization was at a watershed. It was, and I would argue still is, at a crucial time in its history - a time to put the assumptions and the practices of the past forty or so years under the microscope - to discard what is no longer needed, to include new ideas and to change for the better those things that have failed to keep pace with progress. We have made a start, but only a start. Dr Nakajima's report on events in the past year point to some laudable changes in management and in administration - some of them long overdue, some of them not going as far nor as fast as we would like. The questions that we - as Member States of WHO - must now ask are first, whether the scope and the pace of change have gone or show promise of going far enough or fast enough to ensure that the Organization is able to meet the expectations that we have for its future operation and survival. But the most important question of all is one that we, as Member States, have so far avoided. What sort of Organization should WHO seek to become to meet the challenges of the twenty-first century? The warning bells are sounding. They are telling us clearly that what we have now is not serving us well. There are fewer dollars flowing into extrabudgetary-funded programmes. There are problems of cooperation with other agencies. There are also questions of WHO's effectiveness and relevance in the field, and an all-toofamiliar caricature of WHO as a bloated dinosaur doomed to irrelevance or, at worst, to self-extinction. We have a responsibility to ourselves and to the people of the world - particularly the developing world - seriously to address that question, and to do something about it through the process of reform of WHO and its administration. Australia stands ready to play its part. Biomedical ethics is the theme for the Assembly this year. It is an issue that demands our attention as the traditional limits of medical research and clinical practice are transcended. We see too often a politicization of narrowly defined health and biomedical issues. This Assembly is an ideal opportunity to look more broadly at these questions. It is a chance to relate the ethical issues to wider social policy - to legal, to equity and to human rights concerns. We shall not achieve transparent and acceptable regulatory

104 A47/VR/5 page 89 standards, as well as structures and mechanisms to address ethical issues, except through international dialogue. Australia welcomes the emergence of active and constructive debate on the adequacy, the usefulness and indeed the validity of a biomedical approach to ethics that fails to take due notice of the broader social perspectives. Historically, approaches to health and ethics have been articulated from a strictly biomedical perspective - the trial of new medical therapies being accepted as central to health advancement and worthy of ethical debate. Currently, there exists a dynamic view of health as evolving to meet changing social and economic demands. Health research is increasingly incorporating a social perspective that goes beyond the confines of a biomedical paradigm. It has been extended to explore social issues through research and to assess implications of research and treatment implementation. Ethics has simply not kept pace with this changing view of health and remains predominantly biomedical. The rapid and unfettered growth of high technology in the health industry is a prime example of the need to consider social, cultural and resource issues in our expanding view of health. It is not just the ethics of treatment that must be considered in a climate of finite resources, but also of resource allocation both within and between nations. Australia is well-positioned to provide a forum to discuss the social and resource implications of health research and practice which, too often, have remained within the province of medical professionals. I am proud as an Australian to draw the Assembly's attention to the first meeting in Geneva last month of WHO's Global Commission on Women's Health. A most distinguished Australian, Patricia Giles, recently retired from the Australian Parliament, has been given the honour of chairing the Commission. The Commission, I can assure you, is in good hands. Australia is pleased to see that Nauru and Niue have sought to join us as Member States of this Organization. My Government welcomes and strongly supports both these applications and looks forward to the positive contribution to our work that I know both countries will make. I would now like briefly to outline some matters of particular interest to Australia. The World Bank's report, mentioned by other speakers, World development report 1993: investing in health, is a seminal document. It challenges our stereotypical view of health and I trust will have provoked a healthy and constructive debate in this Organization. Its crucial message is the strength of the link between economic development and health. Its analysis points us clearly in the direction of a greater investment of "health dollars" in primary care as giving the best economic return on our investment. It is a cold, hard look at health - not one we are used to, but in these times of rationing of resources, the model is one that challenges our approach to the allocation of research funding. The World Summit for Social Development in March next year will concentrate on three main issues: on the alleviation of poverty, on productive employment and on social integration. The report is highly relevant to this important process, as it signals the challenges of achieving an effective and comprehensive health response to the political, social security and economic dimensions the Summit will address. Our input will be important and must be a considered and forward-looking one. My delegation has raised the issue of tobacco-smoking in this forum in recent years. It is one deserving of more attention and this is supported by the World Bank's report. Its authors point to the economic cost to developed countries - and increasingly to developing nations - of tobacco-related illness and premature deaths. We know from research and from experience that the best way to reduce or stop tobacco consumption by those already smoking, and to prevent our youth from starting, is to embark on health education and promotion strategies, combined with economic and regulatory mechanisms. There is a strong case for WHO to take a much more prominent leadership role on this increasingly important question of public health. In passing we note at this Assembly some progress on implementing last year's resolution to ban tobacco-smoking in United Nations buildings and we note with pleasure that at least one of the coffee lounges, during this Assembly, is smoke-free. But travelling here through many international airports brings us to the conclusion that it is high time that tobacco products are removed from duty-free shops in the world's airports. Australia is a significant contributor to global health programmes and has a strong interest in humanitarian and poverty-alleviation programmes. We place particular emphasis on developing strong health links with countries in our own region. Advances in public health, and ensuring that limited health resources are allocated effectively, cannot be achieved without the support of politicians and those managing national and international budgetary allocations. Effective allocation of limited resources also requires moving resources away from high-cost clinical interventions to lower cost public health and essential clinical approaches. This can mean throwing out a challenge to powerful and vested medical, health and business interests to act in ways that are most beneficial to those most in need. The Philippine and Australian Governments recognized this challenge when they agreed last year to work together to develop the Philippine national drug policy and a strategy based on the use of essential and generic drugs.

105 A47/VR/5 page 90 The seriousness of the AIDS pandemic and its disastrous effects on health and economic development were eloquently highlighted in the World Bank's report. Clearly, there is a need for us all to do more to meet the global challenges of this disease. Many issues relevant to the development of effective global and country level responses to this pandemic were raised by the report. We strongly support the process of consultations on the development of a joint and cosponsored United Nations programme on HIV/AIDS. Yet it is evident that much more work is needed to develop the crucial details of how the programme will work, what it will do and whom it will involve. Such detail is a necessary precursor to an assessment of whether the proposed programme will be successful in overcoming the barriers to a well coordinated and effective global response to AIDS. We urge WHO to cooperate with other agencies on this issue to ensure speedy clarification of these details. Australia is pleased to co-sponsor the resolution on the health of indigenous peoples at this Assembly and, in this regard, the Australian Government has announced it is committed to significantly increasing funding for health programmes and services for indigenous Australians in this current year's budget. Last year in the Assembly we adopted a resolution on the continuing practice of female genital mutilation. This practice is of major concern to my country. Australian health ministers have now declared that female genital mutilation is totally unacceptable in Australia and have agreed that all required steps - both to educate people and to enact legislation - should be taken to put an end to it. At this point I deviate from my prepared text to stress the importance of this issue. Australia places high emphasis on women's health and we urge other countries to take a similar stand. While it is predominantly a women's issue, we urge the men at this Assembly to show solidarity with women and, in particular, to attend tomorrow's briefing on female genital mutilation. The Western Pacific Region of this Organization remains under firm stewardship. I would like to congratulate Dr S.T. Han on his re-election to the position of Regional Director, and assure him of our fullest support during his second term of office. Finally, Mr President, let me reaffirm in the strongest terms Australia's commitment to WHO and to ensuring that our Organization serves the interests of world health in the coming decades. We realize that this may involve some reassessment of our objectives and some redefinition of our direction. We do not shy away from these challenges. Indeed, we are confident that these challenges can be met within the overall context of the on-going response of the Organization to global change and we note the importance, and significant responsibility, of the various mechanisms which the Director-General has created to further this work. We note also the relevance of the group of eminent personalities - the task force on health and development policies - in defining and guiding WHO's way in the ever-changing world of health. We look forward to a speedy return of WHO's reputation for excellence which it has, in years gone by, deservedly enjoyed. Dr YADAV (Nepal): Mr President, Mr Director-General, honourable ministers, distinguished delegates, ladies and gentlemen, allow me to join other delegations in expressing my heartiest congratulations to the President, on his unanimous election to the high office of the presidency of the Forty-seventh World Health Assembly. Congratulations are also extended to the other members of the Bureau for their deserved elections. Our appreciation and gratitude go to Dr Hiroshi Nakajima, Director-General of WHO, for his excellent account of the wide range of activities carried out by the Organization. I appreciate the excellent report prepared by the Secretariat which is before us for our deliberation. We are,particularly, very hopeful as regards initiation of intensified WHO cooperation with the least developed countries, of which my country is one. Various activities have been started under this programme and more activities have been identified for the coming years. Timely approval and initiation of such activities are very crucial if we are to achieve the most progress in the indicators of health, particularly in terms of equity, accessibility and delivery of health services to the people in general, and the underprivileged in particular. I also note that other topics on the agenda of this august gathering cover a wide range of significant issues of the time. The parliamentary democratic system is gaining ground in the Kingdom, and has embraced the fundamental values of human rights, freedom and justice for the people. The democratically elected Nepali Congress Government has for three years been making arduous efforts to deliver social justice to the disadvantaged and underprivileged sections of society through launching various types of programmes targeted on rural areas. A major portion of development expenditure, about 70%, has been allocated for rural development. Nepal faces a daunting development task in overcoming its economic, social and environmental problems. Per capita GNP has stagnated at around US$ 180. There are wide rural-urban gaps, and 90% of the population live in rural areas. The population has doubled in the last 25 years. The

106 A47/VR/5 page 91 declining quality of the environment, resulting in natural disasters such as landslides, floods and soil erosion, is taking a heavy toll on the living conditions of our people. Consequently, development resources have equally been adversely affected. My Government is also concerned with full participation of women in the process of development. Several measures for improving the status of women have been undertaken. The Ministry of Health is greatly concerned at the high maternal mortality rate in our country and therefore has identified the Safe Motherhood Initiative as a national priority programme. To that effect, training and deployment of a very large number of female community-health volunteers and trained birth attendants are some of the positive steps we have successfully so far applied towards reaching the targets. The national nutrition initiative, in line with the recommendations of the International Conference on Nutrition, is another positive step we have taken for the benefit of women and children. Another important issue is the increasing cost of health care. My Government is seriously looking into alternative ways of health care financing; and at the same time is encouraging the expanded participation of the private sector, nongovernmental organizations and the community in the health care delivery system. The current health situation in Nepal is characterized by an unduly high infant mortality rate, including children under five years old, a very high maternal mortality rate and high crude death rate and morbidity rates. Causes are associated with pervasive poverty, low literacy, poor mass education, high population growth, rough geographical terrain, low level of hygiene and sanitary facilities and limited availability of safe drinking water. The problems are compounded by underdeveloped infrastructure, weak management functions and poor coordination. Of course, the infrastructure is improving now. The high level of malnutrition is a serious threat to survival and development of children and women. Emerging health problems include HIV/AIDS and other sexually transmitted diseases, malaria, kala-azar and drug abuse-related conditions. Noncommunicable diseases such as cardiovascular diseases, cancer, diabetes, mental disorders, and accidents and poisonings are on the increase. The Ministry of Health has given priority to the development of health infrastructure and human resources for health. Although far from adequate, a network of health care delivery and supporting facilities has been established throughout the country, based on the principles of decentralization, regionalization, equity and community involvement. With a national health policy under its Eighth Fiveyear Development Plan, Nepal is fully committed to the health-for-all strategy, an integral component of which is strengthening the district health system. I have tried to highlight some of the major issues in the field of health and population in Nepal. I hope that you have gained some fresh insight from our experience, which is a blend of success and failure. We have likewise learned much from your experiences. For whatever success that we have achieved, we would like to share the credit with our donor partners and neighbours, to whom we extend our warmest gratitude. In this connection, I call upon all multilateral and bilateral donors, and technical collaborators to support Nepal in the areas, particularly, of institutional building, human resources for health development, capability building, management and coordination, and strengthening of district health systems. I would like to draw your attention to the pressing needs of least developed countries, of which the number has reached 47 at present. These countries are more dependent on external assistance to meet social sector expenditures than other developing countries. Aid requirements of the social sector are high in the least developed countries, but external financing for the sector does not seem to be receiving all the attention it deserves. Given the pressing needs and underfunding in most least developed countries, further increases in the share of aid devoted to the health sector are urgently needed. Therefore, I urge this august Assembly to pay special attention to the particular needs of the least developed countries and take concrete measures for providing them with greater support from the international community. I would also like to put forward for consideration by this august Assembly some observations on medical education. Medical education should aim to bring changes in the behaviour of people for the better quality of their life. There has to be qualitative change in the present medical education system in order to provide better services according to the needs of the communities. While I have the floor, I would like to express my sincere congratulations, on behalf of my Government, to the people of South Africa for their successful struggle for a new, democratic South Africa. This is a victory of humanity, human rights and freedom of people. I join other delegations in welcoming South Africa to our Organization. Last but not least, I would like to express my appreciation to WHO for its active support and leadership for the better health of the people of the world. On behalf of His Majesty's Government of Nepal and on my own, I wish the Assembly every success in its deliberations.

107 A47/VR/5 page 92 Mrs ALEXANDROVÁ (Slovakia): Mr President, excellencies, distinguished delegates, ladies and gentlemen, allow me to join previous speakers in congratulating the President and all the Vice-Presidents on their election as high officers of the Forty-seventh World Health Assembly. It is a great honour for me to address this Assembly on behalf of the Slovak Government. It is my pleasure to compliment the Director-General for his biennial report. Without any doubt the achievement of WHO has been considerable. We fully endorse sustained high support to children's and women's health, intersectoral coordination in the fight against AIDS, integrated approaches to promote the control of noncommunicable diseases, support to health-and-environment programmes, etc. During the biennium WHO upheld its commitment to health, increasing its direct technical support to countries in most need. I am sure that the proposed Ninth General Programme of Work will lay the foundation of more effective and efficient support to countries also in central and eastern Europe. The situation in my country as well as in other new countries in central and eastern Europe is not promising. Unemployment and recession are increasing. The transformation process in my country towards a market-oriented economy is accompanied by drastic shortage of public budgetary allocations to the health sector. This decline, together with accumulated debts affecting health facilities, have led to a sector-wide financing crisis. To avoid jeopardizing reduction of the quantity and especially the quality of health services, my Government has to adopt the following necessary measures: to quantify and specify real demands of the health sector on the State budget; to find means for the alleviation of budget debt in the health care sector; and to change the existing fee-for-service mechanism. An environment of support for system changes in key fields of health will be created parallel to these necessary measures. My Government will endeavour to create sustainable financing of basic health care, to support the development of the Health Insurance Fund and to secure it with a really self-sufficient economy. The fee-for-service system in operation since October 1993 will be replaced by a more efficient, simpler, more user-friendly and cost-effective system. It will vary according to the different types of providers. In this respect my country is seeking international cooperation: I am convinced that the joint meeting of the WHO Regional Office for Europe and Project HOPE on health and health care financing strategies, to be held in Bratislava (24-26 May 1994),will provide a good chance for sharing experiences in this field. The reform affecting all parts of society, and the health care sector in particular, has shown the importance of implementation of ethical principles and norms and has found its specific reflection in the Deontological Codex formulated by the Slovak Medical Chamber in 1992 as well as in two key acts prepared for approval by the Slovak Parliament in the near future: the Health Care Act and the People's Health Protection Act. These acts are based on the right of the citizen to health protection according to the Constitution of the Slovak Republic. They regulate the following ethical issues: the rights of patients and specific health care interventions, including transplantation and artificial fertilization, biomedical research and other subjects. Patients,rights according to our acts comprise also their responsibility for their health. The ongoing discussion on patients' rights should prevent tensions between health professionals and patients, particularly in the present difficult economic situation. The patient's right to give informed consent for treatment, as well as the requirement for the health care providers to be more accountable, generate new demands on physicians. The requirement of providing appropriate training in medical ethics to health professionals and medical students resulted in the establishment of the Institute of Medical Ethics and Bioethics, which implements the concept of joint authority for undergraduate and postgraduate education in medical ethics and provides a suitable model also for other countries (this was recognized at the European Conference on Teaching in Bioethics, held in Bratislava under the auspices of the Council of Europe in November 1993). I was pleased to learn that the Technical Discussions this year will be devoted to the subject of "Community action for health". The concept of community action is now the object of greater interest and support in my country. Despite all previous efforts of the Slovak Government, the health of our population is alarming, according to life expectancy and morbidity, in comparison with other European countries. The declining life expectancy in adulthood in males is a remarkable feature in my country. It is attributable mainly to cardiovascular diseases, cancer and injury, and to lifestyle factors such as smoking, alcohol consumption, unhealthy nutrition, obesity, stress and lack of physical activity. A new health promotion strategy should therefore comprise restructuring of health services to provide promotion and prevention on one hand, and more efficient involvement of communities in their own health on the other. The national health promotion programme adopted in 1992 has created the foundation for such efforts. The programme, now revised, is based on the health-for-all strategy. The Ministry of Health of the Slovak Republic and the

108 A47/VR/5 page 93 WHO Regional Office for Europe are trying also to tackle this problem by enhancing mutual activities in all the settings of daily life, cities, schools and workplaces. However, here also, success often depends greatly on the availability of financial resources. Ladies and gentlemen, let me express my hope that we all shall reach the targets set by WHO. Mr AL-BADI (United Arab Emirates): : ( ' a^uji D y^ji ju^i P J "V^J I I <3LJÜ I [^Лм ^JAJ^a^ÍjJ I С--; I ylf ôwj ^J I-Лл! ^ Á^Si^j LuaJ I d-*.^-) LaJ I 1 ^JAJ-AIÍJ l^u/ d-> LoJaJuvJ 1 ^Jbuo-o Ls^/ t «J^j^J 1 P I ^ ^ y^u^j <! J La-u/ ( ^ I j'j^j I ^J i A^uü LaJ I I d.ojr>_vo ^ Lf ^ Jlo d^^j^vjj 1 ^ 確 厶! I ^y^sfj ^J Lji-ûJ 1 I ^-ЗчЗ-Я-***^ i \S> djj I <3lo-> 产 i^jlg I i L«aaJ I ^ 1 I jlovl dj^j ci; LyC 1 ( L LS1 3 ^JAJU^S jj 1 I, I yli ó J L_g. Jj duuoj L*J I <Vj>vaJ I jj! <J JlA "«jjl J I L^jJI^J jj I LlûJ I ó Jl^J ^^Liviul л^ш J^J ^LXAÔJI ^ '«LUJLAJI '«LX^CJ I DUOJAJU> J^JI JIL DJ^ J ÜÜL < '<L I JL_J! ^J l-д-л JL<x5 **v 1 JuA-» ^-Jd-uaJU dj^ J ^ I d-o J IJJ I 4-UJJ LsJ I Aj>ws<aJ 1 Д-лЛ-о-г»- JLg.^ I ^j^-jlo 1 ^ ^sxf^ <JIaj^VI^ ^ЯыЛ-. djik-ioji Jjj dili ^ ixu/^^l ^jyül ^J LJL> s? ^o ^j-i l g I Cl» IwOs-w I jil^v A-uxJ Líiü 1 dj>w4âj I ^a LaJ I ^ Jl^J I djl^^cm/ ^rí -^ I c^ ^wo'^-j^ J-ллЛ JaJa_ J l g я ^llji 5J LuJ! I 1 ^^ 气气飞 ClI^JuuaJU Ы1 fuji J^oJI ^^JLc A-^kacJ! 'ÎLU^JI LAjS^ ^pji 己 LajJI J^J^ ^JLAJI 'Â-^aJ! 己 ^ ÔJUV 'ísyc^^ ÓJoJlí ^JLÍJI y^ cjljícji^ I 方 :. <J 1 < ' JL^JI^ ci; 1 JI ^Э ^smliü á^s^jluj I ^ ó^s LûIÂ^y I ^ I,Cl» I-Jslíi-aJLS LA^-JsjJ ás sr"^ ^ VJT^W^1 J^A» JjiJI 己 IkUl ^-b ÓJL^Jlc Vg.^J Ll:!. 丄..J 1 Cl/^l^wo 2^-j-uJl j^jscji ^JU C^l ójjb c^lwli-я-:! jjj\ ^o JAJ^ A-UJXJI c ^ l 3 JI JLCVI ^.^bji j^bj ^^ 人丄 : 1 ^ ÓJla ci^ji с^цкл ^з dujâjuji d-j1 ci^lil L, ci, L.J.I4:;.) I C^Lí/H-ÍOVI jjb ^J! Lisuól L»!ili д-o^cj! ^Jl dj^osj! ^JLaJI Ó JI j I ^ CLLJLCÜJIJ ^^w^ji ^J '«L^^JI ^Jj-JI Jb ^JJI c^l ^- ^Jl ^JLff jij! ^c c i > 1 А^лмО La^ jjti *4 И «jjlci! IjJ ^o^z л ^! I^^J ^ЭI jaj! p UbVl j^sj ^lí wl- ClJ j rt JtZ J J. f LJ^^I ^ag <4.1 J ^J-Lc^ l g.. Q ^-JLoUü! J^J^ ^JájJl ójjb Q!^^JLC ^JIAÍIdJ>L> ^O J.o.g 1.) ôjjua^uji '<Lc>ww0-)l CI^LOJlÍÜJ jüjl 己 I^JaiJI ÓjiA '<5u)LgJ! ^"SjULo LJli 1^1 Jifil p jlatl ciuw CIJ^ JJI ^yuji l^ju, ^LkUl! jjb ^ Lc^^b /l illico 产 ^jso ^J ^^Jl c^lslcc^vl ^ jaaj UJI ) 仏 '<LuxacJ1 s^uw^l3 ^JbJI ójjb JlcL^ I jjb JÜI *«LjlI3 '«LJLJl^ 1 (^bcji f 匕一 P^JI J-^JI U 1 il I ^ ^cuji 11a 0 c U l.a-j^ji JOL^ ^ÍJ^ (J^O JL=JI J-0-ЛЛЗ CIJ^JI AJ^WO ^- P.CC.IJ13 A^LU^M CJLUWL^I^ ^ áo^jlkj! '«LuvA^ÍI ^.1,-b:; H flkcl ' J^JuJI J^U.^-..11 ч г ^. '<L-JsJI 3 JaJI L. UJo ósá PLi^ll ^ j ó L ^ ^c^o l UIa Ij^J C^Vд.. ;'4:; «上 аэ ^Jl ^o^uji,^-jaji ^-JUcJI^

109 A47/VR/5 page 94 ^o ^ло! l^j 卜 J_«:J 1 ул j^ji UJ^ j t JcJ\ «S JLA ^Jl ; JL5 M ^ ^ ^ L$ü ó^jjl CI< 1 j LoV I dj^j J^ílüiJJ Lu/j I 严 JJI 彡 I «J L-fciuV L-. jy^ ^ «JJLA^j^oJ I ^. 11 d-j^ J ^ ^Д-Л-ЬиI...? )!^ ^JLAJI ^-JLaiiJI I i;, - :.. I^«JI ^^iillw^ d-^kaixj 1 LlS-9 I jjo 'àj 1 J I Ljui L-Js> I J I J^f I I Cl. I j LoV I S^si^o L>w A^^^^oJ! 卩 ^JLaJ I ^ 方 LI^/ LÜI ^ISL 丄 JI СI JUO-ÍÜ ^J-O-JLSVI LILÔ^/L, ' J^JJ! CL*JUÛ^> ^J1 ci, I 广 :JJ ' -JLkJ I J I U» O.-.-vaJ I '«LoJjJ 丄 I ^JUcJ! J-cw I ^JJ M ^ о A^j-rJI Cl; I j LoV 1 djjj I ^ ^jól ^o*^ 1 ôâjb ^wo 1 ^jjü Ju-wA_aJ I Aj>v4aJJ <V-usJ LsiJ I Uli ^ ( d^j) 已 1 p Iwi J Lai^lwV dj^ ^ji ClujJbL^ " J^jjj У ^jo I JAÍ I ^jaj^hj ^J l r «.g J J I ^J UaJLw I j ^cjúj 1 I t., «-VLmP Л J^^ í ^J LûJ! jj 1 ^C I JuJiX^ 1 ^ e^ji 丨 J Jb. JA-JJI \Sjb. ójl> lúji C^L-V^J! JJ ^li ' U^^o ^o ^ol ^-Jl djl^j dj^jj! уь ^áji QL^M PL^ ówijl^j óa^loji d^ ^Jl c^l jlo^l dj^j Wr^P JI Jo I j ^.miuj I 1 L40jL^juS АлоLaJj^iâj I ^jjw I LaS, l_ij j 03^s 0 I^ Cl< 1 j Lo^ I ^jjjjmu LllJ I ^xc jj! Д-cûJ LaJ 1 I!. \ g.с Q -*' «S^-uvlûJ! Cl^ Lo-Д LíxuvJJ -.^-Lu/ j^ilj I ^ <UU> LoJ 1 A-W J-AJ ^. JJ 1 с Lt 1 LaJ I *<LuJ Uü I '<L>v4 J I "д-ло^ dlj I 11 ^uüü ^jj! 1 Jxsb LieL<Cu> 1 ^-o «suijâjuîji JI! ÓÜI^ ci/l Jijjcccül «I C^L^JÜJI ^o Ubj^ CI,)!Lao)!í 产 ^JU clljjüji LA'ÁJ^LgJI c^l^llovl H^JJ I^jwUÜ 1 J ^JLc ^IlJJ L) ái-u) LlJ I JjjJl LO-A*V^Í ^OJ^I LAJ I ^Э <V T coj lj 1 ó jrí^**- 0 P^^-UÁJ! <ULLÁJ>vo A3 CL» Iwü^^^uxJ,_r>w l oji ^JL) I PL LC I!JL I jo 二. coj 1 ^JLsClJ! ^ 1 «'V ) I ^ I Vl^JLs.íJ_ : ajüuccu>j I cl. ^JÛ cl» L^cuûJo! 产 ::):;aí^jl^üí 1 ^ I :.*^Jk^ 1 <J «jül*vu)j I ^jbllo cij^- : ^o LJ 丨 o A 丨 己 ^ ^ ksj^^ <3uxj JuúJ I ^JLff áw^w^-l 1 Cl;Laû I ^ I Ju-co <i Jl^Jl^- <sjl>ja I LlJ-1 lij I Jó I! ^ ^ jsj\ ^ < áj ÍXJSLÍOJI^ Ijjb.o,)l P LÁÍ^I 山 JJIJ.«iii 15 <sju 1 :«-Lg 产 ^L^uJl ^ ^улл^} I áju i ^s^ Baroness CUMBERLEGE (United Kingdom of Great Britain and Northern Ireland): Mr President, Director-General, distinguished delegates. May I first of all congratulate the President on his election and assure you of the United Kingdom delegation's full support. On behalf of the United Kingdom Government can I say how delighted we are that South Africa is once again a full member of the World Health Organization. May I also, on a personal note, congratulate Sir Donald Acheson, our former Chief Medical Officer, who has this year been awarded the prestigious Léon Bernard Prize. Mrs Bottomley, my Secretary of State, who has national responsibility for family issues, is unfortunately unable to be here today and I speak on her behalf. Two years ago, she told you of the changes that were taking place in the Urdted Kingdom's health service and of our plans to introduce a strategy for health in line with the aims of health for all. I would like to tell you about progress since then. Three years ago, we introduced the most radical reform of our National Health Service since its inception in The reforms are based on four main principles: the establishment of an internal market, the use of a system of contracts, more freedom for hospitals, and the ability for general practitioners to purchase some services on behalf of patients. The objective of these reforms was to assess the health needs of the population, and on this basis to increase effectiveness and make services more responsive to their needs. Patients are at the heart of those reforms, and we wish to ensure equality of access and high quality care. We are now beginning to see real benefits from such changes, but any process of reform is not easy.

110 A47/VR/5 page 95 It is for this reason that I recognize and understand how much effort the Director-General and his staff have put into the important changes taking place in WHO. WHO is at a critical point. It must look to the future, develop a vision, and do what is required to retain its rightful place as the main player on the world health stage. We in the United Kingdom take a keen interest in the changes which the Organization is currently undergoing. We believe sincerely that the recommendations of the Executive Board provide the best basis for the Organization to meet the challenges that lie ahead. I wish to congratulate Dr Nakajima for the positive way in which he has approached the need for change and set up appropriate structures to take matters forward. In particular I wish to say how helpful his speech to the Assembly was yesterday in setting out the programme for reform. But we must not let up in our pursuit of progress. Accordingly, my delegation will be sponsoring appropriate resolutions to see that this happens. We fully support WHO's commitment to the strengthening of nursing and midwifery services, and congratulate the Director-General on the study-group report on nursing beyond the year It gives a global perspective on the key role of nursing and midwifery in promoting health and health care services. It makes it clear that cost-effective services and improved health can best be developed when the skills of nurses and midwives are used to the full. My Government believes this too. I have told you about the United Kingdom reforms, but no less important is our "Health of the Nation" strategy. This major policy demonstrates a long-term commitment to improve the quality of life and health for the people of our country. It was born out of the health-for-all initiative, and we have acknowledged our debt to WHO. We chose five key areas upon which to focus our efforts: coronary heart disease and stroke; cancers; accidents; mental health; and HIV, AIDS and sexual health. Our strategy has been running for almost two years now and it has had a huge impact on our people. The first year's report, recently published, highlights the considerable activity that has taken place since the launch. It acknowledges the important role and contribution of a number of government departments (environment, transport, education, agriculture), not just the health department, in evolving a comprehensive and effective strategy. Indeed, we have a Cabinet subcommittee specifically set up to drive forward the health of the nation. We have tried to mobilize the population. We want everyone to be part of it - local authorities, voluntary organizations, religious leaders, local groups, industry and commerce - and to develop health alliances. I am excited and encouraged by the results so far. We have been asked to focus on ethics and health in our address today. Consideration of ethical issues must always play a central role in health and health care and the allocation of resources. Although the fundamental ethical principles within which we work remain constant, their application to newly-evolving situations requires continuing debate. Advances in medical science and technology and our increasing life span raise important ethical issues surrounding medical treatment and particularly the ability to prolong life. Last year, a committee of the House of Lords undertook a detailed examination of these matters, consulting with members of the public, patients,associations, religious organizations and lawyers, as well as health care professionals. The United Kingdom Government's concern has been to protect the interests of patients, particularly those in no position to speak for themselves. We wish to safeguard the patients' right to consent, or to withhold consent, for life-prolonging treatment, especially when that treatment offers no prospect of cure or pain relief; and to ensure that action taken to relieve pain and suffering does not involve the deliberate taking of life, which in our view must always remain unlawful. We have welcomed the House of Lords' committee's rejection of the case for the legalization of euthanasia, and endorsed the rejection of the creation of a new offence of "mercy killing". Increasingly, people wish to take responsibility for their own lives and especially for decisions about their health. Our patients,charter sets out rights, standards and guarantees. It includes a clear explanation about possible treatments in order to enable people to make informed choices. For women, we believe, this is particularly important in pregnancy and childbirth, and I have just published a maternity charter. It sets out the right of women to choose, for example, who should be the lead professional providing their care. It could be an obstetrician, or a midwife or a general practitioner. But it is for the woman to decide. My colleagues in the British Overseas Development Administration have built up partnerships with the health sectors of several countries represented in this hall. We have seen - and continue to see - sincere efforts being made to provide effective health care to those who need it most, in a way that makes the best use of very limited resources. In most countries this has meant health professionals and politicians, at local and national level, working together to make extremely difficult decisions. In conclusion, I would like to state again how much we value our membership of WHO, how much we enjoy being part of a dynamic changing organization, and how much we can learn, and gain, from our partnership with other countries. May I wish you, Mr President, and everyone at this Assembly, every success in your deliberations.

111 A47/VR/5 page 96 Mme GARAVAGLIA (ItaHe): Monsieur le Président de séance, permettez-moi avant tout de féliciter le Président ainsi que les Vice-Présidents pour leur élection à cette Assemblée mondiale de la Santé. Monsieur le Président de séance, Monsieur le Directeur général, distingués collègues, nous remercions le Directeur général d'avoir proposé pour le débat en séance plénière de cette année le thème "Ethique et santé". Il représente sans doute un sujet de grande actualité et d'importance tant pour les pays industrialisés que pour ceux qui sont en voie de développement. En cette époque caractérisée, d'un côté, par raccroissement des connaissances scientifiques et technologiques et, de l'autre, par la diminution toujours plus grave de nos ressources, des tâches nouvelles et des responsabilités croissantes ont fait leur apparition, surtout pour ceux qui dans les différents pays sont tenus, en matière de santé, de prendre des décisions. Il est surtout indispensable que leurs choix et leurs actions soient fondés sur des valeurs éthiques de référence afin d'éviter l'exploitation de la science et de la technologie des systèmes de santé tant par le pouvoir économique dominant que par la poursuite d'intérêts personnels. Il faut défendre, toujours et en premier lieu, la promotion de la vie humaine et les intérêts des plus faibles, comme ceux des foetus, des personnes âgées, des handicapés, des mourants. L'éthique de la science, ou plus précisément la bioéthique, ne doit pas se limiter à la promotion des valeurs abstraites, mais susciter une réflexion continue sur la responsabilité des connaissances scientifiques en relation avec les principes de la conservation de la vie, de la maladie et de la mort. De même, l'éthique des choix sanitaires doit se référer aux responsabilités individuelles et collectives quant à la défense de la santé, surtout de la part de ceux qui ont le pouvoir d'orienter les comportements personnels et de contrôler l'apport des méthodologies, des technologies et des services. Le phénomène de la forte dépendance de la demande par rapport à l,offre des services de santé met au jour la fragilité des choix individuels dans ce domaine et rappelle les pouvoirs publics à un nouveau devoir, celui de fournir aux citoyens une information appropriée et une éducation véritable en matière de santé. Seule une adéquate culture sanitaire peut, en effet, donner aux citoyens une vraie liberté de choix. Les concepts de responsabilité,rationalité, générosité peuvent se conjuguer harmonieusement à l'intérieur d'un système de santé moderne, pierre angulaire du véritable état social. Dans cet état, les ressources doivent être employées pour mettre un service efficace à la disposition du citoyen et on doit s'efforcer d'atteindre un équilibre qui ne soit pas mis en danger par la demande mais qui, au contraire, soit en mesure de prévoir les besoins naissants des citoyens les plus faibles. C'est dans ce contexte que doit être placé un accent politique sur la famille, à l'intérieur de laquelle, durant ses diverses phases d'évolution, apparaissent les fragilités liées à l'âge de ses membres et aux pathologies dues à l'âge. L'Année internationale de la famille nous incite à une réflexion culturelle et politique sur le rôle de cette communauté de base, qui doit voir augmenter sa capacité d'assumer ses propres responsabilités lors des choix qui concernent son identité. L'émouvant appel du Pape Jean-Paul II à cet égard doit absolument être écouté. C'est en me souciant des droits des citoyens, et plus particulièrement des groupes les plus désavantagés, qu'au cours de cette dernière année j'ai travaillé à la réforme du système de santé italien qui, comme tous les services de santé des pays occidentaux, fait l'objet d'une réflexion et d'un changement constants. Sur le plan international, nombreux sont encore les problèmes à résoudre et la situation générale est rendue encore plus difficile à cause des tensions économiques et sociales, et surtout à cause des innombrables confits ethniques, religieux et territoriaux qui provoquent victimes et souffrances dans plusieurs parties du monde. Dans ce contexte, il est aisé de comprendre combien difficile est la tâche de l'oms qui doit oeuvrer dans des conditions ardues, tout en recherchant un bon équilibre entre les demandes d'assistance toujours croissantes et les difficultés économiques bien connues de POrganisation. A ce propos, il me semble juste de souligner l'effort accompli jusqu'ici par l'organisation dans le but de réviser et de mettre à jour ses propres structures, sa politique et la gestion de ses programmes pour mieux s'adapter aux changements en cours dans le monde entier et rester le point de référence essentiel pour tous ses pays Membres dans la réalisation de la stratégie de la santé pour tous. Il s'agit d'un processus de réforme interne nécessaire et je suis d'accord avec les priorités déterminées par le Secrétariat suite aux recommandations formulées par le groupe de travail du Conseil exécutif sur l'adaptation de l'oms aux changements mondiaux, surtout en ce qui concerne le renforcement du rôle fondamental de l'organisation dans le rassemblement et la diffusion des données sanitaires au niveau mondial. Je voudrais citer ici certains programmes de l'oms, avant tout le programme d'action pour les médicaments essentiels, qui représente toujours un point de repère extrêmement valable pour les Etats

112 A47/VR/5 page 97 Membres de rorganisation. Récemment, en Italie, le Ministère de la Santé examinait à nouveau sa propre politique dans le domaine pharmaceutique, établissant entre autres une liste des principes actifs qui, sur prescription médicale, peuvent être disponibles gratuitement pour tous les patients. De tels remèdes, appelés actuellement médicaments essentiels, ont été inclus dans la liste susmentionnée sur la base des critères d'efficacité thérapeutique et de sécurité. Compte tenu de ces critères et des autres critères adoptés, on peut affirmer que la liste en question reflète des concepts fondamentaux du programme de FOMS pour les médicaments essentiels. Par conséquent, la récente révision de la politique italienne dans le domaine des médicaments peut être considérée comme un exemple d'application pratique de tels principes dans un pays industrialisé. En passant à un autre programme, je voudrais dire que nous avons appris avec intérêt qu'un processus de redéfinition et de mise à jour du programme spécial de recherche, de développement et de formation à la recherche en reproduction humaine est en cours. A cet égard, je désire exprimer notre satisfaction devant le regroupement des interventions de santé publique qui a été effectué dans l'important secteur de la santé génésique. Cela permettra une meilleure coordination entre les divisions et les programmes qui s'occupent de reproduction humaine et renforcera la recherche dans ce domaine. Pendant l'année internationale de la famille,nous espérons que les activités de recherche sur la planification familiale seront insérées dans un contexte élargi afin d'améliorer la santé de tous les membres des noyaux familiaux, les mères, les pères et les enfants. Je désire aussi me référer au programme de FOMS concernant la tuberculose, une maladie qui afflige gravement les pays en voie de développement, mais qui, en même temps, est en augmentation dans les pays industrialisés à tel point qu'elle est considérée comme une urgence mondiale et qu'elle figure parmi les priorités du neuvième programme général du travail de l'oms. A ce propos, je désire attirer l'attention de cette Assemblée sur le fait que les pays donateurs devront déployer des efforts toujours plus grands afin de rendre plus puissant et toujours plus opérationnel le programme concernant la tuberculose. A un moment où le monde doit faire face à un nombre sans cesse croissant de catastrophes naturelles ou provoquées par l'homme, il est de mon devoir d'exprimer satisfaction et appréciation pour les activités de l'oms dans le domaine des opérations d'urgence et de l'aide humanitaire. Dans les interventions de type humanitaire, nous pensons que l'oms a non seulement mis à disposition sa propre expérience et sës capacités techniques, mais aussi contribué activement à la solution des problèmes humanitaires internationaux. Quant à la coopération italienne, elle oeuvre actuellement dans le but de reconnaître un rôle central au développement humain dans un cadre multilatéral. En plus de la participation du système des Nations Unies dans différents domaines, la coopération italienne est en train de favoriser la collaboration entre organismes des Nations Unies vers des objectifs de développement humain par l'entremise de programmes spécifiques visant à diffuser des méthodes et des schémas organisationnels qui puissent être facilement reproduits. De nouvelles formes de collaboration au sein de l'union européenne sont en cours et, dans le domaine sanitaire en particulier, des initiatives nouvelles laissent entrevoir de bonnes possibilités. En me référant à la coopération sanitaire au niveau international, je voudrais souligner la nécessité de renforcer la concertation et la coordination entre donateurs, tant pour les pays que pour les organisations, afin d'amplifier l'impact de l,assistance sanitaire aux populations et pour en améliorer l,efficacité. Cela nécessiterait la mise en place de programmes et de projets complémentaires ayant pour objectif d'éviter tout chevauchement des efforts et toute dispersion des ressources disponibles. L'amélioration de la santé, au niveau tant individuel que collectif, n'est pas seulement le but auquel le développement doit nous mener, mais elle est également un facteur nécessaire pour la mise en place de tout mécanisme de développement. C'est forts de cette conviction que la communauté mondiale, les organisations internationales et nous tous devons nous consacrer à notre tâche, avec une énergie nouvelle et dans un esprit de plus grande collaboration, de solidarité et de justice sociale. Le PRESIDENT par intérim : Je remercie le délégué de l'italie et je donne la parole au délégué de la Turquie qui va parler dans sa langue; j'ai le plaisir de lui annoncer que l'interprétation simultanée est disponible. J'invite le délégué de la Malaisie à venir à la tribune.

113 A47/VR/5 page 98 Mr DINÇ (Turkey) {interpretation from the Turkish)} Mr President, Mr Director-General, your excellencies, ladies and gentlemen, on behalf of the Turkish delegation, I would like to congratulate the President of the Forty-seventh World Health Assembly on his election. I am confident that under his able guidance this Assembly will achieve its goals in full. I also wish to thank the out-going President, Mr Órtendahl and the distinguished officers who successfully presided over the Forty-sixth World Health Assembly. I would also like to take this opportunity to welcome the new WHO Members, and to welcome back the Republic of South Africa which has successfully concluded its struggle for democracy. The world is approaching the twenty-first century and we have accomplished distinctive developments in health care. We are at the same time experiencing dramatic changes in the political, social and economic fields. We all know that these changes have an impact on every sector, and the health sector in particular is one which is affected first and most intensively. The priorities are changing daily and new objectives and strategies aiming at improving our health status are now included in our agenda. We must, at the same time, accelerate our previous efforts and ensure their continuity. For that reason it is highly appreciated that the World Health Assembly has included in this year's agenda the major global issues concerning health. Turkey has considered education and health as national priorities. On the one hand we are carrying out activities in order to elevate the educational level and on the other hand we are trying to improve the health status by providing effective health services. The primary health care approach constitutes our major national health policy. Within the frame of the health-for-all policies, the World Health Organization is leading the world in providing technical assistance to countries, coordinating international health activities and making intensive efforts in order to decrease the discrepancies in the accessibility to health services. These efforts are appreciated by several countries, particularly by Turkey, and I would also take this opportunity to express my satisfaction for our continuing cooperation in the frame of the mid-term programmes which have been implemented since In the context of this year's programme, together with health-for-all activities, priority has been given to the improvement of the quality of health care, development of healthy lifestyles, supporting the health reform activities, strengthening the information system and activities related to environmental issues. We are pleased to see that the draft Ninth General Programme of Work covering the period includes such topics as integration of health and human development in public policies as well as ensuring equitable access to health services, promotion of health and prevention of some specific health problems. With regard to equity, we are making plans aiming at reaching everybody in order to meet their health needs and we are working for increased accessibility to health services. It is not possible to consider that primary health care services can be achieved by simply establishing infrastructure without considering the implementation, monitoring and quantitative as well as qualitative assessment of services. These objectives for qualitative assessment are an important component of our national health plan and will be followed up by measurable monitoring indicators. Turkey had announced the year 1993 as the "Mother and Child Health and Family Planning Year". During this time, besides launching new programmes for improving mother and child health, we put emphasis on the reinforcement of our routine programmes. For the year 1994, which is announced as the International Year of the Family by the United Nations, mother and child health care services will maintain priority among primary health care targets in Turkey, as in several other countries. Our aim is to accomplish healthy communities by the application of the family health concept, which incorporates improvement of the status of women, and mother and child health care. I am confident that by the year 2000 we will successfully achieve these goals, with already implemented programmes such as the expanded immunization programme, the control of diarrhoeal diseases and acute respiratory infections, family planning and safe motherhood. While the international community is deploying great efforts to develop a cure or a vaccine, AIDS continues to increase all over the world in spite of the measures taken. We highly appreciate the guidance and the assistance provided by WHO with a view to securing international cooperation within the framework of human rights. We are carrying out intensive activities in line with the global AIDS strategies, to create utmost public awareness. 1 In accordance with Rule 89 of the Rules of Procedure.

114 A47/VR/5 page 99 We believe in the necessity for all countries to take the responsibility for regaining control of tuberculosis, which is once more becoming a serious health problem. In this context, mobilization of national and international resources and the call by WHO for urgent application of tuberculosis control programmes should be considered encouraging developments. We all appreciate that it is practically impossible to achieve success in these services and improve health conditions without community participation. Addressing this issue at the Technical Discussions during the World Health Assembly will certainly help shed light on many aspects of these activities. I would now like to turn to a subject which has always been important and sensitive, that is ethics in medicine. The researches carried out on biomedical technology sometimes bring with them problems involving medical, legal and ethical aspects. Research on human embryos and similar studies, for example, cause global concern. I believe that the World Health Organization should also be a leader on ethical issues. Another issue which is undoubtedly closely linked to humanity is the fact that peace constitutes the first condition for health. Today, in this regard, the international community is unfortunately facing a situation which is by no means commensurate with the high levels of economic and technological development it has achieved. The local wars which have been continuing in recent years in Europe, Asia and Africa are forcing masses into unhealthy living conditions that are beyond human endurance. Even after the termination of hostilities, it will not be possible to cure many of the physical and psychological health problems inflicted on the masses, and these effects will even be transmitted to future generations. A report dated 22 April 1994,which the United Nations envoy in the town of Gorazhde, besieged by the Serbs, sent to the United Nations Office at Geneva, contained the cry "here the lucky are the dead". This cry will be erased with difficulty from human memory. The policy and the campaign of genocide, ethnic cleansing and sexual abuse, openly perpetrated by the forces of Serb aggression against the Muslims in Bosnia and Herzegovina will always remain as an unforgettable shame staining our civilized era. Similarly, in Azerbaijan, the Azeris are still losing their lives, health, land and property, under the continuing armed attacks of the Armenians. We must note with gratitude the heroic efforts of the national and international, official and voluntary health personnel who have selflessly committed themselves to bringing help to those subjected to these inhuman attacks. Witnessing these atrocities which are committed in the vicinity of Turkey, my Government and our voluntary organizations are not sparing any efforts within their capacities to make health assistance available in these war regions. However, halting the aggressors and bringing an end to these human tragedies are really dependent upon political will which has to be displayed and enforced with determination by the international community. We earnestly urge all the responsible elements of the international community, the United Nations in particular, to resolve its political will. Once again I would like to stress that the preliminary condition for health for all is peace for all. I salute all the participants with respect and wish success to the Assembly. Mr LEE Kim Sai (Malaysia): Mr President, ladies and gentlemen, firstly, on behalf of the Malaysian delegation I would like to congratulate the President on his election to the presidency of the Forty-seventh World Health Assembly. I would also like to congratulate the Vice-Presidents on their elections. Mr President, ladies and gentlemen, I would also like to thank the Director-General, Dr Nakajima, for his comprehensive report on the work of WHO in WHO has continued to help, guide and motivate Member countries towards the eradication of preventable diseases, as well as in continuing research in the field of medicine. The efforts of WHO to provide leadership to upgrade the standard of health care delivery worldwide, especially in developing countries, is much appreciated. WHO is also continuing to introduce and promote new concepts in health that are contributing towards the achievement of the objective of health for all by the year Some of these concepts have been incorporated by Malaysia in our strategies to achieve our "vision 2020",that is, to become a healthy and fully developed nation by the year The standard of health of the Malaysian population has improved tremendously. This can be seen from the substantial decrease in mortality and morbidity rates. The implementation of an effective primary health care system over the years has indeed contributed towards this achievement. Today Malaysians are enjoying health, higher quality of life and a longer life expectancy. The Malaysian Government, through its primary health care delivery system, has been able to reach the masses successfully,as reflected by the effective utilization of maternal and child health services, as well as in the immunization coverage. The number of safe deliveries has also increased. The rural environmental sanitation programme has a coverage of more than 90%. Only small pockets or areas remain where clean and safe water supplies are not readily available, but could be provided with

115 A47/VR/5 page 100 the use of high technology and adequate funding. Meanwhile, steps are continually being taken to ensure that all our drinking-water is safe for consumption according to WHO standards. Environmental pollution is posing a major challenge to all developing as well as developed countries, and therefore we cannot compromise on global policies and laws pertaining to the preservation of the environment. In Malaysia we are moving towards compulsory environmental impact assessments on all proposals for major construction or development projects. We are enforcing strict control over industries that are polluting our ecosystems. Industries are being told to replace toxic and hazardous materials with environmentally-friendly substances. The public is also constantly informed of the various nonenvironmentally-friendly and polluting substances. Although it has been the aim of the Malaysian Government to bring about changes in the health behaviour of the population, community action for health is the prime mover in bringing about beneficial changes. Our national healthy lifestyle campaign launched in 1991 has been well accepted by the Malaysian community. Individuals are aware of the risks involved in excessive substance indulgence and high-risk behaviours, and are consciously making efforts to change, as is evident from the increasing awareness of diseases related to lifestyles by the people of Malaysia. Health advocacy is well accepted by our community. In our campaign to reduce smoking we have declared all our health institutions as smoke-free zones. Smoking is banned in Government offices and enclosed public places such as theatres and air-conditioned restaurants. Legislation has been enacted to enforce compliance. Community participation in our health programme in our country has been active for a long time. In the rural areas, many of the community projects are carried out through the self-help process, which is the participation by every member of the community in various community projects. Such a community participation process has helped in the building of water supply systems and sanitary toilets and also in the inculcating of health consciousness. This concept has been found to be effective, and we are planning to use it to enhance healthy behaviour in the prevention of diseases. Nongovernmental organizations in Malaysia have also taken a lead role in the promotion of health. The Rotary Club is well known for its contribution towards the immunization of children through its "Polio- Plus" project. Intersectoral cooperation and collaboration with relevant agencies in promoting health are also being forged. AIDS continues to gain the attention of all countries. Our data on AIDS have been derived mainly from the institutional population, and we have introduced a surveillance system covering low-risk and highrisk behaviour groups. Health education programmes on AIDS have been introduced, and elements of AIDS prevention have been incorporated in the subject of family-life education in the school curriculum. We appreciate the continued technical and financial support provided by WHO in our fight against the pandemic. Our prime concern now is the provision of quality service. In order to achieve this, quality management programmes have been introduced at all levels of management. This has further strengthened existing components such as quality assurance, quality control circles and productivity, thus achieving client satisfaction. Client charters have been developed in all our service outlets with the objective of continued improvement in health care delivery. In our endeavour to achieve the goal of health for all by the year 2000, the role of the private practitioners and private hospitals is not overlooked. They play a vital role in sharing the responsibilities as partners in providing medical and health services to the public. They have contributed to the reduction of mortality and morbidity through the provision of complementary primary, secondary and tertiary care. As we strive to develop our country and improve the health of the people, it is well to keep our perspective on our health policy, which is to improve the health of the people and achieve equity in health status. With the rapidly rising expectations of the people in our country, we are emphasizing the importance of prevention and promotion of health in our programmes as we strive to keep up with the demands of medical care. However, improvements in standards of living are extremely important in achieving improvements in health status. To achieve them we have to strive for full employment and satisfactory family income, adequate housing, good nutrition, and adequate educational, cultural and recreational opportunities for our population. We need to work towards raising the standard of living, to emphasize prevention as well as to provide medical care, if we are to reach our objective of improving the health of our people and achieving equity in health status. To us this is not only a social and national objective, it is also an ethical one. Dr SHEMER (Israel): Mr President, Director-General, distinguished delegates, ladies and gentlemen, it is with great pleasure that I address the Health Assembly for the first time. I am here to address you because Mr Haim Ramon resigned from his position as Minister of Health, due to inability to pass the National Health

116 A47/VR/5 page 101 Insurance Law, and a new Minister of Health has not been appointed yet. On behalf of my delegation, I congratulate the President on his election to preside over this Assembly. The Director-General and his staff are to be commended on the comprehensive reports presented to this Assembly. Financing of health systems is an issue with which almost every country in the world grapples. Should health systems be financed by the State, through insurance, by private or public agencies? Should the sick and the poor bear the burden of health costs or should these be borne by the healthy and the wealthy? How does one create a health care system which is equitable, universally accessible and economically viable while maintaining and enhancing the quality of care for all citizens? Actually there is no clear-cut answer. Imitating other countries' examples might prove to be unsuitable and wrong. Each country must find its own solution to answer its special needs and conditions. This Assembly focuses on two important issues: the one is ethics and the other is "Community action for health", which is the theme of the Technical Discussions. Even health economists engaged in the issue of financing health systems have to consider ethical aspects. How do we set priorities within limited financial resources? Is it more important to invest billions of dollars in research associated with the prevention of HIV/AIDS or to set up additional intensive care units which will save lives here and now? Is it more important to invest massive public resources in wonder-working fertility techniques or in dialysis units or in premature-baby units that can save the life of a newborn weighing a mere 600 g? Is it more important to invest large sums in prolonging the life of the elderly or to invest similar sums of money in cancer research? These are some questions which are further complicated by differences in ethical concepts between countries. One could cite numerous examples, which time does not permit. WHO, however, can play an important role in this sensitive area of medical ethics, where conflicts between medical advances and economic considerations might influence judgements and decisions whether to prolong life or not. What kind of morality will exist in the world for the future generations depends on what we do now. All of us should join with WHO in developing guidelines which will be binding to all. This takes us to the second theme, "Community action for health", which also involves ethical issues. The Eighth report on the world health situation says; and I quote: "Community action for health implies a significant change in approach for both communities and government". Change is not easy to introduce. It requires willingness to confront opposing interests and determination to overcome them. It requires the ability to rise above personal interests and to look beyond the short term. Neither is it easy to obtain cooperation on the national level within the health sector and with other sectors. Here, too, WHO has a key role to play in creating international movements for health-for-all components and in being a catalytic force in the formation of coalitions for health for all at the national and municipal levels. Israel has had a long history of community involvement in all facets of our national life and developmental processes, including health. Members of my delegation will no doubt be prepared to go into greater details during the Technical Discussions. May I conclude by saying that our collaborative efforts with the WHO Regional Office for Europe over the past years included activities and workshops on Healthy Cities, health-promoting schools, healthpromoting hospitals, health-promoting community centres and HIV/AIDS, as well as "Tobacco or health", oral health, diabetics, cancer prevention, etc. Public awareness of and the concern for health issues in general are growing. I hope that the current negotiations between Israel and its neighbours will lead to a peaceful relationship of understanding and cooperation and that the World Health Organization will continue to work to alleviate the health problems of populations everywhere in a spirit of cooperation and goodwill,and bring people together through collaborative efforts. Dr AL ARRAYED (Bahrain): 如 ) 一 4 Л LAJ!. 方 JLOJI, : 1 J^i^JI f Lwjj L 1 1 ) à 1 I y^yj^l J^ 1 «JLMMJ I.' J juji ^ 1лл^П ^ cujjl ojla JUÍI JJ<L, 01 <üji Ufb Jj..,oil jji La^j '<LaJL«JI J-*J ^Jl ïjl^ 力 JJI EL)J.I. 'IJ^, CL-W^ 1 R-"^ J ^ - O^ J FJ^JI ^jáláio! (jo! Lu JLàbVI '<LJjVI 1 '..U^l I g... ^ 'i^a-u ^jl^ji j3jji 0I IcS.lia Lu,U M Y. J i U - ^t^ ^^Jl CI-LJ 5

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119 A47/VR/5 page 104 )l áj,ij LJLC^ I l I ÓÍJ ^^JLc juoa-. ^ijl ^-LJI 0..oJ.-g.ll Ц-.-Ьл:;-)l ^ VJO ^L,<JI ^-ЯлЛ /i.я гл о г Д«:; /i ci^ls pidi-bsuji I^MJI ^ J^J Ây^woJI ÓLu>J1 *<Luxj : ^^JLc JucL*^ 1--Я 丄. *' -.^jliji d-j^^íi *«Lu>vaJI JM^ ^ j I c^ 丄 ^ Jl '«La^JI d-.u^l 兵 s-^ ^ ^ o' _" P 1 ^Jl Sü jjájü J^c Iki^.Я ул y ^--JUx; dljij. d-^voji d-.ujj! ^ f 3 L^ 山 tj:,;o J_.:4:v«,.<J I 1 ^ '«LJ^^/I l<jájl 方 ^cj j J^*^; I d^u^ji I J^uj 1 (J T Jux3 ^jjs 1 I Cl. U ^J ójlo UJ I 己 U LbJ 13 J j^laj I Ji ^jls. La Dra. AMADOR (España): j-u^jj '<LL,UJI Señor Presidente, señoras y señores Ministros, distinguidos delegados, señoras y señores: Me es singularmente grato participar en esta 47 a Asamblea Mundial de la Salud en mi calidad de Ministra de Sanidad y Consumo del Gobierno de España. Mi Gobierno valora en toda su medida la labor que desarrolla la Organización Mundial de la Salud en favor de la humanidad y en pro de la solidaridad entre los hombres, dentro de un proceso creciente de mejora de su eficacia, pese a las dificultades que entraña el permanente cambio de circunstancias en el mundo. Hago votos por que este nuevo acontecimiento, que hoy adopta la forma de Asamblea Mundial, constituya un éxito más en la larga cadena que adorna a la Organización desde el inicio de sus actividades. Le garantizo el entusiasta apoyo y la colaboración de mi Gobierno para lograrlo. España, desde su ingreso en la Organización en el año 1951,ha venido colaborando con ella, asumiendo íntegramente sus responsabilidades en el plano internacional y manteniendo su compromiso de solidaridad. Sin embargo, mi Gobierno es consciente de que más que nunca es necesario el esfuerzo coordinado de todos los países y de las organizaciones internacionales para lograr hacer frente a los retos sin precedentes que se plantean a escala mundial. Coincidimos con el Director General en que una de las funciones primordiales de la OMS es fomentar en los individuos y las comunidades una conciencia general de la salud como modo de vida, como una manera de pensar y de vivir; en definitiva, debemos promover una «cultura de la salud». Son bien conocidos los logros de la OMS en el marco de sus programas en estricta colaboración con las autoridades de los Estados Miembros; el descenso de la mortalidad de lactantes y niños; el aumento de la esperanza de vida; el progreso en materia de abastecimiento de agua y saneamiento; y los avances del Programa Mundial sobre el SIDA, descentralizado e integrado en los respectivos programas nacionales. Compartimos los objetivos de la Estrategia de salud para todos en el año 2000,aunque reconozcamos las dificultades que hemos de afrontar en este fin de siglo. Deseo agradecer al Dr. Nakajima su informe Actividades de la OMS , en el que se previeron y comenzaron a adoptarse una serie de importantes decisiones que tendrán repercusiones indudables en la adaptación de la Organización a los cambios mundiales, y mejorarán su eficacia y su capacidad de respuesta a las necesidades planteadas por la nueva situación internacional. Animamos al Director General a que prosiga sus esfuerzos para llevar a buen término todas las recomendaciones que han sido ya hechas y cuantas otras se puedan aprobar en este mismo sentido. Una de esas decisiones nos parece de particular interés: la publicación, a partir de 1995,de un informe anual sobre el estado de la salud en el mundo y sus necesidades, que contenga igualmente recomendaciones sobre las actividades prioritarias de la OMS para satisfacer esas necesidades. Consideramos de gran importancia que este valioso documento alcance la máxima difusión posible y sea publicado en todas las lenguas de la Organización. La sanidad es, quizás, el principal instrumento de desarrollo de la política social de los Estados. En los sistemas sanitarios de los diferentes países se concentra una buena parte de los valores sociales. Pero estos valores pueden dar lugar a diversas soluciones, muchas de ellas perfectamente legítimas. Ayudar a resolver la elección es uno de los objetivos de la ética. Es preciso encontrar y consensuar principios éticos que sean comunes para todos y que todos estén dispuestos a respetar. Todas las decisiones tienen una dimensión ética en la sociedad. Por esta razón, la bioética ha establecido unos principios en torno a los conceptos de beneficencia, autonomía y justicia que deben ser respetados por todos: usuarios, profesionales, gestores y políticos. La ética en materia de salud consiste primordiaimente en proponer los medios más eficaces para alcanzar altas cotas de equidad. Existe un considerable interés en diferentes sectores de la OMS en torno al problema de la responsabilidad ética de los profesionales de la sanidad y de las autoridades con competencia en el ámbito de la salud. No nos encontramos ante problemas artificiosos

120 A47/VR/5 page 105 o abstractos: por el contrario, revelan conflictos y dificultades del ejercicio médico y de la responsabilidad política, que requieren una interpretación adecuada. Conviene destacar dos situaciones concretas que inquietan a amplios sectores sociales. De una parte, la responsabilidad ética derivada de actividades realizadas, en situaciones que pueden dar lugar a conflictos de conciencia por conculcar las propias convicciones y, de otra, el quehacer médico frente a determinadas circunstancias en las que hay que tomar decisiones intentando conciliar las normas deontológicas con los dictámenes del propio juicio ético. La política no puede convertirse en una ciencia pragmática destinada a entender y utilizar los mecanismos de las fuerzas económicas, o en procedimientos de manejo de la dinámica del mercado, o en técnica publicitaria. Si la ética es parte integrante de la medicina, de la ciencia y de la acción política, los profesionales sanitarios deben modelar a este respecto su propio juicio moral, dentro de las coordenadas del papel social del médico como promotor de la equidad. Cualesquiera propuestas ideológicas necesitan insertarse en un entramado ético. Los sistemas sanitarios movilizan cada vez más una ingente cantidad de recursos, la mayoría de ellos públicos. Justicia significa garantizar equidad en el acceso a los servicios asistenciales, independientemente del estatus económico o de cualquier otra característica que no sea estrictamente médica. Ello plantea el problema acuciante del desequilibrio entre recursos disponibles y las demandas potenciales de la población. Una lógica respuesta a esta insuficiencia es mejorar la gestión, evaluación tecnológica y evaluación de las demandas de la población, entre otras medidas. Lo que debe hacer el discurso ético es explicitar los juicios de prioridad, de forma que se tengan en cuenta no sólo criterios de eficacia, sino también otros que puedan ser avalados socialmente. Queda mucha investigación por hacer en este terreno, pero no cabe duda de que una parte importante del debate sanitario de los próximos años se va a entablar sobre estos valores. En muchos países se ha progresado notablemente en el respeto al principio de justicia, pero todavía persisten desigualdades en salud dentro de cada país y, sobre todo, entre distintos países, por la diferente disponibilidad de recursos. La necesidad de equidad, justicia social y solidaridad son principios fundamentales del desarrollo sanitario y condiciones básicas de la paz y la seguridad en el mundo. La salud es indisociable de los derechos y libertades individuales y la Constitución de la OMS establece que el macroobjetivo de la Organización, en colaboración con sus Estados Miembros, es conseguir para todos los pueblos el más alto grado de salud. Disfrutar de la mayor salud que se puede lograr es uno de los derechos fundamentales de todo ser humano. Este es el enfoque del sistema sanitario público de España, una de nuestras instituciones básicas que más fomenta la confianza, el bienestar y la convivencia, y que constituye una conquista de toda la sociedad que tenemos el deber de proteger. La OMS está fomentando la aplicación de criterios éticos mediante la elaboración de un informe sobre principios orientadores para los servicios nacionales de reglamentación farmacéutica y la preparación de un modelo de legislación y un módulo informático de registro de medicamentos, lo cual brinda un procedimiento para controlar la promoción de medicamentos con el establecimiento y aprobación de un nomenclátor de datos científicos. Los criterios éticos para sustentar la promoción de medicamentos están sostenidos por imperativos sanitarios que a su vez tienen un fundamento ético. Su aspecto esencial es que los médicos y los pacientes deben conocer cuáles son los procedimientos terapéuticos más apropiados y tener acceso a esos tratamientos. La reglamentación farmacéutica debe, por otra parte, garantizar la calidad de los medicamentos y la información de sus efectos secundarios y contraindicaciones. La promoción de medicamentos debe ser coherente con su uso racional y, a este fin, todos los países deben disponer de una política farmacéutica nacional en consonancia con las directrices de la OMS, orientada a garantizar un suministro adecuado de medicamentos eficaces, con el mayor grado posible de inocuidad y con las disposiciones legales de procedimiento que avalen su uso. Señor Presidente: Si impulsamos el respeto de los principios éticos y de los derechos colectivos e individuales, orientaremos a la OMS hacia el cumplimiento de su mandato constitucional y de su gran misión ética: instaurar la paz universal y la equidad mediante la salud. Reitero mi convicción de que los debates que tendrán lugar en esta Asamblea Mundial contribuirán una vez más a ello. Le PRESIDENT par intérim : Je remercie le délégué de l'espagne, mais avant de clore la séance, je voudrais vous transmettre deux communications. Premièrement, une séance d'information sur le programme mondial de lutte contre le SIDA va se tenir dans la salle XXII, laquelle se trouve au même niveau que les salles des Commissions A et B. La séance commencera à 12 h 45 et durera jusqu'à 14 h 15. Deuxièmement, nous avons le plaisir de recevoir M. Juan Antonio Samaranch, Président du Comité international olympique, qui s'adressera à nous

121 A47/VR/5 page 106 sur le thème "Le sport et la santé pour tous", et ceci à partir de 14 h 30 précises. Je prie donc les délégués de bien vouloir être ponctuels et de se réunir dans cette salle avant 14 h 30. Merci de votre attention. Je déclare la séance levée. The meeting rose at 12h30. La séance est levée à 12h30.

122 A47/VR/6 page 107 SIXTH PLENARY MEETING Wednesday, 4 May 1994,at 14h30 President: Dr В. К. TEMANE (Botswana) later: Acting President: Dr M. ZAHRAN (Egypt) SIXIEME SEANCE PLENIERE Mercredi 4 mai 1994,14h30 Président: M. В. К. TEMANE (Botswana) puis Président par intérim: Dr M. ZAHRAN (Egypte) 1- ADDRESS BY THE PRESIDENT OF THE INTERNATIONAL OLYMPIC COMMITTEE ALLOCUTION DU PRESIDENT DU COMITE INTERNATIONAL OLYMPIQUE The PRESIDENT: The Assembly is called to order. My first, very pleasant duty, before we continue with our agenda is to welcome, on behalf of this Health Assembly, Mr Juan Antonio Samaranch, President of the International Olympic Committee and the delegation of the International Olympic Committee. The increased joint collaboration between the World Health Organization and the International Olympic Committee, in an effort to improve and enhance the health of all people through physical activity and sport, makes it very opportune that we are honoured by the presence of Mr Samaranch at this Health Assembly. The Sport for All movement of the International Olympic Committee has special momentum in this especially designated United Nations International Year of Sport and the Olympic Ideal. It is therefore with great pleasure that I give the floor to Mr Samaranch. M. SAMARANCH (Président du Comité international olympique): Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs les délégués, je voudrais tout d'abord vous exprimer, Monsieur le Président, au nom de la délégation du Comité international olympique (CIO) qui est à ma gauche, mes vives félicitations pour votre nomination. Je suis convaincu que la Quarante-Septième Assemblée mondiale de la Santé parviendra, sous votre présidence, à définir la politique qui s'impose pour améliorer le bien-être de l,humanité. Je tiens également à exprimer mes sincères remerciements au Dr Hiroshi Nakajima, Directeur général de votre Organisation, pour son aimable invitation à m'adresser à cette auguste Assemblée. Cette année 1994 a été proclamée par PAssemblée générale des Nations Unies, à sa quarante-huitième session, Année internationale du sport et de l'idéal olympique. Je voudrais également saisir cette occasion pour transmettre à travers vous la gratitude du mouvement olympique à vos gouvernements respectifs pour avoir soutenu et adopté cette importante résolution. C'est en effet en 1894 que le Comité international olympique a été fondé à Paris, à l'université de la Sorbonne, par le baron français Pierre de Coubertin. Très peu d'organismes internationaux peuvent se flatter d'être centenaires. Le monde a beaucoup changé depuis un siècle. Le progrès de la science et de la technologie a été fulgurant. Mais cette évolution n'a malheureusement pas réduit l'écart, qui continue à se creuser davantage, entre l'état de santé des populations des pays industrialisés et celui des populations des pays en développement. Les conflits armés et les foyers de guerre ainsi que les catastrophes naturelles se multiplient. Le nombre de fléaux qui aggravent la santé et contre lesquels vous luttez tous va croissant. Mais la mobilisation,sous l'égide de FOMS, des nations que vous représentez va permettre sans nul doute de trouver des solutions et de donner l'espoir à ceux qui souffrent.

123 A47/VR/6 page 108 Le mouvement olympique, qui fait partie intégrante de notre société d'aujourd'hui, a l'obligation morale et le devoir d'oeuvrer auprès de vous, qui êtes les responsables directs de la politique en matière de santé, pour vous faciliter la tâche. C'est ainsi que l'oms et le CIO, fermement convaincus que la coopération est le meilleur moyen de parvenir au but que représente la santé physique, mentale et sociale pour tous, ont renouvelé l'accord signé déjà en C'est dans le cadre de cet accord que nous avons organisé en mars dernier, à Punta del Este, en Uruguay, un congrès sur le thème "Sport pour tous et santé pour tous" en présence du Dr Nakajima et de moi-même. A la fin des travaux, nous n'avons pas manqué dans notre déclaration commune de rappeler les effets positifs du sport et de l'exercice physique sur le bien-être physique, mental et social de tous les individus et la nécessité d'encourager leur développement afin qu'ils deviennent des éléments essentiels d'un style de vie débouchant sur la protection et la promotion de la santé ainsi que sur la prévention de la maladie et de rinfirmité. Nous vous avons lancé un appel pour que vous adoptiez les mesures nécessaires afin d'encourager et de promouvoir la pratique du sport et de l'exercice physique dans un contexte familial dans le but d'améliorer, grâce à une vie saine, la qualité de vie. Le groupe de travail OMS/CIO s'est réuni ce matin même pour identifier les secteurs de coopération et élaborer des projets auxquels les comités nationaux olympiques et fédérations internationales seront invités à collaborer. Le CIO a par ailleurs signé des accords de coopération avec les agences spécialisées des Nations Unies telles que l'unesco, l'unicef, le HCR et le PNUE afin d'apporter sa modeste contribution à la communauté internationale. Notre mouvement olympique est composé en majorité de jeunes qu'il faut protéger contre les fléaux qui secouent notre société. D'où les actions que nous entreprenons en coopération avec les organisations gouvernementales et non gouvernementales. Au sein même de la structure du CIO, la Commission médicale que préside avec dévouement et compétence le prince de Mérode, ici présent, est composée d'experts de tous les continents. Elle a pour tâches principales la prévention et la lutte contre le dopage dans le sport, l'accréditation de laboratoires, l'organisation de stages de médecine sportive et la publication d'ouvrages tels que la série des encyclopédies de médecine sportive. Comme je l'avais déjà souligné en 1985 devant votre Trente-Huitième Assemblée mondiale de la Santé, notre Commission médicale procède à des recherches en matière de biochimie, biomécanique, physiologie, nutrition, ostéopathie et chirurgie, spécialités relatives au sport. Cette Commission prépare actuellement le Troisième Congrès mondial sur les sciences sportives qui aura lieu à Atlanta, aux Etats-Unis d'amérique, en septembre de l'année prochaine. En 1897 一 cela fait déjà bien longtemps, presque cent ans -, au Congrès olympique du Havre, en France, nos prédécesseurs, menés par Pierre de Coubertin, avaient choisi le thème "Hygiène et pédagogie sportives". En 1913, à Lausanne, Suisse, où nous avons maintenant notre siège, un autre congrès avait été organisé, axé aussi sur la santé et le sport. Cela prouve que les problèmes de santé et le bien-être de la société ont toujours été l,une des priorités du mouvement olympique. Pour terminer, le Congrès olympique du centenaire qui aura lieu à Paris du 29 août au 3 septembre prochain aura à traiter entre autres le thème suivant : "Le sport dans son contexte social". Notre commission "Sport pour tous " déploie en outre ses efforts à travers les comités nationaux olympiques et fédérations internationales pour encourager l'activité physique au sein de toutes les couches sociales. Nous organisons aussi chaque année dans tous les pays du monde une course populaire à laquelle prennent part les enfants, les femmes et les hommes sans distinction d'âge. Le CIO soutient également le sport pour handicapés en les associant à quelques épreuves aux Jeux olympiques et aussi aux Jeux d'hiver, mais surtout en favorisant l'organisation des Jeux paralympiques. Je peux vous assurer que sans les Jeux olympiques, il n'aurait pas été possible d'organiser les Jeux paralympiques. Il est évident que l'activité physique est une prévention naturelle pour chaque individu. C'est pour cette raison que nous vous invitons à coopérer avec vos ministères de l'éducation nationale et de la jeunesse et des sports afin de développer une politique qui est aujourd'hui celle de ГОМБ et du CIO, à savoir "Sport pour tous et santé pour tous". The PRESIDENT: Thank you very much, Mr Samaranch, for your inspiring words, your clear vision and your commitment to global health. I would now like to suspend the meeting for a few minutes in order to allow Mr Samaranch to take leave of us. I invite delegates to pay tribute to Mr Samaranch for the support he has given this Assembly through his presence and his words to us today. I invite you to applaud him as he leaves. (Applause /Applaudissements )

124 A47/VR/5 page 109 I shall now ask the second Vice-President to take over the presidency and I accordingly invite Dr Zahran who has replaced Dr Abdel Fattah El Makhzangi, as agreed. Dr M. ZAHRAN (Egypt), Vice-President, took the presidential chair. Le Dr M. ZAHRAN (Egypte), Vice-Président, assume la présidence. 2. DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-SECOND AND NINETY-THIRD SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR GENERAL SUR L'ACTIVITE DE L'OMS EN (suite) The ACTING PRESIDENT: : 'L.UJL.! ^ I ^J ^ J^J-AJI J ^«J DJL T^-W^JULÔJI 已 1 Ó J 1 C-^LSKAOI T^JT.G О И LAJ I ^ ^UJ LLJ I ^J^JLJLÜ I <UÍU3 L*AJ I 1 À^LU I CLu^J 3JLI0J dujsjl ^jjaxi Mr NGUYEN VAN THUONG (Viet Nam): Mr President, Mr Director-General, honourable participants, ladies and gentlemen, may I, on behalf of the Vietnamese delegation, congratulate the President on his election to this Forty-seventh World Health Assembly. Our delegation would like to express its sincere thanks to the Director-General for the report on all the work performed by WHO in the past year. Our Government will follow with determination the policy of WHO for attaining the objective of health for all by the year As you all know, Viet Nam is undertaking a policy of renovation in all fields, particularly in the field of health care. In the past, efforts were made by the Government and the Ministry of Health to set up a large network of health over the country. It was entirely subsidized by the Government. At the most peripheral level, the community also contributed to health care by providing houses, manpower and so forth for their communal health stations, while at district, provincial and central level, all costs were covered by the Government budget. The private sector did not exist (including in medical and pharmaceutical fields). From 1989 private practice in medicine and pharmacy was approved by the National Assembly. This created new problems for the Ministry of Health and many related bodies. Up to the present, there are more than 6000 private practitioners and 4000 private pharmacies, parallel to the State establishments. Great efforts are being made by the Ministry of Health to involve these private practitioners in national health programmes, particularly in the control of social diseases and public health. The system of recording/reporting has to be known and understood by these practitioners in order to have complete figures for the planning of further activities in various national programmes. The Ministry of Health and various medical/pharmaceutical associations have been carrying out activities among practitioners, both in the State-owned and private sectors, to ensure observance of ethical rules. Indeed, in the course of transformation from the subsidized to the market-oriented system, inappropriate trends were observed in some places. The overuse of antibiotics was higher in the private sector than in State-owned establishments, and private practitioners tended to prefer treatment to prophylactic activities, while the strategy of the Ministry of Health has been built on prophylaxis rather than treatment. Ethical problems are also a major concern of the Ministry of Health in the provision of good quality drugs for the people at all levels as poor quality or fake drugs of various origins (locally made or imported) have been detected by the Ministry of Health. The Bamako Initiative in Viet Nam covers at present 687 communes, totalling more than 2 million inhabitants. By provision of drugs to villagers through the revolving fund, local people can enjoy good quality drugs, as they come from reliable sources. That is why in 1994 the number of communes covered will be increased to 2000, with 3 million people. The Bamako Initiative has been one of the ways of providing good quality drugs to people at grassroots level.

125 A47/VR/5 page 110 Ethical rules should not only be observed by present practitioners, but should be taught at all medical schools at all levels for future practitioners. Another problem is ethical rules for traditional practitioners: perhaps special or complementary rules should be included regarding these traditional practitioners. Besides traditional education on ethical rules at medical schools, public awareness should be enhanced through a national movement over the country. In Viet Nam, 27 February has been chosen as the "Viet Nam Medical Day", to promote and encourage in the medical corps behaviour that accords with the motto "The medical practitioner should be, at the same time, a good mother for the patient". In addition, it is proposed that the National Assembly complement the current law on medicine and pharmacy, taking into consideration ethical regulations, when formulating legislation for the coming years. Ethical problems are not new in Viet Nam. But in the course of transformation to the new economic system and with the progress of medical science (organ transplantation), they should be reviewed in order to establish equality for all vis-à-vis health care. Mr STEFÁNSSON (Iceland): 1 Mr President, Director-General, distinguished delegates, ladies and gentlemen, on behalf of the Icelandic delegation I would like to congratulate the President and his fellow officers of this Assembly on his election and wish him every success in his work. For the last three or four years Iceland has experienced an economic recession. This downward turn in our economic fortunes was mainly the result of cuts in fisheries quotas in both 1992 and These cuts were necessary as scientific reports indicated that the situation of some of our fish stocks required stringent conservation measures. As the fiscal deficit was already considerable the Government decided to meet this downward turn in our economy by fiscal consolidation rather than allow an increase in the budget deficit. Consequently the Icelandic Ministry of Health has for the last three years been carrying out various measures in order to reduce the escalating costs of health care services in the country. In order to achieve the necessary cuts we were faced with two options. One was to reduce or even eliminate existing health care services. The other was to introduce service charges to a greater extent, that is co-payments by beneficiaries of these services. As might be expected, reduction or elimination of services was not considered to be a viable alternative. Therefore service charges for various health services that had previously been free of charge were introduced. Furthermore, already existing service charges were increased. Late in 1992 the Ministry introduced proportional co-payments for pharmaceuticals. Early in 1993 similar proportional co-payments were introduced for specialists' health services. However, the principle of free hospital health care for the patient has been firmly guarded. Despite these new co-payment rules the Icelandic patient still only pays around 13% of the total bill for health care and just over 30% of the total cost of pharmaceuticals. In order to ensure that the service charges for health care do not cause financial hardship for anyone needing care, an annual payment maximum has been established. Furthermore, special attention has been given to health care costs of families with many children. Our experience in 1993 of these new rules of proportional co-payment for both pharmaceuticals and specialists' health care services indicates this to be an effective method to decrease cost without affecting the quality of the care provided. Another step that has been taken in order to reduce health care costs without reducing the services is an increased coordination of hospital health care services, not least in the Reykjavik area. Last month I introduced a new plan of cooperation between the hospitals in Reykjavik and the Reykjavik area. This plan minimizes the overlapping of the same type of services between these hospitals. Furthermore negotiations concerning the unification of two of Reykjavik's three largest hospitals are well under way. In the long run considerable reduction in costs will be achieved by this measure. A complete review of the hospital services around the country was carried out in The study showed that the hospitals outside Reykjavik for the most part serve as nursing homes. Furthermore it revealed that those who live outside Reykjavik seek hospital care for more complicated medical ailments in hospitals outside their home region. The report's conclusions and proposals for a plan of action on the development of the hospital health care sector are at present being debated and are under active consideration in the Ministry of Health. 1 The text that follows was submitted by the delegation of Iceland for inclusion in the verbatim record in accordance with resolution WHA20.2.

126 A47/VR/5 page 111 I have recently launched an extensive health promotion project. The goal of the project is to enable individuals and families to achieve their fullest health potential by taking control of the things which determine their health and by making choices conducive to health. The goal of the project is also to strengthen and coordinate various preventive measures in order to promote healthier lifestyles of the Icelandic people and thus improve their health. This project will be carried out in close cooperation with the network of health care centres we have established around the country during the last two decades. This network of health care centres ensures equal access to health care services in rural and urban areas alike. The health care centres thus provide the whole of the population with equal access to health care services and form an excellent basis for a health promotion project of this kind. The Executive Board has invited delegates addressing the plenary meeting to give special attention to ethics and health. Escalating health care costs and the need to decrease these costs has in many countries given rise to extensive discussions on the rational and efficient use of resources and in that context the concept of prioritization. Some of our neighbouring countries have already devised a model on priority groups for health care services where demand exceeds supply. As I have already mentioned, equal access to health care services is considered to be one of the cornerstones of the Icelandic health care system. Hiis means that access to care must not be affected by age, gender, education, payment capacity, the nature of the disease or its duration. In order to control the allocation of resources we are examining some of the priority group models used in our neighbouring countries. Should such models be adopted in our country the following principles will, in my opinion, nevertheless have to be adhered to: the principle that all human beings are equally valuable and the principle that resources should be allocated to those fields, activities and individuals where the needs are greatest. The Icelandic Government is not alone in dealing with the ethical implications that accompany allocation of scarce resources to health care services. Active cooperation is called for and exchange of information is necessary in order to best achieve the goal we all aim at, cutting health care expenditure as painlessly as possible and with as little reduction in services as possible. I believe that in this effort the World Health Organization could and should play a central role. Dr NGEDUP (Bhutan): Mr President, Director-General, distinguished delegates, ladies and gentlemen, it is a great privilege and honour for me to attend the Forty-seventh World Health Assembly. My delegation would like to express the confidence that under the wise and able stewardship of its President, this Assembly will come to a successful conclusion. We would also like to convey through the President our deep gratitude and appreciation to the outgoing President and Vice-Presidents. As a new dawn breaks over South Africa my delegation shares with this august Assembly the joy of welcoming the resumption of her membership and rightful role in the World Health Organization. We take this opportunity to wish the people of South Africa every success as they embark on a new era of freedom, equality, hope and shared prosperity. In recent years the world has witnessed unprecedented political and socioeconomic changes - some beyond our farthest imagination. We have witnessed the shattering of ideological, historical and economic barriers, giving way to freedom, cooperation and integration. Equally sudden has been the manner in which new walls are being erected and divisive forces are becoming active. Civil strife is on the rise and unconscionable acts of violence and cruelty are being inflicted upon innocent people, giving rise to untold human suffering. Even diseases once controlled are re-emerging to challenge the efficacy of wonder drugs. While medical science and technology have advanced to the level of robotic surgery, test-tube babies and mind-altering drugs, teeming millions are still craving for basic health care. I do not aim to sound pessimistic but to remind ourselves of the challenges that still lie ahead and the need to strengthen our will to combat these and to rekindle the hopes of the sick, wounded and deprived. Since the beginning of time, humankind not only learnt to survive through their instincts alone, but evolved with ingenuity, resilience and creativity. However, it also meant "survival of the fittest". As we near the end of this millennium and the birth of the twenty-first century, a world order based on open market economy is being established. While we view this trend positively, it is imperative to be wary of its impact on the weaker sections of our societies. Structural reforms undertaken by many less developed countries have led to a negative growth in expenditure on basic social services, with disturbing consequences for the health sector. Putting even a nominal price tag on basic services could sometimes take such services beyond the reach of certain sectors of our society. Any consideration in our drive towards health for all by the year 2000 must therefore take careful note of this reality.

127 A47/VR/5 page 112 Against this backdrop, my delegation welcomes and fully appreciates the numerous initiatives taken by the World Health Organization under the dynamic leadership of its Director-General, Dr Nakajima, to achieve our cherished goal of health for all by the year Indeed, this goal is merely an expression of our collective desire to fulfil one of the basic human rights of our peoples. In a world where rapid changes are taking place, we have always admired the dynamism with which WHO has been able to evolve its role in order to respond most effectively to changing needs and circumstances. We therefore welcome the establishment of a Global Policy Council under the chairmanship of the Director-General. This, we believe, will ensure the continued relevance and effectiveness of WHO. We are particularly gratified to note that the most needy countries are targeted to receive special consideration. In this context, recognizing the critical importance of appropriate technology and manpower capability within the health sector, the importance of technical cooperation among developing countries needs to be fully emphasized. The concept of essential drugs and vaccines, as promoted by WHO, forms the basis for one of the main strategies of our primary health care programme. In Bhutan, we have developed a basic framework for the efficient and equitable supply of free drugs to all communities throughout the kingdom. The Royal Government is in the process of formulating the Medicines Act and establishing a Drug Control Administration Board to ensure the quality and control of sale of drugs by private dealers. In this context, we welcome the recommendations of the consultation on WHO ethical criteria for medicinal drug promotion. WHO may wish to consider translating some of these experiences into models that could be incorporated into national drug regulations. On the question of communicable diseases, we have noted that several activities have been initiated under the auspices of the Global Programme on AIDS in the last few years. I am happy to inform you that the Medium-Term Plan I of the Bhutan National STD/AIDS Programme is being implemented successfully. AIDS is a growing public health problem that threatens to undermine the health care services in many of the developing countries. Not only are hospitals in some of the less developed countries being overwhelmed by the burden of high and alarming proportions of AIDS patients, but the very process of socioeconomic development in these countries appears to be threatened and certainly impeded by this disease. We welcome the report on the actions taken to develop and establish a joint and cosponsored United Nations Programme on HIV and AIDS. Given the urgency and the complex nature of this programme and in the interest of avoiding duplication of efforts, my delegation would like to recommend that the programme be administered by WHO. Tuberculosis has become a global emergency. Not only in the developing countries, but even in the highly industrialized countries, the disease is making a comeback. Serious and combined efforts are required by all nations to combat this scourge. In this regard, we are pleased to note that the Executive Board has approved the decision of the Director-General to establish a special account for tuberculosis within the Voluntary Fund for Health Promotion. Leprosy is also another major health problem. In this regard, the results of a vigorous effort, shown in the progress report of the Director-General is very encouraging. We are happy to report that this ailment, which is equally a social disease has been virtually eliminated in Bhutan. May I now briefly touch on the central theme for this year's Technical Discussions, "Community action for health". The Alma-Ata Declaration clearly called for international commitment to community action for health. However, the application and outcome in this respect has not been encouraging. The increasing cost and the limited resources available to meet the growing demands for health care underscore the need for a more effective application of community action for health, especially for the developing countries. We are convinced that without the involvement of the community as partners in the health care system, the goal of health for all by the year 2000 is not attainable. Nor will the health care system in our countries be cost effective and sustainable. Moreover, with the onslaught of HIV/AIDS, the active participation of the community in bringing about changes in behaviour cannot be overemphasized. Bhutan stands fully committed to the concept of community action for health. Since the late 1970s the Royal Government has followed a conscious and consistent policy of fully integrating active community participation in all aspects of socioeconomic development under the policy of decentralization. Convinced that it is the villager who is most sensitive to the needs of the village and confident in the collective genius and wisdom of the community to devise the most effective and sustainable strategies towards fulfilling those needs, our national five-year plans are always initiated at the grass-root level. Community action for health in Bhutan is being promoted through village health workers, the programmes for rural water, sanitation and smokeless stoves and other health-related activities. In this regard, women are playing an equally important role. I am confident that the outcome of the Technical Discussions will act as a catalyst to further strengthen community action for health and to achieve a more cost-effective, efficient and sustainable health system within the Member countries.

128 A47/VR/5 page 113 WHO and its partners have achieved tremendous successes in combating major diseases in the last few decades. Through their leadership and unflagging efforts, smallpox has disappeared from the face of the earth, and mortality from diarrhoeal and vaccine-preventable diseases has declined significantly. Yet much more remains to be done. There are still many scourges, such as AIDS and the appearance of drugresistant pathogens. We are confident that WHO, with the support of international, bilateral, multilateral, and nongovernmental organizations and other agencies, will continue to combat these health problems. I would be remiss if I were not to remember with gratitude and appreciation the invaluable role of our former Regional Director, Dr U Ko Ko, in strengthening the health services in our Region. Dr Ko Ko was particularly sensitive to small, landlocked countries like Bhutan. In the same vein, we are happy to welcome our new Regional Director, Dr Uton Muchtar Rafei. I am confident that, with his intimate knowledge and experience of all the countries in our Region, he will guide the South-East Asia Region towards achieving the goal of health for all by the year I would also like to take this opportunity, Mr President, to convey the sincere gratitude of the Royal Government and the people of Bhutan, to WHO, the international and other agencies, and donor countries, which all provide invaluable assistance for the enhancement of the quality of life of the people of Bhutan through better health care. The ACTING PRESIDENT: : ^l^jl ^^Jl c^ 己 ^^ J ЦА^ 一 ^j^uji ^ j^c J ^ O U ^ I Л. У : ^! 己 ' «L Ú L ^ I 山 J J I J ^ ^ L DJ>JI IKIO^ FUU^L J 3JJI I ^ ^ U! ^ j 产 ^ J^JJI DJJB i^lyi^v! Uui.j^J) Li^ JUj^JI 4srJU.^^Jl LJb/l '^juj! ^is ^axuc J^JJI dlb f ^LÜJLO i ^UJV l^xj J>t>1 "yj dj ^U S^JL^J.J^jJI ^^e JJLC ^js. '«iblü.у^э LÁ J^J Ц _ I M. DABIRE (Burkina Faso): Monsieur le Président de séance, Mesdames et Messieurs les Ministres, Monsieur le Directeur général de l'oms, honorables délégués, Mesdames, Messieurs, le message que je vais lire ici, je le ferai au nom des quelques pays africains qui ont été amenés récemment à se réunir dans un cadre informel pour faire face à une situation nouvelle. Il s'agit d'abord des quatorze pays de la zone franc africaine qui, suite à la dévaluation du franc CFA, se sont réunis à Abidjan pour définir et adopter des résolutions en matière de politique des médicaments. Cette initiative de la Côte d'ivoire a permis d'obtenir des résultats qui sont allés au-delà de nos espérances puisque nos recommandations viennent d'être adoptées par quatre autres pays présents à la rencontre d'evian pour une concertation sur les médicaments. C'est donc au nom de dix-sept pays africains, n'appartenant pas à la zone géographique correspondant à la Région africaine de POMS, qui ont décidé spontanément de se réunir pour étudier en commun leurs problèmes de santé de l'heure, que j'ai ГЬоппеиг de prendre la parole devant cette Assemblée. Auparavant, j'aimerais rappeler le nom de ces pays qui sont les suivants : Bénin, Burundi, Cameroun, Comores, Congo, Côte d'ivoire, Gabon, Guinée équatoriale, Madagascar, Mali, Niger, République centrafricaine, Sénégal, Tchad, Togo et Burkina Faso. La plupart de ces pays appartiennent à des organismes ou programmes régionaux de santé publique, et sont donc habitués à concevoir une approche sous-régionale des problèmes de santé. Il s'agit notamment de pays membres du programme de lutte contre l'onchocercose en Afrique de l'ouest, de l'organisation de Coordination et de Coopération pour la Lutte contre les Grandes Endémies en Afrique de l'ouest ou de l'organisation de Coordination pour la Lutte contre les Endémies en Afrique centrale. C'est donc à la fois un honneur et un privilège pour moi de prendre la parole au nom de tous ces pays pour vous faire part de nos préoccupations en matière de santé, et vous signaler quelques points sur lesquels la communauté internationale devra focaliser ses efforts. Toutefois, avant cela, je voudrais saisir l'occasion qui m'est offerte pour adresser au Président, au nom de tous mes collègues ministres de la santé et en mon nom personnel, mes vives félicitations pour sa brillante élection à la présidence de la Quarante-Septième Assemblée mondiale de la Santé. J'associe tout naturellement à ces félicitations les Vice-Présidents qui ont l'honneur de le seconder dans Paccomplissement de sa mission.

129 A47/VR/5 page 114 Je voudrais également saluer la délégation de la République d'afrique du Sud qui, après trente années d'absence, vient de retrouver sa place au sein de notre Assemblée. Sa présence aujourd'hui à cette session est le symbole de la victoire de toute la communauté internationale sur l'odieux système de l'apartheid. C'est également roccasion pour nous de regretter très fortement la situation qui sévit présentement au Rwanda et au Burundi. L'ensemble de la communauté internationale est interpellé pour faire cesser les massacres qui déciment ces peuples et apporter toute l,aide nécessaire à l'amélioration de la situation sociale et sanitaire des populations rwandaises et burundaises. Le monde en général et l'afrique en particulier sont aujourd'hui confrontés à une crise de la santé d'une ampleur sans précédent caractérisée par : premièrement, la résurgence de maladies comme le paludisme, la trypanosomiase et même la tuberculose que l'on croyait éradiquée dans les pays développés; deuxièmement, la détérioration croissante des infrastructures de santé et la dégradation des prestations de soins dues à la baisse des budgets de santé et à la pénurie des médicaments; troisièmement, Fapparition et l'augmentation rapide des cas de SIDA dont les conséquences socio-économiques sont particulièrement graves pour le continent africain. Cette crise de la santé se trouve aggravée notamment par la persistance de la récession économique mondiale qui inhibe les efforts entrepris par nos Gouvernements pour transformer radicalement la situation sanitaire dans nos pays respectifs. La plupart des délégués à la présente session se souviennent des efforts importants déployés par nos Etats pour renforcer les soins de santé primaires dans nos pays grâce à la mise en oeuvre de stratégies fondées principalement sur la décentralisation des services de santé, la participation communautaire à tout le processus gestionnaire et au financement des services de santé, et l,accessibilité géographique et financière des médicaments. C'est dans ce contexte marqué par la volonté et la décision politique de nos Gouvernements d'améliorer la situation sanitaire de nos pays qu'est intervenu le réajustement de la parité de notre monnaie commune vis-à-vis du franc français, je veux parler de la dévaluation du franc CFA décidée le 12 janvier 1994 à Dakar,dont l'une des conséquences immédiates est la dégradation encore plus grande de la santé dans nos pays. Cette dégradation est essentiellement marquée par le renchérissement des prix des médicaments, notamment des spécialités pharmaceutiques, le prix des équipements et la marginalisation plus marquée des couches sociales les plus défavorisées et les plus vulnérables. Malgré l'engagement de leurs partenaires au développement à mettre en place des mesures d'accompagnement pour atténuer les effets sociaux de la dévaluation, ces pays africains auront du mal à maintenir une accessibilité satisfaisante des populations démunies aux soins de santé. Le droit à la santé et l'objectif égalitaire de la santé pour tous exigent des efforts soutenus de nos pays dans le cadre d'une coopération internationale. Notre coopération technique avec l,oms nous est d'un grand profit. Elle nous a permis de consolider nos programmes opérationnels en faveur des régions périphériques et des populations à haut risque que sont les enfants, les femmes enceintes et allaitantes et les personnes âgées. A situation nouvelle, politique nouvelle : l'organisation des Nations Unies en général et l'organisation mondiale de la Santé en particulier ont su aborder, et à temps, le virage nécessaire pour s'adapter aux changements mondiaux. Le rapport du Directeur général sur les mesures déjà prises et à prendre nous donne des raisons d'espérer en ce qui concerne l,efficacité et l'efficience futures de notre Organisation dans l'accomplissement de sa mission. Il convient ici d'adresser nos félicitations à M. le Directeur général de l'oms pour la qualité remarquable du rapport d'activité qu'il nous a présenté. Il me plaît, du haut de cette tribune, de saluer Faction de la communauté internationale qui s'est investie dans le développement de l'afrique, tout en l'invitant à poursuivre ses efforts plus encore que par le passé, pour permettre à ce continent confronté à de nombreux défis de les surmonter pour le bien-être de nos populations. Le développement et la mise en oeuvre de la coopération technique entre pays en développement (CTPD) dans le secteur de la santé constituent en cela une priorité pour nos pays africains, surtout en ce qui concerne la production, rimportation et la distribution de médicaments essentiels dans ce nouveau contexte de dévaluation du franc CFA. Pour y arriver, nous devons surmonter les obstacles liés à la circulation de l,information entre les pays et surtout au manque de sensibilisation des pays aux possibilités qu'offre la CTPD pour le développement de la santé. Cependant, la recherche de solutions pour sortir de la crise socio-sanitaire et économique doit être avant tout l'affaire des communautés. C'est pourquoi je salue le choix du thème des discussions techniques de la présente Assemblée : "L'action communautaire en faveur de la santé". Nos différentes politiques nationales de santé, qui placent les communautés au centre de leur développement sanitaire, ont permis une plus grande participation des populations aux prises de décision et à la gestion des structures et des programmes de santé à travers les organisations de santé communautaires. Après l'étape de la participation financière des populations aux frais de consultation, les

130 A47/VR/5 page 115 activités seront élargies à la stratégie de renforcement des soins de santé primaires à travers le recouvrement du coût des médicaments essentiels rendus disponibles dans les structures de santé et donc plus accessibles aux populations. Ainsi semblent se dégager des axes de réflexion de même que les moyens à mettre en oeuvre pour le financement du système de santé. Les Etats fournissent un appui non négligeable à l'action communautaire en faveur de la santé en participant à la formation des membres des communautés de base, en augmentant le budget consacré aux médicaments et en dotant les districts sanitaires de crédits nouveaux pour la maintenance des infrastructures et la formation continue des agents de santé. Je félicite le Conseil exécutif pour le choix judicieux des programmes contenus dans le rapport du Directeur général, et qui feront l'objet de résolutions. En outre, la mise en oeuvre des résolutions sur rélimination du tétanos et la lutte contre la rougeole, l'éradication de la dracunculose, rélimination de la lèpre en tant que problème de santé publique, la lutte contre Fonchocercose par la distribution d'ivermectine, la mise en oeuvre de ces résolutions, dis-je, permettra, j'en suis persuadé, de faire un grand pas vers Fobjectif de la santé pour tous. Les résultats obtenus par le programme de lutte contre ronchocercose en Afrique de l'ouest sont l'aboutissement d'une coopération sous-régionale et internationale qui doit servir d'exemple dans le futur. La réunion ministérielle sur le peuplement et le développement durable des zones libérées par Ponchocercose, tenue à Paris les 12, 13 et 14 avril 1994, illustre le fait que la santé au-delà du bien-être physique et mental est également le fondement même de Pactivité économique. L'amélioration de la santé peut ainsi contribuer effectivement à la croissance économique en permettant d'exploiter des ressources naturelles qui, situées dans des zones infectées de vecteurs d'agents pathogènes, étaient totalement ou largement inaccessibles; elle libère à d'autres fins les ressources qui auraient pu servir à soigner les malades. Selon le rapport de la Banque mondiale sur le développement dans le monde 1993,les retombées économiques de l'amélioration de la santé sont particulièrement importantes dans les couches pauvres de la population, habituellement plus sujettes que les autres à la maladie et qui ont plus à gagner à mettre en valeur des ressources naturelles insuffisamment exploitées. Ainsi, lutter contre la pauvreté, c'est également lutter pour la promotion de la santé, car la relation étroite entre le développement économique et la santé, notamment celle des pays les plus vulnérables, est un enjeu central qui, rappelons-le, est la base du Sommet mondial pour le développement social prévu à Copenhague en mars L'OMS a le devoir d'inviter les Etats Membres à considérer la santé comme indicateur et partie intégrante de leur développement économique, suite au rapport de la réunion du groupe spécial pluridisciplinaire de l'oms qui s'est tenue à la Carnegie Corporation, à New York (Etats-Unis d'amérique), du 7 au 9 décembre Je terminerai mon propos en parlant d'éthique et de santé dans le cadre de l'approvisionnement en médicaments. Comme relaté au début de mon exposé, les pays africains de la zone franc connaissent depuis quatre mois un problème d,accessibilité financière de leurs populations à des produits pharmaceutiques devenus trop coûteux à cause de la dévaluation du franc CFA. Une des voies que nous explorons pour mettre les médicaments à la portée de nos populations est l'acquisition de produits génériques et de spécialités pharmaceutiques en conditionnement hospitalier. Nous devons être très vigilants et exigeants pour la qualité des produits génériques qui sont distribués dans les pays en développement; ces produits doivent être utilisés par les pays exportateurs et aussi avoir la certification de l'oms. L'adoption du projet de résolution, par la présente Assemblée, sur la révision et l'amendement des bonnes pratiques de fabrication de produits pharmaceutiques de l'oms, nous permettra, j'en suis persuadé, de faciliter et de rendre le commerce international des produits pharmaceutiques plus sûr. Les Gouvernements des pays africains membres de la zone franco du Burundi et de Madagascar réitèrent leur gratitude à la communauté internationale et expriment le souhait que les conclusions de nos assises contribueront de façon déterminante à la sensibilisation des populations, des organisations gouvernementales et non gouvernementales, et des institutions internationales, pour que la santé occupe la place qui lui revient dans le processus de développement socio-économique. The ACTING PRESIDENT: :'.LLjJW l t ^ 1 ^JLÎULO Ui) b л 0) L^wlw 己 Лг^ J^jJI ^o^ 'LJbJ\ 山 jjl y ^J^ ^ з ^ 己 ^ ^ 力 JUlLJI ЛЦ^Р t^j 匕 y :^ l^p ^Jl.^J u^u^i^ji duuj 丨 J S^JI jl fjijj J^jJI

131 A47/VR/5 page 116. 山 jji ^ J^i ^ ^ о '<LJU1 fsj ^ijj^a El Dr. SAMAYOA (Honduras): Señor Presidente: Lo felicitamos por la honrosa elección de que ha sido objeto. Como región centroamericana que durante muchos años tuvo enfrentamientos armados venimos a esta magna 47 a Asamblea Mundial de la Salud a presentar nuestras inquietudes, realidades y planteamientos, considerando a la salud como prioridad dentro de los problemas del mundo y en particular de Centroamérica, siendo el agua y el medio ambiente número uno para nuestro desarrollo agrícola, industrial y de la salud a través de su conservación, uso y tratamiento. Hoy, cuando la lucha armada ha casi desaparecido en nuestros países, el reto es lograr la paz social y la salud, como su pilar fundamental, para beneficio de los grupos más vulnerables. No hay justicia sin equidad de salud y sólo las nuevas dolencias de la humanidad y las presiones que éstas ejercen en todos los países desarroüados y subdesarrollados nos hacen reflexionar en que se pueden desbordar los sistemas mejor organizados ante patologías como el SIDA, que actualmente nos hace sentir impotentes. Debemos orientar nuestro plan de prevención en un enfoque multisectorial definido en tres grandes objetivos: 1) prevenir la transmisión del VIH; 2) reducir el impacto por VIH y SIDA en el individuo, grupos y sociedad; y 3) movilizar y unificar esfuerzos y recursos nacionales e internacionales para la lucha contra esta epidemia. De esta manera se han desarrollado campañas para interrumpir la transmisión sexual del VIH en Centroamérica: promoviendo el desarrollo de una sexualidad responsable en adolescentes y modificando los comportamientos en los grupos con conducta de riesgo; educando a la población a través de los medios masivos de comunicación; promoviendo el apoyo de la comunidad organizada; y mejorando el control de las enfermedades de transmisión sexual, para interrumpir la transmisión perinatal evitando la infección en mujeres en edad fértil y los embarazos en las infectadas. Los gobiernos de Centroamérica estamos sumamente preocupados por el incremento del número de casos infectados por VIH/SIDA. Nuestros principales objetivos son impedir la transmisión, reducir el impacto y movilizar a los países centroamericanos en su conjunto para hacerle frente a este grave problema. Necesitamos fortalecer los procesos educativos, controlar las enfermedades de transmisión sexual, mejorar la participación comunitaria, gestionar las acciones en bloque de las iglesias y reducir el impacto de la enfermedad y la infección; hacemos un llamado a la solidaridad internacional para seguir cooperando con nosotros y ayudarnos a enfrentar esta grave crisis. El cólera ha hecho de nuestra región una víctima más del continente y nos hace recordar que la educación y la salud son dos sectores sociales que no debèn separarse; y no se deben escatimar esfuerzos en campañas educativas frecuentes, intensas, focalizadas para combatir y superar los fuertes aspectos culturales, de lenguaje y las dificultades geográficas o de comunicación que hacen de los brotes del cólera una constante amenaza mortal. No podemos más que decir que el cólera sólo se cura teniendo agua segura. Algunos hermanos del área, como Costa Rica y Panamá, tienen resultados alentadores y gratificantes en su campaña de mejorar el agua para sus conciudadanos, pero aún así el cólera está amenazante. La falta de agua segura, la escasa letrinización y una deficiente educación nos hacen un blanco propicio para este flagelo de la humanidad. Los apoyos financiero y técnico de la OPS/OMS son y será factores determinantes en la lucha contra estas enfermedades del subdesarrollo como el cólera. La Iniciativa de Salud para Centroamérica ha hecho reunimos y estrechar más nuestros lazos de hermandad, resolviendo muchos conflictos, convirtiéndonos en un ejemplo para la comunidad mundial. En salud la RESSCA (Reuniones del Sector Salud de Centro América) ha organizado varias campañas simultáneas contra enfermedades inmunoprevenibles como son la poliomielitis, el sarampión, la difteria, el tétanos, la tuberculosis, y sobre la dotación de micronutrientes como la vitamina A. Hemos empezado a ver resultados significativos en la erradicación de la poliomielitis, confirmándose, a través de la certificación de OPS, y más recientemente en Honduras, que no existe poliomielitis desde hace cuatro años. Lo anterior es simplemente la consecuencia de una cobertura de vacunación en más del 90% en el territorio centroamericano. La niñez es un objetivo primordial, y así como estamos combatiendo las enfermedades inmunoprevenibles damos seguimiento a lo estatuido en la Conferencia Internacional sobre Nutrición que señala los compromisos básicos que deberán cumplir los Estados para combatir el hambre y las muertes por hambre, la inanición y las enfermedades por carencias nutricionales y las deficiencias específicas de yodo, hierro y vitamina A. Las políticas de seguridad alimentaria de nuestros países deben reorientar geográfica, técnica y financieramente los programas de asistencia alimentaria, principalmente en el área maternoinfantil,

132 A47/VR/5 page 117 considerando la extrema pobreza como el indicador fundamental para tratar la marginalidad y las carencias de los grupos más vulnerables. Por lo tanto, en el gasto social reorientado se plantea la necesidad de visualizar el agua como elemento integrador de la producción de alimentos, del desarrollo agroindustrial y de garantía en gran medida de la inocuidad de los alimentos para que en una aproximación sucesiva se alcance un saneamiento adecuado que contribuya a la salud de la población. En referencia a la lactancia materna, en la Declaración de Inocenti se insta a los gobiernos a promover la lactancia natural en todas las mujeres, y lograr adhesión y apoyo a la movilización social de todos los sectores. Deben constituirse organizaciones privadas de desarrollo ligadas a la promoción de la lactancia natural que aboguen por que no se consuman productos industriales que van en detrimento de la lactancia natural. Sin embargo, estas acciones han tenido un bajo nivel de impacto y muy bajas coberturas geograficopoblacionales. En los países en desarrollo, la tuberculosis aún es de alta prevalencia; ésta debe considerarse como problema prioritario y explicitarse en las políticas nacionales de salud. Se deben continuar las actividades de evaluación subregionales y regionales e introducir en ellas el componente de discusión y elección de estrategias para el control de la tuberculosis. Debe darse apoyo técnico y financiero a las investigaciones en tuberculosis identificadas como necesarias por cada país. La racionalización del uso de los medicamentos tiene una dependencia directa de la promoción que de ellos se realiza, y los criterios éticos que deben enmarcar esta promoción son una responsabilidad no sólo de los ministerios de salud pública sino también de la industria farmacéutica, de los prescriptores, dispensadores y de los consumidores. Ante esta problemática común en los países de Centroamérica, se está trabajando conjuntamente para adoptar formalmente los criterios éticos de la OMS y realizar investigaciones que permitan valorar con mayor precisión la situación existente. En el marco del programa de modernización de los sistemas de salud de Centroamérica se define la necesidad de coordinar la cooperación externa, brindándole al nivel local un rol protagónico en la definición de necesidades de esa cooperación. En ese sentido, es pertinente que las directrices y recomendaciones sobre cooperación técnica entre los países en desarrollo (CTPD) surjan desde ese nivel y se consoliden a un nivel central institucional para su debido seguimiento por la instancia atinente. En cada continente debería establecerse un mecanismo internacional de apoyo y seguimiento a las necesidades de CTPD, tal cual son las reuniones de ministros y cumbres de presidentes; podría ser una función específica de una subsecretaría, dirección general u oficina de relaciones internacionales de cada país, para presentar los resultados de las evaluaciones periódicas de la CTPD. La agilización de fondos de organismos internacionales destinados a la CTPD es un factor clave para la movilización de recursos humanos que tengan la capacidad demostrada para ofrecer asistencia técnica. Muchas gracias. El Dr. MAZZA (Argentina): Señor Presidente, señor Director General, distinguidos delegados: Permítame felicitarle, señor Presidente, con motivo de su elección y por sus palabras de apertura. También felicito al señor Director General, Dr. Nakajima, por su gestión al frente de la OMS y por haber iniciado y puesto en marcha el proceso de reforma que consideramos necesaria para superar con eficiencia los problemas prioritarios que afectan negativamente el nivel de calidad de vida y salud de la población. En este sentido, queremos destacar del informe del Director General que los cambios propuestos no son una mera reforma estructural, sino además una profunda reorientación programática. Con satisfacción hemos escuchado la enumeración de actividades propuestas por el Director General con el fin de avanzar en forma positiva, dando respuesta a los constantes desafíos que afronta el sector. También queremos expresar en esta oportunidad la satisfacción del pueblo y Gobierno argentinos ante la incorporación plena de la República de Sudáfrica a la Organización Mundial de la Salud, muestra evidente del constante avance de la democracia en nuestros países. El creciente aumento demográfico, el envejecimiento de la población, la concentración urbana, la desocupación y la pobreza en algunas regiones del mundo, así como en algunas de ellas la reaparición del cólera o de la difteria y el incremento de la tuberculosis en muchas de ellas, entre otras patologías y realidades sanitarias, exigen un urgente replanteo de los sistemas de salud. El avance del SIDA, que supera las fronteras de cada país para transformarse en un problema mundial de gran repercusión sociocultural y efectos negativos para el desarrollo económico y social, merece un tratamiento específico. Frente a este flagelo resulta de fundamental importancia mejorar la articulación y complementación entre los países. Debemos concentrar todos nuestros esfuerzos para combatir el SIDA y sus consecuencias, y por ello nuestro país apoya firmemente la idea de promover un programa de nivel mundial orientado por la OMS, que coordine el uso racional de los recursos provenientes de organismos internacionales, organizaciones

133 A47/VR/5 page 118 no gubernamentales e instituciones colaboradoras, sin que ello limite la posibilidad de los países de implementar y desarrollar sus propios programas nacionales. Otro problema que queremos destacar es el aumento de la violencia social en el mundo y sus graves consecuencias con efecto multiplicador sobre la morbimortalidad, que agravan aún más los serios problemas sanitarios existentes. El año pasado, en este mismo foro, señalábamos la necesidad de actuar rápidamente contra dicho peligro y destacábamos la necesidad de una acción conjunta con el objetivo de disminuir todo tipo de violencia proponiendo la participación activa de la Organización como instrumento estratégico y movilizador. La Argentina ofrece la posibilidad de concretar acciones de cooperación técnica internacional con el fin de contribuir, dentro de nuestras posibilidades, a alcanzar la ambiciosa meta social de salud para todos en el menor tiempo posible y al menor costo económico y social, en el marco de las políticas sustantivas e instrumentales de salud, aprobadas por primera vez en la República Argentina hace dos años por decreto del poder ejecutivo nacional. El señor Presidente de la nación, Dr. Carlos Saúl Menem, ha propuesto la creación de un cuerpo internacional de lucha contra el hambre, que denominamos «cascos blancos», que estaría destinado no solamente a combatir el hambre sino también a contribuir al desarrollo social y al mejoramiento del estado sanitario. Basados fundamentalmente en la posibilidad que ofrece el momento histórico que está viviendo la Argentina, con plena vigencia de las libertades individuales e institucionales, con una democracia participativa y pluralista y con estabilidad económica, entre otros hechos significativos, hemos continuado avanzando internamente en la transformación del rol del sector de la salud en el Estado moderno, colocando al hombre argentino y a su familia como eje, objeto y sujeto de la acción del Gobierno, que está comprometido en alcanzar en el menor tiempo posible esa ambiciosa meta social de la salud para todos. También en busca de la equidad, hemos intensificado la acción sanitaria destinada a disminuir los riesgos evitables de enfermar y morir, privilegiando actividades de promoción y protección de la salud y prevención de la enfermedad, como un modo de corregir muchos de los grandes problemas de salud, olvidados en nuestros países. Hemos hecho mucho hasta la fecha pero todavía falta un largo camino por recorrer y estamos seguros de poder concretarlo gracias al continuo y permanente estímulo y apoyo que nos brindan, tanto la Organización Mundial de la Salud como la Organización Panamericana de la Salud y otras entidades internacionales. Todo sistema de salud debe estar al servicio del hombre, y en tal sentido la tecnología debe ponerse también al servicio del hombre. Por consiguiente, los sistemas deben adecuarse primariamente a este principio. No cabe duda de que debemos congratularnos por todos los beneficios que reporta para las ciencias médicas el avance tecnológico, pero tampoco existen dudas en la responsabilidad que debemos tener en la incorporación racional de la tecnología, de acuerdo con las necesidades y posibilidades del medio y, fundamentalmente, con la implementación y desarrollo de la tecnología apropiada en la organización de los sistemas de salud. Un paso importante en nuestro país ha sido la creación de la Comisión Nacional de Bioética, integrada en forma interdisciplinaria y multidisciplinaria por funcionarios del Ministerio de Salud, y por representantes de la Corte Suprema de Justicia de la nación, de las comisiones de salud del Congreso Nacional, de la Academia Nacional de Medicina, de la Asociación de Facultades de Medicina de la Confederación Médica de la República Argentina, y destacados especialistas y expertos en la materia, entre otros. Una de las primeras actividades desarrolladas fue la creación y reglamentación del funcionamiento de los comités hospitalarios de ética médica, que han sido incorporados al programa nacional de garantía de calidad de la atención médica, uno de los principales instrumentos implementados con el fin de mejorar, con una visión sistémica, los distintos aspectos que interactúan en el cuidado de la salud de la población, que existe en nuestro país y cuyo marco normativo regula no solamente a las entidades prestadoras, sino también a las financiadoras de la atención médica, incluido el subsistema de la seguridad social. Hemos desarrollado el modelo del hospital público de autogestión, con el fin de recuperar para el hospital el prestigio institucional perdido como resultado de largos años de políticas erráticas. El hospital público de autogestión tiene, como objetivos fundamentales, mejorar la eficiencia y calidad del proceso tecnicoadministrativo de gestión institucional, ampliar la accesibilidad y extensión de cobertura de atención médica a la población y aumentar significativamente sus aportes financieros mediante la efectiva descentralización, la programación local, la participación social y la articulación y complementación con otros servicios públicos y/o privados, y el pago obligatorio y automático por parte del sistema de seguridad social, en nuestro país «obras sociales», cuyos beneficiarios utilicen libremente los servicios

134 A47/VR/5 page 119 del hospital. Esta misma obligatoriedad de pago se extiende a los sistemas privados de cobertura médica. Este pago obligatorio y automático tiende a lograr una mayor solidaridad en el sistema, al generar el pago de las prestaciones de los que tienen algún tipo de cobertura, en beneficio de la población sin otra cobertura. De este modo, mediante una estrategia solidaria pretendemos mejorar la equidad, la accesibilidad y fundamentalmente la universalidad de los sistemas de servicios de salud de nuestro país. De este modo, el hospital público de autogestión se transforma en un elemento altamente calificado y eficiente, que tiene en sus áreas programáticas y en la atención primaria de salud la puerta de entrada a un sistema de servicios de salud más complejo, organizado por niveles de complejidad creciente. Otro aspecto importante de destacar es la necesidad de realizar un análisis profundo de algunos avances cientfficos y tecnológicos que, por los problemas éticos, morales y legales que generan, exigen por sus consecuencias, no siempre esperadas, controles y cierto grado de limitaciones por parte de la autoridad sanitaria de aplicación. En tal sentido, estamos convencidos de la necesidad de recuperar en todos sus aspectos la responsabilidad ineludible de todos y cada uno de los integrantes del equipo de salud, y en todos y en cada uno de los niveles de la organización sanitaria, el respeto a las pautas y valores culturales de la sociedad y las normas morales, éticas y legales vinculadas con el ejercicio profesional. En definitiva, basados en las orientaciones programáticas y estratégicas promovidas por la OMS y la OPS, hemos iniciado una larga etapa de profundas transformaciones del sector de la salud en nuestro país, que tienen al hombre como eje de la acción sanitaria y a la salud de la comunidad en su conjunto como la imagen objetivo deseada en el marco de la justicia social. Por ello, felicitamos muy especialmente al señor Director General, a los cuerpos directivos y a la Secretaría, por promover la discusión sobre la ética en el campo de la formación, organización y administración de servicios de salud, solicitando orientar en el futuro las investigaciones, con el fin de aportar nuevas ideas y propuestas orientadas a mejorar la equidad y la eficiencia en los sistemas de salud de todos los países del mundo. Le Professeur FOFANA (Guinée): Monsieur le Président, Messieurs les Vice-Présidents, Monsieur le Directeur général, honorables délégués, Mesdames et Messieurs, la délégation guinéenne voudrait apporter sa modeste contribution aux travaux de la Quarante-Septième Assemblée mondiale de la Santé qui se tient à un moment particulièrement difficile, marqué par une conjoncture économique défavorable et par divers conflits qui aggravent la situation socio-sanitaire déjà précaire des pays en développement, notamment ceux de la Région africaine. De même, la solidarité internationale a tendance à décliner vis-à-vis des pays africains à un moment où ceux-ci sont rendus vulnérables par les mesures d'ajustement structurel et les troubles sociaux engendrés par le processus de démocratisation. Ma délégation constate néanmoins que ces différents aspects de la crise socio-économique mondiale ont été pris en compte dans les rapports du Conseil exécutif et du Directeur général. Face au budget ordinaire à croissance zéro et à la persistance de compressions budgétaires, le Directeur général de l'oms devrait continuer à rechercher les moyens susceptibles de permettre à notre Organisation de mener correctement les activités prioritaires. Cet aspect devrait être pris en compte dans la restructuration de l'oms qui doit renforcer "son rôle d'autorité directrice et coordonnatrice" des activités de santé en vue "d'amener tous les peuples au niveau de santé le plus élevé possible". L'OMS devrait également reprendre son rôle de "leadership" sur le plan technique en matière de santé. Ma délégation appuie fermement les recommandations du Conseil exécutif relatives à rélaboration et à rétablissement du programme commun coparrainé des Nations Unies sur le VIH et le SIDA basé à l'oms et administré par elle. En effet, une coordination efficace de toutes les ressources disponibles est primordiale pour accélérer les activités de recherche et de lutte contre le VIH et le SIDA, pandémie qui ne cesse de progresser en Afrique au sud du Sahara. La Guinée compte un total cumulé, de 1987 au premier trimestre de 1994,de 1147 cas de SIDA confirmés, dont 30 % de femmes et 25 % d'enfants. La mise en oeuvre du programme à moyen terme de lutte contre le SIDA et les maladies sexuellement transmissibles se poursuit convenablement malgré quelques difficultés de financement des activités sur le terrain. Le prochain programme coparrainé de lutte contre le VIH et le SIDA devra davantage mettre l'accent sur la recherche d'un vaccin efficace contre le VIH. La recrudescence inquiétante de la tuberculose face à la pandémie de SIDA nécessite l'application de la nouvelle initiative de l'oms avec l'adoption de nouvelles lignes directrices pour la lutte antituberculeuse. Mon département poursuit la mise en oeuvre du programme national de lutte contre la tuberculose en Pintégrant progressivement aux activités de lutte contre la lèpre et aux soins de santé primaires.

135 A47/VR/5 page 120 En ce qui concerne la nutrition chez le nourrisson et le jeune enfant, ma délégation appuie la résolution réaffirmant la supériorité du lait maternel en tant que norme biologique pour ralimentation du nourrisson. Le Ministère de la Santé publique et des Affaires sociales est en train de finaliser le document relatif à la politique nationale et au plan d'action en matière de nutrition. L'Association des Femmes pour la Promotion de Г Allaitement maternel et la Nutrition infantile, organisation non gouvernementale nationale, mène déjà des activités de soutien à l,allaitement maternel et PUNICEF encourage la création d'hôpitaux "amis des bébés". La célébration du vingtième anniversaire du programme de lutte contre l'onchocercose me donne roccasion non seulement de féliciter le Directeur de ce programme pour sa bonne gestion et son efficacité, mais aussi de remercier tous les donateurs et organismes parrainants pour leur contribution au succès de la lutte contre la cécité des rivières en Afrique de l'ouest. En effet, la Guinée qui a adhéré à ce programme en 1987 enregistre de très bons résultats grâce à la lutte antivectorielle et au traitement à l,ivermectine. La distribution communautaire de l'ivermectine est facilitée par son intégration au niveau des centres de santé et la collaboration avec des organisations non gouvernementales. La santé maternelle et infantile est le volet fondamental du programme national de soins de santé primaires. La dernière évaluation de la couverture vaccinale en 1993 donne pour le BCG 76 %, le DTC et le vaccin antipoliomyélitique (trois doses chacun) 55 %, le vaccin antirougeoleux 57 % et le vaccin antitétanique des femmes 61 %. La mortalité maternelle reste néanmoins très élevée et c'est pourquoi le département met tout en oeuvre pour rendre opérationnel son projet de maternité sans risque avec l'assistance de l'oms. Ma délégation soutient le programme de lutte contre les pratiques traditionnelles néfastes aux femmes et collabore étroitement avec l'organisation non gouvernementale nationale dénommée "Cellule de coordination sur les pratiques traditionnelles affectant les femmes et les enfants". Cette organisation mène d'intenses activités de sensibilisation sur le terrain et, sous la conduite de la Première Dame de la République, a brillamment participé à la quatrième conférence régionale du Comité interafricain en avril 1994 à Addis-Abeba. Dans la conjoncture actuelle de crise économique manifeste, l'oms devrait veiller à assurer aux pays de la Région africaine l'accès aux médicaments essentiels, en favorisant l'acquisition de formes génériques et la mise en place concomitante de moyens simples de contrôle de la qualité. Je voudrais remercier le programme d'action pour les médicaments essentiels qui soutient depuis 1986 le programme de médicaments essentiels de notre pays, base fondamentale du recouvrement des coûts dans nos formations sanitaires. L'OMS devrait aider les pays africains à mettre en place des programmes et plans de préparation aux secours d'urgence dans un contexte de guerre civile, de calamités naturelles et d'épidémies. Il convient de signaler que l,épidémie de méningite qui avait été rapidement contrôlée en 1993 connaît encore une flambée cette année dans les préfectures de la Haute-Guinée et nécessite l'assistance internationale. Par ailleurs, mon Gouvernement soutient fermement toutes les initiatives de rétablissement d'une paix durable au Libéria et souhaite le retour dans la quiétude des nombreux réfugiés libériens actuellement en Guinée. Ma délégation félicite le Conseil exécutif qui a examiné de façon approfondie le neuvième programme général de travail pour une période déterminée ( ),et appuie la résolution y afférente qui met l,accent sur la poursuite du rôle directeur de l'oms pour ce qui est de l'action internationale de santé au XXI e siècle dans un contexte d'adaptation aux changements mondiaux en vue d'atteindre des cibles fixées de façon réaliste. Conformément à la recommandation des Ministres africains de la Santé à la quarante-troisième session du Comité régional de l'afrique à Gaborone en septembre 1993, l'oms doit assurer le suivi de l'appel en faveur d'un nouveau partenariat international afin de susciter un accroissement des investissements concernant les systèmes d'approvisionnement en eau et d'assainissement en Afrique. Le thème des discussions techniques est très important pour la Guinée, car l,action communautaire en faveur de la santé fait partie intégrante de la stratégie nationale de soins de santé primaires. Monsieur le Président, le financement des activités est une condition indispensable à la réussite des programmes de santé nationaux. Le Directeur général devrait mettre en place davantage de mécanismes appropriés susceptibles de mobiliser des ressources financières suffisantes en faveur de la santé, surtout dans les Etats Membres les plus démunis. C'est pourquoi je souhaite que l'oms redynamise son programme de coopération intensifiée avec la Guinée. Ma délégation souhaite que les travaux de la Quarante-Septième Assemblée mondiale de la Santé se déroulent dans un esprit de consensus comme à l'accoutumée et aboutissent à des résolutions susceptibles d'accélérer les progrès de tous les Etats Membres vers la santé pour tous.

136 A47/VR/5 page 121 Professor BREDIKIS (Lithuania): Mr President, Director-General, Dr Nakajima, dear colleagues and delegates, ladies and gentlemen, first of all let me on behalf of the Lithuanian delegation extend my congratulations to the President and to his deputies on their election and wish the Assembly most successful and fruitful work. The restoration of Lithuanian independence in 1990 was led by many changes in political, economic and social life. The demographic situation at present is worse than in western European countries and declining in terms of standard mortality, morbidity and other trends. Lithuania now faces a major challenge in developing and restructuring its health care system. We consider as the most important task and priority the promotion of the national public health care system on the basis of WHO's strategy for health for all and the Lithuanian national health concept that was accepted by the Lithuanian Parliament already in Today it is hard to find a country which is completely satisfied with its health care system. A variety of reforms reorganizing health services were introduced in Lithuania in 1993; economic aspects are very important in all of them. How can we cut expenses without harming patients? To deal with this problem we established a health reform management group with 11 task forces. The main task forces deal with restructuring of primary health care, rationalization of basic hospital care, development of outpatient services, restructuring of specialized services, and other matters. We are taking steps to ensure the free choice of a physician and the possibility for the development of family physicians. The Ministry of Health and within it the departments of pharmacy and of public health are being restructured. Three divisions of the latter deal now with public health strategy, environment and health issues and health promotion. The new department of public health is very active in decreasing risk factors and promoting healthy lifestyles. One of the recent achievements in its anti-tobacco campaign is a total ban on tobacco advertising introduced by special decree of the Lithuanian Government. The present Lithuanian Government is probably the first non-smoking one - all Cabinet ministers have promised in writing not to smoke! I would like to ask the governments of all other countries and first of all the ministries of health to stop smoking. We also have a very original movement called "Healthy People" which is expanding very successfully. The basis of this movement is health, nutrition, physical activity, and harmony in body and soul. This winter we had a temperature of minus 10 C, yet more than 2000 participants of this movement went bathing in the Baltic Sea after jogging. We think it can be a record for the Guiness book. The idea was to invite others to adopt a harder and healthier lifestyle. This year World Health Day was dedicated to oral health and was a success in Lithuania. In all medical institutions, including the Ministry of Health, there were classes and demonstrations for mouth hygiene, special exhibitions were organized in Vilnius as well as the competition "Miss Dental Brush". At present we are looking for extra financing to carry out the programme "caries prophylaxis in children". In connection with the International Year of the Family we have established funds for maternal and child health. We are short of some US$ 50 million to take us out of a critical situation in natal and perinatal health care, and intensive care, and to support other national programmes. Among them the immunization programme is very important for prophylaxis. Vaccine supplied by Denmark helped us to resolve more successfully this year the immunization problem in our country. The Ministry of Health puts all its efforts into ensuring that health care has priority among government programmes. It aims at establishing at government level an intersectoral health committee, with commissions for public health, narcotics and alcohol, tobacco control, food control, and anti-epidemic and environmental issues. I think this Assembly and WHO should invite the governments of all countries and their presidents to be more active in solving problems of public health. We are extending fruitful cooperation with the ministries of health of other countries, especially our neighbours; very active cooperation takes place among the three Baltic States. We should not forget that in Lithuania there are at least four dangerous centres from the point of view of disaster medicine. I can mention the Ignalina, a nuclear power station with a Chernobyl type of reactor, for instance. This is why we need joint programmes of disaster medicine with our neighbouring countries. Support was provided for several projects from the Nordic countries, especially Denmark and Sweden, UNICEF, FAO and the PHARE programme of the European Union through WHO. In my opinion, it is possible to improve bilateral aid and assistance to the countries in transition, including Lithuania. On one hand we - the local managers of health care - have to have clear priorities for shortand long-term policies and strategies to be able to persuade our parliaments, governments and municipal authorities to take an active role in implementing those priorities. On the other hand, I would suggest that WHO, the World Bank, the European Union and other international organizations provide financial resources for the preparation of projects, and support and finance local specialists of target countries, they know better the internal situation and will be in charge of project implementation. Rather than project preparation, evaluation of the projects by foreign specialists would be of greater value.

137 A47/VR/5 page 122 In conclusion, I would like to assure you that Lithuania will act in a way worthy of its membership of WHO by joining in the common effort to improve the health of all people around the world. Mrs RANAWEERA (Sri Lanka): Mr President, Dr Hiroshi Nakajima, Director-General of the World Health Organization, honourable ministers, your excellencies, distinguished delegates, ladies and gentlemen, I extend warm greetings from Sri Lanka to each and every one of you. I congratulate the President on behalf of my delegation, on his election as the President of this august Assembly and wish him all success in steering its deliberations. Let me congratulate you Dr Nakajima, for an excellent report to the Assembly and thank you for the leadership you continue to give the World Health Organization. I would also like to thank the Chairman of the Executive Board for the excellent reports. Sri Lanka is a developing country, whose citizens enjoy a health status which is the envy of other developing countries. Communicable diseases pose a major problem to us even now, while the diseases of development have also made their presence felt. We have been able to reduce the mortality from communicable diseases. But, the morbidity burden has not shown a commensurate decrease. Sri Lanka has been fortunate in developing a close and fruitful collaboration with the World Health Organization and is deeply appreciative of the concern and support given by WHO in coming to grips with present and past health problems. The Ninth General Programme of Work has captured the essence of the global health development requirements for the next three bienniums. The new broad programme areas proposed for WHO country programmes clearly indicate the direction for collaboration with Member Governments. WHO's goal of health for all by the year 2000 continues to be earnestly followed, and for its achievement a comprehensive health development plan is being formulated. The implementation of national health policies especially those related to decentralization of health administration to local levels and mobilization of resources for health is being closely monitored by two high-powered intersectoral committees, namely the National Health Council and the National Steering Committee for the Implementation of National Health Policy. I understand that WHO will be redefining the framework of the Organization's mission for the future. I trust that during this process, the national-level needs and priorities of countries will be carefully identified. More attention also has to be focused on the family as the fundamental unit. Medical decisions and quality of care are increasingly becoming issues of public concern in Sri Lanka, as in many countries in the region. The ethical issues that surface in developing countries are more fundamental to routine medical practice and delivery of primary health care than are the current issues of ethical significance in the West. We are making headway in bringing the concept of ethics into the mainstream of health care delivery and health research and in the application of new technologies. Doctors and other health workers of our countries have an ethical role to play by promoting healthy lifestyles and educating the community in health promotion and prevention. ТЪеу also have the responsibility for monitoring the factors that influence the health of communities and for drawing attention to health hazards such as environmental pollution and to other public health problems. The rights of patients should be looked after as well. One of the guiding principles of our national health policy is respect for the dignity of the user/patient in all health care settings. Realizing the importance of integrating health and human development, all development programmes in the country invariably include a health component. Environmental impact analysis is an important component of any development project proposal and the impact on the environment is carefully weighed before approval is given for development projects. In my country, the women have traditionally played a significant role in mobilizing community participation for development in general and health development in particular. It is women, as grandmothers, mothers, wives, daughters, friends and neighbours who provide health care at the very basic and primary level, namely the home. The terrorist problem in the north-eastern part of my country has created the situation whereby large numbers of displaced populations are in welfare camps. In collaboration with WHO and the Italian Government, we have implemented a project for integrated human development in the areas in which the displaced are located. The project is based on the philosophy of the World Health Organization relating to health and development for displaced populations. I would like to make use of this opportunity to congratulate WHO on developing this programme - a common need of a large number of countries in the world which are faced with the problems of the displaced. An innovative aspect of this project is the

138 A47/VR/5 page 123 tripartite mechanism developed between my Ministry, WHO and the Italian Government to execute the project. By the turn of the century, the elderly (60 years and over) will comprise 9.1% of the total population in my country. The elderly have traditionally played an important role in health and human development by guiding the younger generations and by providing support to their children in bringing up their grandchildren. We need to preserve the traditional support system to the elderly and provide them with opportunities for informal education, for gainful employment and leisure. On the eve of the last World Health Assembly, my country faced the tragedy of losing His Excellency Ranasinghe Premadasa, our revered President. He postulated a programme of poverty alleviation called Janasaviya, which means strengthening the people. The socioeconomic benefits of the programme are specifically targeted on the poorest of the poor through a strategy of income generation at village level. An important component of the programme is the health development inputs called Suvasaviya meaning strengthening health. Women are providing important and vital leadership in this programme both as change agents and as service providers. Sri Lanka is fortunate in having a good health care delivery system with almost universal access. To bring the administration closer to the people and to provide an opportunity for community responsive planning and also to further improve access to health services, the Divisional Directorates of Health Services were created at the start of last year. This was in step with the overall devolution of power to the level of the Divisional Secretariat, which looks after a well-defined geographical area comprising a population of around The process of devolution follows the philosophy set out in the Alma-Ata Declaration. Nutrition is a major health problem among women, and the pre-school child with anaemia is one of the main factors complicating subsequent pregnancy. Poor maternal weight gain leading to an unacceptably high incidence of low birth weight of around 23% indicates a high prevalence of maternal under-nutrition. Nutritional status needs to be improved, especially among women, commencing from early infancy of the girl child. Realizing the importance of nutrition in promoting and protecting health, my Government has launched an all-out attack on the problem of malnutrition. This community-based campaign is led by His Excellency the President himself and steered by the National Health Council chaired by the Honourable Prime Minister. Detailed action plans have been formulated and a series of discussions have been held with officials in the provincial ministries of health. The national campaign will get under way in June with a nutrition week. In a literate society like Sri Lanka, the mass media play an important role in protecting and promoting health. My Ministry has been able to develop a dialogue with the mass media and harness its potential for health development. Seminars on topics of current importance are well attended and a series of articles and features appear subsequently in the mass media on these topics. A donor-funded public education programme using the electronic and print media has been successfully carried out in my country with the objective of eradicating leprosy in the near future. The new strategy to combat malaria agreed upon at the Conference in Amsterdam has been adopted by us, and emphasis has been duly shifted to parasite control with judicious use of insecticides. New insecticides which have greater community acceptability have also been tried out successfully. The new strategy is already yielding good results and we are hopeful that we will be in a position to make a substantial reduction in morbidity. The National AIDS Committee has mobilized the active participation of nongovernmental organizations in the national programme. One major reason for the satisfactory level of health status enjoyed by our people is the participation of the people in health development activities. We have harnessed the rich tradition of voluntary service in this regard Voluntary social service is a cherished aspect of our culture and has its roots in the Buddhist religious concept of Dana, which means sharing. Just two months ago, we in the South-East Asia Region of WHO said goodbye to a dear associate, Dr U Ко Ко, the Regional Director. He devoted 13 years of his life to guiding the health development of the Region and was a close friend of my country. We will always cherish the help and support he extended to us. I also welcome the new Regional Director, Dr Uton M. Rafei, who is no stranger to us. His election is a reflection of the appreciation of his long years of devoted work in the Regional Office, and the acknowledgement of his leadership qualities. We look forward to the new era of health development in the Region under his able stewardship, and wish him well. Mr President, we are living in a period where profound changes are taking place in the arena of world politics. Environmental consciousness is growing. The effects of lifestyles on health are being appreciated. The role of women in development and the importance of integrating health and human development have

139 A47/VR/5 page 124 been acknowledged. I am confident that under the leadership of Dr Nakajima backed by the Executive Board and guided by the World Health Assembly, such issues can be resolved. I wish the Forty-seventh World Health Assembly all success in its deliberations. Dr AL-MUHAILAN (Kuwait): : ( c^^ji ) pm^l ^jji i js I! djü I e 3 f- Lu j j 己 1 t ^-.JuJI ^jjl^ t^j^s jjl ^Li^jl '^LcwLi^ ci^^ul 'ÂJ33 ji^ ài^z ^js ^^s^jl Ó^L^L ^J yl l ^j^i ^ UJUI f- 1 ójlüi ^jjbl 3 a^l^ji '«LuJUül Я^х.11 *A r/.i?.o.>j ^JUJl ^^jljl JUT j.yl L^JJÇ b 力 J JU/l JJ4. ^Uoi. JJ-^ 1 ЛЯ J J^^ ^JLc L^-lo U >л Л.Ц '.л11 ЛЛI ^ ^^ Lg-lo U 1 ( J о I 1 ^wv^w cljlíu-. ««v» 1 Д-очасЛ ^JÍÜ ^ jjloâ J vi-e ó JlA J-JajO 气气 ^s L e I ( ^J^ I <L Lc^J 1 ^ " ^O 1 Jr^ Cl^^j * '<Lc-J=J1 己尸.. б Л CL^^IJI aj^j ^JLC L J1 J-^i ^ '«L^vcJI c^loüjji Ó^U^Í W4_ jjg? cijjl AÜ "...loif.0_,j 'La^OJ] ci,l>jl JI j^ç*^ ciw^ul l^-j^ ^^Jl ójl j^j I LaJ! J j.g.-y^ djj 1 ^juí,j^ u U^yAM ClbS^ l^-j! 二 * *. d^jow^ûji Cl/ l-x^^oj 1 ^ d-j! ciajlo^ Lw <LoL>JI ci^lo1 -g о ) 1 少 :. '1 I Lia^ 实 Üui^Mj p 1 ^«o ^isjî /I 'iju j^bz ^J L6. UJ! ^^^Jl JUb^l JJUJ ' JU <JJ * lijli. ó^uji ^ 气 Û ^ ^iil JLib^l ^^ ; II CLJLSJ 匕.clu U> C1.Iу^ш " JLAJ ^^JLI-C ' JL> ^ ^JLL L*-;!j J^J^-O ) JiJ ) ^Jl jji JUJ^I c^ui^ cimáílíkji ^ jl ^Li^^lî f LJs> c ) AjV 1 JU p LJs^l cljjl < LccoU.. J^l^^l jj <s j j^tî! jua JU 只尸 Г ^ : î Л j, 己 U 3.d-^лоЛ 已 LîJiiJI ^JLc ^^ajl Jj>JJ1 'j-slji ja ) v-j T-_ÂJBU>WO ^JJÜ ^ RTJLR>4-)J-^T^U^C : KAJJLJ")! 1 ^ J-O L^LÛ-» 1 à J I '_' < Л.: 0> I i^jaa^jj I ej 1 j^cj 3 lo I yj I *Â^LûJ>J U^jU CLi^^JI Cl^jJuoI ЛЭ^! jia dojhûj d^j 1 clu>15 ^jb!ал o loiyji '<5JUJ>W < «ÜL> ^Sàz U '<iiu l. Jl^<JI i jjb ^ '<LuJUJ! '<L>wuJl 1oJ xju> j-o ^UcJL- '<LuJUJi I С1/ l:._«-q_,v 丄丄 к % I 1 丄.,_ t^-u>jüj У._л 1 Я )! уй Â-.J 1J^AS. ^JO I J^i Iw. ZM^SJ 1 Jjü 产二.g 二 I ji ^o LsciJЦ» v 1ч ) 1 ^ 1 jmi ^u» Jl>J ^-«- -JuiiJI Л^ЭiS^o JJ-I j ^Ju^J^ ci» L**/1 jü JlA-, J-oliJL ô^jl^ ^J^í i ixáujl ^ ^jljs^/l cjvl áoj^-jl.á 丄 J1 dw^jb^ '«LJaijJÍ Ju> C U LcS JJÍ3 d-jai-jl f ULI. c 广 JÍ 己 ÜHoSlj J^I^JI óiu-.-g:; ^ Clw^J!.' <L1 0^^JU *<L,Loo- [Joî^ JI :. ; J jo ) jji I.\g )I ^Jî dil 1 0,. )I 11 ^ 产 U Lj.«L^i 二 ^^JLc a-^cjj JiLiu> ci^^jl» 己 ^^ jj^ üüoji J-^ ^ ci^^iji fj L^Uo o ^ clji^loj.^l. ci^^j c^lwjlwji ájjb JiuJ f^^b c^^ l o^ J^ wswxaj JU^ JUL 6! ^ Ы 1 ; 1^ c^^1 夕 ^ ^ÍJJI. JilAJl d^jb ^ ^j-si-sjj! ys^ L«jl ^J I 1 ^ I I àjjb C^jl. ó\y J\ Зт^З

140 A47/VR/5 page 125 JUuJI IJLA ^ '<LUJLÎJI c^l^^.jji ^Jl ^ «ciw^ui ^ 火 丄. dujl ^bj î^jluaj^/i ^ ^ LalÂA^f I LlL^lg ^J L»JI K^jyjtJù d-гкло ^js Ijul < *ij LuJI^ CI^IjLmuJI Cli 1 j I ^^-o A-fcOJNl*» ^IlJ I A^a^Lu^J I à^ji A^K^jlh^ f Lj» \ ^ i dj L 4-íOj^ ( dllo I js «dlâ^vo 4 l.o:...,v 1 ^ <Lu>wuaJl J j l ^ o JbJ^aJl Л..-7-^Ü I g: J Ju Lio U j v,)., _: Lo-e '<Ll-JLJ I c^uiüji di^jji^ ' jjlji g ^ a^uwvi ci/lj^kji ^^JLc ' ^U. ^JU 'i^jiiji^ djlij! fjuji J^j d^u- A-jbli^ l>w«xj jjl^ji ^ Ju.^ А^Ы^ ' L j I Chf*^, : j I Ja-^^uJI ^л-ji J^JJ O.o r/.1,9^1 j^juji ILxJaJuJU ^UJI ^JuJI U-u>l5U *<LJâJu>-)L> ^JLoUJI yl«j ylj^l ^-uü LsUî J dju Ло-rxJl^ j-ojl ^JLc Mr SATA (Zambia): Mr President, Director-General, your excellencies, distinguished guests, ladies and gentlemen, I wish to convey to you, the Director-General and his staff, and to this Assembly, the fraternal greetings and best wishes for a successful Assembly from the people of Zambia. I wish to express, my personal thanks to the President of the Assembly and through him to his country for his being elected to this important office. Mr Director-General, Dr Nakajima, my country is greatly indebted for the leadership you have provided through the intensified WHO cooperation with countries in greatest need in support of Zambia's health reforms. We are proud to announce to you that the efforts of your office, working with other multilateral agencies and bilateral donors in supporting our national health reforms have begun to bear fruit. We hope that your commendable efforts and effective leadership will be emulated at the regional level so as to give impetus to the implementation and monitoring of programmes already endorsed by the World Health Assembly and by African Heads of State, notably in the Dakar Declaration. I wish at this moment, to extend my hand of congratulations to the delegation of South Africa. Our dear brothers and sisters, welcome back to your rightful place in this World Health Assembly. For us in the southern and eastern areas of the African Region, South Africa's re-entry into the arena of a multilateral health agency initiates yet another opportunity for improved regional cooperation for better health in the subcontinent. Our Region shares a common health ecology and the aspirations of our people for better health must be tackled collectively. New challenges await all of us now to establish working intercountry networks for the mutual health benefits of our people. We in Zambia have initiated a process of dialogue on regional integration of health systems in the subregion. Our hope now is that open participation of South Africa will become an added advantage for all our people. The challenges for better health in east and southern Africa, as indeed in the rest of Africa, call for a new leadership at our regional headquarters that will act beyond the self-interests of any single entity, personal or national. My foregoing remarks contain a universal appeal to all delegates in this Assembly but more specifically to sub-saharan Africa. Cross-national agencies such as the World Health Organization (with its Regional Office for Africa), which provide the technical leadership, must now respond to new and urgent challenges. In particular they are being called upon to reform their institutional modalities in the service of the authority that legitimates their existence, that is the people in the various Member States. As the official statement of the President to this Forty-seventh World Health Assembly pointed out, Africa is going through a health transition, a crisis in which the diseases of poverty interface with those of affluence in one country. The issues of social entitlements, often presented as the rights of citizens, mean that governments are pressed to respond to the needs of the silent majority who are afflicted by diseases of poverty on one hand, and on the other to a powerful minority who demand sophisticated medical technology. This situation is creating a turbulent health policy environment at the same time as macroeconomic imperatives constrain government capacity to fully respond to multiple demands. Political changes driven by the universal imperatives of democratization, anchored by respect for human rights, compound this policy scenario as social forces complete to influence the structure and the content of our health policies.

141 A47/VR/5 page 126 All of us in Africa, Asia, Europe and the Americas are being pressed to reform the practice of health systems management. For Africa in particular, resource constraints make it all the more urgent that we adapt to the rapidly shifting growth and to the health policy environment. As a consequence of this turbulence, we need comprehensive institutional structuring at both national and transnational levels. The report of the Director-General has highlighted some of the reform measures that WHO is undertaking. Some of these relate to better planning and budgeting, improved management, better funding or resource mobilization and allocation. These are very complex issues. I say so because the impetus that is forcing such reforms within the World Health Organization is that of improved accountability and transparency in the systems of resource allocation and management system regulation. At regional and country levels the challenges are the same if not magnified. The urgency for institutional reform is even more evident. Why? It is simply because governments, just as an elected leader of a multilateral agency such as the World Health Organization, are subject to the pressures for performance arising from their constituencies. When bureaucratic practices overwhelm needed service interventions, when professional elements conflict with policy imperatives, when technique overpowers process and values, political pressures for reform became evident. The needs of our people are urgent and call for effective leadership at all levels, and more especially at the regional level, and for accountability and partnership, nationally, regionally and globally. Towards this end, it is Zambia's sincere conviction that there is an imperative need to democratize further governance and leadership at the regional level. In this connection, my delegation is pleased to recall that at the last Regional Committee meeting held in Gaborone, Botswana, Members considered and resolved to limit the term of office of Regional Director to no more than two consecutive terms with immediate effect. My country is grateful for the wealth of global support for our national health reforms initiated two years ago. We in Zambia believe that together with our cooperative partners, which include WHO, we all need a real success story in health reforms. We need such success consistent with a vision of health that moves away from theoretical models, from more of the same ideas, the same "laundry lists" of demands. Poor health status and poverty are closely correlated. Like nutrition and education, health is both a cause and an effect of poverty. Poor health status causes lower productivity and falling incomes. This is especially serious for the most vulnerable high-dependency ratio households. We in Zambia believe that the sum of our health sector strategies must lead to a society in which Zambians create environments conducive to health, learn the art of being well, and provide the best level of health care for all. I would like to express through this Assembly Zambia's gratitude to all friendly countries, WHO and donor agencies for their continued financial, technical and material support, which has gone a long way towards the realization of our health vision. Dr NAÑAGAS (Philippines): Mr President, Mr Director-General, excellencies, distinguished delegates, honoured guests, ladies and gentlemen, on behalf of President Fidel V. Ramos and the Department of Health of the Philippines, I bring you warm greetings from the people of the Philippines. We also congratulate the President, Vice-Presidents and Committee Chairmen on their election. I wish to commend the World Health Organization on its comprehensive biennial report. It indicates that WHO has taken significant steps and initiated bold reforms for enhanced coordination of efforts towards the attainment of global health goals. However, the enormous challenge to us still remains: to carry on with greater resolve to achieve health for all, and to heed the call for a new health partnership in response to our changing global environment. The Philippine Government heeds this challenge and supports the efforts of WHO to establish greater interdependence in health. In my country, partnership in health has been the chief strategy in promoting primary health care. The national programmes on immunization, blindness prevention and nutrition have been widely implemented through the enthusiastic collaboration of various sectors and private organizations, including the mass media. They have benefited grass-roots communities considerably through basic health interventions, giving us reason to be optimistic about the success of many other possible health initiatives anchored in sectoral partnership. Sustaining the awareness of health that has been created and the momentum of successful health programmes, the Philippine Department of Health moves towards the crystallization of these gains into an enduring philosophy, a way of life: health in the hands of the people, health as a continuing personal goal. This goal enrols not only those who are sick, but especially those who are well and who can be active partners in promoting health. More importantly, this goal transcends the health sector, as the pursuit of

142 A47/VR/5 page 127 health is intrinsic to the pursuit of sustainable development. Thus, the promotion of health takes on a new holistic perspective: health, the environment and development as an integral goal. Concretely, the Philippine visionof attaining the status of a newly industrialized country by the twenty-first century should inevitably incorporate a vision of the nation's health status. Industrialization and health programmes should move together at a steady and synchronized pace. Health should be a standard for defining national economic goals, measuring environmental protection, and guiding all types of development projects, processes and approaches. This demands a recasting of the health sector from its medical orientation to a health orientation, and from health-care based facilities to health-promoting environments. This in turn demands the overhauling of the entire philosophical moorings of the past 50 years in response to the challenges of the twenty-first century. The task at hand is formidable. Three issues confronted by my country in the recent past come to mind at this point. They illustrate the interrelationship and effects of dynamic developmental processes in the areas of politics, economics and the environment. First, in a post-devolution environment where the delivery of basic services has been handed over to local governments, a tension exists between the largely political rationale for decentralization and the nonpolitical nature of health. In a situation where local officials have been made accountable for health care in their areas, the need for an expanded legal mandate for the Department of Health in undertaking the appropriate health policy directions becomes necessary. Otherwise, local governments can choose to ignore national goals, standards and objectives in health. Moreover, while the wisdom of decentralization has been appreciated, the process has not been without problems. Most local governments have required continuous assistance in health care management and financing. The great skill of local executives in lmking issues to other factors in the environment and to models of development has been largely unharnessed for so long and explains the failure of many public health programmes in the past. Diarrhoeas are not controued because water systems are not in place. Pollution-related diseases cannot be addressed because the health sector has no jurisdiction over factories. Secondly, poverty and the lack of economic opportunities have led to a trade in blood which in turn has been compounded by profit-oriented enterprises wishing to cash in on this situation. Recently, however, the Philippine Department of Health has closed down outlets of commercial blood banks that have been found selling contaminated blood supplies. Greater efforts and attention will need to be devoted to the promotion of voluntary blood donation and safe blood transfusion, especially in view of the AIDS pandemic. The question at hand is: should we continue to allow the commercialization of blood? The present challenge lies in the establishment of a network of voluntary blood donation centres employing efficient and cost-effective testing processes, and in the reorientation of personal and social values towards blood as a human resource and blood donation as a voluntary humanitarian act. Thirdly, the Philippine Department of Health has recently been the object of a lawsuit by a pharmaceutical company whose product has been prohibited on the Philippine market. The issue brings to the fore the need for collaborative mechanisms, perhaps at the international level, to support efforts to prevent the proliferation of harmful drugs, especially those that have already been banned in other countries. Questions arise as to the role of the international health community in assisting national governments, especially of developing countries, in thwarting the efforts of some pharmaceutical companies to introduce these drugs when they have been deemed harmful overseas. These do not include chemicals used as industrial and agricultural inputs which have been proven harmful to humans, animals and the environment but are not under the jurisdiction of our Bureau of Food and Drugs. These three issues are among the many challenges confronting us, and reaffirm the need for new partnerships in health, as espoused by the Director-General, Dr Hiroshi Nakajima. Among the major areas where issues in health, the environment, and development come together are: meeting basic health needs, control of communicable diseases, protection of vulnerable groups, meeting the urban challenge, and reduction of health risks from environmental pollution and hazards. Inasmuch as these areas should be approached holistically, efforts to address them require sectoral partnership and cooperation. The Philippine Government acknowledges the crucial role and important task of WHO in our fast-changing global environment. I would like to express our profound appreciation to the Director-General, Dr Nakajima and the Regional Director for the Western Pacific, Dr Han for the generous assistance and attention they have given to the Philippines. I thank you also for the privilege of addressing this World Health Assembly, and to all the delegates of this Assembly I extend my best wishes.

143 A47/VR/5 page 128 El Dr. VIDOVICH MORALES (Paraguay): Señor Presidente, señor Director General: Antes que nada deseo expresar nuestro regocijo por la incorporación de Sudáfrica al seno de esta Organización. Dios quiera que la paz y la libertad como signo de vida saludable lleguen a todas las naciones. Indudablemente el despertar democrático de los países de América Latina, entre los cuales se halla mi país, significa un sinceramiento con la realidad sociosanitaria de nuestras comunidades, comunidades rurales y urbanas donde aparecen nuevos interlocutores - políticos, gremiales, sindicales - que demandan más y mejores servicios que den respuesta a sus necesidades postergadas, y a quienes se debe responder con acciones concretas, oportunas y satisfactorias. En dicho contexto, y desde el 16 de agosto pasado, se ha iniciado una nueva etapa constitucional en el Paraguay bajo la presidencia del ingeniero Juan Carlos Basmosi, cuya plataforma de gobierno propugna la dignificación del hombre paraguayo, y para cuyo efecto se prioriza la educación y la salud del pueblo como estrategia para el desarrollo nacional. Dentro de esta concepción gubernamental, la nueva administración sanitaria ha establecido una línea de acción a fin de revertir a corto plazo las deficientes condiciones de salud reflejadas en los indicadores de morbilidad y mortalidad, donde las enfermedades prevenibles por vacunas, las diarreas, las parasitosis, las complicaciones del parto y la desnutrición siguen ocupando los primeros lugares, conjuntamente con los tumores, las enfermedades cardiovasculares y los accidentes. La precaria implementación y operacionalización de los servicios de salud se manifiesta en la mínima cobertura de atención médica y la baja productividad, así como en el déficit de saneamiento básico. A fin de organizar y de racionalizar los recursos disponibles a nivel institucional y sectorial, se ha elaborado el plan nacional de salud ,que enfatiza la salud pública promocional y preventiva, anteriormente dirigida preferentemente hacia el sentido asistencialista de la labor sanitaria, y somos conscientes de que el desafío para revertir la realidad observada hace evidente la necesidad de planificar y desarrollar acciones conjuntamente con todas las instituciones del sector y de la propia comunidad. De ahí que el plan operativo de salud contemple desde su formulación hasta su ejecución y control la participación activa de los directivos, de los trabajadores de la salud, de todas las instituciones del sector, así como de las organizaciones comunitarias de base, y de las entidades de cooperación externa. Se está impulsando progresivamente el desarrollo de los SILOS y la programación local como estrategia de concertación y conjunción de objetivos y recursos, que se proyecta a corto plazo en la implementación de la descentralización técnica y administrativa, atendiendo al nuevo modelo departamental de organización política de la República. Entre las realizaciones compartidas con la propia comunidad citaré las 143 farmacias sociales establecidas en los últimos cinco meses, dirigidas y administradas por la comunidad a través de las comisiones de salud; la construcción y puesta en marcha de 21 sistemas de abastecimiento de agua potable, administrados por las juntas de saneamiento de cada distrito; la formación de 1200 agentes sanitarios de la propia comunidad para el desarrollo de la atención primaria; el plan de ataque integral de acción sanitaria inmediata ejecutado a nivel de los más pobres asentamientos campesinos y de las parcialidades indígenas, con la cooperación de los gremios de la salud y de los mismos beneficiarios; la programación del internado rural conjuntamente con las facultades de medicina, odontología, bioquímica, enfermería y obstetricia para la formación de pregrado de los nuevos egresados de dichas unidades; y el control de calidad de los medicamentos y alimentos con la cooperación de la Universidad Nacional de Asunción. Esas son algunas de las acciones prioritarias emprendidas concertadamente para afianzar el proceso de gestión sanitaria y mejorar el nivel de salud, preferentemente de los niños, las madres y de las poblaciones que sufren carencias. Paralelamente a esta acción nacional de salud, se han compartido con los ministerios de salud de los países del Cono Sur importantes iniciativas para fortalecer los programas de salud de fronteras, control del cólera y SIDA, vigilancia epidemiológica de enfermedades infecciosas contagiosas, el saneamiento básico, la capacitación y el intercambio de información e insumos en materia de salud, acciones éstas que se vienen afianzando con la suscripción de acuerdos interpaíses y subregionales, en los que la Organización Panamericana de la Salud, con sus expertos y sus recursos, participa y presta aval técnico. Para mi país es una satisfacción que la Organización Mundial de la Salud se halle en un proceso de reforma en consonancia con los profundos cambios culturales, políticos y económicos, como lo ha afirmado en esta Asamblea el señor Director, Dr. Nakajima, de magnitud sin precedentes desde la II Guerra Mundial. Indudablemente los gobiernos de los países, así como las instancias decisorias de los organismos internacionales, deben ajustar sus estructuras internas, sus relaciones y su proceso de gestión en directa correspondencia con los factores que condicionan la expansión del «universo de los pobres», de los

144 A47/VR/5 page 129 desprotegidos en salud y de los desocupados, para mejorar así el acceso oportuno y solidario de todos los sectores de la población a los bienes y servicios destinados a cubrir las necesidades esenciales de vida. Incluso las entidades bancarias, ya sean nacionales o internacionales, han demostrado su preocupación por el incremento de la pobreza, verdadera «bomba de tiempo» que debemos desactivar mediante medidas heroicas de acción concertada y coordinada, por lo que sugerimos a la Organización Mundial de la Salud que la reforma estructural y funcional en ejecución promueva a la vez, a nivel de todos los organismos internacionales de cooperación en salud, una mejor coordinación y complementariedad de los mismos, a fin de evitar la duplicación de esfuerzos y recursos en los mismos programas de acción. Constatamos la profusión de conferencias, seminarios de alto nivel político con relación a metas y objetivos destinados a similares temas de acción, respetamos las loables intenciones, pero la multiplicidad de programas y acciones similares desconciertan a nuestros técnicos y operadores ante la variedad de los compromisos que es menester cumplir, evaluar y controlar. Se hace evidente, por tanto, la necesidad de armonizar las áreas de cooperación externa. Para el efecto, sugerimos al señor Director de la Organización Mundial de la Salud que analice la situación expuesta para encontrar la viabilidad técnica y operativa que posibilite la coordinación de las numerosas y valiosas organizaciones de cooperación externa en materia de salud, a fin de mejorar la eficiencia, la eficacia y la equidad de nuestras acciones, en favor de la salud del pueblo. Finalmente, hacemos nuestras las premisas del señor Director, Dr. Nakajima, al expresar que «para que toda población pueda gozar de una vida saludable y pacífica, hay que erradicar el hambre y la pobreza», y yo, con todo respeto a las loables frases del señor Director, añado: todos juntos. Mr SONKO (Gambia): Mr President, distinguished ministers, distinguished ladies and gentlemen, delegates, allow me to extend to the President and his bureau the congratulations of my delegation and those of the people of Gambia on their election to high office at this Assembly. We are confident that with your wisdom, experience, and leadership qualities this meeting will be steered to a successful conclusion, having achieved our goals and objectives. I also want to take this opportunity to thank the Director-General and his staff for producing such an excellent report. My delegation wishes to acknowledge the dedication and untiring efforts that must have gone into its preparation. On behalf of my delegation, I also want to extend a happy welcome to the Republic of South Africa, taking its place in this Assembly. We wish the country luck and we are very happy that the Assembly saw fit to give its unflinching support by acclamation. Once again, in recent times we have been constantly reminded about the linkages between economic growth and health development. Whilst acknowledging that significant achievements have been made in reducing maternal and infant mortality rates, decreasing the level of severe malnutrition, and instituting communicable diseases control programmes, these gains are at risk of being lost in the face of continued global recession, poorly performing national economies, increasing donor fatigue, increasing population growth with rapid urbanization, and increased environmental degradation. This situation has been made more difficult as Third World countries must now address emerging health problems, such as the chronic diseases, like diabetes and hypertension, declining oral health, increasing road traffic accidents, drug and substance abuse, increasing mental illness and, of course, AIDS. These new health problems are an extra burden on top of existing acute health problems such as malaria, diarrhoea, acute respiratory infections and malnutrition, to name just a few. ITiere is an urgent need to pay attention to this epidemiological transition, to safeguard the gains already achieved. The health resources currently allocated are inadequate to meet existing health problems, and these newly emerging health problems have the potential to absorb all these resources at the expense of the acute endemic health problems. There is a need to emphasize health promotion, health protection and healthier lifestyles as the most cost-effective ways of preventing what could be a catastrophic and unmanageable situation. The need for donor coordination is also important, in order to maximize utilization of scarce resources and avoid duplications, wastage and unhealthy competition. Mobilizing communities' resources, building their capacity and empowering them to make and take decisions about their health are significant investments which will augur well for future sustainable health development. In Gambia we have recently adopted the second national health policy, which will see us through to the end of this century. The policy calls for the optimization of all resources and efforts to ensure efficiency in resource utilization, effectiveness of programmes and quality of care. Being aware of the negative impact that a large population growth rate can have on health, a population policy focusing on fertility reduction and the improvement of the quality of life has been adopted

145 A47/VR/5 page 130 by my Government. A comprehensive maternal and child health and family planning programme features as the main strategy for fertility reduction. The 1993 national census estimated that 40% of the Gambian population live in urban areas; at the same time population growth has increased from 2.8% to 4.1% in the last 10 years. Managing the environment for sustainable development and for improved health is also a serious concern. In response, the Gambian Government has developed an intersectoral environmental action plan that will address the issue of the environment in a more holistic manner. Above all the policy addresses poverty as a main contributing factor to poor health. A strategy for poverty alleviation seeks to make health care accessible to the majority of our population. As we move to the end of the decade, when the goal of health for all should have been achieved, it is clear that the problems and constraints as they present today far outweigh those which were envisaged when the noble goal of health for all was initiated. The role of WHO will be crucial in providing leadership and wise counsel as to the type of investments to be made for health development and delivery systems that should be put in place to provide the greatest impact on disease reduction in the shortest possible time. Finally, the involvement of the private sector and nongovernmental organizations will also facilitate the process, and the breaking of new and exciting ground will be the challenge of our future health development. I am confident that with the same spirit of concern and cooperation we can still achieve our goal of health for all. The ACTING PRESIDENT: I thank the delegate of Gambia for his address and for his kind words. Thus we have exhausted the list of speakers for this afternoon. Ladies and gentlemen, after this meeting a briefing entitled "Noma, a forgotten disease", will be given in room IX from 17h30 to 18h30. Interpretation will be made available in English and French. The plenary meeting will resume tomorrow at 9h00 sharp concurrently with the Technical Discussions on community action for health, which will take place in room XVII. Tomorrow in the afternoon the plenary will deal with the admission of new members and awards, before resuming the discussion on items 9 and 10,concurrently with the resumption of the work in Committee A. The meeting rose at 17hl0. La séance est levée à 17hl0.

146 A47/VR/6 page 131 SEVENTH PLENARY MEETING Thursday, 5 May 1994,at 9h00 Acting President: Dr A. OURAIRAT (Thailand) SEPTIEME SEANCE PLENIERE Jeudi 5 mai 1994,9 heures Président par intérim: Dr A. OURAIRAT (Thaïlande) DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-SECOND AND NINETY- THIRD SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR GENERAL SUR L'ACTIVITE DE L'OMS EN (suite) The ACTING PRESIDENT: It is with pleasure and honour that I preside over this Assembly. We shall this morning continue the debate on items 9 and 10,and before I cau the first two speakers to the rostrum I would like to warn you that I intend to close the inscription list of speakers at the end of our meeting today. I would also like to --request speakers please to keep within the allotted time. I now call to the rostrum the delegates of San Marino and Sao Tome and Principe. I give the floor now to the delegate of San Marino. Le Dr CANDUCCI (Saint-Marin): Monsieur le Président de séance, Monsieur le Directeur général, Mesdames et Messieurs les délégués, au nom de la République de Saint-Marin, je voudrais exprimer mes plus vives félicitations au Président pour son élection à la tête de cette Quarante-Septième Assemblée mondiale de la Santé de l,oms. Je tiens également à exprimer au Directeur général mes plus vives félicitations pour le travail accompli au cours de l'année écoulée, ainsi que pour son rapport qui non seulement donne un résumé de Pactivité de l'organisation, mais en outre mentionne une série de problèmes très importants au sujet desquels nous partageons les mêmes préoccupations. Je voudrais aborder le thème "Ethique et santé", en affirmant tout d'abord que la santé ne peut être complètement protégée s'il n'existe pas, au-delà de l'aspect scientifique de la question, des normes de référence et un système de valeurs. On s,aperçoit ainsi qu'à la fin de ce XX e siècle apparaît la nécessité d'une compétence éthique de la part des agents de santé, ainsi que des responsables de la politique, dans l'élaboration des législations et dans la définition des normes selon lesquelles il est permis d'agir en matière de recherche, de manipulation, de génie génétique, de transplantations d'organes et d'interventions prénatales. Les énormes progrès accomplis peuvent être utilisés en faveur ou aux dépens de l'être humain, pour sa guérison ou pour sa destruction. Aujourd'hui, en effet, nous sommes en mesure de détruire la vie ou même la simple qualité humaine de la vie. L'exigence éthique s'identifie alors avec la prise en charge de notre propre responsabilité, afin de ne pas trahir l'homme et afin de faire des choix en conformité avec la vie humaine. L'éthique comprend donc : le problème des valeurs qui sont liées à toutes les professions de santé (du médecin à l'infirmier, du psychologue à radministrateur de la santé, etc.), un éventail plus large de problèmes sociaux tels que ceux relatifs à la santé publique, à la médecine du travail, à la santé au niveau international et à l'éthique du contrôle démographique, enfin un domaine plus vaste encore que

147 A47/VR/6 page 132 la vie et la santé de l'homme, puisqu'il englobe des problèmes liés à la vie animale et végétale tels que ceux relatifs à l'expérimentation animale et à la défense de l'environnement. Aujourd'hui, on ne peut plus considérer la sanié comme une donnée exclusivement subjective, mais comme une interdépendance de nombreux facteurs à la fois personnels et relevant de groupes nationaux et internationaux. La recherche de la santé pour tous ne peut être productive que si elle comporte également une participation directe de l'individu. En effet, il s'avère indispensable de garantir le droit à l'information, afin d'assurer une prise de conscience en ce qui concerne les interventions thérapeutiques pour lesquelles le consentement conscient du malade est de plus en plus important. Dans les sociétés jouissant d'un haut niveau de développement économique, on assiste à une propagation de plus en plus large de la médecine dite "de convenance personnelle", comme dans le cas des grossesses chez des femmes qui ont dépassé l'âge de la fécondité, ou des problèmes liés à la fin de la vie, en vue d'exercer un contrôle volontaire sur la mort à travers, notamment, la rédaction de "testaments biologiques". Une autre préoccupation des sociétés qui ont inclus, dans leur réponse sociale à la demande de santé, un objectif de civilisation et de justice est de savoir si cette réponse doit également englober des demandes d'interventions sanitaires à caractère futile ou si, par ailleurs,l'état social peut encore se permettre de dispenser une médecine de convenance personnelle. Aujourd'hui, face à une demande croissante de consommation de produits liés à la santé, la modicité des ressources ne nous oblige-t-elle pas à reconnaître que même les pays les plus riches ne sont plus en mesure de satisfaire à toutes les demandes? Il s'avère donc nécessaire non seulement d'élaborer des procédures en vue de sélectionner la demande selon des critères d'équité, mais en outre d'intervenir sur la demande elle-même. Il y a, dans cette préoccupation concernant les ressources disponibles, un juste souci de la solidarité internationale dans le domaine de la santé, qui doit engager les gouvernements et les organismes internationaux à l'égard des pays les plus pauvres, vis-à-vis desquels on pratique souvent une politique de recherche ou d'écoulement de produits de santé dans le seul intérêt des pays les plus riches. A cet égard, il est indispensable d'aboutir le plus tôt possible à une formulation plus universelle des droits de l'individu, qui constituent la base même des principes fondamentaux de l'éthique, à savoir le respect de l'être humain (fondé sur deux critères essentiels : les individus doivent être considérés comme des êtres autonomes et chaque individu a le droit d'être protégé); la nécessité de respecter les décisions de l'être humain et de le protéger contre tous les dommages, tout en assurant son bien-être, afin de traiter chaque individu conformément à la morale; enfin, le respect de l'équité dans la distribution, conformément à la justice. Outre ces principes fondamentaux, il s'avère nécessaire de mettre en place une législation internationale qui assure le respect de la vie depuis sa conception, qui prête la plus grande attention aux abus possibles dans le domaine du génie génétique, ainsi qu'à la sauvegarde de Fenvironnement en fonction de la sauvegarde de la santé et, enfin, qui garantisse une politique de transplantation d'organes en vue d'empêcher le développement d'un marché commercial, au mépris de toute dignité humaine. L'OMS devra non seulement axer de plus en plus ses efforts sur la coordination et la promotion de toutes les stratégies de la santé, mais en outre agir en tant qu'inspiratrice et organe de dénonciation et de contrôle de toutes les violations de principes et de valeurs fondamentales qui portent atteinte à la fois à la dignité humaine des individus et à la dignité de nations entières. Enfin, un programme attentif aux ressources consacrées à la santé ne pourra en aucun cas aboutir à faire prévaloir des raisons d'ordre économique sur le droit à la santé pour tous. Le Dr BRAGANCA GOMES (Sao Tomé-et-Principe) {interprétation du portugais) : 1 Monsieur le Président de séance, tout d'abord, je voudrais adresser mes sincères félicitations au Président pour son élection à la présidence de la Quarante-Septième Assemblée mondiale de la Santé. Je suis convaincue que, sous sa direction, nos travaux seront couronnés de succès. J'aimerais également féliciter les Vice-Présidents et saisir cette occasion pour saluer les honorables ministres de la santé, les chefs de délégation et les délégués ici présents, qui ont à coeur de bien servir et partagent une aspiration commune, à savoir améliorer la santé et enrichir la qualité de vie de toutes les populations. Je souhaiterais en outre féliciter l'afrique du Sud pour la reprise de sa participation aux travaux de l'assemblée. J'aimerais encore exprimer mes remerciements les plus vifs au Dr Hiroshi Nakajima, Directeur général de l'oms, et au Dr Gottlieb Monekosso, Directeur régional de l'oms pour l'afrique, pour les efforts déployés en faveur du développement sanitaire tant au niveau mondial qu'au niveau de la Région africaine. Je ne peux non plus manquer de féliciter le Directeur général pour l'excellent rapport présenté à cette auguste Assemblée. 1 Conformément à l'article 89 du Règlement intérieur.

148 A47/VR/7 page 133 Monsieur le Président, ayant présentes à l'esprit les recommandations du Conseil exécutif, je ne parlerai pas de la situation sanitaire de mon pays. Je préférerais faire part de certaines préoccupations concernant le faible développement économique et sanitaire du continent le plus défavorisé, c'est-à-dire l'afrique. L'Afrique se trouve dans une situation qui l'oblige à gérer des crises multiples interdépendantes les unes des autres, lesquelles englobent les domaines économique, politique, démographique et sanitaire. Avec une économie paralysée ou même en régression, faisant face à une croissance démographique considérable -ce qui l'amène à recourir aux programmes d'ajustement structurel avec des conséquences inévitables pour la vie des populations les plus vulnérables -, si on prend en compte la chute progressive du cours de ses produits d'exportation et du coût de plus en plus élevé des produits qu'elle importe, avec l'instabilité politique de plusieurs pays de la Région, due aux conflits et aux guerres fratricides, menant à l'élimination de vies humaines, au déplacement de populations, à la destruction d'infrastructures, y compris d'infrastructures sanitaires, l'afrique est aujourd'hui un continent où les peuples deviennent de plus en plus pauvres, de plus en plus dépendants, avec davantage de besoins sociaux, auxquels les Etats sont incapables de répondre. Bien que l'on ait maîtrisé certaines maladies qui sévissaient dans la Région africaine, telles que Fonchocercose et la dracunculose, la situation sanitaire actuelle est telle que nous ne pouvons relâcher nos efforts. Les épidémies se succèdent, le SIDA ne fait que se disséminer, en coûtant des vies humaines et en réduisant la force productive des pays, le paludisme demeure l'une des principales causes de mortalité dans divers pays du continent et les enfants continuent à mourir de malnutrition. Pour que l'on puisse atteindre l'objectif que nous nous sommes fixé 一 la santé pour tous 一, i l est indispensable qu'il y ait un climat de paix et de stabilité dans notre continent, que l'on établisse des relations économiques plus justes entre le Nord et le Sud, et aussi que l'on transfère davantage de ressources et de technologies appropriées vers notre continent. Nous devons nous tendre la main et renforcer les activités d'information et d'éducation propres à permettre une plus grande participation des communautés pour trouver des solutions aux problèmes importants. Il faudrait encourager en priorité un engagement plus poussé de la communauté internationale dans la lutte contre le paludisme dans les diverses régions d'afrique. C'est ainsi que nous pourrons, en sécurité et ensemble, vaincre les obstacles qui empêchent notre développement sanitaire. En ce qui concerne l'éthique et la santé, Гол doit toujours tenir compte du fait que la personne humaine, en tant qu'individu et faisant partie intégrante de la société, a le droit d'exiger du système de santé national des soins préventifs et curatifs, des services de réadaptation, ainsi que le plein respect de son intégrité physique, psychique, morale et culturelle. En revanche, elle a des devoirs envers elle-même et envers la société, lesquels ne peuvent être intériorisés qu'à partir du moment où elle est considérée comme sujet actif, associé à la gestion des facteurs qui conditionnent la qualité de la vie et de la santé. Tout cela exige évidemment une certaine façon d'agir et de sentir de la part des agents de santé, qui devraient, notamment, tout faire pour établir des relations de confiance avec Findividu et la population, informer ces derniers de ce qu'ils doivent savoir sur la santé et les facteurs qui la perturbent, et apprendre au malade, avec la prudence nécessaire, ce qu'il peut et doit savoir sur sa maladie, en particulier le diagnostic et ses conséquences sur ses rapports avec la société, le pronostic et le traitement qu'il doit nécessairement suivre. A ce sujet, je souhaiterais encore me référer brièvement aux préoccupations que suscitent l'expansion de répidémie de SIDA et son impact sur rintimité des personnes infectées, ainsi que son incidence sur la vie familiale et sociale, notamment en ce qui concerne la confidentialité, le besoin de conseils et le comportement des personnes infectées par le VIH, afin d'éviter la propagation du virus à d'autres personnes. Il serait souhaitable que les agents de santé soient également conscients que le droit à la vie est un droit fondamental de la personne humaine et que c'est à eux, agents de santé, qu'il incombe d'agir toujours de manière à le préserver. Voilà, Monsieur le Président, quelles étaient mes considérations au sujet du débat sur les points 9 et 10 de l'ordre du jour. Dr LIEBESWAR (Austria): Mr President, honourable delegates, ladies and gentlemen, due to the fact that the Austrian National Assembly is presently engaged in the parliamentary debate of the Austrian European Union Accession Treaty, a debate necessary to pave the way for a referendum scheduled on 12 June, all our Government ministers are required to stay in Vienna in these crucial days and our new Minister of Health, Sport and Consumer Protection, Dr Christa Krammer, therefore is unable to be with us here in Geneva as planned. She has, however, asked me to convey to you her best wishes for a successful and productive Assembly and instructed me to address you on her behalf.

149 A47/VR/5 page 134 May I first of all congratulate the President and Vice-Presidents on their election and assure them of Austria's full support in their important task. I also would like to thank the Director-General and his staff for the excellent preparation of the World Health Assembly. Particularly, I would like to mention the report of the Director-General on the work of WHO in and his report on the collaboration within the United Nations system. We are especially pleased to note that this latter document also provides a comprehensive survey of WHO activities in the field of human rights, including the Organization's substantive contribution to the World Conference on Human Rights held in Vienna in the summer of last year. Furthermore, let me also point out the very clearly structured draft of the Ninth General Programme of Work, incorporating also the comments and corrections introduced by the Executive Board. Austria welcomes the Board's initiative to establish an Administration, Budget and Finance Committee within the framework of the ongoing budgetary reform. Having once served on the Board myself, I can very well imagine the constructive role of such a committee, namely, its dual role of clarifying the budget-setting process and of monitoring the impact of administrative and budgetary measures on WHO's efficiency. Nevertheless, I do not hesitate to add that this Committee should restrain its endeavours and consider itself as a supportive and assisting instrument. At home, too, we would be reluctant to tolerate any undue restrictions imposed on our minister's political discretion. In practice, we sometimes have to clearly convey the message that the minister's political responsibility cannot be delegated to the level of a committee. Delegations to this Assembly have been invited to include in their presentations some reflections referring to ethics and health. Ethical questions are most clearly visible in cases of conflicting interests: often the individuaps interest in the protection of his private sphere contradicts the public interest. A typical example would be the containment of the transmission of infectious diseases. In some cases, the severity of the decision between these conflicting interests may be reduced by the appreciation that medical considerations do not really necessitate limitations to personal rights and liberties. Furthermore, as is clearly to be seen in the case of AIDS, for instance, there can be advantages to be gained by refraining from the containment of groups affected by contagious illnesses: namely that gaining the confidence of this particular group can induce a positive reaction to appeals for responsible behaviour on the part of its members. Genetic engineering can serve as another example. At present, the Austrian Parliament is engaged in the deliberation on a respective law to be passed in the near future. The national debate has already highlighted several ethical questions. On a global scale, even a greater number of conflicts of interest have to be accommodated than on the national level. For instance, in view of the critical situation concerning the ability to nourish the human population in many parts of the world, genetic engineering might open new horizons in the production of new nutritious plants. Undoubtedly, every new technology contains risks that cannot be ignored. Ethically, however, it seems hardly justifiable for countries enjoying the security of sufficient food supplies not to engage in the search for new sources of food, simply because their own necessities have been met. Similarly, it is well known that clinical trials of new drugs pose inevitable risks, but, on the other hand, therapeutic progress has proven unthinkable without clinical experiments being part of medical development. The burden of these risks has to be borne equally and fairly by all societies. But I am confident that ethical responsibility and scientific progress paired together in a balanced way, will enable us to rise to global challenges. Dr GUGALOV (Bulgaria): Mr President, distinguished Vice-Presidents, Director-General, delegates and guests, on behalf of the Bulgarian delegation and on my own behalf I would like to extend to the President, and to his deputies, our congratulations on their election to the responsible posts in the leadership of the Forty-seventh World Health Assembly and to join our distinguished colleagues who have already expressed their satisfaction on this occasion. Please, permit me also to extend my greetings to the Secretariat for its fruitful work and efforts in the past year aimed at promoting and improving health care all over the world. A few years ago the Director-General proposed a new paradigm for health development. This would include the development of a new plan for action directed at global health development consistent with the Organization's general goals of achieving equity and social justice. This plan poses a new challenge to the Member States that compels them to adapt their health care systems to the new political, economic and social conditions resulting from the changes that have occurred in our world. In Bulgaria the process of reforms in the health care sector, as well as its adaptation to the new realities, is gaining momentum. The reform of the health care system in the Republic of Bulgaria is carried out in a situation notable for rapid political and social change directed to the building and consolidation of new democratic structures under

150 A47/VR/5 page 135 the burden of a severe economic crisis. An analysis of health care development in recent years conducted by the Ministry of Health has shown the following realities in existence within the developed Bulgarian health care system: growing dissatisfaction with the functioning of the health sector coinciding with a crisis in values, apparent among both health professionals and patients; inefficient utilization of financial, manpower and technological resources; inadequate management structures; lack of efficient mechanisms for joint discussion and for consensus-building regarding the priorities of the reform with the newly established trade union, professional and other organizations; crisis in the competence of managerial staff which threatens the success of the reform process of the health care system. The efforts of the Ministry of Health in the conditions prevailing in Bulgaria, are directed to achieving the following high priority goals: protection and improvement of the health of the population, monitoring and controlling its health status; guaranteeing equity for all citizens in obtaining accessible, adequate and high-quality health care; further development of the structural reform in the health care system; making the best possible use of the financial resources and know-how provided to our health care system by international institutions such as WHO, the European Union and the World Bank. In pursuing these goals we are looking for the necessary balance of quick and tangible results in certain critical areas of health care on the one hand, and the long-term development of the health sector, on the other. The Bulgarian health care system is focused on the maximum utilization of the experience of the developed countries and of the international organizations in the field of health care. Our new health policy is directed towards the development of new health legislation that would guarantee the stability and irreversibility of the health care reform processes. The Ministry of Health has produced a package including laws on health insurance, drugs and pharmacies in human medicine, medical institutions, health of the nation; professional associations; and blood transfusion and blood products. The conditions created by the transition to a market economy and the budget deficiency have highlighted the need for improved efficiency in the utilization of available health resources, which has led to: development of a health-for-all national strategy; development of national indicative standards for medical needs, related to the optimization of the health care system; development of a contracting system based on costing of the volume and quality of medical activities; development of a cost containment system for regulation of health expenditures; building up the infrastructure of a national health insurance system and its gradual introduction; restructuring the state sanitary control aimed at eliminating existing health hazards; development of adequate information systems for health care management; and development and introduction of a new national drug policy. The reform of a health care system in a democratic society should primarily be based on the elements of public tolerance. In this respect the new strategy of the Bulgarian health system requires shared responsibility for health development and the implementation of adequate mechanisms for constructive cooperation among state institutions, public organizations and health professionals. In searching for new solutions within the health care reform process in the Republic of Bulgaria we are relying on the experience of international organizations, and above all on WHO. The new principles underlying international cooperation include partnership with governmental and nongovernmental organizations, achievement of a balance between technical and investment assistance within the framework of international health projects, establishment of counterpart funds for financing international health projects and building a new managerial system for increasing the national capacity for utilization of technical and financial assistance provided. In conclusion I would like to express our gratitude for the technical and material support extended to us by the European Union through the PHARE and Tempus programmes and for the assistance we have received from the Council of Europe. Finally, I would like to emphasize our firm commitment to the policy and practice of WHO's strategy for attaining health for all by the year Д-р КАСИЕВ (КЫРГЫЗСТАН) Dr KASSIEY (Kyrgyzstan) Господин Председатель, уважаемые коллеги! Прежде всего, разрешите от имени делегации Республики Кыргызстан сердечно поздравить Председателя, его заместителей с избранием на столь высокий пост, а г-на Накадзима, - за содержательный отчетный доклад. Я полностью одобряю ВОЗ за проделанную работу и выражаю благодарность за то, что ВОЗ, его Европейское бюро оказывают всемирную поддержку нашей республике в период обновления и установления рыночных отношений.

151 A47/VR/5 page 136 Уважаемые коллеги! Сегодня мне выпала большая честь выступить с этой высокой трибуны, когда год тому назад, 5 мая, суверенный Кыргызстан принял свою новую Конституцию. Господа! Мне хотелось бы не отвлекать ваше внимание на внутренние проблемы моей страны, ибо они идентичны для многих госудрств. Я хочу в моих коротких выступлениях обсудить вопросы этики в здравоохранении. Этические проблемы и этическая ценность практиков здравоохранения всегда оставались предметами исключительной значимости во всех обществах. Вспомним хотя бы клятву Гиппократа. Медицина моей страны, насчитывающая с учетом преемственности не одно столетие своего развития, внесла достойный вклад в мировую сокровищницу медицинской этики. Однако на сегодняшний день мы все еще далеки от обретения философского камня для разрешения этических проблем, тем более что сама жизнь и медицинская практика по мере ее развития ставят новые, все более сложные задачи в этой сфере. Я не буду пытаться объять необъятное, и тем более рекомендовать какие-либо универсальные рецепты. Позволю лишь изложить свое видение некоторых аспектов этой глобальной темы и обозначить подходы, которые с нашей точки зрения наиболее приемлемы. Мне хотелось бы оттолкнуться от того хорошо известного факта, что высокий экономический, научно-технический уровень общества отнюдь не коррелируется с его способностью легко и быстро решать этические задачи в области охраны здоровья в частности и в социально-политической сфере вообще. Сам по себе быстрый рост качества медицинского обслуживания, какими бы ни были достижения медицинской науки и практики, не гарантирует спонтанного разрешения стремительно накапливающихся за последнее время морально-этических проблем, целый комплекс которых был, например, порожден после обнаружения ВИЧ-инфекции. А какой грандиозный генетический пласт поднимается по мере вхождения в такие области, как репродукция человека, трансплантология, генная инженерия. В нашем общетве, например, в настоящее время во весь рост встает проблема планирования семьи во всем ее многообразии, и мы не сможем закрыть глаза на моральноэтические ее стороны, особенно с учетом национальных и религиозных традиций. Многое усложняется для нашей страны последствиями перехода к рыночным отношениям, о чем уже упоминалось в выступлениях моих коллег стран содружества. Эта общественная мораль в этих странах формировалась на принципах так называемой социальной справедливости, и мы не сможем отрицать, что при всем идеализме этого понятия, были определенные положительные моменты, прежде всего в такой сфере, как здравоохранение. В постсоциалистическом обществе это, конечно, порождает ряд весьма специфических явлений в области медицинской этики, ибо из нашей жизни уйдут, хотя, может быть, и не навсегда, такие гуманные принципы, как общедоступность и бесплатность медицинской помощи. Можно много еще говорить о специфике, однако, я хотел бы перейти к тому на мой взгляд общему подходу к обсуждаемой здесь теме. При всем нашем желании, решение рассматриваемой нами сегодня поистине глобальной проблемы не может при всей ее имманентности сфере здравоохранения ограничиваться пределами здравоохранения, даже сколь угодно расширяемыми. При всей приоритетности нашей с вами роли, то есть тех, кто определяет политику, стратегию, тактику в здравоохранении своих стран, значимость этических аспектов возросла на сегодняшний день до такой степени, что их уже нельзя решать в рамках традиционных структур, то есть, решение лежит на путях вовлечения самых широких кругов общественности, на не только профессионалов в области медицины. Бесспорным в настоящее время является вывод, что потребители медицинских услуг являются полноправными партнерами на всех этапах и уровнях оказания медицинской помощи, и при принятии решений в области охраны здоровья следует учитывать их приоритеты, нравственные ценности и знания. Преломляя сквозь призму понятие прав человека, следует признать неизбежный переход к корпоративной замкнутости медицинских профессиональных сообществ, к

152 A47/VR/5 page 137 организации общественных институтов, создаваемых специально для решения этических вопросов, и, следовательно, для каждой страны характер этих учреждений будет зависеть от культурных, религиозных, экономических и прочих ее особенностей. Тем не менее, одним из основополагающих принципов функционирования подобных общественных учреждений должна быть максимальная защищенность от воздействия со стороны профессионалов, коммерческих, религиозных и политических кругов. Полагаю, вы согласитесь, уважаемые коллеги, что задача по организации такого рода общественных институтов в какой-то мере уже обеспечена универсальной правовой базой в виде Комиссии Организации Объединенных Наций по правам человека, Всеобщей декларации прав человека, решений Комиссии Организации Объединенных Наций по правам человека, рекомендаций Европейского совета. Хотя я должен заметить, что в нашей стране нашему постсоциалистическому обществу потребуется приложить в этом направлении гораздо больше усилий, чем другим странам - членам ВОЗ Европейского региона из-за предшествующей длительной правовой изоляции от мирового сообщества, мы рассчитываем в этом отношении на поддержку Всемирной организации здравоохранения. Потенциал ресурсов последним мне кажется далеко не исчерпанным в контексте рассматриваемой нами проблемы этики здравоохранения. Почему нельзя взяться за разработку базового документа в рамках ВОЗ, определяющего как правовые аспекты, так и концептуальные подходы на современном этапе развития нашего общества? Осознавая, что далеко не все изложенное мною окажется бесспорным, я, тем не менее, счел своим долгом поделиться с вами некоторыми соображениями, используя авторитет этой высокой трибуны. Mr ANGATIA (Kenya): Mr President, Director-General, honourable ministers, distinguished delegates, ladies and gentlemen, on behalf of the Kenyan delegation and on my own behalf, I wish to congratulate the President on his election and wish him success in steering these deliberations. May I also take this opportunity to extend our warm welcome to the delegation of South Africa on assuming full participation in the World Health Assembly. We commend the Director-General and staff for their genuine commitment to the improvement of health worldwide, especially in the developing countries. Last year, during the Forty-sixth World Health Assembly, I alluded to some major challenging issues which Kenya was going through. These included political democratic changes, economic reforms and coping with the refugee influx from neighbouring countries. We have continued to face these challenges during the past year. More recently, the problem in neighbouring Rwanda, in addition to the situation in the Horn of Africa, has compounded the refugee problem, bringing the number of refugees currently in Kenya to about In this connection, we wish to commend the United Nations High Commissioner for Refugees and the many humanitarian and nongovernmental organizations which have come to our assistance. The drought continues for the second year running, affecting about two-thirds of the country and causing failure of crops and death to livestock resulting in the undernourishment of many people. The yellow-fever outbreak we reported in this Assembly last year, which Kenya experienced for the first time since 1943,and which was confined to two districts, Baragoi and Marsabit, in the Great Rift Valley, was quickly brought under control through aggressive vaccination of the entire population at risk, and vector control activities. Following this outbreak, there was a need to develop a long-term plan of action in order to prevent recurrence. Disease surveillance in humans, primates and mosquito vectors was put in place to help in early detection and the prevention of future outbreaks. Vector control measures continued in the affected areas. As a long-term measure, yellow-fever vaccination was incorporated into the immunization programme in the affected areas with a view to eventually making it part of Kenya's expanded programme on immunization. Malaria continues to be the number one cause of morbidity and mortality in Kenya. On 5 April this year, the Government of Kenya launched a five-year national plan of action for malaria control which aims at (1) strengthening case management; (2) intensifying vector control; (3) improving personal protection through the use of impregnated bednets and other materials; (4) prophylaxis; (5) continued research activities.

153 A47/VR/7 page 138 AIDS has continued to pose a great social, economic and health challenge. By 28 April 1994, AIDS cases had been reported, with an estimated infected individuals out of a total population of 25 million in Kenya. The shortage of HIV testing kits, which the National AIDS Control Programme has been experiencing recently, is a matter that I wish to bring to the attention of the Director of the Global Programme for AIDS in WHO. Effective programmes have been put in place which include the following: (1) more than 80% of Kenyans know how AIDS is transmitted and how it can be prevented; (2) over 98% of all blood for transfusion is being screened in all hospitals countrywide and (3) there is effective surveillance to monitor the trend of the epidemic. The Government has adopted a multisectoral and multidisciplinary approach to AIDS control. A national AIDS council, chaired by the Office of the President, will be responsible for formulating policies on AIDS and providing guidelines for development and implementation of control programmes. Budgetary provisions for AIDS control had been made in the national government budget, in addition to external assistance by international agencies and friendly donors. The AIDS problem has resulted in another setback, as it has been shown in Kenya, as well as in other countries, to be directly related to the increase in tuberculosis cases particularly in the large urban centres. There has been shown to be a constant increase in tuberculosis cases in the age group years. The Government has responded to this by intensifying the tuberculosis control activities. We have also made efforts to integrate our AIDS control programme with the control of sexually transmitted diseases in order to make a greater impact in our prevention activities. In all these efforts, we are grateful for the assistance we have received from friendly countries such as the Netherlands and the Belgian Government, as well as other international agencies. We have continued our commitment to strengthening primary health care in our national health system. We have seen an improvement in immunization coverage which stands now at over 77%, and we join the world community in redoubling our efforts in order to eradicate poliomyelitis by the year We in Kenya are fully committed to this goal and are working hard to achieve it. The Kenyan Government is committed to the safeguarding of the health status of women by ensuring equity and by enacting legislation against the harmful traditional practice of female genital mutilation. We have set up a guinea-worm eradication programme and are confident that Kenya will soon be the first country in Africa to eradicate guinea-worm. In the area of substance abuse, which is an international problem, Kenya has embarked on intensive awareness campaigns, as well as efforts for demand reduction. With regard to essential health research, we have set up a national coordinating mechanism to ensure that our research on health is in most essential areas that are cost-effective towards health efforts. In Kenya the top five cancer killers are those of the skin, cervix, breast, liver and lymphomas. As a response to this, we are working on a Kenyan national cancer control programme. We urge WHO to help us to get this programme off the ground. Finally, on health policy and essential reforms, Kenya was one of the countries of eastern Africa which participated in the health strategy workshop convened by the World Bank in Washington DC from 3 to 11 June During this workshop, we discussed the content and relevance of the World Development Report 1993 the theme of which is investing in health. We also made reference to the document entitled "Better health for Africa". As a result of this effort, we have now come up with a national health policy framework for Kenya which illustrates our health sector reforms and future directions. In this regard, we are soon going to hold regional meetings in Entebbe, Arusha, and Nairobi to share and exchange views on how we intend to improve the health of our people. Mr HUUHTANEN (Finland): Mr President, Excellencies, distinguished delegates, ladies and gentlemen, today no major issues of economic, social or political significance can be observed or debated in isolation from a number of other related issues. The increase of interdependence between nations as well as issues seems to be evident. It is against this background that I wish to make a reference to a few international meetings, which show the global character of the issues we are dealing with and where also health development constitutes a vital part. This year the International Conference on Population and Development will take place in Cairo. It is the first global effort to address the interlinkages between population and sustainable development. In the programme of action, which will be adopted at Cairo, and in its implementation, the efforts of all actors at all levels will be needed. Here also WHO has an important role to play. Future policies and programmes in this field should be based on the concept of sexual and reproductive health and rights, and the related activities should be integrated in the context of primary health care.

154 A47/VR/7 page 139 Moreover, in 1995 the World Summit for Social Development in Copenhagen and the Fourth Conference on Women in Beijing will take place. WHO should take an active part in the preparation for these Conferences. As regards the World Summit for Social Development in particular, my delegation feels that health has not been given a proper emphasis in the preparatory work carried out so far. Health should be regarded both as an important goal in itself and as a key means for achieving social development. To ensure that health is adequately embodied in the Draft Declaration and Programme of Action of the Summit, it is necessary for WHO to collaborate closely with the United Nations Secretariat in New York. We must decide what role health and WHO are to play in the global process to be launched at the Summit. This brings me to the issue of health development, as a cornerstone of welfare policies, and to our work. This Assembly will deal with an essential policy framework for the years to come, the Ninth General Programme of Work. The Programme is the third of its kind since the inception of the Global Strategy for Health for All. My delegation welcomes the stress on equity in health development in this programme. No progress will be made without integrating health and human development in overall public policies. There is a multitude of actors involved in this. The role and vision of WHO as the directing and coordinating authority in international health is crucial. Its experience, expertise and power of influence will be tested in its capability to meet the challenges through building new and stronger health alliances for the future world. In this connection I wish to commend the Director-General for the reorganization of the activities of United Nations bodies to establish a joint and cosponsored United Nations programme on AIDS, with WHO acting as the lead agency. We give our full support to this kind of effort for combating AIDS. The issue of health development also invites the question of the role and functions of WHO - another item of importance on our agenda, namely the WHO response to global change. The delegation of Finland notes with satisfaction the new mechanisms to enhance coordination within the Organization as a part of the overall reform process of WHO. In this context, we particularly welcome the establishment of two new organs in the management structure of WHO, the Global Policy Council and the Management Development Committee. We are looking forward to the first assessment of their impact on WHO's capacity to better respond to the growing coordination needs resulting from global change. Furthermore, we welcome the Executive Board decision, submitted for the approval of this Assembly, on the establishment of the new Programme Development Committee as well as the Administration, Budget and Finance Committee. We regard these committees as potentially useful tools for the Board to provide more effective guidance for the Organization and its management. My delegation wishes to emphasize, however, that the organizational changes made and those that lie ahead cannot be ends in themselves; ultimately these changes of structure must translate into effective policy guidance, common goals and strategies that work. As to the WHO response to global change, significant emphasis should be placed also on the development of human resources. Indeed, the internal renewal of WHO should be implemented in an open dialogue and communication with the staff as well. Having a clear picture of where we are going, we are better equipped to anticipate forthcoming challenges. My delegation expresses its appreciation to the Director-General for the work of WHO in the humanitarian field, particularly in complex emergencies. We appreciate the action taken, in line with the Health Assembly resolutions last year, to strengthen WHO mechanisms for emergency preparedness, humanitarian assistance, relief and rehabilitation. WHO activities have borne good results, as the case of the nutrition advice by WHO in Bosnia and Herzegovina pointed out. We encourage WHO to continue its efforts, within its mandate, as part of the coordinated overall United Nations response to humanitarian needs worldwide. Health development entails also the sufficiency and quality of the physical and biological environment. Indeed, the challenge we face today is to bring together and synthesize the responsibilities and traditions of environmental protection and human health. For that purpose the Second European Conference on Environment and Health will be convened in Helsinki this summer. The Conference will offer an unparalleled opportunity to help ensure a healthy living and working environment for future generations. I am convinced that the Conference will go far in bringing together the countries of Europe to work towards sustainable development. I trust that the results will be applicable also globally in building up sustainable health development.

155 A47/VR/7 page 140 Le Dr SANTILLO (Brésil) (interprétation du portugais) : 1 Monsieur le Président de séance, Monsieur le Ministre d'etat, c'est pour moi un privilège de participer à la Quarante-Septième Assemblée mondiale de la Santé. Au nom du Gouvernement brésilien, je félicite M. Temane pour son élection à la présidence de cette Assemblée et je réitère mes félicitations au Directeur général de l'organisation mondiale de la Santé, le Dr Hiroshi Nakajima, et au Directeur régional pour les Amériques, le Dr Carlyle Guerra de Macedo, en leur adressant mes sincères voeux de succès dans leurs multiples et importantes tâches. Au nom du Gouvernement brésilien, j,accueille avec grande satisfaction la réintégration de FAfrique du Sud au sein de l'organisation et je salue le peuple sud-africain pour le succès de sa lutte contre l'apartheid et pour la démocratisation du pays. Je saisis cette occasion pour souhaiter la bienvenue aux nouveaux Etats Membres. Le Brésil participe avec intérêt aux efforts visant à resserrer les liens de coopération avec d'autres pays en ce qui concerne la santé et, en particulier, avec la communauté des pays de langue portugaise. J'ai le plaisir de vous annoncer la tenue au Brésil d'une réunion des Ministres de la Santé de l'angola, du Cap-Vert, de la Guinée-Bissau, du Mozambique, du Portugal et de Sao Tomé-et-Principe durant le second semestre de cette année. C'est avec satisfaction que j'accueille le choix de "L'action communautaire en faveur de la santé" comme thème des discussions techniques qui se tiennent durant cette Assemblée, reprenant ainsi une des stratégies préconisées pour atteindre les objectifs d'alma-ata. Parmi les 157 millions de Brésiliens, 120 millions dépendent exclusivement du système de santé publique, les autres étant protégés par des plans de santé privés. Parmi ceux qui dépendent du système public, universel et gratuit, 32 millions n'ont pas encore un accès adéquat aux soins de santé essentiels. Nous cohabitons avec quelques paradoxes comme celui d'avoir, d'un côté, des dizaines d'hôpitaux d'excellent niveau dans les spécialités médicales les plus diverses, et de l'autre un taux de mortalité infantile de 54 pour Ce taux varie de manière significative selon les différentes régions du pays. Au Brésil, les activités dans le domaine de la santé sont axées sur les 6180 hôpitaux associés à notre système unique de santé, bien que, récemment, nous ayons pris la décision politique de renforcer la promotion et la protection de la santé, sans pour autant réduire le budget destiné à la médecine pratiquée dans les hôpitaux. Nous avons créé trois nouveaux programmes, tous les trois mettant l,accent sur la participation communautaire. Le premier est le programme de santé pour l'intérieur du pays dont bénéficient les communes les plus isolées, sans aucun médecin ou, tout au plus, un seul pour une population de 2,1 millions d'habitants. Nous avons orienté initialement notre action sur l'amazonie brésilienne, où 123 des 398 communes ne disposent d'aucun médecin et 88 n,en comptent qu'un seul. Le programme est axé sur le déplacement non seulement du médecin à l'intérieur du pays, mais également d'une équipe sanitaire de base avec les installations et les équipements essentiels. Le deuxième programme est celui des structures ambulatoires de pointe qui vise à donner une plus grande crédibilité aux services de santé, à répondre à la demande de la population, à offrir un meilleur service aux patients et à réduire la demande injustifiée de soins hospitaliers. Le programme est destiné aux régions à forte densité démographique et dotées de services de santé insuffisants, telles que les périphéries urbaines; il devra atteindre une population de 40 millions d'habitants. Ce programme consiste en Pinstallation de structures ambulatoires fonctionnant vingt-quatre heures sur vingt-quatre, disposant de services de radiologie et de laboratoires, de cabinets dentaires, de lits pour l'observation médicale et d'une salle d'accouchement dans les centres de santé déjà existants. Le troisième programme est celui de la santé de la famille. Il est destiné à desservir, cette année encore, 12,5 millions de personnes habitant les régions démunies dans l'ensemble du pays. Ce programme envisage la création et rinstallation dans les communautés elles-mêmes d'équipes complètes de santé, composées d'un médecin, d'un dentiste, d'une infirmière et de cinq agents de santé communautaires, chacune d'entre elles devant s'occuper d'environ 1000 familles. Le but à atteindre d'ici à la fin de 1994 est l'établissement de 2500 équipes. L'objectif du programme est la recherche de solutions appropriées aux problèmes locaux, basée sur l'analyse des causes et des facteurs déterminants spécifiques, et la stimulation du contrôle social des actions et des services de santé grâce à la participation active des familles. Dans ce même esprit, nous suivons la mise en oeuvre de programmes existants. Le programme des agents de santé communautaires fut distingué par l'unicef-brésil, en 1993,qui lui a décerné le Prix "Enfant, Paix et Santé". Il y a aujourd'hui agents de santé communautaires travaillant dans les régions Nord et Nord-Est. D'ici à la fin de 1994, nouveaux agents s'ajouteront au nombre déjà en place et exerceront leur activité dans les trois autres régions du pays. Avec ses vingt et un ans d'existence, 1 Conformément à l'article 89 du Règlement intérieur.

156 A47/VR/7 page 141 le programme national de vaccination mérite d'être mentionné ici pour avoir obtenu d'excellents résultats. En ce qui concerne la poliomyélite, le Brésil n'a enregistré aucun cas depuis C'est là le fruit de campagnes de multivaccinations réalisées deux fois par an, depuis 1980, chaque campagne atteignant actuellement près de 18 millions d'enfants, soit une couverture supérieure à 90 %. Le Brésil devrait pouvoir prétendre au Certificat international d,éradication de la poliomyélite avant la fin de l'année. A la suite de la vaste campagne de vaccination menée contre la rougeole en 1992, qui a permis de vacciner 48 millions d'enfants jusqu'à 14 ans - soit une couverture de 96 % -,16 fois moins de cas ont été constatés : de en 1991 le nombre est tombé à 3000 en Nous sommes en train d'éliminer cette maladie. Le tétanos néonatal fait aussi l'objet d'un programme visant son élimination. Dans quarante communes du Nord, du Nord-Est et du Centre-Ouest du Brésil, considérées comme étant à haut risque, la vaccination massive de toutes les femmes en âge de procréer doit conduire à l'élimination de cette maladie à bref délai. La vaccination contre l'hépatite В est déjà pratiquée systématiquement dans les régions où celle-ci a une plus grande incidence; elle devra être étendue à tout le pays d'ici à Nous procédons petit à petit à la vaccination contre la rubéole là où elle sévit le plus. Quant au choléra, depuis le début de 1994,nous avons eu cas confirmés. Nous sommes parvenus à en enrayer l'expansion grâce à Paction des agents de santé communautaires, à la distribution d,hypochlorite de sodium, à de simples moyens d'assainissement et au renforcement de l'éducation sanitaire visant la population atteinte. Aujourd'hui, le choléra se trouve pratiquement circonscrit au Nord-Est du Brésil. Nous sommes convaincus qu'en consacrant seulement 11,5 milliards de dollars à moyen terme à rassainissement, nous parviendrons, une nouvelle fois, à éliminer cette maladie de mon pays. Le SIDA est un grave problème pour le Brésil. Depuis le début de l'apparition de ce syndrome jusqu'au mois de mars 1994,nous avons recensé cas de SIDA et morts. Nous avons une politique de diffusion de l'information bien définie. Nous utilisons toutes les chaînes de télévision et plus de six mille postes de radio pour informer et orienter toute la population de manière claire et objective. Le Brésil applaudit rinitiative de l'oms visant à coordonner Paction des organismes des Nations Unies dans la lutte contre les maladies sexuellement transmissibles et le SIDA. Certains principes élémentaires sont le fil conducteur de notre politique de prévention du SIDA. Il s'agit, d'une part, de Fautonomie nationale pour définir et mettre en pratique des stratégies compatibles avec la réalité sociale, politique, culturelle et épidémiologique de notre pays, et de l'autre, de la liberté d'accès aux sources financières. Dans ce contexte, il est important que la participation de l'organe régional de l'oms pour les Amériques soit renforcée. En ce qui concerne le SIDA, le Brésil fera des observations sur la proposition présentée dans le document A47/15 pendant les discussions de la Commission A. Finalement, nous progressons sur la voie de la santé pour tous d'ici l'an Je suis certain que nous remplirons nos engagements en ce qui concerne le plan d'action adopté lors du Sommet mondial pour les enfants. Je réaffirme ici ma conviction que le renforcement de la promotion et de la protection de la santé, le développement de meilleurs services, la participation communautaire et l'implantation de notre système unique de santé dans son ensemble amélioreront la qualité de vie de la population brésilienne. Le Dr GODINHO GOMES (Guinée-Bissau) (interprétation du portugais) : 1 Monsieur le Président de séance, Monsieur le Directeur général, Mesdames et Messieurs les ministres, distingués délégués, Mesdames et Messieurs, au nom du Gouvernement de la République de Guinée-Bissau et de la délégation qui m'accompagne, permettez-moi tout d'abord de féliciter le Président ainsi que les Vice-Présidents et les autres membres du bureau de cette Assemblée pour leur élection. J'aimerais également féliciter le Directeur général et les membres du Conseü exécutif pour les rapports présentés à cette Assemblée et saisir l'occasion qui m'est offerte pour remercier le Directeur général et le Directeur pour la Région africaine de leurs efforts inlassables en vue d'instaurer la santé pour tous, notamment dans mon pays, la Guinée-Bissau. La Quarante-Septième Assemblée mondiale de la Santé a lieu à un moment très particulier pour la Guinée-Bissau, en plein processus de changement démocratique entamé depuis 1990,dont les résultats sont l'existence de nombreux partis politiques, la récente opération de recensement électoral et la tenue dans quelques mois des premières élections pluralistes et démocratiques. Permettez-moi également, Mesdames et Messieurs, de saluer ici le moment historique que vient de vivre le continent africain qui, après plusieurs siècles de domination et de ségrégation raciales sur son propre sol, s'est enfin libéré de ce carcan de l'histoire qui s'appelait "apartheid". Honneur soit donc rendu à tous ces héros du peuple frère sud-africain, dont Nelson Mandela est l'exemple le plus illustre, qui ont dévoué leur vie et même versé leur sang pour libérer leur peuple. Nous saluons donc, parmi nous, la délégation de la nouvelle Afrique du Sud. 1 Conformément à l'article 89 du Règlement intérieur.

157 A47/VR/7 page 142 Notre Gouvernement déploie de nombreux efforts pour que les actions sanitaires soient plus efficaces, correspondent davantage aux aspirations de notre population et suscitent une plus grande participation. Malgré ces efforts et le soutien de la communauté internationale, les besoins de notre population sont loin d'être satisfaits. L'appui de l'oms et d'autres partenaires du développement est donc particulièrement important, afin d'éviter des goulots d'étranglement et de permettre que le système de santé se développe harmonieusement et selon les plans prévus. Nous sommes ravis de voir évoquées dans le rapport du Directeur général certaines questions que nous considérons de la plus grande importance, notamment les thèmes d'une grande actualité, partie intégrante du défi de la santé pour tous qui est lancé à nos gouvernements, en particulier la santé maternelle et infantile/planification familiale, la nutrition, l'environnement, la lutte contre les maladies, l'organisation des systèmes de santé et le développement des ressources humaines. Comme nous l'avons affirmé à maintes occasions, la Guinée-Bissau est un des pays les plus pauvres au monde. Sa situation sanitaire est conditionnée par la crise économique et financière qui affecte le pays, plus particulièrement par le programme d'ajustement structurel en cours, avec le soutien des organismes de coopération bilatérale et multilatérale. Grâce à l'appui technique de l'oms et de nos partenaires du développement, et malgré les contraintes économiques, nous avons enregistré quelques progrès encourageants, notamment une meilleure capacité de gestion de nos services et programmes de santé dans les différentes régions du pays. Dans le cadre de notre politique sanitaire, l'axe essentiel est la mise en oeuvre des composantes prioritaires des soins de santé primaires, de façon coordonnée et intégrée, à tous les niveaux du système, afin de promouvoir une plus grande participation de notre population et de nos communautés. Dans l'ensemble, ces activités constituent les objectifs stratégiques de développement sanitaire à moyen terme, dont les principaux axes visent la formation et le perfectionnement du personnel, l'amélioration et l'équipement des infrastructures, rapprovisionnement et la gestion des médicaments essentiels, enfin le développement du système d'information sanitaire. Pour atteindre ces objectifs, la Guinée-Bissau accorde la plus grande importance à la coordination de l'assistance extérieure fournie au secteur de la santé, en vue d'améliorer la rationalisation et l'utilisation des ressources. A cet effet, nous bénéficions actuellement d'une intensification du programme de coopération technique de FOMS, ce qui nous permettra, sans aucun doute, de renforcer quelques programmes. Nous remercions sincèrement FOMS et les autres organisations ici présentes de toutes ces initiatives concrètes d'appui à la Guinée-Bissau. Comme partout dans le monde, la situation du VIH et du SIDA est très préoccupante en Guinée- Bissau, avec un taux de prévalence du VIH2 d'environ 10 % de la population adulte. La propagation rapide de la maladie ainsi que l'apparition de cas de double infection VIH1 et VIH2 ont aggravé cette situation. La recrudescence de certaines maladies infectieuses et endémiques telles que la tuberculose commence à susciter des craintes pour l'aveiiir et pour la maîtrise de ces maladies; il faut ajouter à cela les mauvaises conditions de vie de nos populations et la fragilité de notre système de santé. Cette année, nous avons organisé avec Pappui de l'oms une révision du programme à moyen terme de lutte contre le SIDA, suivie d'une réunion de consensus pour revoir et adopter les stratégies, en vue de renforcer la coordination intersectorielle, de décentraliser les activités vers les régions et d'intégrer les activités dans d'autres programmes de santé, y compris la promotion active de l'utilisation des préservatifs. Dans le cadre des grandes endémies, nous nous félicitons des succès enregistrés dans la lutte contre l'onchocercose, notamment en ce qui concerne la réduction de la prévalence de la maladie grâce à rutilisation de rivermectine. Nous aimerions également souligner rimportance de la récente conférence ministérielle sur le peuplement et le développement durable dans l'aire du programme de lutte contre ronchocercose, car les potentialités des zones libérées de la maladie sont très importantes du point de vue économique et social. La bonne gestion de ces terres est une condition essentielle pour éviter la dégradation des ressources naturelles, et nous devons faire participer davantage les communautés au développement de ces zones libérées. Nous espérons que les résultats obtenus jusqu'ici seront consolidés grâce à l'appui de nos partenaires, en particulier POMS. Notre Gouvernement accorde une grande importance à la santé maternelle et infantile et à la planification familiale. Il est encourageant de voir que plusieurs éléments de ce vaste programme figurent aussi à l'ordre du jour de nos débats, ce qui permettra de renforcer nos activités visant à réduire les taux encore trop élevés qu'on enregistre sur notre continent en général et dans notre pays en particulier. Tous ces points que nous allons traiter au sein de cette Assemblée s'insèrent parfaitement dans la stratégie de notre Région. Dans le cadre du programme de santé maternelle et infantile, nous aimerions souligner rimportance des conférences préparatoires qui ont conduit à la Conférence internationale sur la nutrition, tenue à Rome à la fin de l'année dernière. Grâce à ces travaux préparatoires, notre pays a pu, pour la première fois,

158 A47/VR/7 page 143 adopter une approche intersectorielle en matière de nutrition et de sécurité alimentaire. Ces exercices ont également permis de sensibiliser les différents secteurs de notre société à l'importance des problèmes nutritionnels, responsables de divers problèmes de santé publique et qui ont un impact sur la morbidité et la mortalité des groupes les plus vulnérables de notre population. Nous sommes en train de préparer le plan national de nutrition, avec l'appui de l'oms et de la FAO; ce sera un outil important pour réduire l'impact des problèmes déjà cités. L'élînination du tétanos néonatal, Péradication de la poliomyélite avant 1995 ainsi que la diminution substantielle de la mortalité et de la morbidité provoquées par la rougeole figurent parmi les priorités de notre stratégie pour la protection de la femme et de l'enfant; ce sont les garanties d'une société saine et heureuse où régneront la paix et le progrès. Pour terminer mon intervention, j'aimerais souligner l'importance que mon pays attache à la coopération technique. Le renforcement de la coopération technique entre les pays en développement et avec les pays développés va sans doute permettre une exécution plus efficace des programmes de santé et une utilisation plus rationnelle des maigres ressources dont nous disposons pour améliorer la santé de nos populations. Monsieur le Président, distingués délégués, Mesdames et Messieurs, j'aimerais vous remercier de l'attention que vous avez bien voulu accorder à mon intervention et j'espère qu'à la fin de nos travaux, nous aurons pu approuver des conclusions et recommandations importantes qui permettront de matérialiser le souhait légitime de nos peuples d'avoir accès à de meilleures conditions de santé et de vie. Dr NOORDIN (Brunei Darussalam): Mr President, Mr Director-General, Mr Vice-President, excellencies, distinguished guests, ladies and gentlemen, bismillahhir rahman nir rahim,allow me first of all, on behalf of the Government of His Majesty the Sultan and Yang Dipertuan of Negara Brunei Darussalam, to align ourselves with the previous distinguished speakers and congratulate the President most sincerely on his election to lead this august Assembly. I am confident that with his extensive knowledge, wide experience and wisdom, assisted by similarly qualified Vice-Presidents, he and his team will guide us in the proceedings of this Forty-seventh World Health Assembly to a successful completion, God willing. May I also take this opportunity to offer my congratulations to Dr Hiroshi Nakajima and members of the Executive Board for preparing the many comprehensive and extensive reports on the activities of the Organization for the biennium and, of course, the Secretariat for the background material prepared in order to facilitate the smooth running of the proceedings of this Assembly. I would also like to express our sincere appreciation and gratitude to our Regional Director, Dr S.T. Han and his staff at the Regional Office for the Western Pacific in Manila for their ever-willing, prompt assistance and support to us whenever required. The central theme of our deliberations this year in plenary is "Ethics and health". All of us who are in the health arena, are more than aware or familiar with ethical issues and dilemmas related to medical practices, such as organ transplantation, human reproduction, treatment of terminally ill patients, abortions, genetic treatment, AIDS, patients, rights and many other complicated issues which seem to crop up regularly. As a simple example, my country has an open-door policy or system for haemodialysis services for patients with chronic renal failure. Renal transplantation is not yet available locally, as we lack the infrastructure and expertise for such specialized services. Only those with available related donors will be sent abroad to undergo kidney transplantation. However, a few of the patients go overseas on their own or are privately sponsored to have the transplantation, usually in the subcontinent; and some have unfortunately returned with complications including delayed rejection and infections with diseases such as malaria, hepatitis В and, most commonly, with bacterial infections. There are of course arguments for and against, within the profession, on organ donation for economic gain. Clearly there are points in favour of kidney "donation" for financial reward, as long as it is made without any coercion whatsoever, as both parties would benefit from this exercise or transaction. However, unethical tactics, of whatever kind, used by profit-minded middle-men supported by members of the profession are to be condemned, without giving it a second thought. Organ transplantation also has raised considerable ethical and moral issues, whereby the definition of cessation of life has to be clearly defined for removal of organs or tissues for transplantation. In most cases life has ceased when there are no longer neurological activities in the brain. In response to major emergencies and disasters, very often Third World countries will receive aid from large pharmaceutical companies and donor countries in the form of drugs, food and medicines. Some of these drugs and medicines very often do not serve any purposes whatsoever. The drugs have either

159 A47/VR" page 144 passed èxpiry dates, are inappropriate in terms of use - as they may require the intravenous route for administration - or arrive without proper information or labelling, and the users may spend precious time in sorting out those drugs. However, the donors are happy in that they have done their duty; but unfortunately the recipients are left with useless drugs and medicine which often have to be stored in a secure place at great cost. Some sceptics would consider this "donation" as legal dumping of unwanted material. Developing countries also face problems of inappropriate promotional practices by multinational drug companies in conflict with fundamental ethical principles. Inducements of various sorts are often promised or indeed given to the health care providers for using the product in question. The World Health Organization's ethical criteria for medicinal drug promotion will serve as a guideline to all relevant parties. Despite a zero-growth budget, the work of WHO for the biennium ,is highly commendable and serves as an exemplary model for all Member countries to emulate. The progress and achievements thus made will be further enhanced by the proposed Ninth General Programme of Work covering the period It is an excellent policy and health programme framework which reflects reforms in WHO and indeed the whole United Nations system which will lead to effective utilization of scarce resources. Speaking of scarce resources, I am sure the Director-General of WHO will appreciate the contribution from Member States and countries which have failed to meet their financial obligations to the Organization. My country is fortunate enough to have achieved most of the global goals and targets set out by WHO for health for all by the year Despite the misgivings of some Member countries, we truly hope governments of all Member countries and the international health community will remain committed to the improvement of health status and provide greater equity in health to all people of the world, by using the health-for-all strategies. Touching on equitable access to health services, health care providers are sometimes faced with the dilemma of having to provide services locally for a few but influential patients when it is more cost-effective if the treatment is undertaken overseas. The policy-makers are therefore placed in a difficult position, knowing that disproportionate investment in hi i-cost technology for the few makes excessive demands on limited manpower resources and may leave other greater needs and priorities unfulfilled or delayed. We have been able to achieve accelerated improved health status and health development because of the peace we enjoy in our region. On this occasion, the delegation of Brunei Darussalam and I would like to join other distinguished delegates in warmly welcoming South Africa back into the family of the World Health Organization and the United Nations and congratulate in advance Niue and Nauru in anticipation of their admission into this Organization as full Members. In conclusion I once again wish to thank Dr Hiroshi Nakajima for his initiative and vision in introducing reforms into the current management and development process of the WHO programme as part of the Organization's response to global change. Our heartfelt thanks and sincere appreciation to Dr S.T. Han, Regional Director for the Western Pacific, for his unfailing support to us throughout the year, which was highlighted by his visit to Brunei Darussalam last March. Mr ABDULLAH (Maldives): Mr President, Dr Nakajima, distinguished delegates, distinguished members of the Executive Board, ladies and gentlemen; at the outset allow me to extend my warmest congratulations to the President on his well-deserved appointment. I also convey to Dr Nakajima our grateful appreciation for his excellent report and leadership. Our congratulations also go to the prize-winners in medical advancement. We are also deeply grateful to Dr Ko Ko for his great contribution to our Region, while we are very encouraged by the vigour and dedication of Dr Uton Muchtar Rafei, the new Regional Director for South-East Asia. I am also honoured to bring with me greetings and good wishes from President Maumoun Abdul Gayoom and our people for the success of this Assembly. We are very happy that this Assembly is being held at an auspicious time, when happy events are taking place, from the Middle East to South Africa. We express our relief and joy at the demise of apartheid and the birth of a non-racial, democratic South Africa, a nation that has contributed so much to health in the past. We extend to South Africa a most hearty welcome. I am also greatly heartened by the many positive developments towards Palestinian self-rule. We hope to welcome Palestine as a full member of the world community very soon.

160 A47/VR/7 page 145 I am also duty bound to salute WHO and to pay a very special tribute to all those who have contributed to the great task of evolving a universal health mechanism. The number of children who would have been orphaned and mothers who would have been widowed, as well as the people who would have died of disease and malnutrition, would have been in the millions if it had not been for the innovative leadership of WHO. Yet these achievements and advances are not enough. There is an arduous march towards achieving our collective objectives. Many problems of deteriorating health need to be corrected before they become a cause for regret. Our collective will and commitment are required more than ever to mobilize our energies and resources. We have to translate our objectives into action, and action can only change the world for the better. We have joined together to save the majority of the world population from pathetic plights. We are encouraged by the many strides we have made in evolving comprehensive health care policies. We have given primary health care our highest priority, for sustainable health for all. Our respective national health policies have been strengthened by multisectoral participation. Thus, we have been able to control many dangerous diseases and provide better health for all peoples. Nevertheless, these positive gains have been offset by such negative trends as excessive population growth and the adverse effects of environmental degradation. Health and environment are indivisible. Our objective, a healthy life, cannot be achieved in the absence of a safe environment. More cohesive action on our part is essential to address this new global concern and to ensure sustainable development. In the Maldives, we have continuously expressed concern about our country's vulnerability to the growing environmental threats. We would be among the first victims if there were a rise in sea level due to global warming. The advancement of women and their greater participation in development is paramount for changing the unfortunate situation of the majority of women. Such action would be also helpful in controlling the population explosion, alleviating poverty and accelerating socioeconomic progress. It is timely to effectively promote and accelerate the advancement of women, maternal and child health care and family planning, as we celebrate the International Year of the Family this year. The new threat, HIV/AIDS, has become a shocking challenge to human advancement. It is one of the biggest threats for the well-being of all peoples. It is sad that priorities set for health services development are being seriously affected by the AIDS pandemic. Formulating and implementing practical methods on the basis of WHO,s broad strategies for the control and prevention of the pandemic should remain a high priority. The efforts to find a vaccine against this deadly disease deserve our support and commendation. While the double burden of cardiovascular disease and cancer continues to pose a major challenge, we need to intensify our efforts to address them more effectively. At the same time, the worsening situation of tuberculosis should not deter us in our work for the control and prevention of other communicable diseases. Although we have achieved much in controlling and eradicating malaria, it still remains a cause of grave concern in many countries. Unless sustainable, cost-effective measures are implemented, it will continue to have more adverse effects on global and regional health development. We are happy to say that malaria is virtually eradicated in the Maldives. In the Maldives, we have had dramatic success in controlling common infections and waterborne diseases. We also maintain more than 90% coverage of diseases under the Expanded Programme on Immunization, which has brought down our infant mortality rate; however, the incidences of noncommunicable diseases have increased. Thus, thalassaemia, a genetic condition, is resulting in the birth of more than 70 children per year suffering from thalassaemia major in a population of Thalassaemia has therefore become a major medico-social problem to our country. The use of tobacco is yet another serious threat to our health objectives. There is growing demand to centralize and expedite more effective control of tobacco. New legislation measures are essential to give maximum protection to people from the dangers of tobacco. I am very pleased to inform this august Assembly that the whole population of one of our 200 inhabited islands has given up smoking and made that island the first tobacco-free island in our country. The widespread drug menace affecting millions of people, especially a large section of the young, is seriously threatening our development. Youth is our greatest wealth, and the participation of young people is vital to our overaü development and prosperity. Rehabilitative measures for drug abusers, strengthened national legislation and activities to fí it against this dangerous menace are imperative. We are assembled here to find practical solutions to our health objectives. Health is our greatest liberty. Health is also the most basic right for existence, which is fundamental to an equitable social order. Health also provides a strong basis for economic productivity and economic growth. We are doing our best to provide our people with the highest attainable health standards and services. However, good health is becoming increasingly unattainable, owing to many problems and to declining ethical standards. In some

161 A47/VR/7 page 146 cases, the cost of services has risen above the reach of the majority of the people. It is sad that such services have become too commercialized in the recent times. This situation could have serious implications for the very purpose of civilized human behaviour. It is therefore our duty to mobilize our resources, together with a renewed political will,to correct the situation and to provide affordable health care to all. Today we are faced with the colossal problem of AIDS, which crosses borders, cultures and values. We are working with our valuable resources to combat this deadly disease. But, we should not forget our responsibility to carry forward the momentum of our evolutionary primary health care project, to ensure that our children grow in good health and enjoy the love and care of their mothers and fathers. Our collaborative action is required urgently to achieve a dignified goal for mankind, that of health for all. Caring for one another and sharing the burdens and responsibilities of achieving good health remain a paramount responsibility. Good health, as we know, is our greatest wealth. No other wealth can be fully enjoyed without good health. We should in this way redouble our endeavours in pursuit of our noble goal, health for all. In conclusion, I wish the President all success in leading our deliberations to a most successful conclusion. Mr MAYAGILA (United Republic of Tanzania): Mr President, honourable ministers, the Director-General, WHO Regional Directors, distinguished colleagues, ladies and gentlemen, allow me to congratulate the President and the Vice-Presidents on thenaccession to their high office. In the same breath, Tanzania, as a front-line State, would like to congratulate the Republic of South Africa on being fully reinstated in this community of nations. Tanzania would also like to register its appreciation of the nomination of its national, Dr Alfred Ole Sulul, as a recipient of the Jacques Parisot Foundation Fellowship for Allow me to bring you greetings, appreciation and good wishes from the President of the United Republic of Tanzania, His Excellency Ali Hassan Mwinyi, as well as from the people of Tanzania. It is a great honour for me and my delegation to address this august Assembly again on the prevailing health issues of my country. My delegation wishes to register sincere gratitude to the World Health Organization, other United Nations organizations and bilateral donors for their continued valuable support to our health sector. Special tribute goes to the Regional Director and his able office for continued technical guidance as well as financial support that has been benefiting the United Republic of Tanzania. My country particularly appreciates the strengthening of our office through the assignment of technical officers who work closely with national experts in the area of primary health care, diarrhoeal disease control, acute respiratory infections and immunization programmes. The United Republic of Tanzania, like other countries, is going through various reform processes, and health sector reforms already instituted include: cost-sharing; encouraging private health providers to take a bigger share in complementing health delivery activities in the country; strengthening and focusing the district as a nucleus for health delivery in the community; and encouraging and empowering the community to take action and participate in communal projects for their own health through multisectoral collaboration. In order to achieve guided community action for health, my country has developed district health planning guidelines which are already in use; it is providing a basic health management information system, and plans are under way to address the urgent need of improving the management skills of both the regional and district medical officers in the country. In line with resolution WHA46.18, Tanzania has strengthened the efforts to reduce maternal and child morbidity and mortality. At present, maternal mortality is 270 per live births. We have instituted a section in the Ministry of Health whose sole responsibility is to support and coordinate regional and district safe motherhood and child survival, protection and development programme initiatives. My country is very gratified to see that WHO is in the forefront of this important intervention and development. The immunization coverage survey conducted in 1993 has shown encouraging results: BCG is 90%, polio-3 and DPT-3 are 67% and measles is 68%. The goals to eliminate poliomyelitis and neonatal tetanus are achievable if the present level of support continues. However, more work has to be done to improve tetanus toxoid vaccination coverage in child-bearing-age females, which is now only 44%. In this regard, my country is most obliged to "Polio-Plus" (Rotary International), WHO, the Danish International Development Agency and the Japan International Cooperation Agency for their support. Communicable diseases continue to be prevalent in Tanzania. Malaria, diarrhoeal diseases and acute respiratory infections are the three most important. My country continues to grapple with these challenges amidst a harsh economic climate.

162 A47/VR/7 page 147 Malaria, which accounts for about 30% of hospital attendances and 11% of causes of death both in mainland Tanzania and Zanzibar, has always occupied top priority in our minds. My country feels greatly honoured to be selected to be one of the countries where malaria vaccine research is being conducted. HIV and the AIDS epidemic continue to be a threat to the whole national development effort. Tanzania called a donors,meeting this year to support the second mid-term plans of the national AIDS control programme which are being implemented by various "line" ministries and nongovernmental and private organizations. There is an increasing and unmet demand for HIV test kits and expendable supplies, especially in the blood-donating centres in the country. Whatever resources we can mobilize go for blood transfusion screening and there is an unmet demand for diagnostic services in all hospitals and for voluntary testing of our people who may need to know their HIV serological status. My country recognizes the increasing demand for occupational health services, both in the agricultural sector, where exposure to insecticides is increasing, as well as for workers in the expanding industrial sector. In collaboration with other ministries concerned we are already developing an occupational health policy and strategies for containing occupational health hazards. Tanzania ratified the convention on the rights of children and subsequently developed a national plan of action to attain the mid-term and national action plan goals. His Excellency the President of the United Republic of Tanzania launched the national iodization programme for the whole country on 21 April this year. Salt iodization, currently at 45% of all salt produced in the country, is expected to be about 93% by Through other short-term measures, the prevalence of visible goitre has been reduced by 20% over the past four years. The political changes occurring in South Africa and neighbouring countries are a matter of great concern to us. Whereas the United Republic of Tanzania is joining hands with the rest of the world in acknowledging and supporting the changes that have taken place in South Africa, the nightmare of Rwanda, carnage and brutal killings and the apparent absence of social order, has resulted in influx of refugees into Tanzania, which has added to our list of emergencies in the country. For example, at the peak of these influxes, four of our districts had to accommodate over one-third of a million refugees. Hiese displaced people have increased the prevalence of communicable diseases. We are now experiencing epidemics of malaria, meningitis, cholera and dysentery. The strain of bacteria currently causing dysentery does not respond to the commonly used drugs. As I speak, Tanzania has received about Rwandan refugees within a week, making a total of about not counting the effect of the previous influx from Burundi, which is more or less of the same magnitude. May I in the same breath request this Assembly to adopt a draft resolution on Rwanda which wiu very soon be tabled before this Assembly. My country, with assistance from the office for the third subregión, is strengthening its "emergency preparedness and relief' unit; in fact, the theme of the last Regional Medical Officers,conference was emergency preparedness. The office for the third subregión, as well as the Pan African Centre for Disaster Relief, participated in the meeting. Finally, allow me on behalf of the President of the United Republic of Tanzania, my delegation and on my own behalf to extend our sincere gratitude for the support WHO has given to Tanzania up to now. I would also like to register our sincere thanks to other Member States and bilateral and multilateral agencies for their collaboration and support in the field of health. M. ADAM (Seychelles): Monsieur le Président de séance, Monsieur le Directeur général, Mesdames et Messieurs les délégués, permettez-moi, pour commencer, de féliciter le Président à roœasion de sa nomination à la position éminente de Président de la Quarante-Septième Assemblée mondiale de la Santé. Que toutes les personnes qui ont été choisies pour l'assister dans cette tâche durant cette Assemblée soient, elles aussi, félicitées. J'ai pris conscience du fait que la somme d'influence dont un Etat Membre dispose dans une organisation dépend des contacts que celui-ci développe avec cette organisation et des occasions qu'il a d,utiliser ces contacts. Pour beaucoup de ministres de la santé, ces rares occasions ne se présentent que deux fois Гап, à l'assemblée mondiale de la Santé et au Comité régional. Les antennes nationales de l'oms qui devraient, en principe, assurer et faciliter les communications, ne sont souvent que des relais postaux réservés aux tâches administratives de routine. Ceux d'entre nous qui ne disposent ni de représentants permanents à Genève, ni d'une équipe importante dans les bureaux régionaux et/ou au Siège, ni surtout de compatriotes dans des postes clés, comment pourraient-ils faire sentir leur influence? Mais je ne cherche pas à me plaindre; je veux plutôt m,assurer que chacun de nous utilise au mieux les occasions qui

163 A47/VR/7 page 148 lui sont données de jouer un rôle dans notre Organisation. J'ai suivi, au moyen du rapport, les discussions du groupe de travail du Conseil exécutif sur l'adaptation de l'oms aux changements mondiaux, et la marche à suivre pour assurer la mise en oeuvre de ses recommandations a retenu toute mon attention. Je crois profondément que l'adaptation de l'oms aux changements mondiaux ne concerne pas seulement les structures et le fonctionnement des bureaux, qu'ils soient régionaux, nationaux ou de direction. Je suis fermement convaincu que la responsabilité des ministres de la santé et des différentes autorités nationales concernées doit avoir une part dans cette adaptation. Cette responsabilité,ainsi que notre engagement à mettre en oeuvre les mesures nécessaires recommandées par le groupe de travail doivent ressortir dans ce que nous faisons à l'assemblée mondiale de la Santé. Je suis donc persuadé que les ministres peuvent et devraient faire un meilleur usage des occasions qui leur sont offertes à cette Assemblée. En ce qui me concerne, je vais tenter d'apporter mon humble contribution chaque fois que je le pourrai et partout où je le pourrai. Je vais par conséquent saisir roccasion de cette Quarante-Septième Assemblée mondiale de la Santé pour, non pas vous donner un rapport national, mais faire des commentaires, comme on l'attend en fait de nous, sur le sujet de l'éthique et de la santé. L'éthique est une question à la fois vaste et fondamentale. Elle est centrale en ce qui concerne la santé et notre vision et notre comportement dans les domaines de la santé et de son développement. La santé pour tous est un concept et un but fondamentalement éthiques dans la mesure où cette affirmation concrétise le principe selon lequel l'homme est au centre de toutes choses et que les choses ne sont là que pour le bénéfice de l'homme. Ainsi, notre attention se concentre-t-elle sur la nécessité où nous sommes de garantir que tous, chez nous, aient accès aux soins de santé. Cela nous remet en mémoire le fait que la santé est un besoin tellement fondamental que, sans elle, le développement a peu de sens. Quelle est la valeur de la démocratie, des droits de l'homme, de la liberté d'expression et de tous ces autres idéaux que nous tous chérissons ici, si l'accès aux soins de santé est systématiquement refusé aux gens? A mes yeux, donc, c'est une considération éthique importante dans le développement des soins de santé que d'assurer à tous l'accès aux services de santé et que cette perspective éthique soit notre guide au moment de définir notre politique et nos stratégies en ce qui concerne la structure et le fonctionnement des services de santé, leur financement, l'établissement des droits et des obligations du secteur privé pour la fourniture des soins de santé, et enfin la souplesse d'un système de santé capable de répondre aux besoins et aux voeux d'une communauté. (The speaker continued in English.) (L'orateur poursuit en anglais.) Ethics and the development of pharmaceutical products and vaccines, and access of the poor countries and poor people to the fruit of such development, is a current and important issue. I have recently received a plea from a group of scientists involved in the development of new candidate vaccines. I understand that they have done the scientific work and are investigating the possibility of manufacturing vaccines that would benefit millions of people. Because, as I was led to understand, the final development and manufacture of vaccines is big business and controlled by a small number of large organizations, small organizations have difficulty in getting support. I must confess that I do not know enough about such issues, but I do ask myself the question: to what extent are the development, manufacture and commercialization of drugs and vaccines motivated by the needs and interests of those who most need those drugs and vaccines? The issue of ethics in medical practice is also of great concern, especially when it relates to the rapid development of technology and the application of such new technology and techniques. Examples of such incidents relating to the area of assisted reproduction have recently received widespread publicity. The desire and the drive to break new ground in science and technology, combined with a sincere intention to benefit mankind with new discoveries and successes, should be clearly separated from gross publicity-seeking behaviour and mercenary interests. It is not always easy to make clear distinctions. The question of euthanasia is frequently debated, and opinions divided between those who find it acceptable,or even noble, and those who find it unacceptable and ignoble, although both views are based on equally sincere consideration of the rights of patients and the duty of practitioners. Ethical awareness cannot be imposed from outside. It should be a fundamental part of all health processes: from the education of health workers to health research, community health and clinical practice. Professional organizations have an important role in ensuring the inculcation of ethical principles and practice into all health disciplines. National health authorities have a role in ensuring that an environment is created in which ethical principles are respected and promoted. Many international organizations (the Council for International Organizations of Medical Sciences is a notable example) have drawn attention to ethical issues and provided guidelines. The World Health

164 A47/VR/7 page 149 Organization should continue to promote discussion and awareness, and continue to offer guidelines for the application and respect of ethical principles in all aspects of health practice. I have touched on only a few aspects of the issue of health and ethics. I shall remain attentive to the statements and comments of other delegations on this important issue. I would like to take this opportunity to express my appreciation to Dr Nakajima, the Director-General and to Dr Monekosso,the Regional Director for AFRO, for the work they, and their staff, have done over the past year. I renew my personal and my country's commitment to furthering the cause of health for ail, and to our partnership with the World Health Organization. I wish all the delegates to this Forty-seventh World Health Assembly, and all the staff of WHO good health. Dr IGREJOS CAMPOS (Mozambique): Mr President, Mr Director-General of the World Health Organization, distinguished delegates, ladies and gentlemen, it is a great honour for me and for the Mozambican delegation to address this august Assembly, to congratulate the President of the Forty-seventh World Health Assembly and other members of the presidium on their election and to wish them success in this difficult but challenging task. I want also to congratulate the Director-General and his staff for the comprehensive report on the work of the Organization in , which describes extensively the important work developed by WHO at all levels to assist countries in achieving health for all through primary health care. I take this opportunity to thank the Director-General for the assistance WHO is giving to my country, especially within the framework of intensified cooperation with countries and peoples in greatest need. We reiterate our determination to do everything possible to improve the health status and the quality of life of the Mozambican people. As mentioned last year, the intensification of the war in the 1980s caused destruction of the rural health network and drastic cuts in the public health expenditure. During the same period, the health and nutritional conditions of the population also deteriorated, coupled with their migration to urban areas for security reasons. The consequences of 16 years of war were widely reported by the Mozambican delegation at previous Health Assemblies and in other international fora. For example, 800 primary health care units have been destroyed or damaged so badly that they cannot function. It is estimated that only 30% of the population have access to modern static health services. The quality of the services has also deteriorated in many areas. The signing of the peace agreement in October 1992 between the Government and the armed opposition brought about complete peace in my country. Following the severe drought of 1992,the onset of rains and the transition to peace, the current economic outlook and prospects are favourable for reconstruction of the economy. The peace in Mozambique brings in a new era which should permit redirection of attention to economic and social development. This will involve actions and measures to address the following issues: resettlement of refugees, internally displaced people and demobilized soldiers, altogether totalling more than four million people; poverty alleviation, as the majority of the population live in absolute poverty; rehabilitation and reconstruction of infrastructure and provision of equipment, as more than a decade and a half of lack of maintenance and repairs caused excessive damage in all sectors of the economy; alleviation of the acute shortage of professionals and skilled manpower and of the illiteracy rate, which ranks among the highest in the world. This situation demands a huge amount of resources and adjustment of the health care delivery policy in Mozambique. Following an analysis of some health sector issues in order to adapt the national health policy (it is worth mentioning the support of WHO in this exercise) to the new economic and social scenario, a general objective was established to restore and reinforce the capacity of existing primary facilities through reconstruction and human resources development. The attainment of this objective will contribute to the provision of health care services at the level that existed before the war. Within this framework, the specific objectives of the public health sector are as follows: reduction of morbidity, mortality and suffering, especially among high-risk groups like women, children and displaced people; keeping primary health care as the basis for providing good quality, sustainable health care and making it accessible to the majority of the population; developing technical and managerial capacities at all levels of the health sector for planning, implementing and evaluating medical health care and support services. My Government is now facing the demanding task of providing immediate assistance to facilitate the reintegration of the people in their former communities. It is clear that access to health care is a pressing

165 A47/VR/7 page 150 issue; however, at present, expansion of coverage is conditioned by both financial constraints and lack of human resources development. As we mentioned last year, the Ministry of Health has developed a comprehensive health manpower development plan for this decade, which is already in the implementation phase. This plan takes into consideration the post-war rehabilitation plan and its financial implications for both recurrent and investment budgets. The latter aspect merits a few more words. Indeed, owing to the war and to the severe economic crisis, the proportion of the recurrent budget allocated to health by the Government has dropped continually to about 5% between ,which means around 1.5% of the GDP in Whilst government spending in the health sector declined nearly 40% in real terms in the last decade, external aid has increased substantially. In fact, foreign aid to the health sector prevented the collapse of the health services. The number of external institutions working with the Ministry of Health increased to such an extent that a coordinating mechanism became necessary to avoid overlap of activities and some areas being left underfunded. Thus, in 1992, regular meetings with the main donors active in the health sector were started to discuss global policies and programmes and to disseminate information. Measures were taken jointly to simplify administrative procedures and accounting systems and to try to accommodate them within the system already in place. In order to improve the management of the funds given by donors,personnel were trained and additional manpower was recruited where required. Administrative procedures were written down. This experience has been very positive and has contributed to improving the efficiency of use of external resources in my country. During the fiscal year 1994,the situation has become worse owing to unforeseen financial demands on the Government's recurrent budget related to implementation of the peace process, in particular for the demobilization and formation of the new army and for the electoral process. My Government therefore launched an appeal at the Paris meeting of donors in December last year for extra support for the social sectors, including health and education, which are most affected by financial constraints. The Ministry of Health has estimated a financial gap in the 1994 recurrent health budget of about US$ 6 million,for salaries and operational expenditures. We are aware that donors are usually reluctant to finance local recurrent expenditures, arguing that they are a government responsibility. The Mozambican experience suggests that not only is it necessary to finance some recurrent expenditures from donations (otherwise the investment may be underutilized or even lost), but it is also possible. Dialogue with the donors, clear administrative and accounting rules and procedures, and decentralization in the use of funds built the necessary confidence for the success of our experience. Let me stress that despite all of the problems and difficulties which my country is facing in the implementation of the health-for-all objective, I can assure you that it is doing its best to develop where possible the health services and programmes. In many respects, the coverage of primary health care activities has improved, and I am proud to announce that more than 80% coverage was attained in most of the eight components of primary health care in urban areas even during the long period of war. While we were just beginning to taste the benefits of peace and stability, my country was once more affected by a natural disaster. In the last week of March 1994, the northern region of the country, where the majority of the people live, was struck by a violent cyclone named Nadia. More than one-and-a-half million people were affected directly and lost their houses, crops and personal belongings. Nearly 80% of cashew trees, one of the most important cash crops of this region, were destroyed. Many schools and health facilities and other socioeconomic infrastructures were damaged. The cost of the material damage is enormous, let alone the loss of lives. At this moment, relief operations and reconstruction of some facilities are in progress. Let me take this opportunity to thank the international community once again for its assistance in mitigating this new tragedy. In the past few years, our region, southern Africa, has been reshaping its political face. The apartheid regime is now past history. I am glad to hear news about the outcome of the first multiracial, democratic elections in South Africa. Allow me, Mr President, on this occasion, to welcome the readmission of South Africa to this forum after years of absence. With the new South Africa, all countries of the region are now more than ever determined to work together to build a new, strong region as an economic and political entity. I want to mention in particular the presence soon of South Africa as a full member of the Southern African Development Coordination Conference. I also take this opportunity to welcome the other new Members of the Organization. The efforts we are making to rebuild our country, devastated by war and natural disasters, would not have been possible without the generous contributions of the international community. We want to thank

166 A47/VR/7 page 151 all of them, particularly those countries with whom we share common borders. We are deeply grateful to all of you, and we hope that this tremendous support will continue in the next years. Dr BEGANOVIC (B osnia and Herzegovina) {interpretation from the Serbo-Croat): 1 Dear Director-General, dear colleagues, ladies and gentlemen, I am honoured to have the opportunity to take part in the Health Assembly again and to speak in the name of both Bosnian health personnel and the Bosnian people. Last year it was from this place that I informed you that citizens of Bosnia and Herzegovina had been killed, injured, and girls and women raped. Today, one year later, there are many more dead, injured, raped, ill and poorly-nourished people. There are fewer Bosnians. There are fewer Bosnian people every day because Serbian-Montenegro aggressors kill women, children and old people without mercy and at the same time try and destroy every trace of the culture and traditional values of Bosnia. Today there are at least another badly injured people, another permanent invalids and disabled, and God knows how many psycho-traumatized persons in Bosnia and Herzegovina; maybe all of them are. Last year I informed you about all this from this place. Then I thought that my cry - which was a cry of the tormented Bosnian people - would be heard in heaven, that it would be heard by all and would penetrate the souls and minds of all generous people. I thought the democratic free world's reaction would be strong enough to silence the cannons, to stop tanks, to comfort the unfortunate and save the innocent. But it seems that nobody has heard my message. There is no hope and no true reaction. There are unfruitful rhetorical debates in process calling us one of the warring parties and we do not even have the means to defend ourselves. Thanks to the people in the heart of Europe, at the beginning of the twentyfirst century, at the zenith of science and technological progress, in the time of emphasized respect towards civilized, cultural and traditional values, one whole nation is disappearing. Tomorrow there will be fewer Bosnians and very soon it may be that we shall not need anybody's help. I am talking about a nation very similar to all of you, equal to all of you, a nation that differs from you only in being exposed to unprecedented genocide. They negotiate about the need for military intervention in Bosnia and Herzegovina. And from this place, I maintain that military intervention in Bosnia and Herzegovina took place two years ago when the arms embargo was imposed on my country. This is so although everybody is fully aware that the Serbian-Montenegro aggressor is well armed and gets help from the East. Yes, it is like that. We resist heroically and health personnel help the citizens of Bosnia and Herzegovina with the highest possible level of sacrifice. Half of the health facilities have been destroyed, medical equipment as well; more than 600 health personnel killed. What we lack to heal our people is everything, except endless will and outstanding professionalism. Chronically ill patients have been waiting for two years for assistance, while facilities are placed at the disposal of the wounded and injured. We lack medicines, dressing material, equipment and hygienic means. Water and electricity are sporadic and it is impossible to maintain necessary standards of hygiene, either personal or community. This is especially the case with refugees and in overcrowded camps for the displaced. The epidemiological situation is very bad. There is more and more enterocolitis, scabies, pediculosis, hepatitis A and, more recently, a huge increase in the number of new cases of tuberculosis. We could discover even more cases of tuberculosis, but we do not have sufficient means for diagnosis, and in some cases even less so for treatment. In spite of the numerous problems we are facing, there is still hope for the future. Together with WHO, we are trying to organize our health services. We have laid the basis for health sector reform, especially health financing, health management and health personnel development. We have laid the basis for primary health care which, I hope will be implemented in the whole of the Federation of Bosnia and Herzegovina. Recently, with the assistance of the Regional Office for Europe we tried to do something pragmatic and concrete in the field of health care in Bosnia and Herzegovina: health representatives of the Government and those who pretend to represent the interests of Croats and Serbs in Bosnia and Herzegovina held talks about current health problems. We would like to express our appreciation to Dr Asvall, Regional Director for Europe, for assistance in organizing these talks. We have been trying to provide essential equipment, medicines and clinical care as well as support for physical and mental rehabilitation,and for repairing health facilities. WHO helps us a lot with all of 1 In accordance with Rule 89 of the Rules of Procedure.

167 A47/VR/7 page 152 this. We have paid special attention to family health, to the creation of the family doctor as a condition for the organization of family health. Despite all our difficulties, we organize immunization programmes and keep the levels of hygiene as high as conditions permit. We undertake programmes to control rodents and ensure environmental health protection. What we have also particularly been engaged in is our own manufacture and use of essential drugs. During the war, our "Bosnalijek" factory produced 14 new drugs. Providing an oral health programme is a major problem because we have no donors to cover this area. This is a big problem and we need help to solve it. Ladies and gentlemen, I have found it necessary to appeal to you from this place in maybe a somewhat unusual manner. Listen and you wül hear the cannon thundering and tanks roaring in Bosnia, children screaming and mothers crying. Stop this fascist monster, because these children cannot run any more. They have lost their legs or arms, or they are so poorly nourished that they are not able to run any more. The ACTING PRESIDENT: I thank the delegate of Bosnia and Herzegovina. I believe that we all hear you today and you receive our sympathy, from WHO and the Health Assembly. Mr GULWAK DENG GARANG (Sudan): j^j dl^ j^i «JJ a^uj! c^ljuc^ji^ TP 1 ^j^ji ^LII-OJ! L***J I T^^U W^J I OKWCAJ I ó i I ^mj^jto I I ^jj^ t I «!d-waj L> Д-xjkII.) I! fjj I JlA^u-» djlj iuol ^J f S i è ^ J\ ЛЛ ju_5.j^^jji ^L^HI ^Jl IJlû, ULI j-fs^j UL.U^JL 兵 3 ^ujljji ^^W^J! J^jJI jji ^J! àj^jà^ ^jjlc '<LJâJuJJ ^LoJI ^-.JuJ! 1,-,15ü..\-..U 3 产 L u J U ^ I <LûJà-LoJ I Cl» L^c^w^ I JltMj I ^ CIj Let/ j\ Jl119 às-! j^j ^ 3 Cl/ CL I j LíkJ^ I u^i't o' 1 sr 1 OW, 1 '" 1 ^Ai ^ <! ^ ^ ^лазн «LoJaJuâJJ ^е^азч! 力 JuoJ î I j^j I Ji^C j^lis jj 1 1 ^-MJ j^ls^ii Lio-JLs! *<L>woJ! "A.;.,.4««. yû> j^isl3 一 jji J->ул^ и^я-. ^э a^ûji QX C^JljJI l. ^-JJ^L CLJ^L> c ^-^J! ' -JUJI C^LJL^JJI^ dj j 丄 cl 产 二 13 vjul>j! ci, b.o'; ^Lo ^o La I ps.\ L03 J-o-JJI d ^ L J jl^-:! ^o ^^IJ I 1 I t Ls L 31 I ^jls. 气八八产 Le j U=u> 1 ^ ci^u Lô^ij J^-^ ^-o ^JijiuJ jj/l» 'LJLÛJJI Leu> Д-^AJI '<L15uiuJI ^ ^M-JI ^ J^JÛ ôjjb ^ LJJj i^^^ji idjjj ^ 一一 I c^ O^j^ 1.^jUcVI d^oji ^jy} diu ^L, ^ '<L>^JU V1 ^l^jbjji 产 LkJI Jj:,.ik. d^ji ^o JSJ 产 l^jlj ci.uouxii.vl àjls>\ cluc^ '«L^V^JI jl^^ji c^lfu^l LJLJJI D,L>JJJL J ^ DJLOLJJI Ô^ÀJ] ^ *<BLJ1 ^ J L : 内 ^ J I CI.1 JLJ^JI3 I 'Ls^cJI ci^loajji J^xil J^s-AJI а-зъ jl^^ji js>í I CLuiJlS 山 ^JbVl *Âij):;5.o '«lo^s^ji v-jjû ^J d ^ l ^pjl Ji f- \j\ j^m^jji ^Jucw d-ij^g-.a-oi ji-cccji Là»l^c! jlsó^j ajokj «sj cl^aaúc I^Líl^I L>uî^^ Aj^^-oJI ci»l^-ict/ CLu>^^ ójlclu^ jj I^S^ Qr.'T: ',q 3 ç eí^^l ^ ^-JULsül Ji L^i djlt C^l Jo X * çj^uw 1 ^ d^câ1 tjcuo L«-J I CL> ^uu I ^J I LlJ I ósjj> v d-lo L«L-c«? 己 «*ôju,ju> t. )L«/1 Á-JLíCu/^l juü^l di ClJ, _ :; ' I SèJ^. jm-j! ^ d-^aji Cl/LoJii>Jl ^ ^ J J I 产 Ш 1 JU^ÎI^ ^-^JL ^ С L H ^ ÓLUJI J-^'B^ ; 1C^UWXIJI 'I^ 1 J 1 二 Jf.L jl

168 A47/VR/7 page 153 duijbuu) d-j J-^ J^IS^U» ^wou ^ dlllô^ Л. J5 JI rtâ-licj I ^ XI 气 f 13JJI ^r..;jr> I ^JI IOALcu) A Jl^ I ^ I Jik} I ^cju. djjb^u) *<Luw/j3 Л-.^.^ ^wj Lius 产 ^àz Q I ^jls. X ) ^ I.ЦI yj! Cl;) I -Lo á^a^s^o А^л^м 1 ji^uj 1 ^-lf 1 Jj).g-.l I * Lllo I Í^J^AS^ Jl**V *<LUjJl л hо:;,a ^-JI j '<LUJLAJI '<L>VOJI dujâjuî v-il jla 13 L^V 1 oj^l^oji ^^JLc ci^ju^l^ Lo^ <LvLu**Jl ójjb Jj 1.У/-Я-/ Up^-i Ij-gJnlq *<Lsj»u4oJÎ *<iijajuji Â-J^Vl d^c^wuaj! 产 Le '^oj^ jr^y' 0-.-.:.-> Li/l jí^j JM-J! '<L^4ACJI c^lkjljj L*U>LÛ J^G J^JL» ^ 1 ^ 1 ^ii ^Jl ^jjb-v..u^iojl ^ 1 < 'Я二 J i dj^jikji ^ 1 t⑴ Л «^jl-.^! < L^MJI ^ol JLiuJI J-u^/ ^JLc djl^íuji ójb Jl ; ^llo Lj^loJU. djiuu) Ji ^IJLJ 0 二二 I jji> ^ i Li;!^ d^ Lie ^^jj 产务 \л XI 寺 ^jo^jù ^^-JU ) 0 ^jj I ) ^o L^^Juu/ LsO-oJ! J JL 二 :,_ J^-ü I «Xj^kA^aJ I Г ^Jl I jj q^-jl Г ^o '«LetI j'j}i ^Jl jjuc^ q! d-3wliji <L>L*uJl ^! t^^sjj^jsjl jiac 己二 :, li ^ jj! ^J^jJI ^cjji ^JLc J^cusJl jj^^cji Jl=0 dj jj 1 JuJla^ duujxsji jl j JÍ l^j^ljl lf>.o.l '<Lu}^3 <Lu>J ^jaj^lj JLS^ 气 Л 气产 Le ^ззу^ jji^ I ájl^ji ^JI! I j clj LJ-V^J I ^j I djk^gj 1 jri'j^ ^j-i ^^rí ^j 二 : ' A-UJL$JI '<L>W^JI ' ujk^o Ji5xi ; jj'u ^j^j! drille ^jjlo ^ ^^Jl C^L^MJJ!^jíg^ jjuvl j-o <iuuu/i j"^i 1 jlïc ^^лсси) L üi Jl^eJI 1-. г^'зи ^ j o I jia d^xiliuj l-uï^aji 'LAJl:.l 1 JíuC^j J^JI áiuiiji ^ 1 ^Sü HiJI.l^lksJ! 'isjuuj\ " л и^уз Vj/-^^ À-вЫ! f^i Vjr 5^^' 己 :. -, 々. 一广 «:1_U üuj ( LJJ^WÎLJ» ^-ГЬ-*/^^ЬО L^^JJ I djo-úáj^í 1 j^f^ Ц^44 ' I- _ * ' I V^ AJ I Lc j ^ LÂ^I yísxh ^wj^jjlj» À.»L^VI 丄»_ ^jü A-JLe JL5Ï-O ^JS^ÛZ ^^^IIJI ^k^jk^ii Uijl^ Â-jJJI ÔJlcL*uJ1 3 jrt^y* '<ül ^fl. c^uv^jl» J-oUco ^cj jucltuju djajluju L& J^uoü «..... ^llj I 11 ^omj Д ;c wjj ^-ojl Cl> l-^l;»^ Sj-sï-ûJ С1/ 1 二丨 1U Jiut L&j, 任 kj ^jjji3 jl^j^íi jl^mui^ l-g-l-115 j>lj! ^ u^mj! lo^lsüi vjii-.-1-k Sè^.,^ 1 ójjb 15.0-) '<L)j^JI ájlf ^-.Jla^ *d-c<j Uü! '<1=клоЛ i л ^o jl jmui ^joja С LcJCuu/'j (J^^uJl ÁiuA-» 产 _::; d-^ujliïjl d^wuajl dujaju» ^o ^^ólojl ^ Uü I c^uslcuji JLwvl^ ' JiuXuJ! JJÍ ^jlt ^ol ^JJI LA^^C J-«i.)L. "dj^ji 4^1 J^-^JI ^ ^ûj I í I vjuá-» ducoj LaJ 1 I rt.<ajr>.'<oclwojuíc^ ^o^oj I ^ 1 ajsu^lj ^J I 31 d-s r",.j 1 í Jl ^JjjJI f,.<ji *<LL> i*v1 Sü c^rí^0 ^^ ç 己.'? ^ ^è-и/ 加 «S^KJ LOJ! «LJ^jJl J ts t^s^" ^* 4 ' { ~ ~ ^ JJi^ I I l.g.o r«.l«u*/ ^Лл^ djs^jmui jv^ü váj I.<J ájjj>i ^jj 1! JLA.* ^ 1 J^uaJI ^з ^u/^aj 1 ^voljj^j! t -'."p 1 ^Jl ^jlm/ douj cujlffl Jlaí. I j ^ J 二. 各 _. 二 1 jí l^l^iu-co ^JUl JI * ^I^V! 11 t M ^ ^U?Ij-iJ jj^-jl 1 VV jjlux-» ^eüj-ji ^JLc *<5U)^5L=JÍ clxüi^ " J^jJI ^J ^-Jl JUbSU «L^JJL XV ^J^l '<LL>PЦ1 а-я». LLsJl jjb 'LA^Jtz cljloj.juao^l jy^jüji ^^juj ^pv^jl^ ^^Vcu.o.11 1 ji c^uici/ju^lj < dl^uji С1/1 ^AûJ! ^lls ^JLc С1лкэ 15 JLÍL5 尸 g "^o^ J IÍLL>V! Ó ЦО l g * I U I ^ 1 jj I JL5Ü^ 一 ^>J d jtlzuj I ^büuül JlaJI J 3 J UlL^Í I '«L^JI^

169 A47/VR/7 page 154 J L ^ C I ^ U AI "<^,>1^)1 01 ^JJL J ' I 尸 ^ I^J V^JU ^ ^.1 气 Л 产 U jj>j\ âju> à y, lokio "л j^cu- ci/lv^jü ^ 丄.J 1 c^lo^s. GL^U^JI ci^uu^ji Ji LJU Le çiy *<ÜU^J! ^ ^ ^^11 ^ ^ jl^ji 分丄 Lui ^ ÜL. V ^ L^UI l^jl^ ^JJ! ^ Jl ;i^o ^ 'LJlu, ^ jlas>j\ I jjb A-JU ^j^î U 1, л/\ 3 J l ^ ^UJ! Le Professeur CIKULI (Albanie): Excellences, Monsieur le Directeur général, Monsieur le Président de séance, Mesdames et Messieurs les ministres, Mesdames, Messieurs, il est très intéressant de réfléchir et de parler d'éthique devant un auditoire aussi important que celui-ci, mais il l'est encore plus de faire part à cet auditoire des problèmes d'éthique récemment surgis dans notre pays, Г Albanie, qui est en plein changement. En effet, dans un pays qui vient de changer de système politique, il n'est pas facile d'installer un nouveau système de santé. Les changements principaux dans le domaine de la santé portent notamment sur la restructuration du système des soins de santé primaires et des hôpitaux, rintroduction d'éléments de privatisation, la réforme du système pharmaceutique. Il nous a fallu élaborer plusieurs lois nouvelles parmi lesquelles les plus importantes sont : la loi sur les médicaments, la loi sur la privatisation de la stomatologie et la loi sur la création de l'ordre des Médecins. Nous sommes en train de travailler sur un projet de loi très important pour la réforme sanitaire, la loi sur l'assurance-maladie. Au cours de ce rapide changement, nous nous sommes heurtés à des phénomènes très importants dans les relations du personnel médical avec les patients. Pour bien servir les malades, il faut avoir deux sortes de motivations, la première étant la motivation financière, la seconde étant le dévouement, qui est d'ordre spirituel. L'ancien régime communiste a bien fait attention à détruire les deux motivations à la fois. D'un côté, il avait minimisé les revenus du personnel médical : les médecins et les infirmières étaient considérés comme "des humbles serviteurs" du peuple. Cela a été fait dans un but très précis : cultiver la mentalité selon laquelle les soins de santé étaient gratuits, ce qui n'a jamais été vrai. De l'autre, il avait complètement détruit l'autre motivation, le dévouement. Même le serment d'hippocrate était considéré comme réactionnaire. En supprimant la religion de par la Constitution de 1976,il essayait d'effacer de la mémoire collective l'exemple surprenant des soeurs de charité qui travaillaient dans nos hôpitaux. Même la Croix-Rouge était supprimée pour de longues années. Dans cette situation délicate, nous avons vu naître deux sortes de problèmes : d'une part, une catégorie du personnel médical (heureusement peu nombreuse) essaie de rattraper le temps perdu en affligeant à la population des tarifs illégaux, certainement "sous la table". D'autre part, à cause de la mentalité précédemment cultivée (la médecine gratuite), nous avons beaucoup de mal à introduire des éléments de privatisation. Pour faire face à cette situation, nous sommes en train d'agir dans trois directions principales : premièrement, Pélaboration de la loi sur l'assurance-maladie qui, non seulement va augmenter les financements en faveur du secteur de la santé (ce qui va sûrement améliorer les services), mais encore va permettre de rémunérer certaines catégories médicales; deuxièmement, le renforcement de l'ordre des Médecins qui veille sur les relations médecins-patients en exigeant le respect du Code déontologique par tout le personnel médical; enfin, la constitution de la Commission nationale d'éthique exigée par la loi sur les médicaments, qui va avoir un rôle très important dans la solution de certains problèmes d'ordre éthique. En concluant, Monsieur le Président, Mesdames et Messieurs les membres du bureau, je souhaiterais vous transmettre les meilleures félicitations du Gouvernement albanais et ses voeux de réussite pour cette longue mais noble tâche que vous allez assumer. Dr GIBRIL (Sierra Leone): Mr President, distinguished delegates, on behalf of the Assembly of Health Ministers of the West African Health Community, I wish to congratulate the President and the Vice-Presidents on their election to preside over the Forty-seventh World Health Assembly of the World Health Organization. We also wish

170 A47/VR/7 page 155 to congratulate the Director-General and his entire staff for his comprehensive report and for guiding the activities of this Organization through the past year. All over the world, the challenges facing the health sector are similar. Resources are getting scarcer by the day. World economic forecasts do not give cause for hope, the health sector is losing its appeal to investors. The demand for health services continues to increase. First, because of increased expectations, but also because of increasing population growth. We can only improve the condition of our people not just by doing more of the same, but by making basic fundamental changes required in the health services, and considering how they are delivered and financed. Many countries have focused their reform process on improving the performance of the health sector and of the ministry of health. Whilst this is understandable, it carries the risk of seeing institutional reform as an end in itself and not a means to an end. These reforms fail to place the patients at the centre of the change processes. Patients and clients are constantly being exposed to uncaring, poorly trained staff, long waiting times, inconvenient clinic hours, inadequate supplies and lack of any confidentiality or privacy. In the private sector, they are at risk of financial exploitation, with no safeguards against potentially dangerous treatment regimes. It is in the light of this situation that we, the health ministers of the West African Health Community, fully endorse the selection of the theme for this year. Never before have the ethics of the health profession been under such scrutiny. The health ministers of the West African Health Community wish to put on the global agenda a problem which at times assumes frightening proportions. I am referring to the problem of refugees and displaced people. Endemic and preventable diseases continue to contribute disproportionately to the ill-health burden in many developing countries. The success of the Onchocerciasis Control Programme in our sub-region gives us cause for hope and fulfilment. There are,however, a number of endemic diseases which need not only national but, we believe, more concerted global and sub-regional efforts. Probable candidates include malaria, schistosomiasis, tuberculosis, guinea-worm and of course AIDS. We in the sub-region are concerned about the steady decline in coverage by universal child immunization. There is need for a renewed strategy for the resuscitation and sustainability of the Expanded Programme on Immunization. To achieve the mid-decade goals for child survival, focus must be on an action plan for integrating the Programme with other health care activities, at the primary health care level. Introduction of other vaccines, such as hepatitis В vaccine, should be part of any childhood vaccination initiative. Mr President, Director-General, ladies and gentlemen, we in the West African Health Community have a lot of confidence in the World Health Organization and wish the Organization all the best in the years ahead. The ACTING PRESIDENT: Thank you very much, distinguished delegate of Sierra Leone. Before the adjournment of this morning's session I have some announcements to make. I should like to remind the distinguished delegates that briefings on technical programmes will be held during the lunch break as follows. At 13h00, briefing on the World Summit on Social Development in Room XXII with interpretation in English, French and Spanish; and also at 13h00 briefing on female genital mutilation, in Room VII, with interpretation into Arabic, English and French. The plenary session will resume its meeting this afternoon at 14h30 to consider admission of new members, followed by awards of the following prizes: the Léon Bernard Foundation Prize; the Dr A. T. Shousha Foundation Prize; and Sasakawa Health Prize. After the award ceremonies, the plenary will resume discussion of items 9 and 10 and simultaneously Committee A will meet in Room XVIII. The meeting is now adjourned until 14h30 this afternoon. The meeting rose at 12h00. La séance est levée à 12 heures.

171 A47/VR/5 page 156 EIGHTH PLENARY MEETING Thursday, 5 May 1994, at 14h30 President: Mr В. K. TEMANE (Botswana) HUITIEME SEANCE PLENIERE Jeudi 5 mai 1994,14h30 Président: M. В. К. TEMANE (Botswana) 1. ADMISSION OF NEW MEMBERS AND ASSOCIATE MEMBERS ADMISSION DE NOUVEAUX MEMBRES ET MEMBRES ASSOCIES The PRESIDENT: The meeting is called to order. The first item on our agenda this afternoon is item 11: Admission of new Members. The documents relating to this item are: A47/35; A47/36; A47/INF.DOC./1 and A47/INF.DOC./2. The Director-General has received applications for membership of the World Health Organization from Niue and from the Republic of Nauru, and I propose that we deal with these items one by one. We shall therefore first consider the application by Niue, and I draw your attention to document A47/35 together with document A47/INF.DOC./1. The application by Niue is now before the Assembly. Are there any observations? I recognize the delegate of New Zealand. Mr LOVELACE (New Zealand): New Zealand is pleased that one of our regional neighbours, the small Pacific Island State of Niue, has applied this year to join WHO. New Zealand welcomes Niue's application. In view of the long-standing constitutional relationship between Niue and New Zealand, I would like to make a few comments about the Niue application. In 1974,the people of Niue opted for full self-government in free association with New Zealand. The free association does not give New Zealand any right of control over the Government of Niue, although New Zealand does retain certain responsibilities for Niue's foreign affairs and defence. These responsibilities are in effect carried out on the delegated authority of the Government of Niue. Given the nature of the constitutional relationship between New Zealand and Niue, the New Zealand Government views Niue,s application for full membership of WHO as entirely appropriate. There is no legal impediment to the Government of Niue assuming full responsibility for аи the obligations implied by this. Since self-government in 1974,Niue has steadily extended and developed its foreign relations. In 1993,Niue was admitted as a full member of UNESCO. Niue is active in the Pacific regional organizations, including the South Pacific Forum and the South Pacific Commission, and it is party to a number of multilateral treaties. Niue's statehood and relationship with New Zealand has developed along the same lines as that of the Cook Islands. The Cook Islands was granted full membership of WHO by this Assembly in Niue's application has the unreserved support of the New Zealand Government, as we trust it will have of all the delegations here. The PRESIDENT: I thank the delegate of New Zealand for his kind words in support of the application. recognize the delegate of Samoa. I now

172 A47/VR/7 page 157 Mr SALA (Samoa): I first wish to acknowledge our thanks to the delegate of New Zealand for his kind words and particularly for supporting the application of our colleagues from Niue. We also wish to have the honour of seconding the application. Yesterday we gave our full commitment to our potential new Members, not only Niue, but also the Republic of Nauru, which will also join in due course. I wish them all the very best and I hope that this Assembly will give them its full support as a sign of health solidarity throughout the world. The PRESIDENT: I thank the delegate of Samoa for seconding New Zealand. I recognize the delegate of the Solomon Islands. Mr WAENA (Solomon Islands): As a fellow member of the South Pacific Forum, Solomon Islands would like to join with New Zealand and Samoa in expressing our heartfelt sense of appreciation and gratitude to this Assembly for considering the application of our fellow neighbour, Niue, to enjoy the full rights and privileges of this Assembly. We would like, at this juncture, to express our best wishes to the Government and people of Niue, because we are small island States in the South Pacific. Mr PRESIDENT: I thank the delegate of the Solomon Islands. In the absence of further comments, I take it that it is the wish of the Assembly to admit Niue to membership of the World Health Organization. I shall propose to you the adoption of the following resolution: The Forty-seventh World Health Assembly ADMITS Niue as a Member of the World Health Organization, subject to the deposit of a formal instrument with the Secretary-General of the United Nations in accordance with Article 79 of the Constitution. The Assembly may wish to adopt this resolution by acclamation, it being understood that the statements made in this connection will be reproduced in extenso in the verbatim of the Assembly? (Applause /Applaudissements) The PRESIDENT: The resolution is adopted. I congratulate Niue on its admission to membership and have pleasure in inviting Mrs 0,Love Tauveve Jacobsen, Minister of Health of Niue, to come to the rostrum and address the Assembly. Mrs JACOBSEN (Niue): Mr President, honourable Director-General, representatives of the Executive Board and staff of the World Health Organization, honourable and distinguished delegates, ladies and gentlemen, it is indeed an honour and privilege for me to represent the people and Government of Niue and to address this distinguished forum. The invitation and opportunity to attend and observe the proceedings of the Fortyseventh World Health Assembly is indeed greatly appreciated. I bring you warm greetings and best wishes from the Premier, the Honourable Frank Lui, and the Government and people of Niue. We furnished you with a small map a couple of days ago to give you some idea of where we are, what part of the world we come from. Further to the documentation you will have already received on Niue, I beg your indulgence to allow me, in the limited time available, to elaborate a little more.

173 A47/VR/7 page 158 Niue, affectionately known as "The Rock and Island of Tranquillity",is one of the many small island States of Polynesia in the Pacific Ocean. Raised out of the water through volcanic action, it has a land mass of 100 square miles and stands approximately feet above sea level. The soil is mainly limestone and therefore is relatively infertile. We have a population of 2500, and live in New Zealand. It may be one of WHO's least populated nations but, hopefully, not the least important. We are bilingual, speaking both Niuean and English, the official languages. Alofi, the capital, is the seat of government, the centre of commerce and the location of Niue's only hospital. An Englishman, Captain Cook, discovered Niue in By 1900 it had formally become a British protectorate. Because of the vast distance separating Niue and Great Britain, New Zealand was charged with the responsibility of looking after Niue. New Zealand administered Niue from 1901 to 1974,at which time, in an act of self-determination under the auspices of the United Nations, Niue opted for selfgovernment in free association with New Zealand. Our national income for the moment is dependent on the constitutional marriage with New Zealand which, in recent years, has begun a weaning process. Our special relationship with New Zealand enables us to enjoy New Zealand citizenship. Over the last year or so, the Government of Niue has considered with interest WHO activities in the various fields within its mandate. In a commitment to help ourselves nationally and be recognized internationally, we have affiliated ourselves to UNESCO. This will enhance the social benefits and wellbeing of the people but without good health they cannot fully enjoy these services nor the fruits of their labours. Paving our way to becoming members of WHO enables our small nation to approach our problems holistically, before they become, in medical jargon, a "condition causing concern". We cannot be complacent, nor can we assume that countries with the smallest populations have the smallest problems. We have our problems too, on a small scale. The first hospital in Niue was built in 1922 and, being coincidental with the visit of the New Zealand Governor-General, Lord Liverpool, it was named after him. Repeated hurricanes in 1959, 1960 and 1990 put the health services under great strain, damaged buildings and led to a very costly exercise of replacing equipment. Niue has enjoyed considerable assistance from WHO since 1960,despite resource constraints. These endeavours have been the work of very caring people, in most recent times Dr David Parkinson, the WHO Representative based in Western Samoa, and Dr Sang Tae Han, Director of the WHO Regional Office for the Western Pacific. Assistance given is in the areas of improved water systems, improved latrine and general sanitation, health services vehicles, vector control equipment, provision of insecticides and vaccines and manpower training, to name a few. All these we have received with much appreciation. As in most countries, health is of primary importance, and my Government is convinced that Niue is in a position not only to contribute effectively to the work of WHO, but also to benefit substantially from the assistance which the Organization can offer. Having studied the Constitution that governs WHO, the Government of Niue pledges and undertakes to abide by its provisions, and to accept all the obligations enshrined in that Constitution. Having achieved this milestone in the history of Niue, I pay tribute and respect to all the health care workers and health support services workers of Niue, from the years gone by to the present day, recognizing their contribution to the health status of our small nation. In drawing this address to a close, I want to publicly thank the Government of New Zealand for its unfailing support in all of Niue,s endeavours on the international scene, and with deep appreciation I sincerely thank you all for your most gracious support and messages of best wishes. You have today fulfilled for Niue a vision of the United Nations in 1946,that global resources are to be shared with those who are otherwise not so well resourced. Your acceptance today gives Niue the opportunity to be born and become part of the world family, a family whose recognition of the rights of every human being to good health, shelter and life is fundamental. The PRESIDENT: Thank you, Mrs Jacobsen. We shall now consider the application of the Republic of Nauru and I draw your attention to document A47/36 together with document A47/INF.DOC./2. The application by the Republic of Nauru is now before the Assembly. Are there any observations? I recognize the delegate of Solomon Islands.

174 A47/VR/7 page 159 Mr WAENA (Solomon Islands): Mr President, sir, I thank you for allowing me to express the support of the Government and the people of the Solomon Islands for the Government and the people of the Republic of Nauru, which is a member of the South Pacific Forum. The entry by Nauru into this august Assembly as an independent nation in its own right has long been overdue. We therefore sincerely wish to tender our support to the entry by the Government and people of Nauru into this august Assembly and into the World Health Organization as a full Member. The PRESIDENT: I thank the delegate of the Solomon Islands. I recognize the delegate of Tuvalu. Mr PITA (Tuvalu): I would like to join my brother from the Solomon Islands in extending support to Nauru in its application to be a Member of WHO. The PRESIDENT: I thank the delegate of Tuvalu. In the absence of further comments, I take it that it is the wish of the Assembly to admit the Republic of Nauru to membership of the World Health Organization. I shall propose to you the adoption of the following resolution: The Forty-seventh World Health Assembly ADMITS the Republic of Nauru as a Member of the World Health Organization, subject to the deposit of a formal instrument with the Secretary General of the United Nations in accordance with Article 79 of the Constitution. The Assembly may wish to adopt this resolution by acclamation, it being understood that the statements made in this connection will be reproduced in extenso in the verbatim of the Assembly? (Applause /Applaudissements) The PRESIDENT: The resolution is adopted. I congratulate the Republic of Nauru on ks admission to membership and have pleasure in inviting Mr Vinci Niel Clodumar, Minister of Finance of the Republic of Nauru to come to the rostrum and address the Assembly. Mr CLODUMAR (Republic of Nauru): Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, it is a great honour and privilege for me to be here today and to represent the Government and people of the Republic of Nauru at this Forty-seventh World Health Assembly. Indeed, this is the first time that the Government of the Republic of Nauru has been officially represented at this Assembly, and I take pride on this occasion in conveying on behalf of the Government and the people of Nauru our sincere appreciation for the kind support given by distinguished representatives of WHO Member States relating to Nauru's admission as a new Member of WHO. Today marks yet another milestone in our endeavour to join another international organization to contribute and share experiences of the diverse health problems that are affecting our people on this planet. Although small in terms of geographical size, Nauru is fully committed to maintaining the health care of its people, and my Government gives this matter high priority on its agenda. Nauru's admission will enable my Government to actively participate in the already established WHO regional programmes and projects. As a Member of WHO, the Republic of Nauru will fully cooperate and respect its Constitution, and I assure

175 A47/VR/7 page 160 distinguished delegates here today that my Government will continue to contribute to the objectives of WHO for the betterment of mankind. Allow me again to take this opportunity to convey my Government's sincere gratitude and appreciation for your support of our application for membership of the World Health Organization at this Forty-seventh World Health Assembly. I also wish to take this opportunity, on behalf of the Government and the people of Nauru, to extend to the Government and people of Niue our warmest congratulations and best wishes on becoming also a new member of the WHO family. The PRESIDENT: Thank you, Mr Clodumar. 2. AWARDS DISTINCTIONS The PRESIDENT: Distinguished delegates, colleagues and friends, we are assembled here today for the presentation of the prizes awarded by the Léon Bernard Foundation and the Dr A.T. Shousha Foundation, and the Sasakawa Health Prize. I have much pleasure in welcoming among us the distinguished winners of these prestigious prizes, who are seated on the rostrum. I am also very pleased to welcome Professor Kenzo Kiikuni representing Mr Ryoichi Sasakawa, President of the Sasakawa Memorial Health Foundation. Presentation of the Léon Bernard Foundation Prize Remise du Prix de la Fondation Léon Bernard The PRESIDENT: We shall start with item 13.1,Presentation of the Léon Bernard Foundation Prize, a prestigious prize, awarded to a prestigious person. It is an honour and a privilege for me to confirm that the Executive Board at its ninety-third session in January this year, awarded the Léon Bernard Foundation Prize to Sir Donald Acheson of the United Kingdom. Sir Donald Acheson is a well-known figure to most of us here. A graduate from Oxford University, Fellow of the Royal College of Physicians and Fellow of the Faculty of Public Health Medicine, Sir Donald has a long record of outstanding accomplishments in the field of social medicine culminating in distinguished tenure of the highest post in that field in the United Kingdom, that of Chief Medical Officer of the Department of Health in England and Chief Medical Adviser to the Government of the United Kingdom of Great Britain and Northern Ireland. Sir Donald discharged these onerous responsibilities with great distinction for eight years, from 1983 to I shall recall here some prominent features of Sir Donald's brilliant career. When, in 1958, he was appointed as Consultant Physician to the Oxford Teaching Hospital Group, he developed a then unique programme of linkage of patient records in and out of hospital, which made possible a succession of important studies in this field. Sir Donald was then invited to become Dean of the new Medical School, established in Southampton in In that position he developed a novel approach, making an unusual use of teaching facilities in the community and in associated hospitals in the region. After the school had been successfully established, Sir Donald returned to the study of the epidemiology of noncommunicable diseases linked with environmental factors as Director of the Medical Research Council Epidemiological Unit in Southampton and Professor of Epidemiology. While serving as Chief Medical Officer he chaired a special committee to review public health medicine in England, producing a highly influential report in 1988 which led to a significant strengthening of the public health profession and of management arrangements for communicable disease control. Sir Donald is currently Professor at the London School of Hygiene and Tropical Medicine, one of the world's leading schools of social medicine. It gives me great satisfaction, in the name of all of us, to present Sir Donald Acheson with the Léon Bernard Foundation Prize for Amid applause, the President handed the Léon Bernard Foundation Prize to Sir Donald Acheson. Le Président remet à Sir Donald Acheson le Prix de la Fondation Léon Bernard. (Applaudissements)

176 A47/VR/7 page 161 The PRESIDENT: I invite Sir Donald to address the Assembly. Sir Donald ACHESON: Mr President, Mr Director-General, excellencies, distinguished delegates. I regard it as a signal honour to have been awarded the Léon Bernard Foundation Prize for At a time when we all must indeed "think globally and act locally" if we are to achieve and sustain better health, the work of the World Health Organization has never been more important. I regard it a privilege to have had the opportunity to contribute to the work of this Assembly and its Executive Board in recent years. Together they constitute a unique forum where the health problems of the world are faced, discussed, ameliorated and sometimes, as in the case of smallpox, resolved. Léon Bernard emerged from medical school at the end of the last century. At that time, as a result of the work of Pasteur, Koch, Noguchi and others, the microbial theory of disease held sway and eclipsed temporarily the older view that ill-health had its roots deep in society. The scientific optimism of the day led to the opinion that further advances in bacteriology, together with vaccination and antimicrobial therapy, would soon eliminate many, perhaps most of the prevalent illnesses. But Bernard's experience as an expert in tuberculosis over the next 20 years finally persuaded him otherwise. As an acute clinical observer he noted that, in most cases of adult pulmonary tuberculosis, the primary infection had occurred and healed in childhood, and that the reactivation of the disease in adults was often due to the effects of poverty or other unfavourable social circumstances. In the era before chemotherapy, little could be done for these patients. It was Bernard's intense frustration and sense of helplessness consequent on this perception which led him to become an advocate of wider social action as a means to improve health and he became an apostle of "social medicine". There followed his role as a leader in the movement for national institutes of hygiene (for example in Warsaw, Zagreb, London, and Budapest) which followed World War I,and finally his key influence in the formation of the Health Committee of the League of Nations. Much, perhaps too much, has been written about the meaning of the term "social medicine", I will not add to this. To describe social action to improve health, I prefer the less ambiguous term "public health", and I draw attention to the fact that in 1952 the first report of WHO's Expert Committee on Public Health adopted a simplified form of Wilmslow's classical definition. According to this, public health is: "the science and art of preventing disease, prolonging life and promoting mental and physical health by organized community efforts". I will conclude my remarks by drawing some conclusions about the work of WHO as we approach the year I shall be brief. I believe that, as a new millennium dawns, two achievements in particular of this Organization in its first half century of work will be seen as having had a seminal effect on the approach to global health. The first of these is the health-for-all policy, including the crucial movement towards primary health care which was inaugurated during the time in office of Dr Halfdan Mahler. The second is your initiative, Mr Director-General, in setting up the WHO Commission on Health and Environment in This places human health in a new and wider context, but firmly at the centre of the increasing concern about the global environment and sustainable development. I have a word to say about each of these. Health for all I believe remains today the only comprehensive policy for health, the principles of which are equally applicable to all countries in the world. It was the first policy to cover not only health care but the lifestyle, social and environmental risk factors which determine health; and was also first to draw attention to the need for collective action by all sectors of government and the community if further improvements in health were to be achieved. The health-for all policy has never to my knowledge been successfully challenged on intellectual grounds. Which country represented in this Assembly not yet in possession of an accessible system of primary health care does not regard it as a high priority to build one? Which health minister does not now recognize that the support of colleagues with portfolios for the environment, for housing, for finance, for agriculture and so on, is crucial to improve health? The fact that these points are now accepted by a large number of people both within and outside this Assembly is a measure of the success of the health-for-all policy over the last 20 years. But even the most successful human endeavours often have a flaw. You will note that I have not included the words "by the year 2000" in my description of health for all. To set what was even at the outset clearly an impracticable target was, I believe, Utopian and a significant tactical error. In some countries this has unfortunately led to ridicule of the policy as a whole. Now, I suggest, may be the time to drop the phrase. As we all know, it is not possible to set a date by which health for all people can be

177 A47/VR/7 page 162 achieved. The best we can hope for is to set targets for a step-by-step improvement marching forward together to a goal far beyond the horizon. The WHO Regional Office for Europe has developed a version of the health-for-all policy with 38 targets. This has been of particular significance because it has countered the criticism, ill-founded though it was, that health for ап is in some way set against the benefits of clinical medicine. The European version of the policy also includes targets tailored to improve the appropriateness and cost-effectiveness of health care with due regard to ethics. In other words, in addition to addressing lifestyle, the environment and intersectoral action, it addresses the cost crisis in clinical care which affects all countries in the world, rich and poor. As we look back from the millennium, I venture to predict that we shall find that in countries other than those directly affected by conflict or economic collapse, health, as measured by the usual fundamental indicators, wül have continued to improve as it has done since the World War. Nevertheless, within this general improvement, very grave degrees of inequality will persist both between countries and within them. A recent estimate suggests that at present no fewer than 2.2 of the world's approximately 6 billion people live in poverty with insufficient resources, services or education to provide a basis for the health of themselves or their children. Yet over the next 50 years, more than 80% of the increase in the world's population will take place in the poorest countries. In contrast, most of the consumption of non-renewable resources is concentrated in Europe, North America and Japan. At present per capita consumption levels in the richest countries are 50 or more times higher than in the poorest countries. In a word, we shall shortly be confronted with the dire consequences of planetary overload and burgeoning waste. When, in 1988,the Chairman of the United Nations World Commission on Environment and Development, Mrs Gro Harlem Brundtland, addressed this Assembly, she placed before us a radical concept which opened up a new perspective - that of sustainable development. This term may be defined as the need to ensure that our efforts to improve the quality of human life do not compromise the supporting ecosystems of our planet and the health - and indeed the life itself - of future generations. The report of the WHO Commission on Health and Environment entitled "Our planet our health" followed this up by enunciating a new framework to help promote lifestyles and patterns of consumption consistent with sustainability of development and health. The key points, which are, I believe, sufficiently important to bear repeating here, include: (1) the slowing down and halting of population growth as soon as possible; (2) the elimination of over-consumption and the unnecessary generation of waste among affluent groups; (3) more equitable access to resources within and between countries; (4) greater attention to education for health, particularly among women; and finally (5) a greater degree of public participation in promoting health and environmental quality. It was as a direct result of the eloquent advocacy of this report that the first principle of the Rio Declaration proclaimed, that "human beings are at the centre of concerns for sustainable development and that they are entitled to a healthy and productive life in harmony with nature". In his time, Léon Bernard was regarded as an apostle of wider action to improve health. While, in terms of complexity, the problems facing this Organization as it approaches the millennium seem a quantum leap from his, he would have recognized their significance. The sheer scale and intensity of human economic action and population growth, often unaccompanied alas by appropriate social development, are creating for the first time the prospect that this generation may confer a negative legacy on those that follow. The WHO global strategy for health and environment together with the health-for-all policy, provide, I believe, an appropriate framework for this Organization to address these issues well into the next century. I thank you again for awarding me the Léon Bernard Prize. The PRESIDENT: Thank you, Sir Donald. Sir Donald introduces an interesting point, especially on the value of target setting, with particular reference to health for all by the year However, I will not open the debate on this particular item, I'll give him immunity to get away with it. Once more, thank you, Sir Donald. Presentation of the Dr A.T, Shousha Foundation Prize Remise du Prix de la Fondation Dr A.T. Shousha The PRESIDENT: We now come to item 13.2,Presentation of the Dr A.T. Shousha Foundation Prize. The Shousha Medal and Prize, named after the first Director of the WHO Regional Office of the Eastern Mediterranean, are awarded each year to a person having rendered significant service in the field of health

178 A47/VR/7 page 163 in that region. They are presented this year to Dr Abdulwahab Al-Fouzan, Consultant in Dermatology and Venereal Diseases, former Minister of Health of Kuwait. A graduate from the Faculty of Medicine of the University of Egypt at Alexandria in 1976, Dr Al-Fouzan obtained an M.Sc. in dermatology and venereology from the same University in In 1985,his studies on cutaneous photosensitivity earned him a Ph.D. from the University of Dundee, in Scotland. From 1977 to 1990,Dr Al-Fouzan held a number of academic positions in Egypt, Kuwait and the United Kingdom. Among other important achievements, he established the first photobiology unit in the Middle East, at the El-Sabah Hospital in Kuwait. Today, this unit provides modern dermatological treatment to patients from the whole Eastern Mediterranean, conducts research and offers specialized training in dermatology. Dr Al-Fouzan has authored numerous publications in this field over the years. From June 1990 until very recently, Dr Al-Fouzan was Minister of Health of the State of Kuwait and Chairman of the Environment Protection Council. Since the war he has been instrumental in rebuilding health services and obtaining the necessary manpower to provide health services to the population of the country. As Minister of Health and Chairman of the Environmental Protection Council he has exerted great efforts to protect the population against environmental pollution caused by the oil-well fires. Dr Al-Fouzan was, in addition, responsible for the establishment of the Specialized Centre for Psychological Diseases and Rehabilitation, the first of its kind in the Middle East. He is also widely credited with developing the Kuwait Cancer Control Centre into one of the best specialized medical centres in the field in the Eastern Mediterranean. To reward such an outstanding contribution to health in the Eastern Mediterranean Region, I now have great pleasure in presenting Dr Abdulwahab Al-Fouzan with the Dr A.T. Shousha Medal and Prize. Amid applause, the President handed the DrA.T. Shousha Foundation Prize to Dr Abdulwahab Al-Fouzan. Le Président remet le Prix de la Fondation Dr A.T. Shousha au Dr Abdulwahab Al-Fouzan. (Applaudissements) The PRESIDENT: I invite Dr Al-Fouzan to address the Assembly. Dr AL FOUZAN: -o 1^1 Jl^ ^jji Cl«1 i ^ I Cl» I jj I 1 yj* J L«4aJ 1 í^ja^js» jl 1 ^ Juuu/ ( 产..<- ^) I jj I djj!^«м-» L> JJLaIÍ ^ jj! duuu LstJ! du>v4ûj 1 d^jâ-la j^sàlù^ ^Jâ- i I á^uj LloJ! ô j^jusj^i 1 JJb ^-o ^j^wu/1 ^ ^JS JS- I ^J I I (Цсм/ LloJ I ó JlA jam^ 气气又 ^ L«J j^lls jj I LuJUJI ój^uj! Óал J t/_.j j^j '«LuJUJI d^zjl '«LxJâJuJ ^^ujuuxjl) ^j^sk: 少.<J 1 ^S-uü L.» jjfc I LaS Llalli» I J L^o Lu-^-Jd I LoJ Lk> ^jl jixcl ^J-^wo l-j Lo Lu/^ j^zsiz '<c«íl.lj 1 ó^jb I.O..JV[SU j^jji '<LuJLsJ1 dj>^ji loj^juj ^LjJI ^-.sjuji 丄 1 Jj^Jl Cl/ LoJu>ü 1 'j^i'j^i*^ i ^L^c^JsJ I 已 U^l JU^, ^ f..: 1 ) Ш l^oajü 'á-ujbji I^UjVI 产 L :jbi J! jij t c ^ l C L J JSU^ 二 _<J1 ^JjI L«J1 '«SuuxacJ! ^SJI ^^tcjl, l^ilit I^ dujulnjl3 d^jjujl ^jôlj^^fl» ^ a^j^jl. ^JLaJI ^ à J^ j\ \ d-jlc ^ci.gjj; ^ jjl á jjbl^j] 'f\ y, jjlji! ^JLaJ ^ ÂsLioJ 1 ^JLcj LJ! ^ ^ ^^-USÛAÛÂILÛJ! Jl^LU^ LO-O <J-JL>1 jj! CL.L».! Jb^iI.! '<Lcc 13 *<Lijv I js>3 Lu^ d L>w<> ^^Lsü I ^ lit 己 LuC I ^ys!vlâi.ja-x/^ujl ' ^JlsJI duujlv'l ygwx^ji ^.^-jji ^ ^^jj! I JJb ^SizJ ^U^aJI 'il>iliuj yj '<LuJUU1 ' ^Jl duj^-ie ju^lc!.^j^m ci/i ^J^^JI ^ÔA U5 J^lc J-JaJ Ja^yuJI J^i (u-jiv ^'jíys I ^ 1 ^-e^u ^vúuaíkiiji 'JSj^JI f- L<ij! «J ^ J ^ <L >L> ^-JLsV 1 jj ;LoaShJ

179 A47/VR/7 page 164 ô^ki. -tu.^l ^Jl J^t ^ dx^j ^ yv ; 乂尸 J3I сц.^и! ^ \ 丄 _11 dflcjl yst^ 'i^-ji ^JS d^ji^jj *<L"... )L>3.Ь " JЦкл 11 JiUuJI^ LU:OJ jwjlj ^jji U UJI c^^ji.jl>^ji I JlA J^JJI '^i'jjcj^ ^ A-uJUJl 'Âjk^JI áujájuo 力 J Uo ^..,<" Л IJ^^JI ^oluju 0I dj ^flj d I ^^LuJ! ôlib ci.ljy^^^ f Ц-0-. ^Якл^! ^ Ci^jil^ ci^aiciwl wis ^ 广 ^iôl clu^ dlüj ^UÍI ' ili j > ^ ^ ^ ^ ^ ^ ^- ujl ^JLc a-aul^ jjjajuj! I ji O ^ О 1 V.//^ VJT^W L b puca^ A^L^J^I ^ '«LUJLÍJI 己 U^lj ^^JsJI plkjjl ^ Jbj^Jl ^-.L^JI '<LuJL*U1 ^j^lj.. JJ j^sàz^ l/ 3^ 0 s 丨 ^ f ícj^aj^ dj I A.1J1 ^-.JLSCJI I JL^-. ^M-aJI j The PRESIDENT: Thank you, Dr Al-Fouzan. Presentation of the Sasakawa Health Prize Remise du Prix Sasakawa pour la Santé The PRESIDENT: Distinguished delegates, ladies and gentlemen, I shall now proceed to the presentation of the Sasakawa Health Prize, agenda item This Prize was established in 1985 by Mr Ryoichi Sasakawa, Chairman of the Japan Shipbuilding Industry Foundation and President of the Sasakawa Memorial Health Foundation. It is a reward for outstanding, innovative work in health development, and is intended to encourage further development of such work. The Executive Board, at its ninety-third session in January 1994,decided that, in view of her exceptional qualities and achievements, the 1994 Prize should be given to Dr Mo-Im Kim of the Republic of Korea. Dr Kim is currently Dean and Professor of the College of Nursing at Yonsei University in Seoul. She obtained her B.Sc. in nursing from the same University in Her academic achievements culminated in a doctoral degree in 1973 from the Johns Hopkins School of Hygiene and Public Health. In the course of her illustrious career, she served as President of the Korean Academic Nursing Society, President of the Korean Nurses' Association, Vice-President of the Planned Parenthood Federation of the Republic of Korea; from 1989 to 1993,she was President of the International Council of Nurses. Dr Kim was a member of the National Assembly and, from 1981 to 1985,served on its Health Committee. Dr Kim has received a number of awards from the Korean Government, the Korean Nurses' Association and the Korean Women's Development Institute. In November 1991,the School of Hygiene and Public Health, Johns Hopkins University, recognized her as one of the 75 heroes of Public Health". Dr Kim has written numerous articles on primary health care subjects ranging from curriculum development to home health care. While a member of the National Health Council (since 1976), Dr Kim played a key role in translating the concept of primary health care into a concrete government policy that would utilize nurses as prime agents of delivery, especially for people in provincial communities. She was instrumental in mobilizing social support for the implementation of primary health care through permanent institutional channels. Today, the Republic of Korea has a total of 2030 community health posts, staffed and managed wholly by nurses trained as community health nurse practitioners. The programme not only provides high-quality primary health care in the remote areas, but also contributes to overall community development. Dr Kim's current efforts are focused on improving the quality of services for low-income families in urban areas. In her position as Dean of the College of Nursing (a WHO collaborating centre), she is

180 A47/VR/7 page 165 directing a pilot project in which the College will work with a health centre in Seoul to reorganize the nursing services in order to bring more efficient ways of delivering primary health care. The award will be utilized to implement the pilot project in other health centres in the country. I now invite Professor Kenzo Kiikuni to address the Assembly on behalf of Mr Ryoichi Sasakawa, the President of the Sasakawa Memorial Health Foundation. Professor KIIKUNI: Mr Sasakawa has asked me to read the following message on his behalf. Mr President, distinguished laureate of this year's Sasakawa Health Prize, Dr Mo-Im Kim, Mr Director-General, Dr Hiroshi Nakajima, excellencies, distinguished delegates and friends, first of all, let me extend my most sincere esteem and appreciation to all my colleagues who are making tireless efforts for the advancement of health and welfare of the peoples on this earth. On behalf of the Japan Shipbuilding Industry Foundation, now called the Sasakawa Foundation, and the Sasakawa Memorial Health Foundation, I would like to express my heartfelt thanks to such a person as Dr Mo-Im Kim, the recipient of the WHO Sasakawa Health Prize this year, whose leadership and dedication are keys to our well-being. I had hoped to attend this auspicious ceremony myself and to meet you and speak to you in person, but my other engagements prohibit my coming to Geneva this year. I have therefore asked Professor Kenzo Kiikuni, Managing Director of the Sasakawa Memorial Health Foundation, to deliver my message to you. It is my firm belief that world peace can only be achieved when humanity is free from hunger, poverty and sickness, and that we should unite our efforts to achieve this end. I also believe that we should not confine our efforts within national boundaries, but should instead organize our actions according to the fundamental idea of "The world is one family: all mankind are brothers and sisters" which, as you may already be aware, is my lifelong creed. I became 95 years old yesterday, but fortunately I still enjoy good health and am keeping active. I believe that this excellent health is supported by many people, so I think,, I should not monopolize it, but share it with everyone in this world. In this far-from-perfect world, there are many people who require attention for the betterment of their health, which led to the adoption of the World Health Organization's idealistic call of "Health for All by the Year 2000". Ten years ago, on the strong recommendation of the then Director-General, Dr Halfdan Mahler,the WHO Sasakawa Health Prize was established with the aim of enhancing this health-for-all programme by adopting a primary health care approach. The past winners of this health prize have clearly demonstrated their dedication and leadership for better health for the world population. I am particularly pleased to know that every year an increasing number of governments and institutions are submitting their recommendations for candidates for this prize. As I learn about the activities of this year's winner, Dr Mo-Im Kim, I am particularly glad that the winner shares my own belief and has clearly demonstrated her commitment to this difficult but rewarding task, and I feel certain that, no matter how tiny the seed may appear at the beginning, it will surely develop and expand to make a foundation for a healthier and more peaceful world. Fourteen years ago, people witnessed the historic declaration of the eradication of smallpox, which had once been regarded as impossible. It was a clear demonstration of an achievement by coordinated efforts worldwide, not only of health professionals but also of community resources. The Japan Shipbuilding Industry Foundation was particularly glad that it was able to make its contribution to this historic human achievement. There are, unfortunately, a number of diseases which are still burdening the people of the world. Among them, leprosy has been one of the most dreaded, as there is no other disease that affects not only the physical, but the mental and social well-being of humankind as much as leprosy. However, thanks to the never-tiring efforts of scientists and public health workers and the advancement of various measures including multidrug therapy, the World Health Assembly was able to declare, in 1991,that leprosy can be eliminated within this century if we all unite our efforts in the remaining years. I trust that most of you here in this hall are well aware of the Foundation's and my own personal concern for and commitment to the welfare of leprosy sufferers in the world. I believe that the Sasakawa Memorial Health Foundation, which was established in 1974 on my seventy-fifth birthday, has been instrumental in the global upsurge of anti-leprosy activities, most notably in the expansion of multidrug therapy, now globally incorporated in the campaign for the elimination of leprosy by the year I am happy indeed to learn of its better-than-expected success up to now and its very good prospects of achieving its goal, provided that all concerned can unite their efforts. I am committed to the success of this global effort, and am happy to announce that the Sasakawa Foundation is planning to contribute five billion Japanese yen over the next five years, to cover around one-third of the drug requirements estimated by

181 A47/VR/7 page 166 WHO. I hope that this will strengthen the efforts of leprosy-endemic countries, as well as WHO, for the completion of our common task. I understand that the success of the elimination programme will also assure the eventual total eradication of this human scourge. That, to me, is an even greater triumph than the eradication of smallpox, because it will mean not only removing the cause of one of the most crippling diseases, but, perhaps more importantly, erasing a source of universal human injustice, which many leprosy sufferers have had to endure. We also have to work together for the control of another very difficult problem, that of HIV/AIDS, which has similarities with leprosy from the social justice and human rights viewpoint. On this auspicious occasion of which the tenth WHO Sasakawa Health Prize is being awarded, in the hope of enhancing health-for-all activities, I would like to express my congratulations and appreciation once again to the winner of WHO Sasakawa Health Prize, as well as to her Government, for the tremendous work she is undertaking. Lastly, I pray for the good health, longevity and happiness of all of you in this Assembly, and of the people of this earth. The PRESIDENT: Thank you Professor Kiikuni. We thank you for your kind words, and for the information on the contribution from the Sasakawa Foundation. It is now my privilege and honour to present Dr Mo-Im Kim with the Sasakawa Health Prize for Amid applause, the President handed the Sasakawa Health Prize to Dr Mo-Im Kim. Le Président remet au Dr Mo-Im Kim le Prix Sasakawa pour la Santé. (Applaudissements) I now have pleasure in giving the floor to the distinguished laureate of the 1994 Sasakawa Health Prize, Dr Mo-Im Kim. Dr KIM: Mr President, Mr Chairman and representatives of the Executive Board, honourable ministers of health, Mr Director-General, the representative of the Sasakawa Foundation, distinguished colleagues and ladies and gentlemen, I am deeply honoured both as a nurse and as a woman to receive the Sasakawa Health Prize at this meeting of the Health Assembly. I wish to share this honour with nurses worldwide, with my colleagues at Yonsei University, with the Ministry of Health of the Government of the Republic of Korea and with my family and friends, who have been my constant supporters in the past. I have worked in various positions throughout my professional life. During my career in nursing and public health and in functional roles as a parliamentarian, teacher, researcher, practitioner, Dean of my college of nursing and, I might add, as the immediate past President of the International Council of Nurses, my foremost personal agenda has always been the advancement of the health and welfare of people, especially the poor, the vulnerable, and the underserved. To this end the goal of health for all adopted by WHO in 1977 and the 1978 Alma-Ata Declaration on Primary Health Care have constantly supported me in moving forward with firm determination to mobilize the largest group of human health resources, the nursing workforce, in order to better utilize their tremendous potential in primary health care. It was my belief back in the 1970s and it remains my belief today that harnessing the vast potential of the nursing workforce in primary health care would serve my country and its people to their best advantage. My country, like most other nations, is burdened with mounting health care costs, increasing demands for more health services and numerous inequities in the health care system. Given this situation, in my opinion, what we must do is to find new methods and new approaches to health care. Let me briefly describe the steps that I have taken in my own country to realize my philosophy on health care. While serving as a member of the National Health Council with concurrent participation in activities tied to the Korean Health Development Institute, I took a lead in translating the concept of primary health care into a powerful government policy that, when implemented, would utilize nurses as primary agents for the delivery of health care services especially in provincial areas, which tend to be understaffed by doctors. While serving as a parliamentarian, in cooperation with government health authorities I saw to it that laws were promulgated in 1980 and 1984 whereby specialized training was made available to nurses enabling them to work as community health practitioners in remote farming and fishing communities. Pursuant to these laws scholarships were granted to nurses for community health nurse practitioner training, thus allowing nurses to diagnose and treat primary illnesses and to become on-site

182 A47/VR/7 page 167 health care providers in these communities. Especially important was the work undertaken in close consultation with policy-makers and health administrators for the purpose of rendering advice, and active and sustainable support to nurses engaged in community health practice. In 1986, new laws were promulgated to support the mobilization of community health nurse practitioners. Salaries and pension rights befitting their work and their responsibility to society were also granted. This new responsibility for nurses allowed them to expand their role as health service providers and to reach many more people in distant communities in need of health care. In effect, training nurses as primary health care providers ensured that comprehensive health services were available and accessible to all people in my country. Today, the Republic of Korea ñas a total oí 2U3U community health posts nationwide staffed and managed wholly by community health nurse practitioners. They are serving approximately 5 million people. The community health nurse practitioners programme not only provides quality primary health care for remote areas but has also made a significant contribution to overall community development. As you can imagine, the programme has received enthusiastic support from the communities that are being served. In fact, this programme is now recognized as one of the best government health policies instituted since I have always been mindful that the implementation of a sound policy requires the simultaneous backing of legislators, favourable public opinion, effective management, an assured budget and a motivated staff buttressed by education, training and ongoing public support. These are the elements that we have brought together to make the community health nurse practitioners programme such a success. To ensure quality care by community health nurse practitioners, I have conducted and supervised a multitude of studies to review, evaluate and improve nurse practitioner training programmes. Continuing education workshops and seminars have become an important element in these training programmes. One of the concrete achievements that has received national recognition was the production of 20 different audiovisual learning and teaching materials for community health nurse practitioners. In addition, I have also published numerous articles addressing important issues including the lessons learned concerning the utilization of community health nurse practitioners in primary health care. These articles have discussed topics ranging from traditional development to home health nursing. They have been widely read in the Republic of Korea and are being shared with other developing countries. Today, the improvement of primary health care for low-income urban families is the focus of my work. As Dean of my college, I am now directing a pilot project to reorganize nursing services in a health centre in Seoul. If successful, this project will ultimately affect some 300 urban health centres in the Republic of Korea. In line with my experience in working with rural communities, we intend to develop new ways of utilizing public health nurses to provide both efficient and cost-effective urban health care. Clearly the experience that we have had in harnessing the potential of the country's nursing workforce has enabled our Ministry of Health to successfully develop and utilize on a national scale the talents and skills of what is surely one of its single most useful and important human resources. In the Republic of Korea, community health nurse practitioners have become one of the centrepieces in the health department's efforts to achieve the WHO goal of health for all through primary health care. Finally, my thoughts return to the many people, colleagues and friends in the Republic of Korea and worldwide who have supported my work and offered me much needed-advice. To them I extend my sincerest appreciation and gratitude. Without their help and support, I would not be here today. To my country's Ministry of Health which recommended me as a candidate, to Mr Sasakawa, for his inspiring concern for public health, and to the World Health Organization for its leadership, I wish to express my deepest appreciation. Last but not least, I would like to share my happy feelings today with my mentors and students and thank them for enriching my knowledge, skills and moral values. Mr President, Mr Director-General, participating representatives, dear colleagues and ladies and gentlemen, I thank you very much. The PRESIDENT: Thank you Dr Mo-Im Kim. We have now completed item 13 and the meeting will be suspended for a few minutes, after which we shall resume the debate on items 9 and 10. Committee A will also resume in Room XVIII and the meeting of the General Committee will be held in Room VII immediately after we adjourn.

183 A47/VR/7 page DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-SECOND AND NINETY-THIRD SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR GENERAL SUR L'ACTIVITE DE L'OMS EN (suite) The PRESIDENT: We shall now continue the debate on items 9 and 10,and I give the floor to the delegate of Pakistan. Mr RABBANI (Pakistan): In the Name of God, the Compassionate, the Merciful! Mr President, Mr Director-General, excellencies, distinguished delegates, ladies and gentlemen, it is a matter of great pleasure for me to address this Forty-seventh World Health Assembly. I would like to begin by welcoming the resumption of its seat in WHO by South Africa. The happy events of the past few weeks herald the beginning of a new era for that country. The people of Pakistan, who always stood for a change in South Africa, wish a very happy future to the South African people. On behalf of my delegation I would like to extend our heartiest congratulations to you, Mr President, the Vice-Presidents and other members of the Bureau on their election at this session. We are confident that, under your able guidance and leadership, the Forty-seventh World Health Assembly will achieve great success. We have carefully studied the report of the Director-General. We congratulate the Director- General and his staff on this excellent presentation. The report clearly demonstrates the active role that the World Health Organization has continued to play in addressing global health problems in spite of shrinking financial resources. During the past two decades, Pakistan has made great progress in expanding access to basic health care. This is manifest from the increase of basic health units from 1587 in 1982 to 4526 in However, coverage quality and service delivery remain inadequate. Preventive health care facilities are often understaffed and as a result they are less effective than they should be. The annual population growth rate has remained on the high side. One important development in the country is the social action programme, developed in response to the imbalances between economic growth and low human development indicators. This programme will address primary education, nutrition, primary health care, population welfare, rural development, water supply and sanitation. The national programme action was conceived in the context of the social action programme which, in turn, is the main thrust of the eighth Five-Year Plan ( ). The Government of Prime Minister Benazir Bhutto is committed not only to increasing the economic growth rate, but also to improving the quality of life, particularly of women and children in the country. The Prime Minister has pledged to address major health and population issues by improving access to, and quality of, family planning and primary health care services in all villages. A bold initiative is being designed to recruit and train female village health workers, beginning in early The objectives of the programme are: to address the main health problems in the community by providing promotive, preventive, curative and rehabilitative services through a primary health care approach. This is being done by involving the local communities themselves in a grass-roots effort and in delivering the end-products of health care to the very doorsteps of the end-users; to raise the availability of family planning services from 5% of the rural population in 1993 to 7% by 1998,and a simultaneous increase in contraceptive usage in rural areas; to disseminate knowledge and information to create awareness and bring about changes in attitudes through community organization and community participation; to select, recruit, train and deploy female village health workers in the rural communities of the four provinces. The successful implementation of the programme requires the adoption of the following important strategies: the use of technology that is scientifically sound, adaptable to local circumstances, acceptable to users and affordable for national resources; ensuring community involvement and coordination between the health and other sectors in order to foster their support to the essential elements and components of the programme; developing appropriate managerial processes to support programme implementation; disseminating policy, technical and popular information to increase community awareness to ensure the community's acceptance of and involvement in the programme. In this regard, religious leaders, community social groups, health professionals and nongovernmental organizations are to be engaged in promoting the

184 A47/VR/7 page 169 programme; backing up the entire programme by a strong motivating campaign through mass media and interpersonal communication. After steady progress in immunization coverage, which reached 80% in 1991,there have been some indications of decline. A review was carried out jointly by the Ministry of Health, WHO and UNICEF in late 1993 to identify the causes. A five-year Government of Pakistan plan would provide the national expanded programme on immunization with major funding. The Ministry of Health recently constituted a national steering committee on health, which advised the Prime Minister to announce publicly the commitment and support of the federal and provincial governments for the expanded programme. The Prime Minister's programme for female village health workers could have a major impact in promoting immunization services and providing tetanus toxoid immunization for women of child-bearing age in rural areas. Poliomyelitis remains endemic in almost all districts of the country. With 1803 cases reported, 22% of the poliomyelitis cases reported in the world in 1993 were from Pakistan. To tackle the problem effectively, the following decisions were taken: to improve the situation, every effort would be made to raise routine coverage with three-dose oral poliomyelitis vaccine beyond 80% in all districts within the next 12 months; 27 April and 28 May 1994 have been designated as national immunization days. The effort requires about 40 million extra doses of oral poliomyelitis vaccine. The tentative returns for the first of these two days, namely 27 April 1994,indicates that approximately 90% of the target was realized. We are grateful to the Government of Canada, which donated 27 million doses of oral vaccine, and to the Government of the United Arab Emirates, which donated US$ for this purpose. Our appreciation is also due to WHO, UNICEF and Rotary International for their technical and financial assistance for these national immunization days. Pakistan has enthusiastically pursued the goal of dracunculiasis eradication, and I am proud to announce that only two girls in one single village had guinea-worm disease during We have every reason to expect that Pakistan will have zero cases this year, making us the first of the currently endemic nations to have eliminated dracunculiasis. We also hope that adequate resources will be allocated by the Director-General to complete eradication globally, and to complete the certification process in a timely fashion. The Government of Pakistan fully supports the global programme against AIDS. The AIDS prevention and control programme was started in Pakistan with the formulation of the Federal Committee on AIDS. The major objective of this programme is to prevent the transmission of HIV infection and to reduce the morbidity and mortality associated with HIV infection. Although Pakistan falls within the group of countries with low HIV prevalence, recent finding are a cause of concern for us. Up to the end of 1993, 38 cumulative AIDS cases were identified. This figure has now gone up to 42. In addition, about 700 HIVpositive cases have been clinically diagnosed and identified. A comprehensive AIDS awareness campaign has continued through electronic and print media telephone hotlines and discussions over the last six months and will be further continued. Tbe strategic plan developed as a follow-up to the medium-term plan provides a broad direction for the future period In matters of health, we live in a global village having a large population without access to or availability of basic health services. Diseases recognize no borders, and viruses require no passports even to cross continents. We have all been sustained by the dream of a healthier world, a world in which at least some of the diseases normally associated with poverty will have been firmly and progressively eradicated. The dream still remains, but we must continue to be committed to it if we are to achieve the ambitious targets that we have set out for ourselves. It is important in this connection to be absolutely clear about our objective. That objective is, and must remain, better health for all. No extraneous considerations, no foreign policy objectives, no inefficiencies, no slow-down in commitment, must be allowed to stand in the way of that objective - health for all. I wish this Assembly all success now and in the future. El Dr. ANTELO (Cuba): Distinguido señor Presidente, distinguido señor Director General, distinguidos delegados: Mis sinceras felicitaciones, señor Presidente, por su elección. Deseo comunicarle nuestra decisión de colaborar junto a usted para el desarrollo de esta 47 a Asamblea Mundial de la Salud. Como ustedes recordarán, el pasado año en esta misma Asamblea hicimos un llamado a la comunidad científica internacional, ante el brote de neuropatía epidémica que afectó a nuestro país, cuya respuesta rebasó nuestras expectativas en el orden del número de misiones que asistieron de diferentes países y las prestigiosas instituciones que estuvieron representadas por destacadas personalidades que las integraron, con una estrecha cooperación de la Organización Mundial de la Salud, muy especialmente de su

185 A47/VR/7 page 170 Oficina Regional para las Américas con su Director Carlyle Guerra de Macedo a la cabeza, que movilizaron recursos y personal hacia nuestro país. Por ello considero oportuno retomar este tema para informarles de que desde el inicio de la epidemia hasta el 15 de abril se han reportado casos para una tasa de incidencia acumulada de 461,9 por habitantes. Transcurridos apenas seis meses del inicio de la epidemia y cuatro meses después de realizar el llamado en esta magna Asamblea, nuestro Ministro de Salud anunció en la Conferencia Sanitaria Panamericana de septiembre de 1993 que la neuropatía epidémica había sido controlada aunque, al presentarse unos casos esporádicos, se había decidido pasar de la etapa de la lucha contra la epidemia a la de vigilancia epidemiológica. Desde enero de este año al 15 de abril se han reportado 65 casos en 8 provincias del país, que a nuestro juicio representan la cola de la epidemia. La enfermedad afectó a ambos sexos, predominando en general en las mujeres. La mayoría de los casos han ocurrido en los grupos de edades entre los 25 y 64 años, encontrándose el mayor riesgo en el grupo de 45 a 64 años, seguido del grupo de 25 a 44 años, siendo excepcional en niños y adolescentes. La forma clínica óptica predominó en los hombres y la periférica en las mujeres. Un pico de incidencia se produjo entre el 28 de marzo y el 10 de abril de Ante el crecimiento exponencial de la epidemia, a principios de ese año se creó una estructura de acción con la participación del Gobierno, el Ministerio de Salud Pública, la Defensa Civil y un grupo de prestigiosas instituciones científicas del país para enfrentar el control de la epidemia y profundizar en las investigaciones, que han funcionado como una estructura nacional de alta eficiencia, lo que posibilita garantizar una de las divisas fundamentales de nuestro sistema de salud: la equidad en el tratamiento y en la atención. A partir de los pesquisajes activos que se realizaron por los médicos y enfermeras de la familia, se incrementó el diagnóstico en un estadio precoz de la enfermedad, lo que contribuyó a la aplicación temprana de la terapéutica y por tanto a un más rápido y completo restablecimiento de los afectados. La evolución, el diagnóstico y el tratamiento de estos pacientes ha requerido una movilización masiva de recursos del país; incluso llegaron a incrementarse en un 30% las camas hospitalarias; la participación de los médicos de la familia como punto inicial del diagnóstico; la creación y dotación de 60 centros de apoyo en todas las provincias para la confirmación diagnóstica por oftalmólogos, neurólogos e internistas equipados con instrumental apropiado como oftalmoscopios, pantallas tangentes para la evaluación de los campos visuales, láminas de Ishihara, tarjetas para el examen de la sensibilidad de contrastes y equipos clínicos de neurofisiología para la medición de la velocidad de la conducción del nervio y respuestas sensoriales evocadas. Todos los pacientes han recibido tratamiento con vitaminas del complejo В por vía oral o parenteral, solas o en asociación con otras formas terapéuticas. La mayoría de los pacientes mostraron una mejoría significativa en su estado neurológico, igual que aquellas con las manifestaciones oculares, excepto quienes han tenido daño del nervio óptico. Sin embargo, algunos pacientes han mostrado recaídas ya en la misma forma o presentando la otra manifestación. No ha habido casos fatales y en general sólo una pequeña proporción ha quedado con secuelas. Se calcula que deben ser menos de 100. Por otra parte, al principio del mes de mayo de 1993 iniciamos la suplementación vitamínica a base de complejo B, vitamina A y ácido fóüco, que se distribuye gratuitamente a los casi 11 millones de habitantes del país, repercutiendo favorablemente como medida profiláctica, por lo que se ha mantenido esta política hasta el momento. La etiología de la neuropatía epidémica parece ser multifactorial, en la que se involucran elementos de déficit nutricional y un probable factor neurotóxico. En cuanto a la hipótesis nutricional, se han realizado numerosas investigaciones y se ha hecho patente que no existe una relación causal directa entre los tenores de vitamina en la sangre y tejido y la presentación, gravedad y evolución de esta enfermedad. Tampoco se encontró desnutrición proteicocalórica en los pacientes. En lo que se refiere a la hipótesis tóxica, se han encontrado indicadores indirectos que pueden hacer presumir la presencia de algún tóxico en el curso de la enfermedad. Sin embargo, no se ha podido aislar ni identificar uno específico como elemento etiológico principal de esta entidad. Al compararse la neuropatía que se registra en nuestro país con otros grandes síndromes neurológicos epidémicos reportados en el Japón, España, Africa y América, se llega a pensar que la hipótesis toxicometabólica con un componente nutricional dado por un déficit de algunas vitaminas es la que más posibilidades presenta. Ello se sustenta con los hallazgos histológicos encontrados en nuestros laboratorios. En tal sentido se continúan realizando trabajos epidemiológicos y de investigación. Lo anteriormente expuesto evidencia que hemos estado realizando una activa investigación en la que participan instituciones cubanas y del exterior con el objetivo de determinar la etiología de la enfermedad. No obstante, no se ha podido esclarecer la verdadera causa de la epidemia ni explicar completamente su comportamiento, manteniéndose vigentes las hipótesis iniciales toxicológica y nutricional, no pudiendo explicarse completamente el papel de un virus en la enfermedad. En la fase actual el trabajo del sistema nacional de salud y los centros de investigación relacionados con la epidemia están orientados a tres vertientes fundamentales: 1) conclusión de la investigación etiológica y fundamentación de la fisiopatología

186 A47/VR/7 page 171 de la enfermedad; 2) seguimiento al 100% de los enfermos para diagnosticar y dar solución a cualquier complicación o secuela que aparezca; 3) vigilancia epidemiológica intensiva para detectar precozmente cualquier variación de la incidencia en el país. No puedo terminar mi intervención sin antes transmitirles el reconocimiento y agradecimiento del pueblo de Cuba a las personas, a los científicos, a las organizaciones y a los gobiernos que han cooperado con nosotros para el enfrentamiento exitoso de esta enfermedad y en la acumulación de experiencias que pueden ser valiosas para toda la comunidad científica internacional. En tal sentido, del 12 al 15 de julio de 1994 se ha convocado en nuestro país un taller internacional de neuropatía epidémica, con la idea de resumir una etapa de los estudios realizados por prestigiosos científicos nacionales y extranjeros. Se espera que el resultado científico de esta reunión contribuya a enriquecer los conocimientos sobre diferentes aspectos relacionados con esta enfermedad. Señores delegados, señor Presidente: La difícil situación económica que actualmente atraviesa nuestro país deriva de la desaparición de los lazos económicos y comerciales que teníamos con el antiguo campo socialista y la antigua Unión Soviética, recrudecida por el bloqueo al que hemos sido sometidos por más de 30 años, que hoy se intensifica mediante una injusta enmienda, la ley ТогпсеШ. Creo que jamás se ha atacado en forma tan rigurosa, prolongada y total, en condiciones no bélicas, a pueblo alguno. Bajo estas extraordinarias circunstancias, al país no le quedó otra alternativa que asumir a partir del último trimestre de 1990 un programa de emergencia denominado «periodo especial». Estas medidas en nada tienen que ver con las conocidas políticas de ajustes, pues se han adoptado partiendo del principio de asegurar una adecuada protección a todos los ciudadanos, especialmente a los grupos más vulnerables. Hemos contado, y esperamos seguir contando, con la solidaridad, la contribución y el apoyo de personas, organizaciones y gobiernos en todo el mundo a las que estaremos eternamente agradecidos, pues su actitud constituye un gran estímulo a nuestra lucha para preservar los logros sociales de la Revolución, dentro de ellos, el más preciado del ser humano, su salud. Muchas gracias. Mr FINETTE (Mauritius): Mr President, Director-General, distinguished guests, distinguished delegates, ladies and gentlemen, on behalf of the Mauritian delegation, I would like to congratulate you on your election as President of the Forty-seventh World Health Assembly and extend the same wishes to the other office-bearers. On behalf of my Government and the people of Mauritius, I would like to welcome the delegation of South Africa, which has been given its rightful place in this Organization after a forced absence of nearly three decades. In spite of significant achievements in many countries, and in spite of great technological advances in medical sciences, the world health situation today does not look too bright. In fact, we are becoming more and more conscious that the goal of health for all by the year 2000 will not be achieved in many countries. While this calls for a readjustment of our strategies, we are all too conscious of the many factors far beyond our control which have contributed to this situation, namely, natural catastrophes, sociopolitical conflicts and economic readjustment programmes. In the African Region, years of drought in the recent past, followed by sociopolitical conflicts, are resulting in untold suffering and human misery. The present crisis in Rwanda, with hundreds of thousands of deaths, and the massive migration of people causing unsurmountable refugee problems, illustrates the fragility of all our health strategies and plans for health development. My own country, which has been doing very well economically, has, along with other Indian Ocean countries - Madagascar, Mozambique - and the island of Reunion - been the target of over half a dozen cyclones this year. We must, in spite of all these setbacks, persist in our efforts towards health improvement. The Ninth General Programme of Work presented at this Assembly is a sound and well prepared document which will certainly give us the direction for global action for health development. The Director-General and all those involved with its preparation deserve our appreciation. In Mauritius, the current third evaluation of the implementation of the primary health care strategy shows some encouraging results. Life expectancy is 69 years for males and 72 for females, infant mortality is 19 per 1000 live births. Apart from a few cases of measles, none of the other vaccine-preventable diseases have been registered over the past few years. There are no indigenous cases of malaria. With 74 HIV-positive cases and 22 cases of AIDS for a population of 1.1 million, our AIDS prevention and control programme seems to be quite effective. Population growth has come down to about 1%. This has been the result of a comprehensive family planning programme on which my country embarked in the late 1960s and early 1970s. Tliis programme is centred on health education involving active community participation and also the application of family planning strategies which suit and respond to the socioreligious aspiration

187 A47/VR/7 page 172 of the population. These results are the outcome of government health policies addressing the improvement of the health status of the population, through improved community health services, improvement of the quality of care in hospitals and getting value for money in the health sector. A critical factor contributing to this achievement has also been the strong community participation the country has witnessed since the mid-1980s. The choice of "Community action for health" as the subject of the Technical Discussions at this Assembly is very appropriate. It has proved its efficacy in my country. There are areas, however, where our health programmes are having limited impact. Alcohol and substance abuse is on the increase, in spite of all our efforts to curb the problem. Cardiovascular diseases, cancer and diabetes are still on the increase. Health education programmes aimed at altering lifestyles are not having their desired impact; a 3% reduction in smoking has been noted between 1987 and 1992,but obesity is on the increase. Careful policy planning and strategy formulation for environmental protection has necessitated the institution of a National Environment Action Plan and, with the enforcement of the Environmental Protection Act, we are gradually moving towards sustaining a viable natural environment within the scope of our industrial development. The cause for concern now and in the years to come is the socioeconomic implication of aging. The population over the age of 60,which stood at 8.4% in 1990,is expected to reach 20% by the year The epidemiological transition from communicable to predominantly noncommunicable diseases, an aging population, and an increasing demand and higher aspirations for high-technology medical care, are all indications of the need to increase funding for health. To prepare a better strategy for the health sector, my Government is presently involved in a complete analysis of all fundamental issues besetting the health sector and the delineation of viable solutions which will be based on a policy framework spanning equity, accessibility, efficiency and effectiveness within the ambit of a welfare state. Our main social target will continue to be the attainment by all our citizens of a level of health that would permit them to lead a socially and economically productive life. This can be achieved if we earnestly and honestly embark on a bold initiative, genuinely empowering individuals and communities to become aware of their health needs and their shared responsibilities in doing so. Finally, I wish to congratulate the WHO Regional Director for Africa, Dr Monekosso, for his unceasing endeavour to convey to all the Member States of our Region the potential and strength to develop the minimum district health-for-all package as an instrument to build upon for the attainment of the health-for-all goal. By way of conclusion, I wish to express our profound appreciation for the support given to us by all development partners, United Nations organizations and especially the World Health Organization - through Dr Nakajima and Dr Monekosso - which have worked alongside us in forging a stronger and healthy Mauritian nation. Le Professeur RAJPHO (République démocratique populaire lao): Monsieur le Président, Monsieur le Directeur général, honorables délégués, Mesdames, Messieurs, au nom de la délégation de la République démocratique populaire lao, je voudrais vous féliciter, Monsieur le Président, pour votre brillante élection à la tête de la Quarante-Septième Assemblée mondiale de la Santé, ainsi que les Vice-Présidents qui ont l'honneur de vous suppléer dans raccomplissement de votre mission. Je voudrais également adresser mes vifs remerciements au Directeur général, le Dr Hiroshi Nakajima, et aux Directeurs régionaux, qui oeuvrent sans relâche et avec compétence à la réalisation de l'objectif de la santé pour tous. La décennie 90 a été celle de ^exacerbation et de la multiplication des contrastes 一 entre la croissance, le niveau de développement, les modes de vie et l,accroissement démographique - qui existent entre les Etats, entre les régions, entre les villes et les campagnes, voire entre les quartiers des grandes agglomérations. Les taux de mortalité et de fécondité élevés ont baissé et continuent à diminuer chaque année dans de nouveaux pays. Il est d'autres contrastes qui opposent la diminution des maladies infectieuses à l'augmentation des affections chroniques et dégénératives dues au vieillissement de la population dans le monde. La pandémie de SIDA nous mène à une situation telle que les pays enregistrent une mortalité élevée parmi les jeunes adultes, qui aboutit à une perte considérable de membres actifs et productifs dans la communauté et à un accroissement du nombre d'orphelins à la charge de la société. Et ainsi, l'actualité nous pose un problème qui demande plus que jamais une réflexion déontologique. Depuis Alma-Ata, la notion de santé pour tous recouvre une vision plus large. Comme le disait notre Directeur général : "La santé pour tous n'est pas seulement la santé pour tous les individus, mais aussi la santé par chaque individu à toutes les étapes de sa vie". Des notions plus précises s'y sont ajoutées, telles

188 A47/VR/7 page 173 que la productivité des agents de santé, Pacceptation par les valeurs et la culture locales, enfin l,efficience et l'efficacité de ces agents. C'est aussi la responsabilité individuelle et l'utilisation d'un cadre uniforme au cycle biologique de la vie de l'homme pour lancer des actions en faveur de la santé. Cette responsabilité va de l'étape de l'enfance, en passant par Fadolescence et l'âge adulte, pour se terminer à la vieillesse. L'objectif est de renforcer la capacité et la volonté des individus de prendre des mesures à chaque étape de leur vie, favorables à leur santé, à celle de leur famille et à celle de leur communauté - à la maison, à l'école, sur le lieu de travail et pendant les loisirs. Une importance particulière a été accordée à la planification des activités liées à chacune de ces phases. Nous voudrions seulement mettre en relief les mesures et les activités en faveur de la santé des adolescents et celles qui sont favorables à la promotion de la santé des personnes âgées. En ce qui concerne la santé des adolescents, comme la moitié environ de la population des pays en développement se compose d'enfants et d'adolescents, ces pays pourront tirer des avantages de la réalité des relations entre comportement et santé. Souvent, on néglige la phase cruciale du début de Padolescence : c'est le stade décisif de la vie pour la formation de modes de comportement durables, susceptibles d'influencer la santé. Les efforts visant à améliorer réducation pour la santé et les stratégies favorables à des comportements sains revêtent une importance considérable. Certains comportements ont une incidence néfaste sur la santé : maladies vénériennes, accidents graves dus à Fabus d'alcool et, ces dernières décennies, le SIDA. La prévention des grossesses chez les jeunes adultes doit également retenir notre attention. Aussi faut-il établir de nouveaux programmes pour réduire l,incidence de ces grossesses ou donner des moyens adéquats pour améliorer Pexistence des mères adolescentes et de leurs enfants. En ce qui concerne la santé des personnes âgées, rallongement de respérance de vie, la réduction des taux de mortalité, la baisse de la natalité entraîneront un vieillissement de la population dans un certain nombre de pays en développement. La vie moderne, la migration vers les grandes villes,l'urbanisation, ^industrialisation transforment profondément le sens traditionnel de la famille. La responsabilité de subvenir aux besoins des membres âgés de la famille dépasse la capacité d'une population jeune qui les soutient et dont le chiffre ne cesse de diminuer. D'autre part, révolution de la dimension et la nouvelle structuration de la famille moderne entraînent une modification du rôle des personnes âgées ainsi que des soins qu'elles reçoivent. Aussi ont-elles l,impression d'être abandonnées : elles ne retrouvent plus la chaleur du "foyer", lieu d'affection au sein de la famille,et le sentiment d'être aimées et respectées. Il faut trouver une solution appropriée pour ces personnes afin de leur redonner confiance en elles-mêmes, car elles espèrent retrouver Гатоиг, la compréhension, la commisération chez leurs enfants. Dans un certain nombre de pays, on trouve un système de soutien en leur faveur qui leur permettrait de continuer à prendre une part active à la vie de la société et de la famille et grâce auquel les familles continueraient à subvenir à l'essentiel de leurs besoins. La République démocratique populaire lao a fait son chemin depuis Alma-Ata en ce qui concerne la stratégie de la santé pour tous, un chemin jalonné d'obstacles, de leçons tirées des erreurs comme des succès. L'évaluation de la mise en oeuvre de cette stratégie fait apparaître un certain nombre de réalisations. Elle révèle aussi les fossés qui subsistent entre les riches et les pauvres, entre les grandes villes et les campagnes, entre les citadins et les minorités ethniques. Mon Gouvernement procède depuis une année à une transformation des structures économiques et politiques. Trois résolutions ont été décrétées : elles concernent le développement socio-économique, le développement des ressources humaines et le développement des zones rurales. Tout commence par les zones rurales où 80 % de la population vivent en communautés dans lesquelles chaque famille doit parvenir à un développement durable, car les êtres humains sont au centre des préoccupations relatives au développement. Les services de santé, en collaboration avec d'autres secteurs, travaillent en harmonie avec les communautés pour garantir au moins un niveau de vie minimum acceptable qui réponde aux besoins fondamentaux, tels qu'un approvisionnement sûr et suffisant en eau potable, une alimentation saine et nutritive, un logement convenable. C'est de cette façon que nous diminuons la profondeur du fossé qui sépare riches et pauvres, citadins et campagnards. Le développement des ressources humaines, par la même occasion, est un facteur clé pour mener à bonne fin le développement des zones rurales et parvenir au progrès social et économique. La santé de tous est axée sur la justice sociale et l'équité. L'un des aspects importants de Paction est rengagement à assurer une couverture universelle au moyen de services efficaces, d'une accessibilité qui la rende acceptable en fonction des valeurs et des cultures locales. Pour garantir la qualité, il faut également un personnel efficace et une technologie appropriée. C'est dans cette perspective que mon Gouvernement a décrété en premier lieu deux résolutions : la première concerne le développement socio-économique d'ici Гап 2000 et la deuxième le développement des zones rurales. Ce concept repose sur Finteraction santé-développement et sur une participation

189 A47/VR/7 page 174 communautaire avec l,autoresponsabilité au niveau de l'individu, de la famille et des personnels de santé. C'est par ce moyen que nous aurons la chance de diminuer la profondeur du fossé pour être fidèles à notre engagement pris à l'égard de la justice sociale et de l'équité. Parce que santé et développement sont indissolublement liés, parce que rimportance de la santé est telle qu'il est nécessaire de placer cette dernière au centre des politiques de développement, notre entreprise ne sera couronnée de succès que lorsque nos ressources humaines seront utilisées à bon escient. Une troisième résolution vient donc renforcer les deux premières : il s'agit du développement des ressources humaines. Nous visons premièrement à investir dans le potentiel humain, que ce soit dans le domaine de l'éducation, de la santé ou de la formation, le but étant de permettre aux gens de travailler de façon productive et créatrice, deuxièmement à imposer la nécessité de veiller à ce que la croissance économique soit équitablement répartie, et troisièmement à donner la possibilité à chacun d'avoir la chance de participer à tout plan de développement. C'est un engagement difficile, un devoir qui implique des responsabilités du point de vue éthique et qui demande une participation communautaire avec Pautoresponsabilité au niveau de Findividu, de la famille et des personnels de santé. Avec une volonté et une détermination communes, nous atteindrons sûrement notre but. Dr MAGANU (Botswana): Mr President, honourable ministers, heads of delegations, Director-General of WHO, Regional Directors, honourable delegates, ladies and gentlemen, the delegation of the Republic of Botswana offers its greetings to all delegates and officials of the Forty-seventh World Health Assembly on behalf of the people of Botswana. The delegation congratulates you, Mr President, on your election to this important office, together with the rest of your bureau. Your election confers special honour on our delegation, which you head. I would first like to express our appreciation to the Director-General and to the Chairman of the Executive Board for their reports. These reports are of particular significance this year, as there are subjects dealt with and open to discussion in the Assembly, which are of profound importance for the future of the Organization. Those that specifically come to mind are the WHO response to global change, and the formation of a United Nations Programme on HIV/AIDS. The world is going through a tou^i period of great change. People all over the world are demanding to be heard, they are demanding transparency and democracy. The health sector has not been left behind, hence there is so much criticism of health systems in the individual countries and of WHO at the global level. For our Organization to emerge from this criticism and scrutiny unscathed and stronger, it has to undertake a great deal of introspection and undergo necessary changes. If there need to be changes in its structures, or in its management and budgetary procedures, or even in its approaches to world health issues, then these changes should be implemented. Like all organizations, including ministries of health, WHO has to determine if it is spending its money on priority health problems and not simply satisfying a selfmaintaining bureaucracy. This exercise needs to be undertaken to salvage the image of WHO, so that it can continue to attract extrabudgetary funds that are so important for some of the programmes. The Executive Board is to be given due credit for its exercise on the WHO response to global change, which addresses the very concerns I have just raised. We all know that it is not only the politics of the world that are changing but, concurrently, the economics. We also know that economics has a most profound impact on health because, when there is economic growth, then money is available to households and to governments for spending on items essential for better health. The world is dividing into major economic blocks, and the weak countries of the world are becoming marginalized, with dire consequences for their health services. We can only hope that the new economic order, which advocates free market systems and the free flow of goods across borders, will not serve only to further impoverish the smaller economies and hence cause a deterioration in their health situations. We shall trust WHO to act as the advocate for weak countries in these difficult times. WHO and UNICEF have done a commendable job sensitizing the world to the impact of structural adjustment programmes, and work should continue on studying the impact of fluctuating economic performance on health care and health status. Permit me to say a few words on ethics and health, the subject which has been recommended by the Executive Board to be given special attention by delegates when addressing the plenary. Ethics is the central guiding principle in the practice of all health professions. However, developments in the health field over the last few decades have affected the attitudes of both the health workers and the public in relation to ethics. Whereas in the early days of medicine, for example, practitioners were self-

190 A47/VR/7 page 175 employed and essentially part of the community in which they practised, medical and other health practitioners are now largely employees of either big establishments and conglomerates, or large government hospitals. Services provided have thus become impersonal, and the relationship between the practitioner and the client has become more mechanical than personal. My delegation believes that a lot can be done to improve ethics in health services by incorporating the requisite elements into the education of physicians, nurses and other professionals. The management of public health services also needs to be conducive to good ethics on the part of employees, by making them feel they are part of the decisionmaking processes. In this very forum, the Health Assembly, many issues of great ethical importance have been discussed. Two very important ones have been the marketing of breast-milk substitutes and the marketing of pharmaceuticals. It is well known that it is the profit motive that led to unscrupulous marketing practices in both these areas, where the ignorance of consumers was exploited in order to secure higher sales. The role played by WHO in rationalizing the marketing practices of the manufacturers of these commodities is commendable. There is no end to the areas in which the application of ethics in health is critical. Commercialization has crept into such important components of medical care as organ transplantation, blood transfusion and in vivo and in vitro fertilization. One reads about people being induced to sell their organs or their blood, and they do it to try to alleviate the poverty under which they live. However, those who induce them to do it must be subjected to very strong sanctioning. There is great scope for international cooperation in curbing such practices, because this kind of trade usually transcends borders. WHO should become one of the lead organizations fighting the trade in human organs, blood and similar products. Ethical issues involving biotechnology in relation to human beings are probably still to a large extent confined to the developed world, as they are technology-intensive and expensive. They present a combination of moral and practical issues that will occupy great minds for a long time. Subjects like artificial procreation {in vitro fertilization), surrogate motherhood, prenatal diagnosis of hereditary diseases, malformations, gender and genetic screening and testing, are all subjects that _ while offering mankind great opportunities - can also be exploited for gain and tempt people to ignore basic morals. Since the basis of morality itself differs from society to society, each country needs to promulgate its own laws regulating biotechnology in medicine. But like so many other controversial matters, countries can learn from one another's experience, and this is where WHO is so important. The Organization should continue to be a clearing house for new information relating to these issues and to support those countries that do not have the expertise to develop their own regulatory and legal instruments. It is therefore our hope that WHO will generally help develop the capacity of developing countries to cope with issues relating to ethics. In addition to developing legislation, these countries need also to be helped to put monitoring mechanisms in place. It is, however, for each country to end up deciding on its own principles, as is the case with the interminable controversy on abortion. Professionals should also be helped to cope where their personal principles differ from those of societies or governments. This is a big and complex subject. My delegation only hopes it will in future receive the attention it deserves. To conclude my address, let me wish you all fruitful discussions in this Forty-seventh World Health Assembly. There are many subjects of great importance and I am confident that this Assembly will deliberate them frankly and sincerely, and come up with decisions that will be truly responsive to the current world health situation. I would like heartily to welcome our neighbour, the Republic of South Africa, back to active participation in WHO. I know that southern Africa will be much the richer for the inclusion of South Africa in the various sub-regional organizations. Mr CHRISTOPHIDES (Cyprus): Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, every year we devote a considerable proportion of time to thanking and congratulating the President and the Director-General. As it is virtually impossible for the human mind to devise more than 150 different ways of expressing our thanks and congratulations, the result is a stereotyped repetition. I am of the opinion that it would have been better to follow a new practice - to adopt a unanimous resolution expressing our appreciation and thanks to our colleagues and officials. Without prejudice to this submission and following the standard practice, I would like on behalf of the Republic of Cyprus to congratulate you Mr President on your well-deserved election to the Presidency of the Forty-seventh World Health Assembly. I have no doubt that your wisdom, experience and skills will guide our deliberations to successful conclusions. I also

191 A47/VR/7 page 176 wish to convey my sincere gratitude to the Director-General, Dr Nakajima, the Regional Directors and the staff of the World Health Organization for the excellent preparatory work and the dedication being displayed in organizing this Assembly. We salute the victory of democracy in South Africa. We share, in this historic moment, the enthusiasm, the joy and the pride of the people of South Africa, and we wish them every success in the difficult course for justice, democracy and freedom, peace and happiness. We wholeheartedly welcome the re-entry and participation of South Africa as a full Member in the activities of WHO and its Assembly. Following the historic Declaration of Alma-Ata, most countries adopted health policies to achieve the ambitious goal of health for all by the year Today, at the threshold of the twenty-first century, only five years before the year 2000,let us ask ourselves whether this goal is within reach, or is it still an elusive remote and unachievable target? It is undeniable that the progress achieved in the field of health is both substantial and spectacular. Many countries are justifiably proud of having provided their citizens with adequate health care at all levels and have achieved enviable health standards for their entire population. A substantial share of the credit goes to WHO for the imaginative and pioneering programmes it has initiated and promoted, and for the wisdom of its leadership in coordinating the world struggle for health. But it is also indisputable that the ambition of offering adequate health to everybody has not yet materialized and has not fulfilled mankind's great expectations. Many regions of the globe still have a long way to go in the short time before the end of the century. ТЪе plight our fellow citizens find themselves in in some of the poorer developing countries constitutes an insult to human dignity. Over 780 million people or 20% of the population of the developing countries are undernourished. Nearly 13 million children under the age of five die every year from infections, hunger and malnutrition. We cannot plead ignorance of this situation, as the media bring these shocking scenes into our homes every day. Poverty, the prime cause of hunger and malnutrition, is exacerbated by rapid population growth, an unhealthy environment and lack of education. The lack of sufficient energy in the diet and micronutrient deficiencies cause severe illnesses and disabilities. It is a sad fate to escape death in childhood only to face the rest of life with chronic health problems. The following words of the late President John Kennedy match in the best way with the spirit of the Alma-Alta Declaration: "I believe in a society where every family can live in a decent home in a decent neighbourhood, where children can play in parks and playgrounds (not the streets of slums), where no home is unsafe or unsanitary, where a good doctor and a good hospital are neither too far away nor too expensive, and where the water is clean and the air is pure, and the streets are safe at night". According to a wise proverb, "health is wealth", but it should not escape our attention that "wealth is health". International communities should wage an effective total war on poverty. The challenge to fight poverty knocks on our door. In the meantime, the development aid for health which represents a mere 2.5% of health spending in developing countries should be increased generously. It is paradoxical that countries have, at the same time, to fight the health-related problems deriving from affluence. They have to take measures against the so-called lifestyle diseases, such as heart disease and certain cancers which are in constant increase not only in developed countries but also in many developing countries. These diseases of civilization constitute a severe drain on the economy by wasting valuable human potential. I am tempted to mention here the experience from my own country, where as a result of the western type of diet coronary heart disease and cancer now constitute the two major causes of morbidity and mortality. According to a report published more than 100 years ago, these diseases were then virtually unknown because of the healthy and simple Cypriot diet consisting mainly of bread, onions, olives and olive oil - the famous traditional Mediterranean diet. Unfortunately, poverty and famine and the diseases of affluence are not the only challenges of today's health-related problems. Tuberculosis, and the old foe malaria, and the AIDS pandemic have appeared in the arena, despite the success in controlling many of the traditional communicable diseases. Today we are witnessing an explosion in the number of elderly people and we face the urgent need to reform current health care systems and offer to this expanding segment of the population good quality care which it has earned and deserves. To tackle the problem of aging is a challenge for us all. It is of the utmost importance to adopt policies and to reallocate public funds from tertiary medicine to public health and essential clinical services, the most cost-effective way of improving the health of the population. It is imperative to introduce proper management methods and techniques to reduce avoidable inefficiencies and waste in the system. It is also high time to take into account the health impact of economic policies, otherwise our health care system will be facing increasing severe strain which will constitute another impediment to progress. We live in an era when medical knowledge has given us the capacity to intervene in the life of the individual and in the development of society as a whole. As a consequence legal and ethical questions arise

192 A47/VR/7 page 177 and new issues of an ethical nature call for urgent consideration. The answer is to be found in the spirit of the Hippocratic oath, which for two-and-a-half thousand years has constituted a safe and tested guidance. However, as we approach the twenty-first century, the progress in medical technology and the development of society gives rise to other problems beyond that of patient autonomy and informed consent. Health is a fundamental human right and it is a contradiction to show interest for health but no interest for life. It is also a contradiction to include among our targets for the year 2000 the increase of life e^ectancy and yet to remain apathetic when millions of young people are losing their lives in armed conflicts around the world. WHO has an imperative duty to raise its voice in every international forum and demand absolute respect for the inalienable rights of health and life. The presence at our Assembly of the Chairman of the International Olympic Committee reminded us of the wise maxim from classical Greece "a healthy mind in a healthy body" and also the practice of suspending hostilities during the Olympic Games. Today, the world community wages the Olympic struggle for health, health for all by the year It would be worth emulating this unique and wise practice in our turbulent world by suspending hostilities even for a symbolic period of time every year during the Olympic struggle for health. WHO has a particular duty to stress and advocate that war and all forms of violence are socially unacceptable. WHO should take the initiative and lead the way. The PRESIDENT: The next speaker on my list is the delegate of Ecuador, who will speak on behalf of the following Andean countries: Bolivia, Chile, Colombia, Peru, and Venezuela. The chief delegates of these countries are seated on the rostrum. Before giving the floor to the delegate of Ecuador, due to pressing commitments, and the fact that he will speak a little longer because he is representing several delegations, the meeting will close after his speech. El Dr. ABAD (Ecuador): Señor Presidente, señor Director General, distinguidos delegados: En nombre de los países andinos: Bolivia, Colombia, Chile, Ecuador, Perú, Venezuela, a los que represento, me place felicitar al señor Presidente por su elección y a la vez manifestar nuestra complacencia por el reingreso de Sudáfrica a esta Organización tras 30 años de aislamiento; esta actitud demuestra que en materia de salud ni la religión, ni la raza, ni las ideologías pueden ser un impedimento para buscar cooperadamente la ansiada meta de salud para todos en el año La subregión andina es un escenario de gran complejidad, donde un sinnúmero de enfermedades impiden el normal desarrollo de nuestros pueblos. La América andina tiene que resolver grandes desafíos sanitarios como es la alta mortalidad maternoinfantil, la elevada prevalencia de enfermedades transmisibles como el paludismo, el dengue y la tuberculosis, y otras prevenibles como el sarampión y el tétanos neonatal. La presencia de enfermedades diarreicas y de infecciones respiratorias contribuyen junto con la desnutrición y la deficiente infraestructura sanitaria a que tengamos que continuar lamentando la desaparición de muchos de nuestros niños menores de cinco años en proporciones realmente preocupantes. Los esquemas tradicionales centralistas de administración en la salud bajo la premisa de que ésta no tiene precio y que el Estado debe ser el proveedor exclusivo han hecho que los conceptos de eficiencia y equidad vayan desapareciendo. Quienes realmente necesitan del subsidio por parte del Gobierno no alcanzan a recibir una atención digna y de calidad. Por otro lado, la ausencia de elementos gerenciales para el manejo de la compleja situación sanitaria de nuestros pueblos ha hecho que los bajos presupuestos que los gobiernos asignan sean manejados con poca eficacia. Este panorama ha obligado a que los países andinos iniciemos reformas importantes tratando de cumplir con los principios de eficiencia, eficacia y equidad. El Gobierno de Venezuela describe sus estrategias en la acción preventiva buscando mejorar sus servicios. El Estado venezolano, rector de las políticas de salud, se encuentra empeñado en un proceso de descentralización que involucra la reforma de la seguridad social dándole un papel preponderante a los gobiernos regionales. Una concepción nueva de atención hospitalaria permitirá redimensionar el papel que juega esta institución en la red de atención médica. Con la focalización de sus programas maternoinfantiles y con la ejecución del programa ampliado de inmunización lograrán alcanzar una cobertura de salud que sirva a por lo menos el 80% de la población de alto riesgo en los años siguientes. Chile ha dado claras demostraciones y avances al haber implementado reformas tempranas en relación a los otros países del área. Los índices de mortalidad maternoinfantil han disminuido importante-

193 A47/VR/7 page 178 mente. Los procesos de descentralización, desconcentrando su administración en los gobiernos regionales municipales e incorporando los seguros privados de salud, han puesto a este país en una situación ventajosa. Hoy la preocupación mayor es la búsqueda de mecanismos que permitan acceder a todos los sectores sociales con mayor equidad a un sistema de calidad. Las tareas en materia de políticas de salud se han hecho más complejas por la transición epidemiológica y demográfica; hoy el pueblo chileno tienen condiciones ambientales y humanas asociadas al subdesarrollo que coexisten con causas de enfermar y morir más parecidas a un país desarrollado, pues sus principales causas de muerte son enfermedades cardiovasculares, tumores y accidentes por violencia. Perú, gracias al esfuerzo de su pueblo y Gobierno, ya no es una zona amenazada por la violencia y el terrorismo. Las condiciones para favorecer el desarrollo adecuado de su pueblo han sido definidas. La reforma del sistema de salud se orienta a la descentralización y regionalización en un ambiente de coadministración entre la comunidad y el Estado. Ha iniciado un programa de fortalecimiento en los centros y puestos de salud basados en el equipamiento y capacitación de recursos humanos en cerca de 3000 unidades operativas. El Ministerio de Salud peruano aspira ampliar su programa de vacunación alcanzando una cobertura del 85% al 90% de la población en los próximos años. El programa de lucha contra la tuberculosis ha sido reconocido por la Organización Panamericana de la Salud, y se aspira a erradicar la poliomielitis para finales de Las cifras de cólera en este país del sur han disminuido importantemente en los últimos tres años. Bolivia ha reestructurado su poder ejecutivo y ha creado los llamados Superministerios de Desarrollo Económico, Desarrollo Humano y Desarrollo Sostenible, cuya misión fundamental es lograr niveles aceptables de desarrollo social. Con esta nueva visión la salud, junto a los demás sectores componentes del desarrollo social, ha sido ubicada de manera preponderante en la estrategia del desarrollo humano. La descentralización a través del fortalecimiento de las secretarías regionales de salud, ex unidades sanitarias y los sistemas locales de salud (SILOS) facilitan y amplían la participación social en los niveles institucional y popular y buscan el objetivo central de extender la cobertura de servicios y reducir los altos índices de morbi -mortalidad que actualmente tiene este país. Se aspira durante este año a erradicar el sarampión en una campaña masiva que va a iniciarse en los próximos días. Con el asesoramiento de organismos internacionales y nacionales no gubernamentales se inició un proceso de transferencia de servicios a la comunidad basados en la administración privada, lo cual ha sido reconocido fuera de sus fronteras como un ejemplo de iniciativa en la coparticipación entre comunidad y Estado. En Colombia el sector de la salud ha estado tradicionalmente dividido en tres subsectores, cada uno de ellos para un grupo social diferente. El público, dirigido a atender los grupos sociales más débiles; el privado, que a un alto costo cubre el 12% de la población con mejor capacidad de pago; y el subsector de la seguridad social orientado casi exclusivamente a la población económicamente activa asalariada con una cobertura cercana al 20% de los habitantes. Hoy Colombia ha empezado la construcción de un nuevo sistema, novedoso y ambicioso, que integra todos los elementos del fragmentado y caótico que los ha regido hasta ahora en un sistema único, el sistema general de la seguridad social en salud, que por mandato de la Constitución y de la ley deberá garantizar a todos los colombianos los servicios contenidos en un mismo plan obligatorio de salud. Esta ley constituye una síntesis equilibrada entre la vieja utopía, salud para todos, entendida ésta casi como sinónimo de universalidad, integridad y equidad y, por otro lado, lo que podríamos llamar los valores de la modernidad, la eficiencia, la calidad y la competitividad. Mi país, el Ecuador, ha marcado como un claro reto la dura responsabilidad de encontrar un nuevo rumbo para los sistemas oficiales de salud en las vísperas del siglo XXI. Ese reto no es otro que el de ofrecer más y mejores servicios a una población que crece y requiere atención de mejor calidad en el contexto de una situación económica, social y política como la presente, signada por una de las peores crisis que ha afectado significativamente el financiamiento de los programas sociales y por el cuestionamiento más importante formulado al papel del Estado. El Ministerio de Salud Pública del Ecuador pretende el desarrollo de un solo sistema nacional de salud que contemple políticas y estrategias que permitan a todos los ecuatorianos acceder al derecho de la salud. Esta misión no es responsabilidad única del Estado, si no de toda la sociedad, buscando un equilibrio entre lo público y lo privado. La reforma sanitaria se fundamenta en el rediseño de la organización y la dinámica del Ministerio de Salud, mediante la desconcentración y descentralización de los servicios organizados en redes locales de atención denominadas áreas de salud. El país ha sido dividido en 180 áreas, que son espacios geográficos con administración autónoma y que únicamente dependen de la planta central del Ministerio en cuanto a normas y políticas; la operación y ejecución está desconcentrada. El fortalecimiento de los servicios básicos de salud, con especial énfasis en la dotación de servicios de agua segura y letrinización son argumentos sólidos a nuestra gestión; en las áreas de salud la cobertura en la atención maternoinfantil deberá llegar a más del 80% de la población en los próximos años. La

194 A47/VR/7 page 179 participación comunitaria, de las organizaciones no gubernamentales y de la empresa privada es esencial en el nuevo enfoque de la administración de salud. Nos encontramos en el proceso de asignar un costo a los servicios, para aquellas personas que puedan contribuir económicamente. La gratuidad absoluta para quienes no pueden pagar un costo se encuentra garantizada mediante el sistema de subsidios cruzados. La consecución de un programa de medicina genérica con fármacos de reconocida calidad y de bajo costo deberá darse durante este año. El desarrollo institucional del sector de la salud implica la disminución del número de empleados administrativos, la racionalización de la utilización del recurso humano y el mejoramiento del personal médico y paramédico. Las reformas legales que están en curso permitirán la reestructuración de varias dependencias del Ministerio, la participación activa de la empresa privada como proveedora de salud, la real descentralización y la apertura de un mercado farmacéutico incentivado por la oferta y la demanda. Finalmente, es claro, señor Presidente, señor Director General, señores delegados, que el propósito de modernizar los sistemas de salud de los países andinos es un objetivo prioritario. Pensamos que buscar la eficiencia administrativa y financiera es la única alternativa viable para llegar de manera justa y solidaria a todos los sectores de nuestra población. Los logros y fortalezas podrán ser alcanzados únicamente en un ambiente de cooperación e intercambio entre todos los países del mundo. Muchas gracias. The PRESIDENT: I thank the delegate of Ecuador on behalf of the other countries, namely Bolivia, Chile, Colombia, Peru and Venezuela. Mr HAMAD AL THANI (Qatar): : ( 0b jt huji í l^ujuj! '«LJ^xJuJ pujl ^Juj!,. t^acuuji. " " <JJJ! r,lg t^-u)ухгчхл j^i^jl t LâcI^ 件 UjuI ^^Jl Isj^JL e 0 i^zujs c ju c 01 J^ j/l JRI^ ЪКЛСЛ FUJI ^JUJI J J 0) J/L US I Ô^JJI áíjlo Lo ^-Ь rt^o-.-lav\ Ш L ^-JLoLaJI ' juji 己 )^Juíji;.!! ^.UuJl 户 ^! cli^ijsj) t ijijuji LgJUl ci^íji ^il^l Ü :J LIJB ^ J \JJ\ ^ ^JBJ 尸 L J I FUJI J U J Ü O L J^iy Cr frf^ oh 4 f ójoju» jlk^íl) jjlji JAAJI JJJ^ U-. 厶 ' < L J L Y ^ ^JUJ! FU/L JS M J L ^ O ^ U J L ^ jucüi '(LUJLAJI '<UUJI 己 g,v> C 0 J.50 l^u. 4 ^Uw^Vl^ jil^jj! ^ j^j^ji jj /. ^Jx U^u^v l v-jlc^, ijjè ^ di^^o ^jsz 1 3 ^ 1 JoajJI i ó <i->v4 l^ áj^j J- 0 -^ ob < 1 U L J I Li ^ LoJ I Cl/Lo^iJI ^JS. 匕,.«> ^-lij^i I ^^i^jl F U/L, ^ ^UJ^ J DWI L~ J Î ( ) I I ^ O t l g "«."V L^O,..; áj^jt^o j!t>3 J j^jíz^ ^_L>JI 山 J ^ Jl>I jixs «Ü^ J \ I^JMjlIWI A-.1 JO jju> Í jbj dj^j ^^J/^uJl ^jojs> JLD^ l^l^hol. L^xaJ Lg-jHu/ 1^>ÍO Ô. r/- ^^ÛJLJI ^! з ^jlásji ^wii^ji LJ ji-» 1'«L^Jl ci,ujl JÍ ^ 彡二 ^Jj ^^^JU J-олЛ ^JLc ci.l^u^^! 3 ^^cj! JU^JI Ju»jJI cl^l^jl з^цо ^ls. U^b 尸 SLs jjj\ L 丄 I i lg ÜJUOH L.,I_. 力 ÔJJLU LO D-^ЛГЛ DU>A J 1 ^ ^E H^UJ I JJ-JI '«LL^J! C^LI^JU ^! IJJÂJ DJLI T D J ^ J ) 1 ^UoJI l-g-lo^i-, ^ l ^ lu,lo) -jíjzz di,..,.. II JUffl 0 U d-u>üji ci,m iju 3 á-jlui^ '^^LJI ÓLuJI y, ^jlb QS Lü) Í '^Lii^l^ Á-^Lux-^l ci/li^juji ^o '<Lli^Jl LJ j ^Jl Lá^ 'áuuaco *<iibj^j La)".g yz^ j^j 1 j П ^J13 p UU Lj^i.) I )

195 A47/VR/7 page 180 llloj I ^ ^-owxj^j I [ J^y-*^ j^j^^j t jècui ^suqjviio j ^ixs ÂJ^ J ^-JwJ I JlS^ L&ü.: duij^ül J-Ú_ÍÜ1 广力 "ÁÍ.-C-JI '«LLs^J "<3UJUÜ1 '«LvL^Jl,^ L^^Lo^ dj^-jl, ILLsCuJI LAJ I <L=>WOJ I JRÍJ3 I Ó JLA ^JAJ I YSB J I ÓZ LOJJV JLÏU» DJ ^-«JI JJL Л.. G Q " J L>WO Loi â^ujl^j jji.jrjl jjwfc^ Lo djl> JA.,'ig л )! ^JÀ! J^AI I v9 L^iZS I 产 Lû J ^ Jl^ rt_..'.g о ) I <i->w«aj 1 ^ИЛЗ ^^JU^.Л. ) I «î j I ci» Le IjmûJ I j jj I ^Js Lio ^aj^co z Ub L ^ - s Lg-ii^ Cl/ Lo Ju> A-o 1 duxaûj 1 à j! ^J! lg.4a.4o ^IlJ I <L**vj JuoJ 1 d^ixûj I Cl^ Lo^lSÜ La I y, 己亡 jl^^bjj U^J 1 ^ '<L-JaJI J 么丄二 i «气气 ^Lc "<L^cJ1 '<LUjJÍ.diJjJ ' ллол J^l jl^ji _» 4«丨 ^-t*/j JuoJ I (J^-CCÍJU loj^ji Cl/Ló-oüsCJ! dji ^ ^-JUcJI ^Jl JwA:J-оЪ LuU ^Jai ' J3JU, 3 doül JJ 3-co^uJI 山 ^ UMJaj! 3 二丄 Í V J^JL^ ^..q.-s, 1 ) I : ysb^ d-ujuüi dowvcji '«LxJá-Lc «ц. ^^Li^ ^JJI3 J,. _.uj 1, g )I.. a J U I 'Loj^J^ 3.^JLsi^ AJUI The PRESIDENT: Before I adjourn the meeting I would like to remind you that inscriptions for the list of speakers for items 9 and 10 will be closed after this meeting. I would also like to remind you that the General Committee will meet now in Room VII, and the meeting of the Credentials Committee will take place tomorrow in Room IX at 14h30. The meeting is now adjourned. The meeting rose at 17h20. La séance est levée à 17h20.

196 A47/VR/5 page 181 NINTH PLENARY MEETING Friday, 6 May 1994, at 9h00 Acting President: Dr В. VOLJC (Slovenia) NEUVIEME SEANCE PLENIERE Vendredi 6 mai 1994,9 heures Président par intérim: Dr B. VOLJC (Slovénie) DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-SECOND AND NINETY- THIRD SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO IN (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR GENERAL SUR L'ACTIVITE DE VOMS EN (suite) The ACTING PRESIDENT: Hie meeting is called to order. Distinguished delegates, ladies and gentlemen, I am very pleased to have the opportunity to serve as President of the Assembly this morning. Before we continue with items 9 and 10,I should like to report to you the decisions of the General Committee regarding the Programme of Work of the Assembly. Last evening, the General Committee decided that the debate on items 9 and 10 will continue today in plenary concurrently with the Technical Discussions this morning. In the afternoon, the plenary will consider item 14. The General Committee decided that this will be followed by items 9 and 10, if these are not finished in the morning. Committee В will meet in the afternoon following item 14. On Saturday, 7 May, in the morning, Committee A will meet concurrently with the Technical Discussions. On Monday, 9 May, both main committees will meet at 9h00. Given the progress on the programme of work in the main committees, consideration of document A47/15, on the Joint and cosponsored United Nations programme on HIV/AIDS, and agenda item 21,will be transferred to Committee B. The plenary will meet at 12 noon to adopt reports from the main committees and to consider item 12, "Election of members entitled to designate a person to serve on the Executive Board". Following this, the General Chairman of the Technical Discussions will present a report. If necessary, the General Committee will meet at approximately 12h40 to review the progress of work. In the afternoon, both main committees will meet. On Tuesday, 10 May, both main committees will meet at 9h00. At llhoo, the plenary will meet to approve the reports of the main committees. At 12 noon, as I mentioned previously, there will be a ceremony concerning the establishment of the foundation for the prevention of substance abuse, during which Her Majesty, the Queen of Sweden, will address the Assembly. In the afternoon, both main committees will meet. On Wednesday, 11 May, Committee В will meet in the morning and afternoon, and it will also be necessary for Committee A to meet. At llh30, the plenary will meet to approve reports of the main Committees. On Thursday, 12 May, the main committees will meet at 9h00 to finalize drafts and reports. At llh30, the plenary will approve the reports followed by item 16, "Closure of the Forty-seventh World Health Assembly". We shall continue the debates on items 9 and 10. Since we agreed to close the list of speakers yesterday evening, I now ask Dr Piel, Director, Cabinet of the Director-General, to read out to you the remaining speakers on my list. Dr PIEL (Cabinet of the Director-General): Thank you, Mr President, I will read out the names of the remaining speakers on the President's list: Colombia, Barbados, Cape Verde, Bahamas, Bolivia, Namibia, Eritrea, Belgium, Suriname, Democratic

197 A47/VR/7 page 182 People's Republic of Korea, Federated States of Micronesia, Mongolia, Iraq, Solomon Islands, Czech Republic, The Former Yugoslav Republic of Macedonia, Cambodia and Zaire are to be taken this morning and, if time permits, Angola, Ethiopia and Palestine. Now, due to the tightness of our schedule and other important appointments, it may be necessary to carry the last two or three speakers over into the afternoon, in which case they will follow the 20-year commemoration of the control of onchocerciasis, which is scheduled to take place at between about 14h30 and 15h00. So, Mr President, those are the remaining speakers on your list. The ACTING PRESIDENT: Thank you, Dr Piel. I now call the first two speakers on my list, the delegates of Colombia and of Barbados. And I give the floor to the distinguished delegate of Colombia. El Dr. ALVARADO SANTANDER (Colombia): Señor Presidente, señor Director General, señores delegados: En nombre del Gobierno de Colombia, queremos felicitar al Sr. Presidente por su elección y desearle el mayor de los éxitos en la conducción de esta Asamblea, para lo cual le ofrecemos todo el apoyo de nuestra delegación. Felicitamos ai Sr. Director General por el informe presentado a la 47 a Asamblea Mundial de la Salud, al tiempo que le manifestamos nuestro agradecimiento por la permanente colaboración brindada al país para el desarrollo de algunos programas prioritarios. Actualmente en la región, y probablemente en el mundo entero, están siendo cuestionados los sistemas de salud de los países, tanto por el desencanto de los usuarios como por la frustrante evaluación que por parte de los técnicos y las autoridades de salud se ha venido haciendo sobre su gestión. En esta oportunidad el Gobierno de Colombia quiere compartir con la comunidad internacional, y con la OMS en particular, la euforia que embarga al país por el logro, al término de 1993, de una ley que transforma radicalmente la concepción, la estructura y los procesos de nuestro sistema de salud, de tal manera que se corrigen los ancestrales defectos que mantuvieron nuestro sistema con bajos niveles de cobertura, aberrantes manifestaciones de desigualdad y graves problemas de eficiencia y calidad. Tradicionalmente el sector de la salud de nuestro país ha estado dividido en tres subsectores, cada uno de ellos para un grupo social diferente. El público, dirigido a atender los grupos sociales más débiles, con criterios de caridad más que de garantía de un derecho humano, y además con frecuentes problemas de financiamiento; el privado, que a un alto costo cubre al 12% de la población con mejor capacidad de pago, y el subsector de la seguridad social, orientado casi exclusivamente a la población económicamente activa asalariada, con una cobertura cercana al 20% de los habitantes. A pesar de la existencia de esas tres estructuras, que invierten en total en salud alrededor del 7% de nuestro producto interno bruto (PIB), uno de cada cuatro colombianos no tiene acceso a los servicios de salud. Hoy, Colombia ha iniciado la construcción de un nuevo sistema, novedoso y ambicioso, que integra todos los elementos del fragmentado y caótico que nos ha regido hasta ahora en un sistema único, el Sistema General de Seguridad Social en Salud, que por mandato de la Constitución y de la ley deberá garantizar a todos los colombianos los servicios establecidos en un mismo plan obligatorio de salud. Queremos destacar que este significativo avance está en consonancia con la Declaración Universal de Derechos Humanos, que incluye la seguridad social como uno de ellos, el cual debe desarrollarse de manera integral con un componente de salud de amplia protección, un mecanismo de sostenimiento altamente solidario y una estructura de funcionamiento plenamente eficiente que incorpore sin duda los grandes avances conceptuales logrados a instancias de la OMS en relación con el énfasis requerido en materia de promoción de la salud y prevención de la enfermedad. A nuestro juicio, el texto logrado en la ley de seguridad social, que es apenas la primera piedra de este gran desafío, constituye una síntesis equilibrada, ecléctica quizás, pero ante todo necesaria, entre dos propósitos para algunos incompatibles, pero para nosotros inseparables en un país que quiere afrontar con decisión los retos del siglo XXI; por un lado, la vieja utopía ni siquiera avizorada en el horizonte de nuestro país, Salud para Todos, entendida ésta casi como sinónimo de universalidad, integridad y equidad; por otro lado, los que podríamos llamar, valores de la modernidad: la eficiencia, la calidad y la competitividad. La combinación de aquello que para muchos es agua y aceite puede ser la clave del desarrollo exitoso de los sistemas de salud de muchos de nuestros países.

198 A47/VR/7 page 183 El desarrollo económico de la región y la transición epidemiológica que lleva aparejada hacen necesario un sistema que no sólo atienda los problemas de salud pública asociados a las enfermedades transmisibles y a los problemas de salud maternoinfantil, los cuales no han sido superados a pesar de los importantes avances logrados, sino que aborde también decididamente el control y prevención de los trastornos cardiovasculares, el cáncer, la drogadicción, el VIH/SIDA y fenómenos como la violencia, que ha sido particular y dolorosamente epidémica en Colombia. Para este propósito, nada más oportuno que un sistema de seguridad social integral que, dependiendo de lo que hagamos de él, podría ser una herramienta útil en la construcción de una auténtica cultura de la salud, férreamente articulado con todo el sistema de salud pública, y no solamente un costoso mecanismo de protección y curación frente a las patologías causadas por nuestros estilos de vida poco saludables. Nuestro sistema pretende lograr en un lapso de 10 años la cobertura universal, mediante la afiliación obligatoria de todas las familias,la contribución proporcional a sus ingresos económicos de todas las personas con capacidad de pago, y el subsidio de la afiliación de los más pobres con recursos fundamentalmente estatales. Introduce además la competencia entre múltiples entidades, públicas, privadas y otras de economía social solidaria, y la libertad de elección por parte del afiliado sin restricciones por causa de su condición social o económica. Para garantizar la solidaridad y evitar la selección del riesgo por parte de los aseguradores en competencia que se denominan Empresas Promotoras de Salud, se ha creado un fondo nacional único llamado Fondo de Solidaridad y Garantía, el cual reconoce a cada una de éstas una unidad idéntica en dinero por persona y tiempo, sin tener en cuenta la diferencia de las aportaciones individuales al sistema. Se han previsto mecanismos de prevención y control de la selección adversa contra grupos sociales susceptibles como los ancianos, los enfermos, los pobres y las mujeres en edad fecunda. Toda esta gran reforma supone una adecuación urgente de la infraestructura pública de servicios de salud y su actualización tecnológica, pero ante todo el mejoramiento y adquisición de herramientas de gestión hospitalaria que les permitan adaptarse a las exigencias del nuevo sistema. Ya estamos avanzando en esa dirección,al tiempo que se consolida un proceso de sustitución parcial del subsidio a la oferta de servicios de salud por el subsidio a la demanda de los mismos, que tiene como resultado un incremento global de los recursos públicos destinados a la salud, sin que por ello el gasto total en salud como participación en el PIB amenace con desbordarse. Los estudios de carga de la enfermedad y de costo-eficacia de los procedimientos serán en adelante el soporte técnico para la definición concertada de los planes de salud, una vez hecho el inventario de necesidades y recursos. Por fortuna, esta revolución sectorial se acompaña de un vigoroso proceso general de descentralización política a nivel nacional que entrega la responsabilidad y los recursos a las autoridades locales y posibilita sin cortapisas una auténtica participación de la comunidad en la toma de decisiones sobre aspectos cruciales que atañen a su salud, e incluso, en algunos casos, en la administración de los recursos del subsidio a la demanda a través de empresas solidarias de salud. Deseamos invitar a conocer y seguir la experiencia que apenas comienza, y especialmente solicitamos la colaboración de los países, la OMS y demás organismos internacionales en este proceso de implantación del Sistema General de Seguridad Social en Salud, al tiempo que deseamos que la OMS haga cada vez más hincapié en el análisis del tema de la seguridad social, en sus principios teóricos, en sus mecanismos de funcionamiento y en sus múltiples posibilidades. Finalmente queremos manifestar que Colombia se siente orgullosa de haber ofrecido al mundo la vacuna antimalárica. Sabemos que los estudios que adelanta la OMS, así como los desarrollados en Colombia por el científico Manuel Elkin Patarroyo, brindarán a la humanidad la seguridad de contar con un valioso instrumento en la lucha contra el paludismo. Continuaremos trabajando en la producción de ésta y otras vacunas de carácter sintético y en la difusión de otras experiencias innovadoras de organización de la gestión de los servicios de salud, como el manejo de los suministros o el mantenimiento de equipos hospitalarios, que pueden ser de utilidad para otros países cuya situación es parecida a la nuestra. Por último, señor Presidente, manifestamos nuestro decidido respaldo a la propuesta del Sr. Presidente saliente en el sentido de realizar esta magna Asamblea cada dos años y destinar el excedente a programas de salud en países que tienen grandes necesidades de apoyo económico y técnico. Muchas gracias, señor Presidente.

199 A47/VR/7 page 184 Mr WALKER (Barbados): Mr President, my delegation joins in congratulating the President and the Vice-Presidents on their election to preside over the Forty-seventh World Health Assembly. I am sure that under their guidance our deliberations will reach a successful conclusion. I take this opportunity to welcome Niue and the Republic of Nauru to the World Health Organization. I am particularly happy that on this - my first occasion at the Health Assembly - I was involved in the full reinstatement of South Africa. My country, Barbados, sent six persons, including two members of our Parliament, to monitor the recent elections there, and we are looking forward to close relations with the people of South Africa in the future. My delegation congratulates the Director-General on his comprehensive report and the real effort made by the Organization in seeking to meet the needs of its Members. My Government recognizes health care as a fundamental human right without which none of the other human rights guaranteed under our Constitution can be attained. As we strive to attain quality health care of the highest standard possible and at a cost the country can afford, my delegation is heartened to note that delegates were asked to focus on ethics and health in their addresses to the Assembly. This quality care must be equally available to all residents regardless of colour, race or financial status, and must be governed by the highest ethical considerations. That is why we maintain that the aims of the United Nations Global Conference on the Sustainable Development of Small Island Developing States, currently being held in Barbados, cannot be fully achieved without due consideration of the issue of health. The traditional economic measures, such as per capita income, do not and cannot by themselves reflect the level of development; though important, they fall short of indicating the true human condition. It is my belief that social indicators such as basic human rights, political freedom, access to education and health status must be added to these quantitative factors. Barbados has maintained a strong social responsibility with emphasis on equity in the delivery of social services, and the organization of our health care services has been an outstanding example. Consistent with the Declaration of Alma-Ata, we continue to strive for an adequate and high level of health care for all Barbadians by the year 2000 and beyond, in the face of shrinking financial resources. The ethical questions which face us in common with other developing countries are: Will we have to reduce our present services? And if so, in what direction? Should particular categories of persons be given priority? How do we balance investment in needed new technology, which may be detrimental to ongoing basic and essential programmes? These questions involve fundamental moral issues but they must be interposed with some pragmatism, given the present circumstances. Although pragmatism and ethics appear to be an uncomfortable mix, some balance between the two must be achieved. My delegation considers that the key has to be greater community involvement, which will allow for more effective use of our limited resources. The greater interaction of the community with the medical and health care professionals will allow for a better understanding of the needs of the community and the identification of the areas in which it can be of assistance. The relationship between the health professional and patient will undergo fundamental changes as the community becomes more informed and active. The effects of such a dynamic relationship will be felt throughout the health services in terms of what we do and how we do it. This enhanced relationship must be in the forefront as medical knowledge and technology change even more rapidly. We live in a world where transplants are an everyday occurrence, artificial systems can be used to maintain life, and the production of clones of ourselves is no longer in the realm of science fiction. The issues which confront us must be addressed in terms of social, legal and religious concerns. Health care professionals and the public they serve must reflect and seek to reach consensus on these issues which fundamentally affect us all. Traditionally, health professionals have been expected to decide on medical ethical issues. However, and I give my region as an example, medical students only have a brief exposure to ethics in their first undergraduate year. No attention is paid to it at post-graduate level, and there is little discussion on such seemingly esoteric matters when they enter the working environment. Our failure to come to grips with these issues is clearly seen with the advent of AIDS. Because of the nature of this epidemic, a number of issues, such as rights, obligations, confidentiality, trust and prior consent have come to the fore and have had to be addressed. If we accept that HIV/AIDS should be a notifiable disease, what about the individuals right to privacy? Should the unsuspecting public be at the mercy of the HIV carrier and those affected with AIDS? Should patients be aware that the health care professional is infected with the HIV virus? What about discrimination in the workplace?

200 A47/VR/7 page 185 It is evident that health care, law and ethics must engage the attention of social and health planners, the. legal and health professions as well as the community at large with à view to arriving at ethical guidelines to be followed in the delivery of health care. In the Caribbean as we start to grapple with these matters, it has been agreed that ministries of health should set up clinical ethics committees. Two seminars on medical ethics sponsored by our regional university have led to increased sensitization on this subject, and practical recommendations pertaining to the responsibility of health professionals and the rights of patients have been submitted to the university and ministries of health for consideration and implementation. It is important in any health care delivery system to be in a position to provide health care that meets the needs and wants of both the community and the care-givers. This care must also be delivered in such a fashion that the rights and privileges of the patients are not violated while at the same time the integrity and professionalism of the care-givers remain intact. As we approach the twenty-first century and seek to achieve the goal of health for all, we cannot limit our consideration to the issues of prevention and cure of diseases alone; we must broaden our horizons to include the questions of ethics and values, as well as their impact on the health of our communities. Le Dr MEDINA (Cap-Vert) (interprétation du portugais) : 1 Monsieur le Président de séance, Monsieur le Directeur général, honorables délégués, Mesdames et Messieurs, c'est un grand honneur pour moi de pouvoir m,adresser à cette Assemblée si distinguée. Permettez-moi avant tout de féliciter le Président, ainsi que les Vice-Présidents et les membres du bureau, de leur élection à leurs fonctions respectives à l'occasion de cette Quarante-Septième Assemblée mondiale de la Santé. Monsieur le Président, honorables délégués, l'assurance de Fégalité des chances pour tous les citoyens en ce qui concerne l'accès aux soins de santé, l'humanisation de la prestation des soins et la moralisation des services constitue l'un des principes de la politique nationale de la santé inscrits au programme du Gouvernement de la République du Cap-Vert. La promotion et la protection de la santé, facteurs influant sur le développement socio-économique et à leur tour dépendant de celui-ci, font partie intégrante de la politique nationale de développement. Nous cherchons à atteindre le plus haut niveau de santé compatible avec les ressources disponibles et le développement économique du pays, et ce dans un but d'équité. Cet effort en faveur de la promotion de la santé est influencé par les changements politiques, sociaux et économiques qui se font sentir dans le monde, et auxquels le Cap-Vert n'est pas indifférent. C'est dans ce contexte de crise économique que nous, responsables de la santé, devons malheureusement essayer, dans la limite de nos maigres budgets, de faire face aux besoins de plus en plus pressants de notre peuple. Que doit-on faire pour promouvoir la santé des populations, surtout sur une base équitable, à un moment où les mouvements de restructuration économique défient rimagination et limitent la capacité des gouvernants de répondre aux besoins essentiels des populations? Toutefois, la santé ne peut être améliorée sans une croissance économique. Où peut-on trouver les ressources nécessaires pour que la prestation des soins de santé ne soit pas simplement un but vers lequel on tend, mais plutôt une réalité large et concrète? Dans ce cadre, certains facteurs perturbant le développement équilibré des secteurs sociaux se manifestent d'une façon plus accentuée. Le développement des systèmes de santé ne peut être considéré isolément; il suit plutôt la même dynamique que les secteurs économiques de façon globale. Les progrès techniques semblent être insuffisants pour résoudre les problèmes de santé - fait dont témoignent Pimpact de la dégradation de l'environnement sur la santé des communautés, la pandémie de,sida, la transmission des maladies et les conséquences des modes de vie modernes sur la santé. Les inégalités croissantes et profondes en matière d'offre et de demande des services de santé, les écarts qui se font sentir dans la prestation de ces services perturbent le système de fourniture des soins. Par ailleurs, lors de la mise en oeuvre des choix politiques que nous avons faits, nous sommes confrontés à d'autres obstacles. L'attitude adoptée par beaucoup de professionnels de la santé face aux problèmes qui se posent et à la demande de plus en plus pressante est fondamentale, particulièrement en ce qui concerne les modes de prestation et la qualité des soins dispensés aux communautés. L'éducation de ces techniciens se fait principalement à l'étranger, dans les écoles de sociétés plus développées sur le plan socio-économique. Leur formation est essentiellement technologique et spécialisée et l'apprentissage des causes des problèmes sociaux est insuffisant. Enfin, ils sont formés dans un système qui leur permet d,utiliser des équipements sophistiqués mais qui ne leur offre aucun enseignement pratique 1 Conformément à l'article 89 du Règlement intérieur.

201 A47/VR/7 page 186 pour ce qui est de la résolution des problèmes de santé qui prédominent dans notre pays. Il est cependant essentiel que les écoles et les universités envisagent de façon nouvelle les problèmes prioritaires de santé et les choix qui s'offrent pour les résoudre, plus particulièrement dans les pays en développement. Monsieur le Président, honorables délégués, nous nous félicitons du choix du thème "Ethique et santé" proposé par le Directeur général et le Conseil exécutif et nous espérons recevoir de cette auguste Assemblée des enseignements profitables. Dr DUMONT (Bahamas): Mr President, Director-General, ministers, delegates, observers, intergovernmental and nongovernmental organizations, ladies and gentlemen, may I warmly congratulate the President on his election, and may I also congratulate the Vice-Presidents and other members of the bureau of this Forty-seventh World Health Assembly who will support him in office during the year. The Bahamas delegation is deeply grateful to the Director-General of this esteemed Organization for the accomplishments of the past year and looks forward to even greater successes as he continues to upgrade and streamline the administrative machinery of WHO. My delegation also wishes to thank the Director-General for his excellent report. The Bahamas joined the international community in its struggle against the evil system of apartheid. Today we celebrate its formal abolition. We are, therefore, very pleased to welcome South Africa back into the community of nations and, in particular, to this World Health Organization of ours, and the admission of Nauru and Niue to WHO. The Bahamas welcomes the request of the Director-General that delegates address the subject of ethics and health on this occasion. Clearly, he seeks to lift our deliberations to a more global plane and thereby give direction to the future discussions of the Executive Board. While the ethical issues facing our countries may differ, depending upon their religions and their customs and mores, our common personhood will allow an appreciation of those issues and a respect for each other's expressed concerns. The Bahamas, and indeed our subregion, could have become very angry nations, having experienced the introduction of unknown diseases transported from Europe by Christopher Columbus and his band of adventurers and having subsequently been colonized by the Europeans and plundered by pirates both ancient and modern. We choose, however to not hold onto anger, which is not only self-defeating but is downright dangerous to health, welfare and ultimate survival. Instead, the Bahamas welcomes over two-and-a-half million persons annually from every corner of the globe and shares with them the natural beauty and the infrastructural and social services available to Bahamians generally. Recently, the burden upon our health services has been exceedingly severe as untold boatloads of our Haitian brothers and sisters who seek to reach the United States of America are shipwrecked, involuntarily or voluntarily, on our islands, cays and reefs. In recent times the arrival of a significant number of Cuban nationals has exacerbated the situation. And therein lies a major dilemma which must be addressed without delay. In this regard the Bahamas has taken special note of proposed agenda item 31.2 entitled "Collaboration within the United Nations system: health assistance to specific countries". The Director-General, in the referenced agenda item, outlines the emergency assistance provided to some countries, including Haiti. The report states that the situation in Haiti "had not improved by the end of 1993 and indeed had worsened". The Bahamas can attest to the worsening situation, as our country is faced with the influx of thousands of Haitians who are fleeing their homeland and entering the Bahamas. This has placed an intolerable burden upon our health care and other support systems, and we take this opportunity to appeal to the international community to assist in finding a solution to the desperate situation now existing in this Caribbean nation, even as similar efforts are exerted on behalf of our sister nations in Africa, which are being inundated by displaced persons from Rwanda, and on behalf of our sister countries in Europe. Let me, now, against that very sketchy background, bearing in mind the small size of our global village and the uneven distribution of resources available for health care, enumerate a few of the issues affecting health which require our consideration: first, should the lives of two-and-a-half-pound neonatals be saved at any cost when their prognosis is less than good for a healthy life? Should the immunization of children be suspended so that resources might be applied to the care of AIDS patients? At what stage, and under what circumstances, should reproduction be controlled by the State? Would it be appropriate to differentiate between the truly mentally ill and the self-inflicted psychotics (due to drugs and alcohol abuse)

202 A47/VR/7 page 187 in terms of level of care? Should persons be entitled, for instance, to renal dialysis treatments by virtue of the availability of the technology, irrespective of the cost? And finally should the transboundary movement of hazardous wastes be continued, bearing in mind the potential for spills, wrecking or explosion and the attendant risks to the health of the total ecological system? The Bahamas is as convinced as Singapore is that health promotion is a national imperative. Also, we congratulate France on its initiative with respect to its upcoming summit on AIDS. On the one hand we recognize the long-term need to ensure that our people take responsibility for their own health: on the other, we acknowledge the urgency for action to prevent the decimation of the earth's population. Both demand the commitment of the world's resources - manpower, supplies, equipment and finance. Interestingly, education and AIDS are equally available to all ages, all sexes, all races and all religious persuasions. We can, as a caring family, choose to use our earth's resources to preserve life and health for all, or, we can, as an uncaring family, elect to hoard our resources so that our global village will be rich unto itself after our demise. May I urge that the ultimate ethical consideration in relation to health is this: that health is an economic good whose value transcends individuals and nations and manifests itself in the dignity of personhood before God. God bless you. El Dr. MONASTERIOS (Bolivia): Señor Presidente: La delegación de Bolivia se suma a las felicitaciones a usted y ala Mesa directiva, por haber sido elegido para presidir esta importante reunión, y agradezco la gentileza por permitirme hacer esta exposición. Empezaré hablándoles de la reforma estructural del Estado. Bolivia, como casi todos los países en desarrollo, ha confrontado en la última década los embates de la recesión económica. Como casi todos los países de América Latina, desarrolla una democracia representativa, que soporta los efectos de la crisis social derivada de la acumulación de necesidades insatisfechas durante la época de las dictaduras y la reciente recesión. Habiendo sido uno de los países más duramente castigados por la hiperinflación, hace diez años, la estabilización monetaria se ha convertido en uno de los paradigmas del mantenimiento de una economía cuyo lento crecimiento no ha logrado que se recupere el poder adquisitivo de los salarios ni de los ingresos, ocasionando los altos índices actuales de informalidad. En este contexto, el licenciado Gonzalo Sánchez de Losada, que accede al Gobierno en 1993 con amplio apoyo popular, decide enfrentar la crisis, buscando acelerar el ritmo del crecimiento económico mediante la capitalización de las empresas públicas, que serán transferidas por acciones a la población, y a la captación de capital privado nacional y extranjero, cediéndole la administración para garantizar la transferencia tecnológica y la eficiencia económica. En el área social, el Gobierno ha decidido transformar el Estado para adecuarlo a las necesidades del desarrollo humano y sostenible. Es por ello que en su reestructuración, la política social se concentra en el Ministerio de Desarrollo Humano, que mediante secretarías de Estado con funciones ejecutivas específicas logra atender coordinadamente las necesidades de la población en materia de servicios públicos esenciales. Igualmente se crea el Ministerio de Desarrollo Sostenible y Medio Ambiente, destinado a lograr la viabilidad estratégica del desarrollo en el mediano y largo plazo, racionalizando el uso de los recursos naturales en función de la satisfacción global de las necesidades de la población nacional. La ejecución de la política social tiene al municipio como eje de articulación intersectorial en el nivel local. La municipalización de todo el territorio mediante la ley de participación popular, recientemente promulgada, garantiza que los recursos destinados al desarrollo social lleguen efectivamente allí donde más falta hacen, en base a un principio de equidad y en un sistema de reparto de la coparticipación tributaria, que usa como indicador de distribución el tamaño de la población. Estas profundas reformas del Estado boliviano significan un desafío interno de gran magnitud, dado que la dispersión poblacional rural, la concentración en la periferia urbana, la escasa vinculación caminera interna y la carencia de vías adecuadas de comunicación con el exterior determinan que cada una.de las regiones y municipios deba actuar dentro de un criterio amplio de descentralización para lograr una solución efectiva de sus más acuciantes problemas y al mismo tiempo mantener los paradigmas de la política actual destinados a consolidar la unidad nacional. A continuación les hablaré de la situación de salud de Bolivia y de la reforma estructural del sector. Los más de 10 años de democracia tienen resultados positivos en la salud. Desde las grandes movilizaciones populares realizadas en 1984 hasta esta última gran movilización que se lanzará este 15 de mayo contra el sarampión, los logros más relevantes han sido los siguientes: la erradicación de la poliomielitis, cuya certificación se logrará este año y de la cual no se reportan casos desde 1986; la erradicación virtual

203 A47/VR/7 page 188 de las deficiencias por carencia de yodo en la dieta, con una cobertura universal en la distribución y el consumo regular de sal yodada; la virtual eliminación del sarampión, con la vacunación masiva, que incluye a la población escolar para cubrir la que eventualmente no hubiera sido vacunada oportunamente; el control del cólera, que desde 1991 ha sido fuente de especial preocupación en el país, ha logrado en este último año una reducción a menos de la mitad de los casos presentados en el año anterior y ha permitido reactivar la lucha contra la diarrea, que es la causa principal de mortalidad en los menores de 5 años. Estos logros han sido alcánzados mediante la aplicación de programas destinados a controlar cada uno de estos daños. Si bien el éxito alcanzado es notable, es una necesidad ineludible coordinar esfuerzos para reducir las altas tasas de mortalidad materna y del niño menor de 5 años, determinadas por la desnutrición, para reducir las enfermedades transmitidas por vectores como la malaria y la enfermedad de Chagas; para controlar la tuberculosis y las enfermedades de transmisión sexual, cuya mayor amenaza es la de expansión del SIDA; para controlar las drogodependencias, de las cuales las de mayor gravedad son el consumo excesivo de alcohol, el tabaquismo, las drogas inhalantes y la pasta básica de cocaína. Es para lograr éxitos en la reducción de la mortalidad, en el control de los principales riesgos y en la estructuración de una red de servicios que atienda regularmente las necesidades más apremiantes de la población para lo que necesitamos una reforma del sector salud, que en Bolivia como en otros países comparte los servicios públicos con los de los seguros y con los que prestan un sinnúmero de organizaciones no gubernamentales. Es para la estructuración de este nuevo sistema nacional de salud para lo que se está sustituyendo la base laboral del acceso a los servicios por la base territorial. Mediante la instalación de los sistemas locales de salud y un esfuerzo compartido por los subsectores involucrados, se pretende cubrir a toda la población asentada en cada circunscripción territorial, que puede estar formada por un distrito en los municipios urbanos, o por uno o varios municipios en los distritos rurales. El proceso de implantación de esta reforma está orientado por la aplicación del plan VIDA, que se constituye en la propuesta de salud del Plan de Todos. El Plan de Todos es el instrumento que está reorientando la profunda transformación que vive el Estado boliviano para lograr el desarrollo humano con equidad y el crecimiento y la sostenibiüdad del desarrollo económico y social. El plan VIDA, entonces, es la gran consigna nacional para que en el marco del desarrollo humano logremos la reducción acelerada de la muerte materna, perinatal, del niño menor de 5 años y la causada por las principales enfermedades endémicas existentes en Bolivia. Es para este gran esfuerzo nacional para lo que requerimos la atención y el apoyo de esta 47 a Asamblea Mundial de la Salud, porque, en la medida que podamos avanzar en la solución de nuestros problemas sociales, estaremos contribuyendo al perfeccionamiento del sistema democrático y al ansiado logro de la paz mundial. Muchas gracias. Dr IYAMBO (Namibia): Mr President of the Forty-seventh World Health Assembly, Mr Director-General, Dr Hiroshi Nakajima, excellencies, distinguished delegates, ladies and gentlemen, on behalf of the Republic of Namibia and my delegation, allow me to commence my remarks by congratulating the President and the members of the bureau on their election to lead and guide the deliberations of this august Assembly. At the outset, I would like to take this opportunity to express my delegation's delight in seeing our friends and comrades of South Africa being readmitted into the democratic fold of nations. We have been requested this year to pay special attention in our plenary addresses to the theme ethics and health and to focus on global policy strategy issues rather than country reports. This to our mind is very welcome as it allows us in this Assembly to have a common focus from which could be distilled at the end of the presentations the essence that will make a vital contribution to the development and modification of ethical policy on health issues in line with changing global circumstances and trends. It is against this background that we welcome and applaud the World Health Organization ethical criteria for medicinal drug promotion report by the Director-General, which will be discussed under agenda items 9 and 10. In the field of medicinal drugs, WHO played a vital role in ensuring that countries adopt cost-effective strategies in drug procurement, utilization and therapy through the Action Programme on Essential Drugs. In spite of the success of this Programme, it is evident that other problems related to medicinal drugs continue to arise which must be addressed seriously under the leadership of WHO. These have been identified, among others, as: the inappropriate promotion of medicinal drugs, leading to irrational use that is not only wasteful but in some cases hazardous; the absence in many developing countries of drug regulatory authorities and monitoring systems, thereby enabling substandard drugs and drugs that are not registered in their countries of origin to be dumped into the developing world; the production and promotion of counterfeit drugs that find their way into those countries that have no drug regulatory authorities or monitoring systems.

204 A47/VR/7 page 189 We would like to see the WHO Ethical Criteria for Medicinal Drug Promotion initiative expanded and intensified to the extent that it supports countries to strengthen their national and regional capacities to control the inappropriate promotion and utilization of medical drugs, as well as establish effective drug regulatory and monitoring authorities which will stem the influx of substandard and counterfeit drugs into those countries where this is currently the practice. Some of our countries have commenced initiatives to counter the problems I have mentioned. For instance, in Namibia, we have recently established the Medicines Control Council, which will look into all the problems related to drug promotion, prescription patterns and drug standards. However, on an individual basis it can prove very difficult for a small country to contend successfully against the pressures of large interest groups like drug industries and health professional groups, whose positions on drug promotion and utilization might be at variance with national policies, as was the case when the concept of essential drugs was first introduced. For this reason, it is vitally important that WHO develop effective strategies to strengthen and consolidate the efforts that countries are making in the establishment of medicines/drug regulatory authorities. I have so far confined my comments on ethics and health mainly to the medicinal drugs field, simply because this is an issue we especially requested the Director-General to look into through resolution WHA45.30, and not because I belittle the other major issues that should be given consideration under the theme. We are all aware of our ethical responsibility to ensure that our health systems are equitable. Equally, we should not forget the need to correct the violation of ethics that continues to favour the rich against the poor in terms of health at both the national and international level. Last but not least, our technological advances are calling into play many health-related ethical questions which demand not only intellectual analysis but enlightened insight into human nature as well as wisdom. As we approach the twenty-first century, questions of ethics and health assume greater and greater importance. Let us hope that we will be granted the insight and wisdom to answer these questions in the interests of posterity, for the good of both the human race as well as that of our planet as a whole. Dr MEHTSUN (Eritrea): Mr President, Director-General, your excellencies, honourable delegates, distinguished guests, ladies and gentlemen, allow me first of all to express our heartfelt congratulations to the people and the delegates of South Africa on their successful democratic election process and on rejoining the world community of nations. Mr President, the Forty-seventh World Health Assembly is a very significant event to the people of Eritrea. It marks a happy chapter in the history of Eritrean health, whereby Eritrean representatives, for the first time as full members, gladly confer with the Health Assembly regarding the health and well-being of the world at large and the particular health situation in Eritrea. Our history of health tells sad stories of neglect and deprivation caused by colonialism, 30 years of war for liberation, and recurrent severe droughts. To some it may be difficult to conceptualize, in this era, a country unable to design its own health plan, to propose creative approaches and to operate its health resources for the benefit of its own people. This task has been the prerogative of another nation which has mercilessly intended to prevent our entry into the world community of nations by destroying us. The result has been a record of health services deprivation. The 30-year war for independence also had a hand in the destruction of the ecological balance and the paralysis of the scanty health services, while unexpected droughts played their negative roles unchallenged. Displacement of populations, and recurrent epidemics have resulted in high mortality and morbidity, loss of agricultural production and the disruption of social, political and economic activities, reducing the Eritrean people to dependence on food handouts. Nascent Eritrea now resolutely faces its future with dignity and concern. Its independence, which is the result of its people's steadfastness in war and in peace, has been rewarded with a successful referendum, a referendum for peace, democracy and stability in the region, and for sovereignty with unanimous membership in the United Nations. Many nations, among them former foes, peacefully and fruitfully interact with us. We have no place for war and hatred; we strive for peace and cooperation. However, the present health situation leaves much to be desired. The poisonous fruits of war have left us to cope with global tragedies of refugees, dispersed families, homeless children, destroyed houses and villages, former freedom-fighters seeking rehabilitation,and the maimed victims of war. Our economy is hardly in a position to tackle the myriad problems of health and build the necessary foundations to develop a viable health care delivery system. Yet there lies a glimmer of hope in the culture and experience of the people. They are creatively enterprising and highly motivated to help in the realization of health-enhancing programmes. The 30 years

205 A47/VR/7 page 190 of struggle have also served as a learning situation, where the people's full creativity and potential resources for health organization have been activated. The concern for health has featured as one of the main tenets of the liberation front policies. Primary health care, as part of a well-organized health delivery system, had its roots in the early 1980s during the war for liberation. In the history of liberation struggles it is the first time an efficient health delivery system has been organized and run, not only for member combatants but for the entire population in the liberated and semi-liberated areas as well. With the little resources available it was possible to deliver primary health care, conduct immunization programmes, give training in various specializations and categories, and run a full-fledged pharmaceutical production plant aiming at self-reliance, all with the full participation of the people. This is the secret behind the high level of awareness now prevailing among the Eritrean people. The present organization of the health service in Eritrea is designed according to this proven experience. The national health policy is based on the concept and principles of primary health care. Community participation, through planning and operation of health and sanitation programmes and by contributing funds and voluntary labour to the construction of health facilities, is a common practice nation-wide; and the prospect for future community participation looks brighter. In addition to government input, the Ministry of Health expects the private sector to contribute to health delivery. Accordingly, nongovernmental organizations, bilateral donors and private initiatives are actively encouraged to participate in both its curative and preventive aspects. This has resulted in a considerable contribution by a number of donor agencies. The Ministry of Health is also encouraging intersectoral collaboration in achieving health for all, and is adapting its policy to the general principles of decentralization on which the Eritrean Government is working at the political and administrative levels. A baseline survey on health and nutrition, and horizontal programmes, such as communicable disease control, maternal and child health, family planning and the expanded programme on immunization is under way. However, although the will of the people is strong and the commitment of the Government exemplary, the problem is beyond the means of a country mercilessly shattered by war and poverty. The needs of postwar Eritrea are not limited to resources required for running programmes and services alone, but extend to resolving major bottle-necks in the rehabilitation of the health care delivery system throu 曲 assistance in institutional capacity building, building physical infrastructures, training of intermediate level health professional and rehabilitation of ex-combatants all beyond the current financial and material capabilities of the State of Eritrea. Now that we are here to join its noble membership, we call upon this Assembly to show its utmost concern, for we were not here when plans were made to save the world from the scourge of diseases and disabilities. We were not here when programmes were designed, approaches considered and procedures were agreed upon. We need your collective experience on how to tackle the task of making healthy people, responsible for their own lives and for the good of the world community. We appeal for your know-how, resources and technology, so that we shall be a deserving Member able to shoulder global responsibilities in faith and trust. M. VAN DAELE (Belgique): Monsieur le Président de séance, Messieurs les Vice-Présidents, Monsieur le Directeur général, l'organisation mondiale de la Santé - notre et votre Organisation - dont le Président guidera les débats pendant une année entière, et dont le Directeur général portera la charge et la responsabilité pour ce qui est de l'exécution du programme, a connu, depuis sa création, de fiers succès. Outre les multiples études réalisées qui ont abouti à l'établissement d'un nombre impressionnant de normes dans les différents domaines qui touchent à la santé 一 l'air que nous respirons, l'eau que nous buvons, les denrées alimentaires que nous consommons, les matières chimiques que nous concentrons et auxquelles nous pouvons être exposés -, l'organisation a connu des succès remarquables sur le terrain : qui peut oublier l'éradication de la variole? Toutefois, le travail est loin d'être achevé : nous constatons une recrudescence de la tuberculose et du paludisme, sans oublier de nouvelles pandémies comme celle de SIDA. En plus de tout cela, des guerres fratricides n'ont cessé de détruire des nations et d'hypothéquer un avenir qui, pour nombre de personnes, était déjà lourdement chargé. Ces grands fléaux menaçant la santé et ces catastrophes dues à l'intervention humaine ont certainement drainé la majorité de vos ressources humaines et financières, Monsieur le Directeur général, et cela à un moment où réconomie mondiale oblige les Etats Membres à maintenir leur contribution au niveau actuel, et même à la réduire. Vous êtes confronté, comme nous tous, à des exigences financières toujours croissantes dans tous les domaines - le combat contre le chômage dans un monde en transition vers une autre économie de production n'étant pas, avec toutes ses répercussions sur la santé de nos populations, l,un des moindres -, mais aussi à une médecine qui, connaissant un développement technique

206 A47/VR/7 page 191 effréné, risque de se déshumaniser tout en absorbant une part toujours grandissante de nos ressources. Tout cela doit nous mener vers une gestion de la santé publique fondée sur des bases tenant compte de ce phénomène technique, en vue de mieux comprendre ce qui se passe sur le terrain, de pouvoir le suivre et, le cas échéant, de le guider en informant les acteurs des conclusions qui s'imposent après analyse des données. C'est en partant de cette obligation de fonder notre politique de santé sur des bases plus sûres que nous avons imposé à nos hôpitaux tant universitaires que généraux et psychiatriques de nous transmettre les données minimales cliniques et les données minimales infirmières pour chaque patient admis dans ces établissements. C'est en présentant le résultat des études sur ces données, du point de vue tant des moyens mis en oeuvre et des résultats définitifs obtenus en matière de santé que des frais encourus et des informations épidémiologiques qu'elles contiennent, que nous allons demander à des représentants des différentes disciplines concernées de parvenir à des consensus sur des méthodologies adaptées aussi bien sur les plans médical que financier, et d'engager, grâce à la méthode de Гехашеп par les pairs, la discussion au sein de chaque entité médicale. Nous sommes convaincus qu'il n'est plus acceptable du point de vue de l'éthique de gonfler la partie "dépenses de santé" de notre budget national sollicité par tant d'obligations nationales et internationales, sans avoir au préalable analysé l'emploi des ressources actuellement disponibles, sans avoir cherché avec les dispensateurs de soins responsables si, à qualité égale, les sommes nécessaires au développement futur ne peuvent être trouvées dans la masse budgétaire disponible. Cet examen de conscience, qui s'impose à tous ceux qui ont des responsabilités en matière de santé publique, nationales ou internationales, ne pourra d,ailleurs être complet que si, au-delà des techniques médicales et des données financières, s'ajoutent les données sociales, afin de s'approcher ainsi de la définition si complète de la santé adoptée par l'oms. Les trois Communautés dont la Belgique s'est dotée, et auxquelles une large partie de la responsabilité en matière de santé publique a été dévolue, ont adopté des politiques parallèles, en mettant toutefois l'accent sur certains aspects spécifiques. C'est ainsi que la Communauté flamande a opté pour une désinstitutionnalisation maximale en développant un réseau complet d'aide à domicile qui va des nouveau-nés aux personnes âgées, en passant par les malades ne devant plus être hospitalisés mais requérant encore une surveillance médicale et des soins infirmiers. Un coordinateur en assume la responsabilité en accord avec les malades et leur famijle, après les avoir informés des options possibles. Un statut particulier d'aide à domicile est aussi en préparation. Une attention spéciale est accordée aux soins palliatifs devant permettre aux malades en phase terminale de mourir dans la dignité. Cela implique une formation continue de tous les intervenants, tant volontaires que professionnels. Les centres d'anthropogénétique, suite au développement des connaissances en matière d'hérédité humaine, suscitent vivement l'attention de la population. Il est d'un intérêt majeur que ces centres continuent à s'interroger sur les aspects éthiques et sociaux de leur mission. La lutte contre l'abus de la consommation d'alcool et d'autres drogues est basée sur la notion de la "non-exclusion". On ne peut raisonnablement espérer bannir complètement l'emploi de ces substances dans notre société, mais il faudrait pouvoir arriver à maîtriser leur développement et à réduire leurs effets néfastes aussi bien pour les individus eux-mêmes que pour la société dans son ensemble. Enfin, grâce à des actions intégrées, la Communauté flamande est parvenue à un équilibre dynamique dans la lutte contre le SIDA. Cet équilibre semble maintenant être atteint dans la propagation de cette épidémie et, en tout cas, révolution de celle-ci ne suit pas la courbe ascendante qu'elle a dans la plupart des pays européens. Rompre les tabous qui entourent encore cette affection, créer un climat de confiance, rendre chacun conscient de sa responsabilité personnelle, tels sont les buts de cette politique. Une hygiène sexuelle évidente, une ouverture à la discussion des rapports de forces dans les relations doivent en découler. Partant d'une préoccupation presque identique, la Communauté française de Belgique a créé, à côté de son "Agence SIDA", un Conseil scientifique et un Conseil éthique. Le monde médical, confronté aux possibilités techniques qui sont actuellement à sa disposition, a dû constater que rautorégulation n'a pu empêcher que certains se soumettent trop facilement aux exigences égocentriques d'une certaine clientèle. Il semblait urgent de créer un cercle de réflexion où se rencontreraient et où discuteraient les représentants de toutes les disciplines et tendances philosophiques présentes dans le pays. C'est ce qui a conduit à la création du Conseil bioéthique. La situation budgétaire du pays, l'appel à des techniques de commercialisation pour faire passer les messages d'éducation pour la santé ont créé une situation où les intérêts publics et privés se sont retrouvés intimement liés avec toutes les conséquences que cela peut entraîner. Là aussi, les problèmes éthiques sont réellement présents. Nos messages d'éducation pour la santé sont-ils du même niveau que les informations

207 A47/VR/7 page 192 publicitaires? Pouvons-nous nous permettre les mêmes exagérations et incertitudes qui sont le propre de la publicité du marché? Pouvons-nous accepter le soutien financier de firmes qui commercialisent des produits visés par notre information en matière de santé? On peut allonger la liste des questions éthiques auxquelles nous sommes déjà confrontés ou qui s'annoncent dans un proche avenir. Nous sommes convaincus que l'oms nous fera bénéficier de ses capacités conceptuelles et nous fournira les lignes directrices nécessaires à ce sujet. Dr KHUDABUX (Suriname): Mr President, distinguished delegates, Dr Nakajima, Director-General of WHO, ladies and gentlemen, it is an honour for me to address this august body, and share with you some of the more important problems and challenges facing my country. Since last year, economic deterioration has continued unabated, with inflation running at 300% and socioeconomic development stagnating. Since health and socioeconomic development are intimately related, the erosion of our currency has had a severely negative impact on society. Among a variety of key social areas, such as poverty alleviation, education and agricultural and environmental activities, the health sector has been particularly hard hit. Community and individual health status have suffered the consequences of a deteriorating economy and may be perceived in many forms, from malnutrition to malfunction of services. Nevertheless, all is not disastrous, and I should like to report on some of our assets, plans and achievements. In the first place I should like to mention the most precious investment we have: all those health workers and civil servants who keep serving their country, in spite of an eroding salary position, making all sorts of sacrifices and efforts to keep services going. We are also guided by the ideal of health for all and the philosophy of primary health care, a philosophy aimed at making rational use of all our national health resources. Thus we strive to maintain health status, promote improvements and strengthen our local health services, and at the same time seek quality of care at the highest level that our development allows. We enjoy the support of friendly nations, among which the Netherlands, and also Belgium and France stand out; and we have a long-standing tradition of working with nongovernmental organizations. With such backing and assistance we could not fail to achieve a measure of success. I am particularly proud to announce that Suriname has not had a single case of poliomyelitis in well over a decade. We will be prouder still for Suriname to stand among those nations who have contributed to making the Americas the first polio-free region of the earth. And we also look forward to being there when PAHO/WHO declares the Caribbean and Suriname measles-free. We have set the goal of national leprosy eradication by the year 2000 and I believe we are well on the way to achieving it. We continue to do battle with malaria, and we are currently evaluating the possibility of using the malaria vaccine under development in Colombia. Our national AIDS programme continues to be successful, with an extensive programme of activities, including those directed at adolescents and sex workers. Up to 90% of our entire population lives on the coastal plain and are served through a network of clinics and community hospitals. The hospital of Albina, which was destroyed during the civil war, came back into operation at the level of a health centre, with a contribution from the French Government. Efforts are under way to restore it to its original functions. The remaining 10% of our population lives in the vast hinterland and is served through a network of small hospitals, health centres and health posts by the medical mission, a private religious organization partially subsidized by the Government. Emergency evacuation by airplane is available for referral to the Medical Mission Hospital in Paramaribo. This activity represents a fine example of collaboration with nongovernmental organizations. Our population is, by and large, still adequately covered with easily accessible health services that up to now have been free of charge. However, under the impact of deteriorating socioeconomic conditions, and in an effort to further strengthen primary health care, painful changes and reforms are necessary. The Department of Regional Health Services is at present undergoing reorganization. With the assistance of the Inter-American Development Bank an analysis of financial allocations in the health sector was made. Alternative forms of financing health services are being developed. An effort towards transparency and rationalization of the hospitals is under way. Proposals for strengthening infrastructures have been prepared. Negotiations with the Government of the Netherlands on funding are expected to be concluded in the near future.

208 A47/VR/7 page 193 The restoration of the Nickerie Hospital at the frontier with Guyana, with a loan from the Inter-American Development Bank, is nearing completion. Next July, we expect to join the regional organization CARICOM and look forward to new possibilities for improvement of the health conditions of our people through close participation in a regionwide health strategy. At this point, I should like to pay a special tribute to РАНО/WHO and its local office in Suriname. It is the only United Nations agency with a physical presence in the country, and our collaboration has always been satisfactory. We foresee difficult times ahead, at least in the short run. Our health sector will continue to suffer the ravages of socioeconomic and developmental stagnation, including a painful brain-drain, but we have the resolve to keep fighting and to win. I believe, as Emerson once said, "It is on the debris of your despair you build your character". We are facing the challenge, and we shall overcome. Mr РАК Chang Rim (Democratic People's Republic of Korea): Mr President, Mr Director-General, distinguished delegates, it is a great pleasure for me to address this august body on behalf of the head of my delegation, who is unfortunately not able to attend this meeting today for an unavoidable reason. Allow me first of all to congratulate the President and Vice-Presidents on their election, and Mr Director-General for his excellent reports presented to this Assembly. The World Health Organization confronted unprecedented complex situations and problems during the period The Organization, however, exerted an active influence in keeping with its mandate at national, regional and international levels to overcome the world health crisis with a global strategy of health for all as the main target. In particular, the efforts of the Organization in drawing up the Ninth General Programme of Work, reassessing its aims and activities to cope with global change and bringing its policies and programme management closer to reality were conducive to new optimism and hopes for the health of societies in the world and humanity in general. It is an important initiative, reasonably and timely taken, that the ninety-third session of the Executive Board agreed to give special attention to "Ethics and Health" at the plenary meetings of this year's Assembly, since the extraordinary progress of biomedical sciences and medical technology during the last three decades, its application in medical practice, and the actual state of world health confront us with new ethical problems. Ethics in health is one of the fundamental human rights; it should not be regarded as a mere moral and technical concept, but an important policy matter. In view of this, we consider that special attention should be given to health policy ethics in connection with the subject of "Ethics and Health". People are the most valuable beings in the world, and ethics based only on a humanity which loves values and cares for people could at the present time contribute to the development of public health. I therefore believe that a State should implement the principle of shouldering responsibility for taking care of its people in all fields of public health. The State, which is responsible for the people's well-being and good health, should base its health policy on providing medical services as well as material and financial support, rather than on economic calculations. In many countries, financial input into the public health sector is being reduced and medical fees are increasing, while the ability of individual persons to pay for them is declining; many people are therefore excluded from access to the public health service. We are compelled to express particular concern about the social phenomenon that medical technique is being commercialized for profit: many people have their organs removed and their body experimented on to provide a livelihood and all this is openly practised without any moral restriction. It is our view that these are important problems which need to be solved as a matter of urgency. We welcome the measures taken by WHO with regard to the problem of ethics, including the establishment of guidelines on ethics in biomedical research, and we think it is WHO that will be able to take the lead in properly dealing with ethical matters in public health. We, in our country, have established a public health system and popular health policy, geared to the individual, including free medical care, and we see to it that medical doctors are loving and devoted to the people. Under this policy, medical doctors in our country serve their patients with parental love and devote everything to the life of their patients, and a campaign of "devoted service" is becoming a trend among medical professionals. The average life-span of our people has reached 74.5 years and this is attributable to the popular health system and policy, as well as to the devoted service provided by medical doctors to the people.

209 A47/VR/7 page 194 As is the case in other sectors, the public health sector is also witnessing a widening gap between the developed and the developing countries. In developing countries, 550 million people are starving due to severe food shortage, not to speak of receiving medical treatment, and 18 million people die of hunger every year. In some developing countries, child mortality is 18 times higher than in the developed countries, whereas medical expenditure per capita is one-eightieth and the number of doctors per 1000 inhabitants is one-sixtieth compared with OECD countries. In our view, it is a humanitarian and moral duty for the developed countries to help the developing countries in the public health sector. One of the main functions of WHO is to cooperate with Member States. We express our hope that WHO will contribute to all the peoples of the world benefiting from an equitable health service, by paying greater attention to cooperation between Member States, especially with the developing countries. Dr PRETRICK (Federated States of Micronesia): Mr President, Director-General, excellencies, distinguished delegates, ladies and gentlemen, allow me on behalf of my country to congratulate the President on his election. My congratulations also go to the Vice-Presidents. Also on behalf of the Federated States of Micronesia I congratulate Niue and the Republic of Nauru for becoming full Members of the World Health Organization. I am honoured to deliver this address to the Forty-seventh World Health Assembly on behalf of the Federated States of Micronesia. As one of the newest Members of WHO, the Federated States of Micronesia is privileged to be able to take part in the discussion and formulation of a global policy for world health, and privileged to have the opportunity to express its views to this august body. My delegation also wishes to thank the Director-General and the Executive Board for their guidance and direction in helping Member States to develop a focus on the relevant issues which we must consider and address at this Health Assembly. We would similarly extend our congratulations to the Secretariat for the competent and efficient manner in which it has enabled the delegations of the Member States to come together for this important meeting. We have been asked to focus our remarks on global policy issues, and to give special attention to the topic of "Ethics and Health". This has not been an easy topic to address. What is meant by this word "ethics" in the context of developing a strategy for world health planning? There is no singular definition of the term "ethics". Certainly we can look in our dictionaries and extract a definition equating "ethics" with a body of accepted moral precepts, or a code of conduct or behaviour. But what does this word "ethics" mean when we speak of policies, or plans, or strategies for world health? As one of the developing nations of this finite planet Earth, the Federated States of Micronesia maintains that, at the very least, the concept of ethics when applied to the formulation of a global plan for world health demands that the intrinsic worth of each individual human being must be valued and counted, and that this world does not depend upon the person's station in life, country of ori ' age, sex, race, religion, disability or sexual preference. There are those who would say the definition and delineation of "ethics" and "ethical behaviour" is necessarily coloured by cultural considerations, and that the boundaries of ethical behaviour can never be clearly identified. And, perhaps for the most part they are right. But, in the context of what is meant by this illusive term "ethics" in the arena of world health perspectives, can we not find an approach which extracts a universal truth - a tenet in which we can all believe and accept? In fact, is this not our mission to decide upon a programme for the promotion and achievement of world health and a system of resource allocation which is based upon and recognizes an underlying universal belief in the intrinsic worth of each human being? When deciding upon whether a particular plan, strategy, programme or action is ethical or not ethical, is there at least a common thread that runs between the varied cultures of the nations of this world, that each of us can grasp as providing a boundary for ethical behaviour? We believe that there is such a common thread, and that there are at least two precepts which should be universally accepted and applied when we speak of "Ethics and Health". The first ethical precept which we believe must be held as universal is that each person has an equal right to good health and good health care. The second is that each person has an equal responsibility to undertake such actions as will promote the health of every other person, irrespective of that person's station in life, country of origin, age, race, religion, disability or sexual preference. Thus, together with the right to health, goes the responsibility to engage in affirmative action to ensure that the rights of others are given due regard.

210 A47/VR/7 page 195 At its ninety-third session, the Executive Board considered the Ninth General Programme of Work for the years 1996 through We will engage in debate as to whether or not the Executive Board has identified those policies which will be most effective in obtaining at least the minimum in global health action we wish to achieve. Those policies have been set forth in the report of the Executive Board on its ninety-second and ninety-third sessions. Our delegation accepts and agrees with the four stated policy orientations of the Board. We will now briefly address each. (1) Integrating health and human development in public policies: the Federated States of Micronesia is committed to the goal of integrating health and human development into the public policy of the nation, its states, municipalities and villages,and believes that this policy objective must be addressed on an international level as well. We would congratulate WHO and others who prepared the background document "Community action for health" to be used in the Technical Discussions of the Forty-seventh World Health Assembly. The Federated States of Micronesia finds this document to be extremely useful in suggesting ways in which the objective of integrating health and human development in public policies can be achieved by community action. This is especiafiy relevant for the Federated States of Micronesia, where implementation of specific policies for health and human development must receive the acceptance and support of traditional leaders at the village-community level if such policies are ever to be accepted and applied by the community at large. (2) Ensuring equitable access to health services: as a developing nation this second stated objective is of primary importance to the Federated States of Micronesia. In order to achieve the objective of ensuring equitable access to health services we and other developing nations must be assured of an appropriate allocation from the world's resources. Without such resources the developing nations cannot even hope to achieve equitable access to health services. If we accept that every citizen of a developing nation has a right equal to the right ôf citizens of developed countries to access the best available health services, then we cannot deny that it is the responsibility of the developed nations to provide the resources which will allow for health services to be available for access. Ethical considerations involved in ensuring effective access to health services require that the responsibility for effective and equitable allocation of resources must be borne by those in a position to direct the flow of such resources (including the developed nations, the international organizations such as WHO and UNICEF, as well as other, nongovernmental health-related organizations). (3) Promoting and protecting health: the Federated States of Micronesia believes that ethical consideration demands that each State must not only approve of, but actively participate in, the policy objective of "promoting and protecting health". At the national level, each State is ethicauy bound to ensure that its citizens are educated as to the dangers of communicable diseases, including sexually transmitted diseases such as HIV. There must be an intense effort at national and international levels to promote changes in lifestyle conducive to healthy living and to fostèr effective measures of health protection such as the use of condoms to deter the spread of HIV. (4) Preventing and controlling specific health problems: with respect to this stated policy orientation, the report of the Executive Board on its ninety-second and ninety-third sessions has, among other specific health problems, enumerated leprosy as a public health problem targeted for world eradication, and the implementation of tuberculosis control activities as warranting the institution of a special account within the Voluntary Fund for Health Promotion. The Federated States of Micronesia is deeply concerned about the prevalence of leprosy and tuberculosis within its boundaries,and applauds the efforts made in respect of these diseases. The Federated States of Micronesia, recognizing its responsibility to engage in all available measures to prevent the spread of leprosy and tuberculosis into other nations, encourages the other members of the Health Assembly to approve these two targeted diseases as specific health problems warranting the close attention of WHO and the world community under the fourth policy orientation in the Ninth General Programme of Work for The Federated States of Micronesia would like to thank the President once more for having assisted us in our efforts to find ethical and effective ways to address the health problems of the world community. No State can afford to fail to take responsibility - responsibility for the problems - and to act. Each State has a duty to protect the citizens of this world community to which we all belong. Dr DASHZEVEG (Mongolia): Mr President, Mr Director-General, distinguished delegates, first of all please allow me, on behalf of the Mongolian delegation to extend my warm congratulations to the President and to the Vice-Presidents of this Health Assembly, on their election to their high offices.

211 A47/VR/7 page 196 The Mongolian delegation; is highly appireciative of the outstanding ability of Dr H. Nakajima, our Director-General. Under his leadership, the World Health Organization has made valuable contributions to the protection of people's health by overcoming all kinds of difficulties. We are pleased to say that with the further development of the strategy for health for all by the year 2000,medical and health care services for the people have continued to improve in all countries. The initiative on research and development of children's vaccines and the implementation of acute respiratory infection control programmes have effectively safeguarded the healtl: owth of emdreu the world over. The "Tobacco or health" action plan has made increasing гшш of people aware of the dangers of tobacco smoke and the need to eííniínate them. The implemeiitation of the AIDS prevention control strategy has enabled widespread dissemination of scientific knowlec%e on AIDS prevention, and clinical researdh and drug development have brought hope of survival for AIDS patients. hi short, implementation of WHO's effective strategies and provision of services for the health of mankind have steadily increased the Organization's reputation and influence. This is the result of joint efforts made by the Director-General, Dr Nakajima, all WHO staff and Member States. Неге I would like to extend our heartiest thanks to WHO headquarters and the Regional Office for South-East Asia for the support and cooperation they have given our country in the implementation of WHO strategies and collaborative programmes. As a Member State of WHO, Mongolia has always worked very hard to develop its health services in line with its national conditions and to follow closely the various WHO strategies. In 1993 positive changes took place in our medical and health services. At the national level, 1993 saw intensive parliamentary debates on two proposed laws, which are very important from a public health perspective: the law on the struggle against the threats of tobacco and the law on the prevention of AIDS. These two laws were passed in December last year. The objectives of the law on the struggle against the threats of tobacco are the protection of the population from danger of tobacco, the determination of the responsibilities of economic entities, organizations, families and citizens in tobacco control activities, the specification of requirements on manufacture and sale of tobacco and the regulation of relations concerned with their implementation. This law plays a significant role in the prevention of adolescents and young people from using tobacco and in the protection of the health of non-smokers. The law on the prevention of AIDS provides facilities to prevent disease and strengthen information on infection and morbidity of AIDS; and to promote education, research, epidemiological surveillance and protection of human rights in connection with AIDS infection, as well as the professional training of health workers and medical doctors. Another very important document for us was adopted in This is a law on citizen's health insurance. Now both compulsory and voluntary health insurance are functioning in my country. The three important laws mentioned above came into force in The Government of Mongolia has approved a national programme on immunization, by implementing which we will attain the target of 90% immunization coverage for the "seven vaccines" at national level in We have launched mass vaccination against hepatitis В which has successfully reduced the number of cases by over 30% after the first year's vaccination programme. Despite progress, much more needs to be done to accelerate health development in Mongolia in order to achieve the goal of health for all within the next six years. The issues of improving equity in health and the quality of health care are of utmost importance. They are not easy tasks, considering the current situation in Mongolia. Health care in Mongolia is suffering from the growing economic crisis which has occurred and is occurring in my country, and the associated poverty, unemployment, inflation and reduced national resources. In the past three years national income and production have declined by 15% and 14.8% respectively. The per capita national income has also fallen to the level it was ten years ago. This has led to increasing unemployment - for example, on 1 January 1994,there were over people without work. This is 33% higher than at the same time last year; and 16% of the population is now below the "poverty level". The above economic stresses of this transition period in Mongolia have had a severe detrimental effect on the health delivery system of the whole country, and all parameters have deteriorated. The general health of the people has become worse and no doubt will continue to worsen in the foreseeable future. For example, the number of births has decreased by 20.6%, with an unfortunate increase in infant and maternal mortality. Infections and parasitic diseases have increased by 1.4%. With our socioeconomic and associated changes, other health problems have also increased, including malnutrition, anaemia, gastrointestinal disorders, alcoholism, mental diseases, and disorders of the nervous respiratory and circulatory system. The infant and maternal mortality rates remain very high. The infant mortality rate in this country is 62 per 1000 live births and the maternal mortality rate is 20.4 per live births. The Government of Mongolia wholeheartedly supports the efforts of the world community and the dynamic activities of the United Nations for the well-being of children who are the future of mankind. Attaching paramount importance to the health and social well-being of children, my Government has adopted the "National Programme of Action for Development of Children in the 1990s".

212 A47/VR/7 page 197 At this Assembly, we will emphasize the subject "Ethics and Health". Ethical issues in medicine have been attracting greater attention during the last two decades. The advances in medicine, the changing perception of the public and physicians, greater availability of information to the community and political developments, have led to the ethical aspects of medicine becoming more important. Ethical issues are emerging in relation to resuscitation; organ and tissue transplantation; some aspects of family planning, including application of contraceptives and the carrying out of abortions; treatment of AIDS patients, clinical trials with the objective of introducing new drugs into health practices; treatment regimes and technologies. The list could be continued. Before concluding my statement from this rostrum, I wish to convey on behalf of my Government sincere thanks to the Director-General, Dr Hiroshi Nakajima, and to the Regional Director for South-East Asia, Dr Uton Rafei, for their understanding of the health problems of Mongolia and for the support we are getting to improve our medical care. In this connection, the most important form of the collaboration with WHO is WHO's intensified cooperation with countries in greatest need. It would be a failing on my part if I did not record our appreciation of the invaluable help that we continue to receive from WHO, UNICEF, UNDP and UNFPA, as well as from friendly countries, in our efforts to render better health services to the Mongolian people. Dr MUBARAK (Iraq): (jl^jl) ^Uo ci^ju> 一 /l ^jji ÓJJ! ^^ mjl i 'iuujuji 'á^jl lok^j ^UJI ^.Jujl,\ r.,ji i^^s^ji ly w ". ^ Lu/^ jj I JUíl L e 0 L ' Si ^JU 内 ÍOrfJ4Ji\ s i^uji o- 0 '-e^wr^'' л-лл jri^^ 0 s 己 J^JI Aie í^^c^i^j!.' J^l.Lo^JI -.U^t flk: JjjJI ^ ^ J U, ç^^ju i^ji 0'l V il. IJ^I '.L^J! f J O ^ 1 ^i 'o^1 ^ fjbji J^j ^ ^ii ^ il^ jj UjUL^L fukji 11л 0I auj.jju iiil±iji ;L^iJI ".LJ^I ÏL^JI ^UjJI ful^i.. n^ji clo^iji ^ ^ ^Jc: ijj^l _."-.U^l Л....", ^Jx jl^j! sr^ 1 1 一一 d U l j f, 5. I^MjJI^ и^ккл ; ^ ^ Ü J ^ o ü ^ I ^ Í J ^ I ^ igj...-." j ^ J ^ ^ ^ 'ssj^1 们 JU^C^L, düi 3 JLg^Vl ^ çclji ^JLL=JI irju^,, S S?- 1^^1 o' 1 'JV J^^- 1 oj^ Ór^s."..,> «U^JI 一丨力 一 JJU 丄 ^Jl jl^jl ^ ^ m. pb ^ 'ájliiu. l^t U l 0 3J JUb^/l c^ljj OJO: 0is 己..,_ «Jlib^l ^ LJ-, e ^ O - ^ ' Ц-^Ц'З M'ír fu ^ (í 气 VTV).(o^Lij A Vr) ) ) ^Г fu 一 «(' Uj ГГ ol ) <И. fu ^ jl^ 一 ^ ^ J l 仏 0li U l J⑷I o- o ^ ^ 1 ClixUc J i JlA^JI <= ^J! d, -.IL, и,(-<ili_5 VA Uc S 尸 ГГ ^VU o^ifuc JI>JJ - ^JL, UJi. МП fu ^ ^ ci^li Ui ;^ ÍV ^Jl f U чи O- f^aíxa b 0 c^ ^ У u^l 0j>i M V ^ ^Js o^li.и1г ^ '/Л^ МП- ^ 丨尸力 ^,Or^ o' 1 ' juji JiL> 一 ^^Jl sh "-^ 1 山 山 Л o- ^ s^ ' U^JIj ^ ^JU, r,,ll JI^V l^o^ji^ ' jiyiji U l i JjL^o ^ ' j^o l^jlc l^^jul, ah 3.S^y^J] I j^i 山 J ^ c^^uji И.Ш1 ^l^ajbj! J^ib d._... "^ (JLJI ^ 一 cr" 'WíM U a j.iia^ji "á^ji JUr,,.1 dji j\ji ^^lio^lj JUJI

213 A47/VR/10 page 198 ' jl; ^Jl Sà jl^ji ^ju^-îii JU^JI c; 丨 LU ог>уло Jli^Jl J ^ ^ J ^.' i^ji P! 3JJ1 i^ij üij '^LJI ^ I^L, M mv ол^ 1. ^ (I^^I) ^ ^ ^ u ^ Ji^di 015 ^ <М1Г ^ -LU,! I 八 1 ^LUVl doücjl SU ^J^iül juui ^L^JI c^ ^ ^-U IdAj. i.ul 1 Л1 1 У 13Л 气 ^ Jjp jj ^J c^lui d i Ui^ < М^Г fu.ul 1 T ^ '.UVl сил, JUJH/I 1 Al ^ i^ul Л П1Г ^ 1ЛЛ c^l^i jj^ _L О. ) 1Д1 C^ ^ G 5 仏 МЛЗ fu UJ^ jl^ji 0li djiij fu.ппг fu hui 11 lo V la^sî SjLiVl ^ AJi ' juji 3 c^l.v.,.,.ji i^^sjji ^ ^ <;LOUJI LJL^'l ^.L: Ui 一 UJ_5 ^ - h: ^b^ju dju. JÜLL LJ ^ ^UJI UJUJ1 -L^JI с^ъ asi JliJI J ^ < JSJ^ ' J^JI ^Jl jj jl^l 1 J ^ jbluji ^ ^ 1Л* y, 1 气气.^ycJJ f>ji ^ c ^ ^ -Le 匕 I ïilk^. I ^JI I -kai I о f <;,.1^0ai; GIASL^ UJI J 片 UJ ü^ui 4-j ^-y. ^jjl ^ 'U^J- 11 j^oji 方 JtoJI).UJ! 为 Jujl o^^jj yl-^l fu^^i J^U i ' -^Jl 匕 v ^ - U U ^ I jl^o ^IJ. ^и^м GUÜJUJ!, ^ ^jji ^^Jl juj^ji ^ W 1 Ц? c^ljifl^ji é±, ^ H i íjuil 'O." d j 1".,,.л 4 j Ï^j^I 1-JLJUJI Ï^UÛI ^ ^-JL )l L.:. ṙ.. L: ^ UIko ^J^? Juj^Jt dj^ oj&l^i Lb ^ 0li LÜJ <%1 L. cuujul) djb J-.JL3L; JJLi. 彳 I l). J Jloj d^llc (ЗА? 己 ^^5 l-. : ' 丄 ;.Lo^aS. l_ J_j3j I I i Jrf^-o 一? ^-i^ji.^jl^ji dy 夕 Jl^Jl ^ d) ÏjL- Д :,. h 1 V^bJI jt^jt J^^l ' Ji-uJI 山 aji -t^^ji.l^jaji ^U^li-^Jt íj-а. л^лл ^н» ^IJSÍ о' J^^JI ^ Jlj^ül ^.-kai ' -L.UJI ^UJI J-ii^; Ggjui^-jl 0'\ э. ' U=JJ. iiiji ^o^^jji 己 Ц) " JoL-S^w^Ü ju Jio i ^ 己 Lo)h.. JT;^^. Ц > 1 尸 1.-лII ^ S fl 力 ⑴ ^ 尸 Jy^ VcU^JI.^-^JLa^JI (^iubl à Ü U^. u^ 0- СУ^Г^' OS^J^ ^JO) JJLOJ t J LvCU>ü 1 ' LiiUoJ ^o^oji Ji^oJI Ji^JI I-ÍA 0I ij 1 1 化 C^UI^I 丄 Jl^l o't ^ ç ^ - J I o - 夕 丨 ^ 'j 1^-" cl^jji ^ ^ f 1 尸 ii 1 Í^Sí ^jj 1 P 1 o^ d J ' ^ j J 1 ^ 1 LJ/^, LuJUJI.U^JI 夕 l Ji^JI J^U ^ V ^ 1 e1i_ JI 5 с IjoJI JUj^i J-la JlíO^I pas ^ J-o^J 1 ) ^ jji Jí-I ^ jjju^ L)jJ ^A-íJ J 5JJI '.LJU^J f l ^ l ^ ' a^l^ji J^I ^ ijijcjj iouji ^Jl HjjJL, Jl^jl.l^U'l ^ Lc^bj^ J ^ " J^l ijm ^ ^ Щ, ^iji ^jliji jsy^u I ^ t

214 A47/VR/10 page 199 Mr WAENA (Solomon Islands): Mr President, Mr Director-General, honourable Ministers, Vice-Presidents and distinguished delegates of Member States of this very prestigious decision-making international and august Assembly, it is indeed with enormous honour and privilege that I humbly address you. At the outset, I wish to sincerely congratulate Dr Temane, and indeed his nation, Botswana, on his accession to the esteemed office of the President of the Forty-seventh World Health Assembly. We are confident that his guidance will lead to the successful conclusion of this Assembly's proceedings. I bring to this distinguished Assembly greetings from my Prime Minister, the Government and people of Solomon Islands, a tiny island Member State, in the peaceful blue South Pacific Ocean. We thank the Director-General for his comprehensive report, which enlightened us not only on past achievements but even more so on the future hopes and aims of WHO in its concerted efforts to provide services to mankind. We applaud the leadership of the Director-General. Solomon Islands upholds its national motto: "to lead is to serve". Indeed, all of us here are leaders, comprising this venerable international body, the Health Assembly. WHO is unique in the particular principle of serving and saving mankind, especially the poor, the disadvantaged, the oppressed and the "have nots". It is for this fundamental reason, we believe, that we are here as a family of Member States. Indeed, it is for this noble consideration that the Solomon Islands delegation wishes to humbly make this intervention. Allow me to record before this august Assembly, the support of Solomon Islands for the readmission of the people and Government of South Africa, to take their rightful place within WHO, thereby fulfilling their obligation and assuming their rights in accordance with the WHO Constitution. The historic attainment of all rights and privileges associated with full membership of WHO, which this august Assembly unreservedly and unanimously accorded to South Africa at this Forty-seventh Health Assembly, has indeed established a very significant historic milestone of achievement by WHO on the eve of the closure of the twentieth century. Solomon Islands took part in monitoring the recent historic multiracial elections in South Africa through the participation of the honourable speaker of our National Parliament. May I record our sense of gratitude and appreciation, to the distinguished delegates of Zimbabwe and Nigeria, for successfully proposing the draft resolution, which this Assembly deliberated on and assented to. Nearer home, the Solomon Islands delegation unreservedly tenders its brotherly and neighbourly approval and support for the admission of Nauru and Niue into the family of Member States which constitute this Health Assembly. We wish the governments and peoples of Nauru and Niue, the joy of becoming members of this august Assembly, as of immediate effect. Congratulations, Nauru Government and your good people, and congratulations Niue Government and your good people for accession into this Health Assembly. Our little nation in the South Pacific Ocean with just over people, living on several tropical islands, though making some progress in its social and political development, still faces enormous tasks in the development of its economy. It still needs, and will continue to need, the support of our partners, the developed nations. Even though this is so, our people have thoroughly and continuously enjoyed genuine peace and tranquillity, which our present and past governments have ensured at all cost. We think of our many unfortunate brothers and sisters in areas where there are wars and conflicts and those who do not know what true peace is like. The Solomon Islands delegation earnestly pleads with all Member States to continuously strive towards bringing peace and hope to mankind, where there is war and oppression. Health care and welfare services can only be meaningfully brought to people in need, disadvantaged communities, children and women, when there is peace. Health for all, which is our concerted and noble goai, can never truly happen except where there is peace. It is the unavoidable obligation of the Member States, as a community of nations, and on us who are leaders to pick up the encouraging trend of development that is taking place in South-East Asia, southern Africa and elsewhere, to expedite the process of peace to all the peoples of our one home, the planet Earth. In this respect, I sincerely urge, as we in the South Pacific strongly advocate, that all weapons of mass destruction be eliminated and that all forms of nuclear weapons be considered illegal, in the quest to make planet Earth a safer home for mankind. Much-needed financial resources saved from military budgets could usefully be utilized by WHO to save women, children and indeed men from the perils of sickness and disease which beset the whole of the human race. Solomon Islands, like other Member States, has its own share of problems. Our Government has, however, clearly made its commitment to address priority health problems. The problem of infectious diseases, especially malaria, is enormous. I wish to sincerely record our most profound thanks for the support of WHO. I particularly wish to thank our very efficient Regional Director, Dr S.T. Han, who especially visited our nation to personally confirm the support of WHO alongside our other bilateral and

215 A47/VR/10 page 200 multilateral partners, who have supported our efforts, in particular the governments of Australia, Japan and the United Kingdom as well as the European Union. We sincerely hope that through this cordial and essential partnership of efforts, malaria will soon no longer be the main public health problem in our beautiful islands, both for our own people and for friends who may visit us. The Solomon Islands delegation believes that during this time of scarce resources and unfavourable global economic circumstances, the welfare of our communities will improve only if the demands of our population can be wholly met at an acceptable level. The Solomon Islands, with an annual population growth rate of 3.5%, which is very high by any standard, is struggling to meet the needs of its increasing population. Our uncontrolled population growth rate causes very high school drop-out rates. Unemployment is on the increase, and high illiteracy is a potentially explosive situation which will continuously pose a high risk to community members. Addressing the population issues has been our utmost priority in establishing sustainable development programmes and policies. The support of our bilateral and multilateral friends is vital. It is our view that a society can be healthy only if it can feed, clothe, educate, employ and provide adequate health care services to its people. The Solomon Islands looks forward to the International Conference on Population and Development in Cairo in September this year. Developing countries like ours will continue to need the support of developed Member States to achieve our aims and objectives. Today, the world community is becoming more and more united on issues of common interest. It is becoming more and more a peace-loving global community of nations, with democratic development occurring in eastern Europe, Africa, Asia and elsewhere. Whilst it is essential that peace is quickly restored, particularly in the new areas of conflict, which is putting sadness into the lives of millions, the potential threat by the worrying global climatic and environmental changes which are taking place are of considerable concern to the small island nations of the world, such as those in the Pacific Ocean. The "greenhouse effect" is indeed an especially major concern for us, the island Member States, scattered in the many oceans and seas of our little planet. These small States, including the Solomon Islands, are still underdeveloped, with numerous social and economic problems and challenges. They are thus not in any position to adequately help themselves against such global climatic change, if and when it should occur. We therefore, emphatically plead to the developed and industrialized Member States to seek to minimize or better still cease to emit toxic wastes and gases into our atmosphere, to delay this impending grave risk. It is indeed the future of the small island Member States that is at stake. Industrialized nations have the resources and know-how to identify and use environmentally safe alternatives to make our world a better and safer place for us to live. This world needs to be made a safer place for ourselves, our children and those generations yet to come. The Solomon Islands has in the past years made some progress in developing health care services appropriate to its people. It is currently embarking on a structural adjustment programme to make our development and services more appropriate and sustainable within our capabilities. These achievements have been made possible with the support of many bilateral and multilateral agencies, many of which are represented in this august Assembly. On our behalf, may I thank you all, most sincerely, especially the Director-General of the World Health Organization and his good staff. In our region we thank our Regional Director. To the European Union, and the Governments of Australia, Canada, Japan, New Zealand, the United Kingdom and so forth we thank you for your kind assistance. WHO is indeed the main international body on which we, the developing countries, rely in our health development strategies and programmes. The World Health Assembly is the main forum through which we share our views, hopes and aspirations, as well as fears. This, then, is our humble intervention. The Solomon Islands delegation wishes the President and his office bearers a very fruitful term in office. Mr VENERA (Czech Republic): Mr President, Mr Director-General, your excellencies, distinguished delegates, ladies and gentlemen, I avail myself of this opportunity to extend to the President, as well as to other officers of this esteemed high-level forum, my sincere congratulations on their election and best wishes for all success in their responsible work. The Czech Republic has taken considerable forward steps in its transition to a market economy. It has finalized major reform transformations in the spheres of its political system, national economy, finance, legislation and, of course, social life. Within the last three years, the health care system of the Czech Republic has passed through a fundamental change. Our counterparts in transition economies are deeply interested in receiving information about privatization of health facilities in our country. Let me comment briefly on the developments in this field.

216 A47/VR/10 page 201 The process of privatization is generally regulated by provisions of the laws and decrees of the Government. In the health sector, privatization started in September 1993 and has advanced significantly since then. Direct sales to interested individuals represent a major part of property transfers. The future owners are selected on the basis of recommendations made by relevant privatization committees, and final privatization projects are approved by the Government. In come cases, different methods of privatization are applied; for example, "free of charge" transfers to municipalities, to churches or to other legal entities. So-called "mixed ownership", namely combined ownership of the State and a domestic entity, is also applicable. Facilities not intended for privatization have, in principle, around 30% of the total bed capacity of hospitals. A reform of public accounts is one of the most important elements of the economic transformation of our country. At the same time, it is directly interconnected with health transformation. In the past, predetermined by central planning, the structure of the national budget was not transparent. Prevailing inefficiency in the use of public financial resources resulted, inter alia, from this lack of transparency. Under the new conditions, the reform of the national budgetary system has been targeted at the creation of transparent financial flows, expenditure restrictions and stabilization of public funds, setting clear strategic goals and priorities, reaching a desirable budget balance and diminishing the role of the State budget in the redistribution of GDP. In implementing economic and health reforms, we have acquired considerable experience, which proves, in our opinion, that there is a certain parallel between the financial resources of the State and those of international organizations, including the effectiveness of their use in a national and international context. In other words, any supply in the health sector sooner or later finds an effective demand. In this respect, the development of health services in the Czech Republic has already reached a stage at which it seems essential to impose certain limitations in order to preserve the viability of other sectors. Similarly, we all share a common responsibility for ensuring a well-targeted, effective use in an international context of international resources that are acquired through national tax payment systems. We must therefore insist on transparency of use of our contributions to those budgets. Our undeniable responsibility includes defining a clear strategy, setting well-grounded priorities and implementing control mechanisms of budgetary allocation of existing resources. Notwithstanding an indispensable degree of solidarity, which is crucial for any kind of public accounting, we would appreciate if some of the WHO regional committees, with their urgent needs and limited capacities, get more financial resources from the global WHO budget than they do today. Accomplishing basic systemic reiforms in my country, our attention focuses more and more on the definition of further new qualitative changes. There is one key issue which is connected with one of the global topics of this Assembly, namely the relationship between partners in "giving and taking" of health care. As we inherited from the former regime somewhat distorted moral criteria of relations within society, we deem it necessary to determine new ethics in providing health services. We are of the opinion that a clear definition of general ethical rules is one of the essential prerogatives of the State and of international organizations like WHO. These rules should find their reflection in relations between patient and physician and in criteria for the quality of health care. Logic tells us that the State should at the same time define adequate instruments to preserve these ethical rules. Endeavours of WHO to define a global ethical code point to an unrivalled role of the international community in the field of health. Such a code could become a "mode d'emploi" in, for example, psychiatry, treatment of malignant diseases, transplantation of human organs, including tissues and blood, trade with them, clinical testing, distribution and promotion of pharmaceutical products, surrogate motherhood, euthanasia and others. We feel that WHO should promote the establishment and development of an "alliance for health" which will add new value to health awareness. Finally, let me express our appreciation of the work so far done by WHO in a global and,particularly, all-european framework. The tangible results of WHO activities, will, we believe, prove the effectiveness of the Organization and confirm the unique role it plays in our contemporary world. Professor TOFOSKI (The Former Yugoslav Republic of Macedonia): Mr President, Mr Director-General, distinguished representatives, ladies and gentlemen, first of all, I want to extend my congratulations to the President of the Forty-seventh World Health Assembly on his election, and to express our conviction that, under his presidency, this Assembly will successfully discharge its duties. He can count on our full support in his efforts. I would also like to extend our congratulations to the Vice-Presidents and to the other elected officers of this Assembly.

217 A47/VR/10 page 202 I have the honour and pleasure to transmit to you regards from the Government of the Republic of Macedonia and especially to the Director-General, the distinguished Dr Hiroshi Nakajima, under whose leadership the World Health Organization continues to work successfully. Our country is passing through a very difficult time of transition. But in addition to this, we have very unfavourable surroundings, such as a blockade of our main lines of communication: to the north, United Nations sanctions towards the Federative Republic of Yugoslavia, to the south, an unprecedented embargo - absolutely unprovoked and unjustified - by a Member State of the European Union, with almost catastrophic consequences for our economy. All these have seriously detrimental effects on the financing and functioning of the health care system and the health status of our population. Bearing in mind the universal condemnation of the Greek embargo against my country, we hope that it will be lifted without delay. Apart from having war in the near vicinity, the influx of large numbers of refugees has increased the need for health care even more. In such conditions, we have to make reforms and restructure the health insurance and health care system. At this point, I would like to stress our sincere gratitude to the governments of countries of the European Union, especially Germany, the Netherlands and the United Kingdom, through the programmes of ECHO and PHARE, Project Hope of the United States, WHO and UNICEF and other governmental and nongovernmental organizations who have participated in supplying us with essential drugs and disposable materials and enabled us to maintain the functioning of our health care system. With regard to health reforms, we have been offered very valuable assistance from many sides; from WHO, World Bank, European Union and some bilateral investors from European countries. All this, in essence, is very positive but almost all of them insist on using their own experts and consulting teams. While we highly appreciate the intentions and good will in assisting us in the planned reforms we consider that the most useful and effective contribution would be an integrated well-coordinated programme where the leading role would be played by WHO with the participation of all interested parties. Understanding that health is a continuous and inclusive development process involving all countries, all individuals and communities, it is clear that national health development is a very important factor in the support and promotion of peace and development inside and outside the region. Besides the enormous efforts of WHO and Member States, there are still many common problems for the majority of the world population, such as infant mortality, health of women, AIDS, tuberculosis and malaria, as well as some more specific to some regions, subregions or countries. I would like to take this opportunity to inform you that the strategy of my government in the field of health aims at the following: first of all, to safeguard social peace in the country through the functioning of the vital health service, which is our real programme now; to carry out regularly all programmes for preventive medical care - preventive medical care and services, compulsory immunization of the population against certain infectious diseases, preventive measures to avoid the spread of tuberculosis, protection of the population against HIV and AIDS, active mother and child medical care, promotion of blood donation and others; also to maintain sanitary and hygiene standards; to start the preparation programme for transformation and reconstruction of the medical care services and insurance system; to promote close and continuous cooperation with the medical services of developed countries; and further promotion of the programme on health for all by the year Our cooperation with WHO continues to be successful and fruitful. We appreciated the visit to our country of the Director-General, Dr Nakajima, accompanied by Dr Asvall, Regional Director for Europe, and we are pleased to note that the programmes agreed upon are in the process of implementation and we hope that we will be able to conclude more in future. On the subject of our cooperation with WHO, it is my duty to mention that, for reasons unknown to us, my country, a member of WHO, was not permitted to enter the host country and thus could not participate in the 1993 session of the Regional Committee for Europe, held in Athens last year. I am sure that all necessary actions will be taken to ensure that in future no Member State of WHO experiences a similar situation. Finally, my delegation would like to express strong support of the initiative of the Director-General to study in depth an increasing number of ethical issues and to reaffirm, promote and establish, where necessary, new WHO ethical criteria on many questions, such as: equity of access to health care; dissemination of international humanitarian law according to the Geneva Conventions and additional protocols; biomedical ethics; genetics technology; experimentation on human subjects; transplantation of organs; euthanasia; medical research in a wider meaning; and the rights of patients as a part of basic human rights, which have been properly elaborated recently in a major European conference held in the Netherlands.

218 A47/VR/10 page 203 The ACTING PRESIDENT: I thank the delegate of The Former Yugoslav Republic of Macedonia. Distinguished delegates, I have received a request from the Greek delegation to exercise its right of reply in accordance with Rule 59. I will give the floor to Greece at the end of this meeting to make a brief statement. Distinguished delegate of Cambodia, you have the floor. Le Dr CHHEA (Cambodge): Monsieur le Président de séance, Monsieur le Directeur général, honorables délégués, Mesdames et Messieurs, au nom de la délégation cambodgienne, permettez-moi de m'associer aux autres délégués pour féliciter le Président, les Vice-Présidents et les autres membres du bureau à roccasion de leur élection à cette Quarante-Septième Assemblée mondiale de la Santé. Je félicite également le Directeur général, les Directeurs régionaux et tous les fonctionnaires de l'oms pour leurs efforts et leurs bienfaits en faveur de la santé pour tous. Monsieur le Président, Mesdames et Messieurs, c'est un mélange d'honneur, de fierté et de joie pour la délégation du Royaume du Cambodge de pouvoir participer à nouveau à cette auguste Assemblée après une si longue période d'absence. Pendant toutes ces années où nous avons été coupés du monde, nous avons connu les horreurs de la guerre avec son cortège d'atrocités et de douleurs physiques et morales. Les opérations de l'organisation des Nations Unies au Cambodge ont été un grand succès pour rhistoire de rhumanité et je voudrais profiter de cette tribune qui m'est offerte ici pour exprimer les remerciements les plus sincères du peuple cambodgien à l'autorité provisoire des Nations Unies pour son action au Cambodge. Pourtant, nous nous débattons encore contre les suites de cette guerre. Elles sont nombreuses et variées. Elles persistent non seulement dans nos cauchemars mais aussi dans la réalité journalière : des familles disloquées, des communautés dysfonctionnelles, et aussi des mines parsemées dans tout le pays qui continueront à mutiler, pendant plusieurs décennies encore, notre peuple et surtout nos enfants. Ce problème des suites de guerre en temps de paix ne se pose pas seulement au Cambodge et mérite encore plus d'attention de la part de tous les pays et des organisations internationales et humanitaires. Monsieur le Président, Mesdames et Messieurs, au moment de la Déclaration d'alma-ata sur les soins de santé primaires, le Cambodge était replié sur lui-même, il souffrait d'une famine généralisée et connaissait un génocide qui allait bouleverser le monde entier. Cette Déclaration, pour notre nation, est un symbole d'espoir. Mais comment satisfaire cet espoir? Notre politique sanitaire s'efforce de se frayer un chemin vers ce noble but. Cependant, si politiquement il est facile de se fixer un objectif, le manque de ressources nationales est un obstacle difficile à surmonter. Il est donc nécessaire de pouvoir compter sur l'aide extérieure pour y arriver. II incombe aux communautés et aux gouvernements de rechercher la meilleure santé pour tous. Toutefois, la question d'éthique que l'on est en droit de se poser est : quelle est la responsabilité de la communauté internationale dans le cas d'une guerre ou d'une catastrophe naturelle où une nation entière n'a pas les moyens voulus pour soulager les victimes? Certes, la tradition veut qu'il existe une aide d'urgence, qui n'est qu'une aide de substitution, et nous sommes très reconnaissants à la communauté internationale pour cette générosité. Néanmoins, quelle éthique doit guider l,aide internationale pendant la longue période de reconstruction et de développement qui doit suivre? Parfois, nous avons l,impression que certains minimisent nos besoins afin de limiter la solidarité internationale à notre égard. Pourtant, c'est là que nous pouvons acquérir les moyens de mener vraiment nos activités afin de rétablir la santé pour tous. Nous avons encore besoin de l'aide de la communauté internationale, de l,oms, de l'ensemble des organisations internationales et non gouvernementales pour travailler, dans un esprit de coordination et de coopération, à l'amélioration de notre système de santé. Nous avons besoin de ces partenaires non pas pour travailler à notre place, mais pour nous aider à mieux faire, à restaurer et à promouvoir une santé meilleure pour notre peuple. L'aide extérieure au pays sera plus profitable si elle vise à assister la population dans la maîtrise des conditions de son environnement social et de celles qui influencent la santé. Avec le concours d'une multitude de donateurs, notre service de santé publique est en train de s'atteler à d'énormes tâches pour restaurer la santé de notre nation afin d'atteindre l'objectif de la santé pour tous d'ici Fan Ainsi, en nous entraidant, nous pourrons construire un Cambodge uni dans le respect des différences, un Royaume dans lequel hommes, femmes et enfants pourront vivre en harmonie, dans la tolérance et en parfaite santé. Le thème "Ethique et santé", objet de cette session,et les nombreuses interrogations soulevées par les participants montrent que le slogan "Santé pour tous" doit permettre de rallier toutes les forces vives de la planète afin que nos enfants puissent vivre sans menace de mort.

219 A47/VR/9 page 204 The ACTING PRESIDENT: I thank the delegate of Cambodia. In accordance with Rule 59 regarding right of reply, I give the floor now to the Greek delegation to make a brief statement in regard to the address of the distinguished delegate of The Former Yugoslav Republic of Macedonia. Greece, please make your statement from your seat. Mr YANTAIS (Greece): Thank you, Mr Chairman, I noticed that Minister Tofoski in his intervention referred to the "Republic of Macedonia". I have to remind you of two things; first, that the correct denomination under which this country was admitted to the United Nations system is that one of The Former Yugoslav Republic of Macedonia; Security Council resolution 817/93 is extremely precise in this respect. Secondly, regardless of what the country wishes to call itself, one should not forget that a denomination chosen in the United Nations system was not fortuitous and has to be adhered to when speakers address the Organization or the forum. Tliese things are quite clear, so no further interpretation is required. Professor Tofoski also mentioned the fact that he was not allowed to join the Regional Committee for Europe meeting last September in Athens. To clarify, I wish to inform you that problems between our two countries notwithstanding, every arrangement was made from the Greek side to allow him to attend the meeting. But then Professor Tofoski sent a telegram for hotel booking to the Greek Ministry of Foreign Affairs under the heading "Republic of Macedonia", which, to say the least, was not considered as a conciliatory gesture by my authorities. They should not be expected to give a visa to nationals of a country the name of which they question. 1Ъе distinguished speaker mentioned also measures taken by my country which hamper the free flow of goods to and from his own country. To this I have to reply the following: WHO is not the appropriate forum to raise this issue for two reasons. Firstly, and most obviously, health material is not concerned by the measures, the health situation is not impaired, so the remark is pointless. Secondly, the measure is political and as such does not lie within the field of competence of this Organization. Thank you very much, Mr President, The ACTING PRESIDENT: Thank you, Greece. In accordance with Rule 59,the delegation of The Former Yugoslav Republic of Macedonia requested authorization to make a brief comment on the remarks of the delegate of Greece. You have the floor. Mrs TASEVSKA (The Former Yugoslav Republic of Macedonia): Thank you, Mr President. I regret that the representative of the Republic of Greece considered it necessary to use this meeting for presenting matters which unnecessarily take the time of this Assembly. Under Security Council resolution 817/93,and the relevant statement of the President of the Security Council, my delegation is fully entitled to use the constitutional name of our country, which is "The Republic of Macedonia". The relevant service for the interpretation of resolution 817/93 is the Legal Department of the United Nations. We recommend the delegate of Greece to consult the Legal Department of the United Nations whenever he wishes to discuss the use of the constitutional name of our State. The delegate of Greece is right in stressing the importance of the trade embargo against my country. However, he omitted to mention that the embargo of his Government against my country has been universally condemned, and there is no justification whatsoever for it. The sooner it is annulled the better for both countries. It is widely known that we would like to develop the best possible relations with Greece based on mutual respect and interest. We would like to enter that period without any delay. Thank you. The ACTING PRESIDENT: Thank you. According to the same rule, Greece has requested another reply, which will be the last in this connection.

220 A47/VR/10 page 205 Mr YANTAIS (Greece): Thank you, Mr President. Of course it will be the last. Let me just make first a remark to the President. The right term is "The Former Yugoslav Republic of Macedonia". Secondly, the text in itself, as I said, is quite clear and does not require further interpretation. Thirdly, let me add that The Former Yugoslav Republic of Macedonia failed to raise the issue of the trade embargo in other forums much more appropriate than this Organization. For instance, the last round of discussions between GATT and this country would have been much more appropriate. Finally, without entering into a debate about the legitimacy of the measure, I will only remind you that similar measures have been taken in the past by some countries toward others, and several are still in force. Thank you very much. The ACTING PRESIDENT: Thank you, Greece. All will be correctly recorded. Thus we do not need to continue this discussion. The plenary meeting is now adjourned, and will resume at 14h30 this afternoon for the commemoration of 20 years of the Onchocerciasis Control Programme. There are two other items: I would like to inform the delegates of the following two briefings which will be held today during the lunch break: a presentation on "Banking for health - Nigeria's experience", in Room VII, and a briefing on WHO's activities in research on reproductive health in Eastern Europe, in Room XXII. The meeting is now adjourned. The meeting rose at 12hl5. La séance est levée à 12hl5.

221 A47/VR/10 page 206 TENTH PLENARY MEETING Friday, 6 May 1994, at 14h30 President: Mr В. K. TEMANE (Botswana) DIXIEME SEANCE PLENIERE Vendredi 6 mai 1994, 14h30 Président: M. В. К. TEMANE (Botswana) 1. TWENTY YEARS OF ONCHOCERCIASIS CONTROL VINGT ANS DE LUTTE CONTRE L'ONCHOCERCOSE The PRESIDENT: The Assembly is called to order. As agreed, we shall now consider item 14: Twenty years of onchocerciasis control. I have pleasure in welcoming, on behalf of the Assembly and the World Health Organization the following guests who are with us today especially for this agenda item and who are seated on my right: Mr Bruce Benton, Coordinator, Onchocerciasis Unit of the World Bank, Washington; Dr Lucien Bernard, former Assistant Director-General of the World Health Organization; Mrs Sità Candau Reelfs, widow of Dr Candau, former Director-General of the World Health Organization; Dr René Le Berre, former Chief of the OCP Vector Control Unit; Mr Martin Mazurek, representing Merck and Company Incorporated; Professor David Molyneux, current chairman of the OCP Expert Advisory Committee; and Dr Bernard Philippon,former Chief of the OCP Vector Control Unit. I am also pleased to welcome a representative of the OCP donor community; representatives of the OCP participating countries and a representative of the OCP Committee of Sponsoring Agencies. These guests are seated on my left. I now invite the Director-General, Dr Hiroshi Nakajima, to say a few words. The DIRECTOR-GENERAL: Mr President, Members of the World Health Assembly, excellencies, ladies and gentlemen, twenty years ago we embarked on a major undertaking aiming at eliminating river blindness as a public health problem and an obstacle to socioeconomic development in West Africa. At that time, up to 10% of the populations living near the infested rivers had lost their sight due to onchocerciasis and entire communities had moved away from fertile riverine zones through fear of contracting the disease and becoming blind. Today, the Onchocerciasis Control Programme in West Africa has succeeded in removing the threat of river blindness from 11 West African countries. Close to 10 million children have been spared the risk of blindness, about 1.25 million people have been cured of their onchocercal infection and have been prevented from going blind. This was also made possible through the generosity of Merck and Company, which donated its drug, ivermectin, for large-scale distribution and treatment of onchocercal eye lesions in humans, in OCP countries. The area of the Programme, which is now practically onchocerciasisfree, covers roughly 25 million hectares; that includes 15 million hectares of previously abandoned land, which have been made available for resettlement and production - enough to feed 10 million people. The achievements of OCP are the fruits of 20 years of intensive field operations. To ensure that the human reservoir of the onchocercal parasite is brought down to an epidemiologically insignificant level in the extension areas where vector control started late, Programme operations must continue for another few years. The participating countries are already preparing for the post-ocp period, when national epidemiological surveillance and control will safeguard the achievements of the Programme. The international community must not let up on its efforts until devolution is successfully concluded. It must

222 A47/VR/10 page 207 also support the sustainable human and economic development of the onchocerciasis-freed areas. This will be the best guarantee that our past efforts have not been in vain but are a lasting investment for the health and prosperity of all the peoples of West Africa. Mr President, ladies and gentlemen, the success of OCP would not have been possible without the strong and lasting support to the Programme of all the participating countries and the donor community. I therefore wish to express the gratitude of the World Health Organization to the OCP donor community, to the participating countries, to the expert advisory committee, to the sponsoring United Nations agencies, to the industry (Merck) for its support, and, last but not least, to the competent and devoted field staff. May this support remain constant during the few years left until the successful conclusion of the Programme. The PRESIDENT: Thank you, Dr Nakajima. I now invite Dr Monekosso, Regional Director for Africa, to speak to us. Le Dr MONEKOSSO (Directeur régional pour l'afrique): Monsieur le Président de l'assemblée mondiale de la Santé, Monsieur le Directeur général de FOMS, Excellences, Mesdames et Messieurs les Ministres, Mesdames et Messieurs, je voudrais tout d'abord adresser mes remerciements et rendre hommage à tous les pionniers qui, par leurs initiatives, leur courage et leur détermination, ont bâti ce programme de lutte contre Fonchocercose et ont hautement contribué à lui donner ses lettres de noblesse. Je veux parler d'abord des prédécesseurs du Dr Nakajima, le Dr Marcollno Candau et le Dr Halfdan Mahler, sans oublier le Dr Alfred Auguste Quenum, mon illustre prédécesseur, de M. MacNamara, Président de la Banque mondiale à l'époque, des responsables du PNUD et des pays donateurs, qui ont conçu ce programme dans le but d'éliminer la cécité des rivières et de libérer des terres fertiles pour Fagriculture et le développement socio-économique. Cet hommage s'adresse également à M. Marc Bazin, fonctionnaire de la Banque mondiale et premier directeur du programme qui, grâce à ses talents de manager, en a jeté les bases gestionnaires et entrepris les premières actions décisives. Sa gestion verticale rigoureuse a été bien suivie par son successeur, le Dr Ebrahim Samba. Nous remercions tout particulièrement les bailleurs de fonds venant de pays amis, qui se sont constitués en un forum qui a su guider les activités de ce programme au fil des vingt dernières années. Nous nous réjouissons tous aujourd'hui de la réussite de ce bel exemple de la coopération internationale entre les gouvernements de neuf pays de l'afrique de l'ouest et la communauté internationale. Nous rendons hommage aux gouvernements de ces pays, qui ont persévéré en contribuant activement à la lutte et en acceptant le transfert des responsabilités liées au processus de dévolution. Aujourd'hui, les enfants nés dans l'aire du programme ne risquent plus la cécité des rivières. En effet, la transmission de la maladie par les mouches est effectivement interrompue et les terres fertiles peuvent être récupérées pour le développement. Au cours de toutes ces années de lutte contre l'onchocercose, le Bureau régional OMS de FAfrique a eu la responsabilité dans le domaine de la supervision technique, administrative et gestionnaire du programme, en collaboration bien sûr avec le Siège. Pour faciliter la mise en oeuvre quotidienne de ce programme prioritaire, nous avons procédé à certaines dérogations afin de décentraliser le maximum de responsabilités vers le directeur du programme. En outre, le Bureau régional a contribué financièrement aux activités du programme en faisant appel au budget ordinaire de la Région africaine. C'est ainsi que, depuis 1989,j'ai personnellement accru le soutien au programme en affectant un épidémiologiste expérimenté pour coordonner les activités interpays dans les domaines de la planification et de la mise en oeuvre des activités liées à la dévolution. La décentralisation de ces activités est facilitée par le cadre africain de développement sanitaire qui prône la décentralisation vers le district et donne la responsabilité aux populations des collectivités décentralisées à la base. C'est ainsi qu,à Finstar des activités de lutte contre la dracunculose, les activités de prise en charge liées à la dévolution commencent par la base, avec l'appui des autorités locales. Ce cadre de développement, adopté par les ministres africains de la santé et célébré aujourd'hui dans les discussions techniques sur Paction communautaire en faveur de la santé, est le terrain propice pour l'administration de l'ivermectine dans la lutte contre l'onchocercose. L'ivermectine est venue à temps, juste au moment où la capacité de lutte antivectorielle commençait à s'essouffler. La distribution de ce médicament au sein de la population, qui a débuté comme une activité verticale, pourrait et devrait par la suite être incluse dans les activités de soins de santé primaires. Par ailleurs, les activités de lutte contre l'onchocercose devront être incorporées aux activités de surveillance des épidémies en Afrique de POuest et de lutte intégrée contre celles-ci. Le Bureau régional,

223 A47/VR/10 page 208 en collaboration avec le programme, a déjà élaboré des matériels de formation en épidémiologie pour les équipes de santé de district. La bataille contre l,onchocercose, dans les neufs pays de l'afrique de l'ouest, est quasiment gagnée, mais il reste plusieurs pays d'afrique occidentale et centrale et d'afrique de l,est qui doivent bénéficier de notre soutien et au sein desquels nous avons entrepris des efforts de lutte intégrée et de distribution d'ivermectine à la population. Pour terminer, permettez-moi d'adresser mes remerciements et de rendre hommage surtout à tous ces hommes et toutes ces femmes de terrain, de tous pays, qui évoluent au sein de l'équipe du programme en tant que membres du personnel de FOMS. Ils ont, par leur dévouement et leur courage, contribué à la réussite de ce programme qui est - et restera - un bel exemple de coopération internationale. The PRESIDENT: Thank you, Dr Monekosso. I now invite Dr D. Hansen-Koenig, Director of Health of Luxembourg, speaking on behalf of the OCP donor community. Le Dr HANSEN-KOENIG (Luxembourg) (représentant des bailleurs de fonds pour le programme de lutte contre l,onchocercose): Monsieur le Président, Monsieur le Directeur général, Excellences, Mesdames, Messieurs, c'est un grand honneur et un grand plaisir pour moi de pouvoir prendre la parole au nom de la communauté des bailleurs de fonds à l'occasion de cette célébration du vingtième anniversaire du programme de lutte contre l'onchocercose en Afrique de l'ouest. Au cours des vingt années passées, ce programme, coparrainé par le PNUD, la FAO, la Banque mondiale et l'oms, a connu des succès réels. Sur le plan entomologique, une lutte antivectorielle vigoureuse et efficace a permis de maintenir les espèces cibles de savane de la simulie à une densité si faible que, dans la majeure partie de l'aire initiale du programme, la transmission est pratiquement interrompue. C'est un succès incontestable! L'élimination des populations vecteurs est envisagée au bout de quatorze ans, le temps qu'il faut pour que le réservoir humain du parasite disparaisse. Sur le plan épidémiologique, la charge microfilarienne dans les communautés a été réduite à un niveau pratiquement nul dans la majeure partie de l'aire initiale du programme. En outre, permettez-moi de le répéter, 30 millions de personnes sont actuellement protégées contre rinfection, et il est estimé qu'environ 10 millions d'enfants nés dans l'aire initiale du programme depuis son lancement ne risquent plus d'être frappés de cécité onchocerquienne. Près de personnes ont été guéries de leur infection onchocerquienne et quelque autres ont été sauvées de la cécité. C'est le mérite du programme et je tiens à adresser mes sincères félicitations à toutes les personnes impliquées dans cette lutte acharnée. Aujourd'hui, je voudrais profiter de l'occasion pour examiner sommairement quelques-unes des raisons du succès de ce programme. D'abord, je voudrais souligner que le programme s'est fixé des objectifs clairs et précis dès le début : il s'agissait d'éliminer Fonchocercose en tant que maladie ayant des implications importantes sur le plan de la santé publique, et en tant qu'obstacle au développement socioéconomique de toute l'aire du programme, et de s'assurer que les pays participants soient en mesure de maintenir cette réalisation. Le programme a oeuvré dans ce sens et a remporté le succès qu'il mérite. Ensuite, en tant que représentant des bailleurs de fonds pour le programme, je dois insister sur l'importance d'une gestion financière parfaite et absolument transparente. Dans un monde où les scandales politiques et financiers se suivent, il est crucial de se doter de procédures et mécanismes financiers clairs. C'est le cas du programme de lutte contre l'onchocercose, et je voudrais adresser mes remerciements à la Banque mondiale qui a joué, à cet égard, un rôle déterminant. Finalement, permettez-moi de mettre en exergue le rôle des hommes et des femmes impliqués dans la gestion du programme. La qualité des ressources humaines engagées dans la réalisation des objectifs a été, à notre avis, déterminante pour le succès obtenu jusqu'à présent, et j'aimerais exprimer mon respect et ma profonde gratitude à l'équipe du programme. Nous avons eu le plaisir d'accueillir à Luxembourg le Comité conjoint du programme de lutte contre l,onchocercose pour sa quatorzième session en décembre dernier. Cette réunion a été d'une importance capitale car le Comité a été appelé à prendre des décisions qui auront une portée considérable pour la définition des lignes de conduite du programme en 1994 et au-delà. Il s'agit maintenant de préserver les acquis et d'intensifier les efforts dans les zones d'endémie restantes, ce qui, évidemment, nécessite la poursuite du soutien des donateurs pendant quelques années encore.

224 A47/VR/10 page 209 Pour ravenir, je souhaite bonne chance à tous ceux qui participeront au programme, afin que la lutte contre Fonchocercose puisse être, comme par le passé, un modèle de coopération fondé sur la solidarité entre nos pays, entre le Nord et le Sud. The PRESIDENT: Thank you Dr Hansen-Koenig. I now give the floor to Professor Какой Guikahue, Minister of Public Health and Social Affairs of Côte d'ivoire, speaking on behalf of OCP participating countries. Le Professeur KAKOU GUIKAHUE (Côte d'ivoire) (représentant les pays participant au programme de lutte contre l,onchocercose): Monsieur le Président, Monsieur le Directeur général, honorables délégués et invités, Mesdames et Messieurs, au moment où la Côte d'ivoire, mon pays, qui occupe la vice-présidence de la quatorzième conférence du Comité conjoint du programme de lutte contre Ponchocercose, s'apprête à accueillir la quinzième réunion du programme à Yamoussoukro, et à l'occasion du vingtième anniversaire de ce programme, j'ai l'honneur d'évoquer en votre nom à tous le bilan et les perspectives de ce programme dans les pays de la zone qu'il couvre. Je ne voudrais pas commencer mon intervention sur ce programme sans m'inspirer des analyses de deux de nos chefs d'etat, LL. EE. Abdou Diouf, du Sénégal, et Biaise Compaore, du Burkina Faso, lors de la récente réunion organisée à Paris sur le peuplement de la zone libérée de l,onchocercose. Oui, l'onchocercose, avec son handicap majeur, la cécité, a bien constitué un frein au développement. Les zones d'infestation, souvent fertiles, se dépeuplaient; les populations se dirigeaient vers des régions.. moins favorables à la dégradation desquelles eûes contribuaient du fait de la surexploitation. Aujourd'hui, vingt ans après le lancement des activités du programme de lutte contre Fonchocercose, il est réconfortant de constater que la situation a évolué très positivement. La transmission de la maladie est interrompue dans plus de 80 % de l'aire initiale. Le risque de cécité a pratiquement disparu. Tout d'abord, Monsieur le Président, honorables délégués, permettez-nous de saisir cette occasion pour rendre un vibrant hommage et renouveler notre sentiment de profonde gratitude à toute la " communauté internationale, et plus particulièrement à vous tous, pays et organismes donateurs qui, depuis vingt ans, ne cessez de conjuguer vos efforts pour assurer à ce programme tout le succès qu'il connaît aujourd'hui. Ensuite, je voudrais remercier le directeur du programme ainsi que tout le personnel pour leur gestion efficace. Cependant, pour éviter que la maladie ne ressurgisse dans ces vallées et ne compromette à long terme les efforts de développement entrepris, un certain nombre de conditions devraient être remphes, et ce afin de consolider les acquis antérieurs. Ces conditions portent sur la manière dont s'achèvera le programme, le degré de préparation des pays participants pour la prise en charge des activités résiduelles du programme, et les mécanismes de coordination entre les pays concernés. Les données techniques et scientifiques accumulées durant les vingt dernières années indiquent clairement que tout est en place pour une victoire totale du programme d'ici l'an Toutefois, ces mêmes données indiquent que si, pour une raison quelconque, le programme était contraint de mettre un terme à ses activités avant l'an 2000,les excellents résultats qu'il a acquis seraient rapidement compromis par une recrudescence de la maladie d'abord dans les zones d'extension du Bénin, de la Côte d'ivoire, du Ghana, de la Guinée, de la Sierra Leone et du Togo, puis dans son aire initiale. C'est pourquoi je voudrais adresser à la communauté internationale, au nom des pays de la zone du programme, le message suivant : il faut maintenir, pendant sept à huit années supplémentaires, l'engagement de financer les activités de lutte antivectorielle et de traitement des malades nécessaires à l'assainissement définitif des zones d'extension. Pendant ce temps, les pays bénéficiaires, avec l'appui technique du programme, auront à redoubler d'efforts pour prendre en charge les activités résiduelles. Notre engagement de sauvegarder les acquis de ce vaste programme reste ferme et se concrétisera à travers le processus de dévolution. D'ici l'an 2000, nos pays devraient renforcer leur capacité de surveillance épidémiologique des endémies majeures, afin d'être en mesure de détecter à temps et de maîtriser toute recrudescence éventuelle de l,onchocercose. C'est pourquoi chaque pays a déjà élaboré un plan national de dévolution dans lequel il a associé la surveillance de Fonchocercose à celle d'autres endémies telles que la trypanosomiase humaine africaine, la bilharziose, la dracunculose, etc. De vastes campagnes de sensibilisation et de mobilisation de nos populations sont en cours. Dans toutes les zones assainies où les épandages larvicides ont été définitivement arrêtés, des équipes nationales

225 A47/VR/10 page 210 mobiles formées par le programme ont déjà démarré des enquêtes épidémiologiques longitudinales dans des bassins fluviaux présentant des risques élevés de recrudescence de la maladie. Quant au traitement des malades de Fonchocercose par Wvermectine, il s'effectue déjà de manière intensive par l'intermédiaire du personnel de nos structures nationales de santé et avec une participation de plus en plus active des communautés rurales elles-mêmes. S'agissant du renforcement des acquis du programme, il serait hautement indiqué de mettre l'accent sur les actions concertées de nos pays en matière de détection et de maîtrise de la recrudescence de l'onchocercose dans toute la zone concernée, de même qu'en matière de peuplement des zones libérées. Monsieur le Président, honorables délégués, Mesdames et Messieurs, je ne saurais conclure sans saluer encore une fois les efforts louables qui ont déjà été consentis et que continuent de déployer, dans la mise en oeuvre du programme, les pays et organismes donateurs, les pays participants, le Comité OMS d'e^erts et le Comité des Organismes parrainants à qui nous devons le succès du programme de lutte contre l'onchocercose. The PRESIDENT: Thank you Professor Какой Guikahue, I give the floor to Mr Benjamin Gurman, Senior Programme Manager, United Nations Development Programme, who will speak on behalf of the OCP Committee of Sponsoring Agencies. Mr GURMAN (United Nations Development Programme, representing the OCP Committee of Sponsoring Agencies): Mr President, Mr Director-General, excellencies, delegates, ladies and gentlemen, on behalf of the UNDP Administrator and the Committee of Sponsoring Agencies of the Onchocerciasis Control Programme, I am ^eatly honoured by this opportunity to participate in the commemoration of the twentieth anniversary of OCP. Too often meetings are convened to address economic, political and social crises or to consider what went wrong in our development strategies and programmes. OCP is a remarkable exception, perhaps the most successful government, donor and private-sector technical cooperation alliance in Africa. There are many reasons for this success story. I would like to mention briefly three OCP attributes: first, the sustainability of the OCP development alliance within Africa and with the donor community; second, prolamine accountability; and third, the OCP health and development synergy which has consolidated this unprecedented programme alliance. The strength of OCP lies in the alliance developed between African countries and the donor community to pursue the dual long-term programme objective: to eliminate onchocerciasis as a constraint to both health and development. African leaders, scientists, health professionals, and donor organizations have worked as equal partners to plan, monitor and assess programme operations. As new control strategies were identified and tested, the pharmaceutical industry joined the alliance,making ivermectin available, free of charge, to all endemic countries. The nongovernmental organization community is now playing an important role in bringing this control tool to the community level. The second success attribute, mentioned also by the representative of the OCP donor community, is accountability and transparency, the confidence-building blocks that underpin the OCP foundation; translating into clear goals, measurable outputs, sound technical strategies, strict budget control, staff excellence, and finally but certainly not least, strong leadership. We are honoured today to pay tribute to the outstanding OCP leadership of Dr Ebrahim Samba. The third contributing factor to the OCP success story is the Programme's health and development synergy. From the beginning, the goal of this Programme has been to eliminate onchocerciasis both as a health and as a development constraint. The architects of OCP in the early 1970s saw the clear linkage between health, productivity of people and lands, environmental protection and growth, all basic elements of what we now refer to as a people-centred sustainable human development strategy. Three weeks ago the Committee of Sponsoring Agencies sponsored a ministerial meeting on sustainable settlement and development, highlighting the development potential as well as the environmental degradation risk resulting from the resettlement process taking place on the 25 million hectares of land freed from river blindness. At the Paris meeting, African ministers of health, agriculture, environment and rural development from the 11 OCP countries exchanged experiences on land settlement within their countries and considered policy options supportive of sustainable human development. While recognizing the diversity of country situations, African participants reached a consensus on a set of guiding principles

226 A47/VR/10 page 211 for sustainable settlement and development that will facilitate the formulation of national strategies for follow-up actions. At the meeting, the Committee representatives expressed interest in building on the successful OCP collaboration and facilitating a policy dialogue, investment, and a capacity-building programme development and resource mobilization strategy at the country level for social and economic development follow-up. The role of the Committee's partners (WHO, World Bank, FAO,and UNDP) is to facilitate the evolution of OCP through its various stages. The best side of United Nations system cooperation is in evidence and we are proud to be OCP partners. We offer our congratulations to WHO, as the executing agency and for the excellent support provided by WHO headquarters and the Regional Office for Africa, and to all of the OCP partners on achieving this milestone. I wish to conclude with an appeal to all partners to continue support to OCP during this final operational phase and to the devolution process, in order to assure the sustainability of the results achieved. The PRESIDENT: Thank you, Mr Gurman. I now ask Dr Ebrahim Samba, Director of the Onchocerciasis Control Programme, to say a few words. Dr SAMBA (Director, Onchocerciasis Control Programme): Mr Chairman, Director-General, honourable ministers, distinguished ladies and gentlemen, please excuse my voice; I have a little cold. Fortunately, everything to be said about OCP has already been said by the previous speakers. I would just like to underline the fact that OCP is a truly collaborative effort, starting with the African governments and people represented by the 11 ministers sitting in front of you. All of them have contributed money, logistics and many other facilities to make our task extremely easy. As for the donors, we cannot thank them enough. After 20 years, after over 400 million dollars, last year in December in Luxembourg, after we presented our budget they approved the budget within ten minutes and then said to me: "Please come again if you need more. This, by any standards, is remarkable in this climate of economic constraints. For the donors to approve your budget within such a short period, and to say "Come again if you need more" - you will agree with me that they do deserve our extreme gratitude. As for the Committee of Sponsoring Agencies, the World Health Organization, the World Bank, UNDP and FAO, they have been exemplary in their support, and I would like particularly to thank the Director-General, Dr Nakajima, and his staff in that they are available to me at any time with very, very short notice. The Expert Advisory Committee, twelve extremely busy professors who come from all over the world, spend their time not only at OCP meetings, but visit the field and give us the benefit of their expertise. I cannot conclude without mentioning the role of private industry, of institutions in Europe, in America and in Africa. You have all heard repeatedly what Merck and Company has done in regard to giving us ivermectin free of charge for as long as is necessary. The list of companies is very long I need not go into all of them, but we started with one larvicide and today we have seven, all of them from private industry, from the United States of America, from France, the United Kingdom, Germany, Japan, Switzerland, Belgium, the list goes on. Without exception, all of them, after we have complained of our budgetary constraints, reduced their prices, some of them by 50%. Again I am sure you will agree with me that they all deserve our gratitude. Truly, OCP is an example of fruitful collaboration, North-South, South-South and North-North. For me, it only remains to thank WHO, to thank all the partners for having given me the opportunity to serve you and to prove that we can do some good in Africa as well. I thank you very much indeed. The PRESIDENT: Thank you Dr Samba. Before closing this ceremony, I would like to invite Mr Mazurek, representative of Merck and Company Incorporated,to confirm the commitment of his company to the Programme. Mr MAZUREK (Merck and Company Incorporated): Mr President, Mr Director-General, excellencies and distinguished delegates, it is a great honour to represent Dr Roy Vagelos and be here and to meet personally a group of people who have contributed so

227 A47/VR/10 page 212 much of their skill and energy to helping solve the pressing problems in Africa and to advance economic development, health care and education there. In accepting this recognition, I want to make it clear that in the battle against onchocerciasis, Merck could not make Mectizan available to the people who need it without the support and hard work of many individuals and public and private organizations. It was the incredible insight of one Merck scientist, Dr William Campbell, which motivated our research laboratories to investigate the use of ivermectin against parasites in humans. These efforts resulted in a revolutionary, once-a-year therapy for the treatment of onchocerciasis. However, we did not know how difficult it would be to make the drug available to the people who so desperately needed it. Merck concluded that only by donating it could we remove a major obstacle to its widespread use. Thus Merck made the commitment in October 1987 to donate it for as long as is necessary to treat onchocerciasis. But six years after initiating this effort, we are not satisfied - and we will not be until everyone who needs the drug has the chance to receive it. This, I believe, is our greatest challenge and Merck cannot do this alone - it must be a shared responsibility for all of us in the public, private and voluntary sectors. Thus, I invite you to become partners in this battle against onchocerciasis. I promise you that Merck's commitment will remain strong. We will continue to donate Mectizan for as long as it is needed to treat onchocerciasis. On behalf of Merck, I am greatly honoured and very proud to be here and to say that we will continue to share in the WHO goal of health for all throughout the world. The PRESIDENT: Thank you, Mr Mazurek. I wish to express, on behalf of the Health Assembly my thanks to the speakers who have given us a picture of this remarkable Programme and its considerable achievements. My thanks also go to our guests who have in one way or another been intimately associated with the Programme and who have honoured this meeting with their presence. I would like to congratulate all the members of the OCP community, the participating countries, the donors, the OCP Expert Advisory Committee, the sponsoring agencies and, not least, the staff - on the outstanding success of the Onchocerciasis Control Programme in West Africa. OCP has proved to the world that health action and socioeconomic development are intrinsically connected. This concludes this part of the proceedings. 2. DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-SECOND AND NINETY-THIRD SESSIONS AND ON THE REPORT OF THE DIRECTOR-GENERAL ON THE WORK OF WHO FOR (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-DOUZIEME ET QUATRE-VINGT-TREIZIEME SESSIONS ET SUR LE RAPPORT DU DIRECTEUR GENERAL SUR L'ACTIVITE DE L'OMS EN (suite) The PRESIDENT: We now continue our debate on agenda items 9 and 10,while Committee В resumes its work in Room XVII. I still have three speakers on my list. I give the floor to the delegate of Angola. Le Dr EPALANGA (Angola): Excellences, Monsieur le Président, Monsieur le Directeur général, honorables et distingués délégués des Etats Membres, Mesdames et Messieurs, au nom de la République d'angola, j'ai tout d'abord le grand honneur de m'associer aux délégations précédentes pour vous féliciter, Monsieur le Président, de votre élection au poste le plus élevé de cette auguste Assemblée. Nous sommes convaincus qu'avec le concours des autres membres du bureau, vous mènerez nos travaux à très bon terme. Pour commencer, nous devons reconnaître une fois de plus rimportance du travail digne d'éloges accompli par l'organisation mondiale de la Santé en vue d'assurer à tous les habitants du monde les soins de santé essentiels grâce à l,utilisation de technologies appropriées et au fonctionnement de systèmes de santé adaptés à chaque contexte. Nous félicitons le Dr Nakajima, Directeur général, et le Dr Monekosso, Directeur régional, pour les succès enregistrés par l'oms.

228 A47/VR/10 page 213 Dans mon pays, l'angola, la population subit les conséquences d'un des conflits les plus meurtriers du monde, conflit sans précédent, qui a presque paralysé la vie sociale et le système économique du pays. La guerre progressant, le système de santé s'est contracté, pour se limiter aux zones de tranquillité relative mais surpeuplées à cause du déplacement de populations cherchant abris et sécurité, avec toutes les conséquences néfastes que cela entraîne naturellement sur les conditions de vie et l'état de santé des populations directement affectées. Plus concrètement, outre le nombre élevé de vies humaines perdues, le nombre important de handicapés et Fampleur des traumatismes psychosociaux provoqués par la guerre, la population angolaise pâtit encore d'une pénurie alimentaire générale et d'une aggravation de la situation nutritionnelle des enfants en bas âge (ceux de moins de cinq ans); d'un taux de mortalité infantile parmi les plus élevés du monde; d'une réduction de la couverture vaccinale et d'une recrudescence des maladies cibles du programme élargi de vaccination; d'une prévalence très élevée de certaines maladies transmissibles, telles que les maladies diarrhéiques, le paludisme, la tuberculose et la trypanosomiase humaine, maladies difficiles à maîtriser; d'une augmentation progressive du nombre des cas de SIDA et sûrement aussi des taux de séroprévalence du VIH; de la destruction des infrastructures sanitaires et de la dispersion du personnel de santé dans les zones affectées par la guerre; du non-fonctionnement enfin du système d'orientation-recours faute de moyens de transport et de communications. Monsieur le Président, honorables délégués et participants, la situation sanitaire de mon pays ne peut être qualifiée que de désastreuse. Malgré cela, nous poursuivons l'objectif de la santé pour tous fondé sur les soins de santé primaires dispensés de façon systématique dans un nombre limité de districts, car nous accordons la priorité absolue aux populations sinistrées par la guerre, et ce avec la collaboration du Département des Affaires humanitaires de l'organisation des Nations Unies, qui coordonne les interventions des différentes institutions spécialisées du système des Nations Unies en Angola. La situation de crise provoquée par la guerre et la complexité des problèmes qui se font jour ont conduit tout récemment le Gouvernement à adopter un programme économique et social visant à concentrer les moyens et les efforts pour surmonter la crise. En ce qui concerne le secteur de la santé, d'une part nous renforçons le système de santé dans les districts non affectés par la guerre, et d'autre part nous fournissons des soins médico-sanitaires et une aide humanitaire aux populations des zones directement touchées par le conflit militaire. Pour répondre à cette situation, nous avons essentiellement besoin de remettre en état les infrastructures sanitaires, d'acquérir des médicaments, des équipements et du matériel médical, et de former et de recycler le personnel de santé, en particulier dans les domaines de répidémiologie, de la nutrition et des soins intensifs. Nous avons aussi besoin d'une meilleure coordination de rintervention, sur le plan technique, des différents organismes de coopération, y compris des organisations non gouvernementales agissant sur le terrain. Au nom du Gouvernement angolais, nous saisissons cette occasion de remercier, pour toutes les contributions déjà reçues, le Département des Affaires humanitaires de l'organisation des Nations Unies, les pays pratiquant la coopération bilatérale (en particulier la Suède, l'italie et la France), les organismes de coopération multilatérale et les organisations non gouvernementales. Cette solidarité de la communauté internationale a beaucoup contribué à soulager la souffrance de millions d'angolais frustrés par les violences de la guerre. Nous remercions également l'oms de l,assistance qu'elle nous a déjà accordée et souhaitons l'intensification de la coordination des interventions techniques et de la mobilisation des ressources. Comme nous l'avons déjà dit, Monsieur le Président, la crise économique et financière que traverse le pays touche le secteur de la santé de façon toute particulière et négative; c'est la raison pour laquelle nous renouvelons notre appel en faveur d'un renforcement de l'aide humanitaire en cours, l'accent étant mis sur la composante santé. Il est évident, et nous en sommes conscients, qu'il est impossible de mener à bien le développement sanitaire dans un contexte de guerre; à ce propos, j'aimerais vous assurer que notre Gouvernement a pris rengagement très sérieux de négocier une paix durable dans notre cher pays. Dr TAMRAT (Ethiopia): Mr President, Mr Director-General, excellencies, honourable delegates, respected guests, ladies and gentlemen, on behalf of the Transitional Government of Ethiopia and my delegation, I congratulate the President and Vice-Presidents for their election, and join my Eritrean brother in expressing my heartfelt congratulations to South Africa. Excuse my temerity if I present our sincere welcome to all new Members of the World Health Organization. My country Ethiopia, a land of 51 million people, a land of many nations and nationalities moving firmly along the path of democratic decentralization, counts about 6.7 million people threatened by drought

229 A47/VR/10 page 214 and famine. Unfortunately, they have been revisited by recurrent droughts, which are of great concern to my Government. Despite all this, Ethiopia proceeds with determination to effective decentralization, with renewed commitment to primary health care. The many policies launched officially last year and this year, are all people- and development-centred, and are consistent with community empowerment. The Wereda, the smallest units of administration, of which there are about 647, have a local government elected by the people, thus bringing administration and decision-making to the people. Such structures ensure transfer of human as well as financial resources. The different policies - health policy, education policy, population policy, science and technology policy, the Emergency Code, to mention only some - are all without exception based on community participation and effective community empowerment. With regard to health, my country with 55% health coverage and high infant, child and maternal mortality - puts the accent on prevention. Malaria, tuberculosis and AIDS are the priorities among the priorities. The video which is being displayed and viewed at this Forty-seventh World Health Assembly reaffirms our belief that community mobilization and participation in the malaria control programme in Tigray is the road to success and achievement. This film, shows but one facet of the many success stories of people's participation. I take this opportunity to renew our appreciation to the malaria control programme of the World Health Organization. The tuberculosis control programme which is integrated with leprosy control, will undoubtedly share the support of many partners who were successful in leprosy control. Our AIDS/sexually transmitted disease control activities have enjoyed the participation of religious leaders, women, youth and artists in increasing awareness through thousands of AIDS communicators. Branded programme on immunization coverage has more than doubled this year. In harmony with our new health policy, which emphasizes mid-level health professional training, new schools are being established for midwives, laboratory technicians, nurses and environmental health professionals. Curative medicine, which is a burden on our health budget, is being streamlined. Basic health services ravaged by war are being rehabilitated through international and WHO assistance. The new drug policy puts the accent on essential drugs and ethical standards. In accordance with the economic policy, cost recovery in health, particularly in curative health, is being thoroughly studied, drawing inspiration from the e>q)erience of sister countries. Poor indeed, but rich in determination and commitment, my Government takes up the challenge of the twenty-first century, capitalizing on its wealth: namely, its people - and their culture - whose energy is being harnessed for the betterment of their life. Finally, Mr President, it remains to me to thank all organizations of the United Nations system, particularly WHO, for their continued support, all governments and nongovernmental organizations who are by our side in this exciting challenge of democratic decentralization, leading to peace and justice, the modest gift of our 51 million people to the world. Dr ARAFAT (Palestine) «лзl«j 1 ^ ju*«j1 «j^i^jt p '<L>woJ1 f Ijj^ Ó^LuJ! ( ^LsJI ^juji, ṙ y, 'djlüi ^JlaI LÙS " j^jj! Ó,A g ) La^Sj ^is,_ r,.j I ^-iai ^^-Jau^JLs U ^ j ^з ^J-JyJI^ ç-u-ji i^j LjuCut j-u^j,, ;UJJ1 fl^j jl^ji^ ^j^sjji ^ J Í LJSUJS) ' -OU. "Ó 广 H ) CIU^L ^JJI J^JJLJ LÍU^JL ^SISI LOJK \ 3. ÓJ^JJI 产: "dijar.,1 ) ' aslji djji-. a.^ \л d-j»îc^uuk^vl» ^-JxaJ] Ц,. «々,^.liS J^-Ju Ig Vi l^j " A 广 h \л ^Jl jí^j 0 U Jl 1.Ц.Я.У; jjli dl^lloj! ^ Э ^^as^j aj I «,l«sij J ^ A jji I J! ^jjijl длв 15JI tjûi^jpâg 1 J\JAIMJJI J ^ U ^ - J^íjJ! 乏 SU jlùjy^ dj ji ^. djucuji a^l^^îi leüjuji âssb j ^-U ajlc ^jjo A^JL^Û LAJ \ ^ ^J^MJ ^ j^júío^ ^ JJJSW/I^ LlJ <SLOX jj Jxu/^lloJl I ^jjùj.o^u \ ^JLAJI 0 ; ṙ h м. U11 己 L»s j^js^] d^ülsji à^sj ^Л-.к.» lá И ;1 Ju«J> JlïJ ^Juwa/ 防 áia-jjy; ;jji Uwj'l^ d^i ^ C^L-vu.JVL ^ouji JUÜ'ÍÍ! çjj^: а^ь ^jji3 ^ixjuil^ cjl 彡 ^IJ^JJI^ V^L^l^oJI ^ f- I^JV dlji Ji. '< LLJU J1 j^o ^ A^UJ-. LJI d^sl«j^ djulw^ JJLC Д ó^j^cuz ^-íajxl^» ^S ^íi-uijl) ^-«.«mj 1 ) 1 Ц» JJl^iioJ 1

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231 A47/VR/10 page 216 二.-a.п"Л j ^JLot i^jjjbjj Lu li > _. ^ «M 11 1 JJb I I j ^ O J Ü V Cl/^-ûJ! ^JJD 己 < I J. 'O O ^J I LiT ' ^ L o j l 0:. ГШ LL^A-Í ^cjj Ul3 i^^ul. ^U'l ь ^ Ju VO- -" dj,си» ^ J^^^ 1 f 尸 fjbj! ^ ^ VO"' o^i, I ^Js Ц. Jühf LIAJIX Ls^O 己 juojj ^SJ LAX 1 ^ I ^ôw ) ^! 二 JL^JJ LUJ 1 ^ ci; I I I ^j^jüs ^ojj I ^^JLc Lái^jo^-' ( j^j^ ^ Ijuil 彡 Ijj i ya ^JLjum/ LaIXj» Lu ^ 1-áül9 I _Лз 1.j^jl^JI 二 1 З VJ^AJI J-Ô-AJI У^З^И A-IA DÛI ^JLÍÜ! CL^JLJ "Á^SJÂ LIOL>L,J ) я.,с ^^JaJI ^J I^ "Â-.1 JLjJI l^jl LeLc ^JLfil3. d-oucji ' og д П JlA^ 少 1 1 ^JljÜI 1 JLA "Â5j LXuJU L A - к9jl^jü Мло^о I LliL^o ^ l - L L o L i l i l jjl5 ^.tsua'j L^uJI ^JU jü'â-c>wwcji dj5liu> ^^JLc ^J^JJI t-v.no:;.^.o о I '<L^^Jl <)jlû J>1> 1 J j J-j.1 J Uil3 ^.Jsu^Ji J Ubi 4-J ^JU jojlsji LieJU fli^ ^. ^ LeJI J Labi LJb^il I jsjo^ ^M^MJ I ^ The PRESIDENT: I thank the observer from Palestine. Le Dr MBOYO (Zaïre) : 1 Monsieur le Président, m'exprimant du haut de cette prestigieuse tribune au nom de la République du Zaïre, j'ai le plaisir et l'insigne honneur de vous adresser mes chaleureuses félicitations pour votre élection à la présidence de la Quarante-Septième Assemblée mondiale de la Santé, et de souhaiter un plein succès à cette Assemblée sous votre direction éclairée. Nous adressons également nos sincères félicitations aux Vice-Présidents et à tous les membres du bureau de cette Assemblée de la Santé. La qualité et la riche expérience des éminentes personnalités qui forment le bureau sont certainement de bon augure et constitueront la meilleure garantie du bon déroulement des travaux de cette Assemblée. Nous tenons par ailleurs à vous assurer, ainsi qu'à tout le bureau dans sa lourde et délicate mission, de l'appui sans réserve de toute la délégation du Zaïre. Excellences, Mesdames et Messieurs les Ministres, honorables chefs des délégations, distingués délégués, alors que je vous adresse le salut cordial du peuple zaïrois, permettez-moi de saluer chaleureusement l'avènement d'une ère nouvelle, particulièrement riche d'événements heureux en Afrique du Sud. En effet, après le bon déroulement des élections libres et multiraciales, la Quarante-Septième Assemblée mondiale de la Santé a autorisé dès son ouverture la réintégration de l'afrique du Sud dans notre Organisation avec la pleine jouissance de tous ses droits et privilèges; bientôt, probablement avant la fin de nos travaux, nous serons certainement informés de la mise en place de nouvelles institutions, qui concrétiseront la volonté des électeurs et le souci de voir régner rharmonie et la concorde au niveau national. Il s'agit d'une série d'événements historiques exceptionnels qui mérite à notre avis d'être saluée solennellement. Monsieur le Directeur général, la délégation de mon pays et moi-même nous présentons nos vifs remerciements et nos sincères félicitations à vous-même, à tous vos collaborateurs, en particulier au Directeur régional de l'oms pour l'afrique et à son personnel, pour les remarquables qualités de votre rapport, qui pour être très clair et concis, n'en est pas moins très complet. Ce rapport offre un cadre pertinent à des orientations exhaustives précises et souples pour le développement sanitaire du monde et des Etats Membres. Le chemin parcouru depuis l'adoption en 1978 par la communauté internationale, sous rimpulsion pertinente et courageuse de l,oms,de la Déclaration d'alma-ata, du concept et de la stratégie des soins de santé primaires pour la réalisation de l'objectif ambitieux de la santé pour tous d'ici Гап 2000,nous 1 Le texte qui suit a été remis par la délégation du Zaïre pour insertion dans le compte rendu, conformément à la résolution WHA20.2.

232 A47/VR/10 page 217 conforte tous dans la pertinence, la noblesse et la conformité à l'éthique et à l'équité de cet objectif de la santé pour tous et de la stratégie des soins de santé primaires, et nous conduit à relever dans le rapport du Directeur général à la fois des motifs de satisfaction pour les succès éclatants enregistrés ici et là, mais aussi et surtout des motifs d'inquiétude fondés face à l'état de santé du monde en général et à celui des pays en développement en particulier, et spécialement ceux de l'afrique subsaharienne. Pourrait-il en être autrement dans un monde où le rythme des changements, des bouleversements et des conflits rend aléatoires toute prévision et toute planification, où le fossé des inégalités se creuse chaque jour davantage et où la convergence des effets pervers de la pauvreté, de la faim, de la maladie, de rignorance, du chômage, de l'environnement insalubre et hostile, et rémigration forcée sont le lot quotidien du plus grand nombre des habitants de la planète, entretenant un climat de tension et des conflits qui mettent la paix en péril, enfin où les ressources déjà inéquitablement réparties s'amenuisent et deviennent rares tant au niveau des institutions internationales et régionales, qu'à celui des pays et des communautés, et cela en dépit de la multiplication des situations d'urgence requérant davantage de ressources? Ces considérations montrent que le développement en général et le développement sanitaire en particulier sont très largement tributaires de l'éthique et de l'équité dans l'ordre politique et dans l'ordre économique international, qu'il faudrait normaliser par des efforts soutenus afin d'éviter des débats et des actions inutiles. S'il est généralement admis que les tâtonnements et même les erreurs ont leur place dans toute communauté vivante et que Геггеиг enseigne souvent plus que le succès, qu'elle permet de mieux comprendre les limites à ne pas dépasser et de baliser Pavenir, les enjeux de Paction de santé, non seulement ne peuvent s'accommoder de l,accumulation d'erreurs et de retards, mais requièrent aussi que la communauté internationale s'engage résolument et sans perdre de temps dans les voies les plus adéquates pour relever le défi de la santé pour tous et tirer le meilleur parti possible des atouts identifiés et à identifier. Après les efforts de normalisation de l'ordre politique et de l'ordre économique international qui constituent le premier atout qu'il convient d'engager dans la voie du respect de Féthique, de l'équité et de la moralité pour le développement, l'autre atout qui mériterait qu'on lui accorde davantage d'attention et de considération est incontestablement l'homme. A cet égard, il faudra accorder une attention toute particulière aux différents rôles que l'homme joue ou devrait jouer dans le cadre du développement sanitaire individuel, communautaire, national et international ainsi qu'à sa culture. En effet, à chaque étape du développement sanitaire, l'homme occupe toujours la place centrale. On le retrouve ainsi, agissant successivement seul ou en groupe, au niveau de la conception, de la prise des décisions, de la mobilisation et de la gestion de ressources, de la production et de la distribution des ressources sanitaires, biens et prestations. A chacune de ces étapes importantes pour le développement sanitaire, rimpression qui prévaut est que, si l'homme était préparé à assumer correctement et avec toute la compétence requise la mission qui lui est dévolue et les responsabilités qui en découlent, le défi de la santé pour tous serait rapidement relevé. C'est pourquoi il nous semble fondamental, dans le cadre du nouveau programme, de faire de l'homme, à tous les stades de sa participation au développement sanitaire, un partenaire pleinement conscient de ses responsabilités concernant sa propre santé, celle de sa famille, de sa communauté et de la communauté nationale et internationale, et de ses devoirs et de ses obligations civiques et morales de solidarité et d'éthique envers ses semblables; d'insister sur l'urgence et l'importance de la moralisation des relations entre les hommes, entre les communautés et entre les nations; et d'étudier et de mettre en oeuvre des mesures appropriées pour que chacun ait la pleine maîtrise du comportement à adopter en toute circonstance face aux problèmes de santé. Les efforts de valorisation des ressources humaines ne devraient plus être limités aux seuls dispensateurs des services, mais être élargis adéquatement à tous ceux dont dépend, pour une très large part, le succès du développement sanitaire à divers titres. D s'agit, certes, d'une entreprise de longue haleine, mais tellement porteuse d'espoir à terme, qu'aucun effort ne devrait être épargné pour sa pleine réalisation. Les changements fréquents dans ce monde en mutation ont vite fait de mettre à jour le caractère inadéquat et la fragilité des grandes institutions et des grandes administrations minées de l'intérieur par la lourdeur de la bureaucratie et par leur voracité budgétaire, en même temps qu'ils ont montré que les ressources humaines au sens large sont en définitive celles qui restent les plus constantes et dont il convient d'exploiter judicieusement les énormes et inépuisables potentialités. Grâce au dynamisme et au génie créateur de l'homme et des communautés, on a réussi en République du Zaïre, depuis près de quatre ans, à maintenir des activités de santé à un niveau nettement au-dessus des prévisions les plus optimistes; ce qui nous a confortés dans Fidée qu'il faut avoir foi dans l'homme et dans la communauté.

233 A47/VR/10 page 218 M. SIDIBE (Mali) : 1 Monsieur le Président, Monsieur le Directeur général de POMS, Mesdames et Messieurs les Ministres, honorables délégués, Mesdames, Messieurs, j'ai l'honneur, au nom du Mali, de vous adresser mes vives félicitations pour votre brillante élection à la Présidence de la quarante-septième session de l'assemblée mondiale de la Santé; je félicite également les Vice-Présidents qui ont l'honneur de vous assister dans la conduite de cette session. Je ne saurais continuer sans noter que, par ma voix, le Mali adresse ses chaleureuses salutations à la délégation de la République d'afrique du Sud, qui vient de recouvrer la plénitude de ses droits au sein de notre Organisation. Monsieur le Président, ma délégation apportera sa modeste contribution à la résolution des grands problèmes qui affectent dangereusement la santé des populations dans le monde entier et plus particulièrement en Afrique. Nous sommes conscients de la crise que connaît le secteur de la santé consécutive à la crise économique persistante et au développement du SIDA, toutes choses qui compromettent les acquis certes faibles, mais combien précieux, dans le délicat domaine de la santé publique. Nous sommes tout aussi conscients qu'une véritable mobilisation sociale est à même de redresser la situation. Nous apprécions la pertinence des questions soulevées et examinées dans le rapport du Directeur général et nous sommes particulièrement attentifs à celles qui ont trait à la survie et au bon développement de l'enfant ainsi qu'aux suggestions tendant à améliorer la santé et le bien-être de la femme. Au regard de Péradication, l'élimination ou la maîtrise de maladies constituant des problèmes de santé mondiaux, nous souscrivons aux résolutions relatives à l,éradication de la poliomyélite et de la dracunculose; à l'élimination de la lèpre comme problème de santé publique, du tétanos néonatal et de la rougeole; à la maîtrise du paludisme et de la tuberculose; et à la lutte contre l'onchocercose par la distribution d'ivermectine. Dans cette perspective, deux aspects méritent d'être soulignés : la qualité des médicaments essentiels et leur disponibilité; la santé communautaire, prélude à un meilleur état de santé des populations. Appartenant à la zone franc et confrontés au renchérissement des produits pharmaceutiques depuis le changement de parité du franc CFA vis-à-vis du franc français, nous sommes préoccupés, comme bien d'autres pays, par un approvisionnement performant en médicaments essentiels de qualité et au moindre coût. Face aux effets directs de ce renchérissement sur l,accessibilité aux soins de santé et à des effets pervers comme le développement de la fraude, l'oms doit consolider et élargir son rôle moteur dans le développement de la politique pharmaceutique. Nous devons plus que jamais soutenir et intensifier la politique des médicaments essentiels et les pays de la zone franc se sont fortement engagés dans cette voie; nous ne doutons pas de l'appui et de l'assistance de l'oms pour rendre leur politique pharmaceutique davantage opérationnelle. Nos acquis dans le cadre de l'initiative de Bamako doivent être préservés, surtout au moment où la santé communautaire connaît un essor certain. Au Mali, les populations, de la famille à la communauté et aux collectivités décentralisées, doivent prendre elles-mêmes en charge leurs problèmes de santé. La décentralisation est Fun des acquis fondamentaux de notre nouvelle Constitution. Cependant, le Mali avait une tradition communautaire qui remontait à la nuit des temps et des expériences de type soins de santé primaires avaient eu lieu bien avant Alma-Ata. Force est de reconnaître que, malgré quelques succès, la plupart avaient été des échecs. Les programmes étaient parachutés vers les populations à partir du niveau central et par le canal des bailleurs de fonds étrangers; au niveau local, la gestion était accaparée par l'administration locale; les populations n'étaient pas au préalable consultées sur leurs besoins profonds. Actuellement, la création des centres de santé communautaires part d'abord de la volonté librement exprimée par un groupe de population formant une association de plusieurs villages,lesquels élisent leurs responsables, mettent en place leurs comités de gestion et recrutent leur personnel. L'engouement des populations est tel qu'une centaine de centres de santé communautaires seront opérationnels d'ici à la fin de Une législation appropriée a été mise en place par le Gouvernement pour préciser le partenariat entre l'etat et les communautés. Bien qu'étant autonomes, les centres de santé communautaires doivent, pour bénéficier de l'aide de l'etat, s'engager à respecter la carte sanitaire, assurer un ensemble minimum d'activités aux populations, respecter la politique des médicaments essentiels, participer à la lutte contre les endémies. L'Etat garde son rôle de contrôle et d'arbitre. Des problèmes subsistent cependant, liés en particulier aux faibles capacités gestionnaires des populations, aux relations entre les secteurs 1 Le texte qui suit a été remis par la délégation du Mali pour insertion dans le compte rendu, conformément à la résolution WHA20.2.

234 A47/VR/10 page 219 communautaires et privés, aux besoins spécifiques des zones urbaines. Nous espérons, grâce au développement harmonieux des trois secteurs, étatique, communautaire et privé, améliorer notre couverture sanitaire de 40 à 60 % d'ici Dans cet effort que nous menons actuellement vers l'objectif de la santé pour tous en Г an 2000,l'aide de notre Organisation est précieuse et c'est pourquoi sa situation actuelle 一 problèmes politiques, problèmes de gestion et d'efficacité - nous préoccupe. Sur le plan politique, la démocratisation de la prise de décisions doit demeurer la règle pour éviter de futurs blocages au cas où on aurait à prendre de grandes décisions. Cette règle vaut pour l'ensemble du système des Nations Unies. Nous nous félicitons de la nouvelle réorganisation de ce système qui permettra une meilleure coordination intersectorielle de la santé par le PNUD, les autres organisations (OMS, UNICEF, FAO) jouant chacune leur rôle spécifique. Quant à la réorganisation de FOMS elle-même, des résolutions pertinentes ont été prises lors de la Quarante-Sixième Assemblée mondiale de la Santé et nous espérons les voir aboutir, car il nous faut une organisation efficiente dans son administration, ses choix et ses stratégies, pour atteindre Fobjectif de la santé pour tous à l'horizon le plus proche. Mr LOVELACE (New Zealand): 1 Mr President and Mr Director-General, may I start by congratulating you, Mr President, on your election to high office, and Mr Director-General on your reappointment for a further term. New Zealand particularly wishes to welcome two new Members to the World Health Organization. In particular we are pleased that our regional neighbours the Pacific Island State of Niue and the Republic of Nauru have been accepted. We also look forward to the return to active membership of South Africa, which has undergone such dramatic changes since the Assembly last met. We note the progress the World Health Organization has made in response to global change and in the reform of its budgetary process. We have high expectations of the practical outcomes of these developments, and encourage the Organization's efforts to continue along the road to reform. I would like to take a few minutes to update the Assembly on what has been happening in New Zealand in the last twelve months. In 1993 the Associate Minister of Health, Maurice Williamson,reported that New Zealand was about to embark on a major restructuring of its health system. The health reforms would separate the purchase and provision of health services and introduce some form of competition between publicly and privately owned providers. Population-based health services would be separated from personal health services to protect them from the more immediate demands of acute health services. Increasingly providers would be contracted to purchasers to produce an agreed range and quality of health services, with clearer understanding about priorities and appropriateness. The Government would remain the dominant funder, providing between 75-80% of total health expenditure. The health reforms were set against a backdrop of major structural reform in the New Zealand economy, brought about in part by a prolonged period of low economic growth. With an economy facing debt and budget deficit burdens, and some severe health status problems, particularly with Maori, it was essential we find a way both to manage within a limited budget, and to refocus our health services to ensure they actually made a difference to our health outcomes. A high priority was to get the best possible value out of the money available for health. We are now beginning to see evidence that we are emerging from the period of low economic growth. Growth rates between 3.5-5% a year are predicted, although unemployment rates will remain high for the foreseeable future. We are developing into an open, prosperous, small trading nation with a mixed population of people of Maori, Pacific Island, Asian and European origin. We have the population profile of both developed and developing nations, with young populations in the Maori and Pacific Island groups and aging populations within those of European origin. Our social policy sets out to create jobs for all those willing and able to work, to include all ethnic groups, to provide high quality social assistance for the disadvantaged, and to protect and enhance our environment. We are developing a strong sense of unique national identity and a growing ability to play a positive role in world affairs, particularly in the South Pacific. All of this should make it easier for us to achieve health for all by the year To return to the health restructuring, in July last year four regional health authorities were set up to purchase all personal health services. A public health commission is purchasing population-based public health services. Each purchaser has contracted with the primary care, community-based and hospital services within its region to provide health and disability support services to their populations. At this stage some contracts are rather general in terms of specifying the range, quality and conditions of access to 1 The text that follows was submitted by the delegation of New Zealand for inclusion in the verbatim records in accordance with resolution WHA20.2.

235 A47/VR/10 page 220 services, but the purchasers are rapidly developing the skills they need to become effective purchasers. A national committee was also established to advise on core health services, or the basic package of services which the Government should fund to a level which ensures everyone has access to them. The committee is currently concentrating on identifying the most effective interventions for a range of health needs to ensure only the most appropriate are used. It is developing a more rational and consistent approach to determining priorities for health services, which is able to take both individual circumstances and community priorities and available resources into account. The committee's recommendations are built into the basic package of core services, known as "service obligations", which regional health authorities must buy for their populations. Each agency has a statutory obligation to consult with their communities as part of their purchasing function. The purchasers are taking this obligation very seriously and a number of examples of their consultation documents are provided for the Health Assembly's technical discussions on community action for health. At the time the new health agencies were established, the Government issued them with some government objectives, some priority health areas and six pilot health goals. These ranged from ensuring improved access and efficiency, giving greater priority to mental health and Maori health, to specific goals such as reduced cervical cancer rates. In the coming years we will strengthen and build on the model begun in July We have developed a set of objectives for all health agencies to cover the next three to five years. These include four health gain priority areas where purchasers will be monitored to ensure real progress. The four health gain priority areas are Maori health, child health, mental health and physical environmental health, particularly food and water safety and hazardous substances. These areas were chosen because of our relatively poor performance on a number of international indicators, and because of their improvement potential. АД purchasers are expected to give special emphasis to these priority areas when making purchase decisions and allocating resources. Purchasers must also operate within a framework of principles, including improved equity, effectiveness, efficiency, safety, acceptability and risk management. Over the next five years we expect to see primary care providers take on an expanded role. Primary care providers will directly coordinate a wide range of services provided in the community, and will hold the budget for a variety of related services. Many services traditionally provided from hospitals will come into the ambit of primary care. As primary providers become purchasers of services or budget holders, better linkages will also develop between community-based and hospital services. An important development will be the involvement of Maori, New Zealand's indigenous people, as budget holders and providers of services for Maori. I would like to make the link between the technical discussions on community action for health and the involvement of Maori in the provision of health services. Although it is too early to evaluate the impact of the health reforms, the new system has clearer accountabilities, the potential to achieve efficiency gains through the ability to manage care within integrated budgets, and a much sharper focus on achieving real gains in health status. The change in approach from funding inputs to holding purchasers and providers accountable for improved health status outcomes and effectiveness is fundamental. It will take time to see results. We are confident, though, that the stronger disciplines ensuring best use of health resources will ensure we achieve our objectives. At the end of May the Regional Office for the Western Pacific will be convening a meeting in New Zealand to examine trends in health reforms particularly those of New Zealand. The results of this meeting will be published and made available to countries interested in what is happening in New Zealand and other countries in the Western Pacific region. I would like to spend a bit more time exploring our strategies in the health gain priority area of Maori health. On almost every count Maori health lags behind the health status of the non-maori population. For example, the death rate from lung cancer for Maori women is among the highest in the world. The Maori infant death rate is amongst the highest in the OECD countries. The Government's objective for Maori health is to "increase the health status of Maori so that, in future, Maori will have the same opportunity to enjoy the same level of health as non-maori". Three main strategies have been identified to meet this objective. The first is enhancing the capacity of mainstream services to respond to Maori. All purchasers and crown-owned providers are explicitly required to consult with Maori and ensure that their activities and services are appropriate for Maori. The second strategy is increasing Maori self-sufficiency by involving Maori in choosing systems and structures which work for Maori. This includes working with the tribal and family structures of Maori society, and finding ways to ensure Maori can care for their sick and elderly in ways which reflect traditional practices. A long history of attempting to assimilate Maori into European institutions and ways of approaching health has not worked in terms of health outcomes, the time has come when we need to look seriously at resourcing Maori to do it their way. This fits with the Alma- Ata and the World Health Organization's primary health care strategy. The third strategy is advancing

236 A47/VR/10 page 221 Maori socioeconomic development. Clearly health and social and economic development are closely interlinked. The issues for Maori closely parallel those of most indigenous peoples around the world. I would like to take this opportunity to strongly encourage the World Health Organization to think about what it might do towards the International Decade of the World's Indigenous People which starts on 10 December this year. The International Decade will build on the results and lessons of 1993, the International Year of the World's Indigenous People. Its goal is to strengthen international cooperation for the solution of problems faced by indigenous people in such areas as human rights, the environment, development, education and health. We would assert that basic human rights, the physical and social environment, human development and education are integral to health. The issue meshes with WHO activities in several areas under discussion at this Assembly. These include health and development, the global AIDS strategy and collaboration within the United Nations system. Related current United Nations activities include the International Conference on Population and Development, the World Summit for Social Development, Agenda 21 and the activities relating to women and health. None of these can be addressed without considering the place of indigenous peoples and the need to develop strategies which can encompass a diversity of cultures, approaches and world views. The World Health Organization's Ninth General Programme of Work covering the period provides us with an opportunity to systematically consider health issues for indigenous peoples and build them into the programme of work. New Zealand would like to see the connection between the objectives and framework of goals and targets and policy orientations clearly linked to the goals of the International Decade of the World's Indigenous People. Mr President, thank you for your time. I am certain our new health system will ensure New Zealand can achieve the goal of health for all by the year 2000,and that our renewed emphasis on efficiency and health gain priorities will help us face our greatest challenge, to ensure the best health outcome for our population within available resources. Thank you very much. Le Dr BIZIMUNGU (Rwanda) : 1 Monsieur le Président, au nom de la délégation rwandaise et en mon nom personnel, j'ai Pinsigne honneur de vous adresser nos chaleureuses félicitations pour votre brillante élection à la présidence de la Quarante-Septième Assemblée mondiale de la Santé et de les adresser également aux membres du bureau. Votre expérience et votre sens du devoir ont permis de conduire avec brio les travaux de cette Assemblée. Monsieur le Président, Monsieur le Directeur général, si l'organisation mondiale de la Santé a pu continuer à jouer un rôle déterminant dans la prévention des maladies et la lutte contre celles-ci, c'est grâce au dynamisme et à Passiduité de son Directeur général, le Dr Hiroshi Nakajima, des Directeurs régionaux et du personnel du Secrétariat. Nous apprécions à sa juste valeur la contribution que chacun d'entre eux apporte à la réalisation des objectifs de notre Organisation. Monsieur le Président, Monsieur le Directeur général, Excellences, Mesdames et Messieurs les Ministres, distingués délégués, au moment où je m'adresse à vous du haut de cette tribune, mon pays, le Rwanda, vit des moments fort douloureux et tragiques de son histoire. En effet, alors que les différentes forces politiques étaient en consultation pour la mise en place des institutions de transition sur une base élargie, conformément à Paccord de paix signé à Arusha (République-Unie de Tanzanie) le 4 août 1993, des ennemis de la paix ont abattu l,avion présidentiel alors qu'il était sur le point d'atterrir à l'aéroport international de Kigali, le 6 avril 1994,tuant sur-le-champ le Président Juvénal Habyarimana du Rwanda, le Président Ntaryamira du Burundi et les membres de leurs suites respectives. Le Front patriotique rwandais a immédiatement profité de cet assassinat - dont il est fort vraisemblablement Pauteur - pour ouvrir des hostilités dans la ville de Kigali, où se trouvaient un de ses bataillons et plusieurs personnes qui s'y étaient infiltrées, ainsi que sur le front nord dans les préfectures de Byumba et de Ruhengeri, près de la frontière rwando-ougandaise. Simultanément à cette reprise des hostilités, la mort du chef de l'etat rwandais a créé un effet de surprise, de stupeur et d'état de choc au sein du peuple rwandais et provoqué la fureur chez une bonne partie des militaires des Forces armées rwandaises qui, spontanément, ont réagi en s'attaquant à des personnes soupçonnées ou supposées être responsables ou complices de l'assassinat du chef de l'etat. C'est dans ce contexte que des massacres - condamnés sans réserve par le Gouvernement rwandais - ont eu lieu dans plusieurs régions du pays. Dans les zones contrôlées actuellement par les rebelles du Front patriotique rwandais, plus particulièrement dans certaines communes des préfectures de Byumba, Kibungo et Ruhengeri, les 1 Le texte qui suit a été remis par la délégation du Rwanda pour insertion dans le compte rendu, conformément à la résolution WHA20.2.

237 A47/VR/10 page 222 informations qui nous parviennent font état de massacres aveugles de civils innocents par les rebelles. Dans la partie du pays contrôlée par le Gouvernement et les Forces armées rwandaises, les représailles qui y ont été observées au cours de la deuxième quinzaine du mois d'avril semblent s'acheminer vers un arrêt complet grâce à Paction de pacification menée énergiquement par le chef de l'etat intérimaire et son Gouvernement. Au moment où je vous parle, on ne connaît pas le nombre exact des morts. Une estimation provisoire indique que plusieurs centaines de milliers de Rwandais ont été tués. II va de soi que la reprise des hostilités a provoqué un déplacement de populations tant à rintérieur qu'à l'extérieur du pays. Ces personnes déplacées - qui vivent dans des conditions pénibles et souffrent énormément - se chiffrent à plusieurs centaines de milliers. On s'efforce actuellement d'obtenir un cessez-le-feu. Les Nations Unies et certains pays amis du Rwanda sont à pied d'oeuvre pour tenter d'amener les protagonistes à signer et à observer un cessez-le-feu. Malheureusement, le Front patriotique rwandais et ceux qui le soutiennent, dont les visées expansionnistes et la prise du pouvoir par la force ne sont plus à démontrer, s'emploient à torpiller tous les efforts de la communauté internationale. Le nouveau Gouvernement de transition a été mis en place le 9 avril 1994 par le nouveau chef de l'etat qui a pris ses fonctions conformément à la Constitution de la République rwandaise du 10 juin 1991, et plus spécialement à son article 42. Il fallait rapidement installer un nouveau Gouvernement pour combler le vide institutionnel qui s'était produit suite aux décès du Président de la République et du Premier Ministre. Ce Gouvernement s'est fixé trois objectifs majeurs : assurer la gestion effective des affaires de l'etat en mettant un accent particulier sur le rétablissement rapide de l'ordre et de la sécurité des personnes et des biens; poursuivre les discussions avec le Front patriotique rwandais pour la mise en place des institutions de transition sur une base élargie, dans un délai ne dépassant pas six semaines; et s'attaquer énergiquement au problème de la pénurie alimentaire en cherchant les moyens de secourir les populations sinistrées de certaines préfectures et les personnes déplacées du fait de la guerre. Monsieur le Président, vu les difficultés que pose la compilation des données sur la situation sanitaire actuelle, je ferai une évaluation qualitative des problèmes de santé majeurs auxquels le Rwanda fait face. Le paludisme, les maladies des voies respiratoires supérieures, la malnutrition, le SIDA et les maladies diarrhéiques figurent parmi les pathologies qui frappent de plein fouet les Rwandais. A ce tableau peu reluisant, il faut ajouter les mauvaises conditions de vie, surtout chez les personnes déplacées, la famine et l'arrêt des importations qui touche également le secteur pharmaceutique. Le contexte est tel que les pertes en vies humaines augmentent chaque jour et qu'il est malheureusement difficile de les quantifier dans les conditions prévalant sur le terrain. Le Rwanda a un besoin urgent d'aide : les souffrances et les pertes en vies humaines sont effarantes. C'est pourquoi je lance un appel pressant à toutes les organisations internationales et à toutes les institutions de bienfaisance pour qu'elles viennent en aide à la population rwandaise en détresse. La communauté internationale a le devoir moral et une obligation humanitaire d'aider les Rwandais à arrêter la guerre et à négocier entre eux les dispositions à prendre pour mettre en place un pouvoir partagé dans une ambiance de justice, d'équité et de véritable démocratie. Je saisis cette occasion pour réitérer nos remerciements à rorganisation mondiale de la Santé pour les appuis qu'elle n,a cessé d'accorder à mon pays dans le passé. Monsieur le Président, la description du drame que connaît mon pays a certes occulté toute intervention sur les dossiers majeurs abordés lors des présentes assises, mais vous pouvez être assuré que ma délégation a pris une part active aux travaux qui vont s'achever bientôt. Je ne pouvais conclure sans remercier du fond du coeur les pays qui ont parrainé la résolution WHA47.29 qui vient d'être approuvée en commission. Que vive rorganisation mondiale de la Santé! Que vive la coopération internationale et qu'advienne un monde dépourvu de conflits, de souffrance et de misère! La Sra. MORENO (Puerto Rico): 1 Señor Presidente, señor Director General, distinguidos delegados y representaciones, señoras У señores: En nombre del Estado Libre Asociado de Puerto Rico deseo felicitar al Sr. Bahiti Temane por haber sido desliado Presidente de esta magna 47 a Asamblea Mundial de la Salud, así como al Dr. Hiroshi Nakajima. Representa para Puerto Rico un honor y privilegio participar en esta productiva Asamblea como Miembro Asociado de la OMS, dada la reciente integración de nuestra isla a esta prestí- _osa Organización. Entre otras cosas, nos une la meta común de la «Salud para todos en el año 2000», siendo la salud un estado o condición de bienestar físico, social y emocional que permita al ser humano el pleno disfrute de la vida individual y familiar y como una prioridad en las metas que tratamos de obtener 1 Texto facilitado por la delegación de Puerto Rico para su inclusión en las actas taquigráficas, conforme a lo dispuesto en la resolución WHA20.2.

238 A47/VR/10 page 223 todos los países del mundo. La prestación de servicios de salud por niveles representa una estructura ideal en la consecución de las metas mencionadas. Al igual que en otras partes del mundo, Puerto Rico ha tenido un sistema dual y discriminatorio: dos sistemas de salud desiguales, uno para las personas de muchos recursos económicos, en un sistema privado, y otro para las personas de escasos recursos económicos, a través de un sistema público de menor calidad. Esta situación es discriminatoria en vista de que los servicios médicos recibidos deben estar relacionados a la condición de salud y no a la condición económica de las personas. A los efectos antes mencionados, y acorde con la acción sanitaria internacional, nuestro Gobierno se ha propuesto la ingente tarea de promoción de la salud, y la seguridad de que todos los habitantes de escasos recursos tengan acceso a un sistema único de servicios de salud donde predomine la calidad, dentro del Programa de Reforma de Servicios de Salud de Puerto Rico. Esta propone una serie de cambios socioeconómicos de una magnitud y complejidad sólo comparables con otros dos sucesos históricos en Estados Unidos de América, como son la Gran Sociedad de Lyndon В. Johnson y el Nuevo Trato de Franklin D. Roosevelt. Siendo Puerto Rico un Estado Libre Asociado de los EE.UU., los procesos políticos, económicos, sociales y la Reforma de Servicios de Salud formulada por la Presidencia del Nuevo Gobierno norteamericano tienen un gran impacto directo en nuestra isla. La transformación social sufrida en Puerto Rico durante los últimos 50 años ha traído como consecuencia un aumento significativo de la longevidad y la expectativa de vida. Se espera que este patrón continúe y que para el año 2030 un 15% de la población pertenezca a la categoría de personas envejecientes (65 años o más). Esta y otras tendencias, como la conversión de una sociedad agrícola y rural a una urbana e industrial, han traído cambios en la morbilidad y mortalidad del país. El cuadro medicodemográfico ha variado de una población con enfermedades tropicales infecciosas agudas a una que se caracteriza por enfermedades crónicas degenerativas, con alta prevalencia de enfermedades cardiovasculares, enfermedades neoplásicas y el consumo de alcohol, tabaco, y la vida sedentaria. Diariamente enfrentamos en mayor grado, al igual que en otras partes del mundo, una situación altamente problemática de complejidad creciente, como es la enfermedad del SIDA, la reaparición de la tuberculosis y los embarazos de adolescentes. Ello genera, por fuerza, la necesidad de mayores recursos económicos a fin de poder ofrecer a toda la población el apoyo sanitario requerido. Entre los logros alcanzados podemos mencionar: 1) en marzo del año en curso se ha completado la campaña de vacunación encaminada a eliminar el sarampión; 2) el control de la epidemia del cólera, que apareció en el territorio sudamericano en 1990 y en Centroamérica en Gracias a las acciones sanitarias desarrolladas, ningún caso de cólera ha sido reportado en el territorio de Puerto Rico desde el inicio de esta epidemia; 3) el Programa de Enlace Comunitario y la Colaboración Intersectorial y Participación Comunitaria nos ha facilitado la distribución de recursos externos como los fondos «Ryan-White» que recientemente fueron adjudicados a consorcios de la comunidad, además de ofrecer asesoramiento técnico y programático. Esta relación se da también a través de organismos estatales y organizaciones cívicas y religiosas. También se han desarrollado actividades de educación, prevención, tratamiento y apoyo a las personas infectadas y afectadas por el VIH/SIDA. Por otro lado, en la Unidad Pro-Derechos del Paciente VIH/SIDA se realizan actividades de colaboración intersectorial; 4) se comenzó la implantación del plan piloto dirigido al Proyecto de la Reforma de Salud de Puerto Rico, incluyendo la inscripción al Nuevo Plan de Salud que da acceso a los pacientes de escasos recursos económicos; 5) se ha establecido un proceso administrativo que desarrolla la función normativa, fiscalizadora, evaluativa y preventiva de los servicios de salud mental y adicción; y 6) se han creado leyes que regulan el uso del tabaco tanto en instituciones del Gobierno como privadas. Puerto Rico ha desarrollado centros diagnósticos de enfermedades infectocontagiosas, los cuales ponemos a disposición de la comunidad internacional. Puerto Rico ve la necesidad de una mayor cooperación con la comunidad internacional para canalizar recursos hacia el proceso de extensión de cobertura y mejoramiento de la calidad de servicios para la población puertorriqueña, especialmente para los grupos más vulnerables. También Puerto Rico busca el fortalecimiento de la cooperación técnica, estrechando los contactos con otros países a través de los programas que la OMS y la OPS desarrollan para esos propósitos. A la OMS y a todas las organizaciones y países cooperantes con el pueblo de Puerto Rico les estamos profundamente agradecidos. The PRESIDENT: Honourable delegates, the debate on items 9 and 10 is now concluded, and I give the floor to the Director-General, Dr Nakajima.

239 A47/VR/10 page 224 Le DIRECTEUR GENERAL : Monsieur le Président, Excellences, honorables délégués, Mesdames, Messieurs, à la fin de ce débat sur les points 9 et 10 de l'ordre du jour, je souhaite faire quelques remarques sur les premières conclusions que je tire de vos interventions. Le thème général "Ethique et santé" qui vous était proposé a fait Pobjet de nombreuses réflexions et suggestions, très riches et utiles pour l'orientation future du travail de l'oms, et, de cela, je tiens d'abord à vous remercier. Je note ainsi que vous avez tous souligné la nécessité d'intégrer la dimension éthique à l'enseignement médical, pour toutes les sciences et professions de la santé. Et que beaucoup d'entre vous ont demandé à l'oms de les aider à assurer cette intégration. Tout comme vous avez souhaité que l'oms apporte aux pays son aide et ses avis pour la mise en place de comités et de législations couvrant les exigences éthiques de la recherche et de la pratique médicales, de la santé en général. J'ai entendu votre demande selon laquelle l'éthique de la santé ne doit pas être limitée aux seuls aspects techniques de la médecine. Tous, en effet, vous avez souligné que l'éthique - à l'instar de la santé - est d'abord et avant tout une dimension fondamentale de la vie et des relations des hommes. Monsieur le Président, c'est la délégation même du Botswana qui nous a rappelé que l'éthique de la santé trouve sa première actualisation dans le face-à-face, humain et personnel 一 donc responsable -, du médecin et du malade. Et que le souci éthique risque de se perdre dans la distance et l'anonymat d'une pratique médicale froide, c'est-à-dire réduite à des techniques et à une instrumentalisation tant du médecin que du malade. Pour que l'éthique trouve sa place, il faut qu'il y ait relation, confiance, respect et responsabilité mutuels. C'est une vérité simple, mais qui mérite d'être aujourd'hui rappelée. Dans la même ligne de pensée, vous avez dit que l'éthique de la santé ne peut être rajoutée, après coup et de l'extérieur, à notre approche médicale, qu'elle doit s'élargir aux dimensions sociales et culturelles qui fondent le sens de la vie et des relations des êtres humains et des sociétés. Nous avons pris bonne note du voeu repris par la plupart d'entre vous que l'oms continue et intensifie son travail normatif en proposant à la communauté internationale des critères qui soient à la fois scientifiques et respectueux de la valeur et des droits de l'être humain. Là encore, vous estimez que l'oms a un rôle essentiel à jouer, qui lui est propre, et que favorisent sa compétence et son expérience techniques ainsi que sa représentativité de tous les peuples du monde. A cet égard, je me réjouis de voir l'oms toujours parfaire son universalité. Je veux souhaiter très chaleureusement la bienvenue officielle à Nauru et Nioué qui rejoignent la communauté des Etats Membres de l'oms. Je veux aussi dire à la délégation et au peuple tout entier de l'afrique du Sud combien je suis heureux qu'ils soient à nouveau des nôtres, réinvestis de tous leurs droits et de tous les moyens de travailler avec nous tous à la santé du monde. En effet, nous ne serons jamais trop pour mener à bien, ensemble, la tâche considérable qui nous incombe, et pour relever les difficiles défis sanitaires et sociaux d'un monde en transition, inquiet, à la recherche de ses repères et en quête d'espérance. De cela aussi, vous avez tous fait état, dans vos interventions, soulignant la nécessité de continuer notre lutte contre la maladie, contre la violence et la pauvreté, pour la justice sociale et la santé. Je vous l'ai dit, j'ai toujours conduit l'oms dans cette conviction -qui est la mienne - que la santé est une pièce maîtresse de la paix et d'un développement humain durable. Et que, pour réaliser une tâche d'une telle ampleur, il nous faut travailler ensemble, dans un esprit de partage. C'est ensemble que nous devons dégager les lignes et les conditions concrètes d'une action de santé commune. C'est dans le travail quotidien et non dans l,abstraction et les déclarations d'intention que doivent se forger les valeurs communes de rhumanité. Je l,ai dit aussi au début de cette session de l'assemblée, et je le répète avec force, conforté par l'appui que vous m'avez apporté : la profondeur de nos convictions, quant à la priorité que nous donnons à la santé d'abord et à la solidarité internationale, ne sera pas mesurée seulement par nos définitions, discours et déclarations. Elle sera lue, très directement, par les peuples du monde, dans nos politiques budgétaires de santé, sur le plan tant national qu'international. Ce que nous aurons exclu de nos politiques budgétaires, nous l'aurons par là même exclu de notre définition de la santé et de notre responsabilité vis-à-vis de l'être humain. De cela, il faut que nous ayons conscience. Une éthique de la conviction, de la responsabilité et de la solidarité, voilà le fondement de notre action de santé et de la coopération internationale. Améliorer la santé des peuples du monde, instaurer l'équité dans l'accès aux soins, réduire les inégalités entre les pays et à l'intérieur des pays, telle est notre tâche. Pour s'accomplir, cette tâche doit être menée dans la durée et par l'effort concerté de tous. Nous sommes comptables de la vie, du bonheur et de la dignité de milliards d'êtres humains, aujourd'hui et demain. C'est cela l'enjeu réel de notre objectif commun, la santé pour tous, que tous ici 一 au cours de ce débat - vous avez, avec moi, réaffirmé au sein de l'organisation mondiale de la Santé.

240 A47/VR/10 page 225 The PRESIDENT: Thank you, Dr Nakajima. After hearing the statements of the delegates, we are now in a position to express an opinion in the name of the Assembly regarding the Director-General's report on the work of the Organization for the period ТЪе Chair, after hearing the comments of the various delegations, has the clear impression that the Assembly wishes to express satisfaction with the manner in which the Organization's programme for this biennium was implemented. In the absence of any objection, this will be duly recorded in the records of the Assembly. Before we adjourn, I would like to remind you that Committee A will meet tomorrow at 9h00 in Room XVIII. The next Plenary meeting will be held on Monday, 9 May at 12 noon. The meeting is adjourned. The meeting rose at 16h05. La séance est levée à 16h05.

241 A47/VR/14 page 226 ELEVENTH PLENARY MEETING Monday, 9 May 1994,at 12h00 President: Mr В. K. TEMANE (Botswana) ONZIEME SEANCE PLENIERE Lundi 9 mai 1994,12 heures Président: M. В. К. TEMANE (Botswana) 1. SECOND REPORT OF THE COMMITTEE ON CREDENTIALS 1 DEUXIEME RAPPORT DE LA COMMISSION DE VERIFICATION DES POUVOIRS 1 The PRESIDENT: The meeting is called to order. I invite Dr Shamlaye, Rapporteur of the Committee on Credentials to come to the rostrum and read out the second report of the Committee on Credentials, which is contained in document A47/45. Dr SHAMLAYE (Rapporteur of the Committee on Credentials): The Committee on Credentials met on 6 May 1994, under the Chairmanship of Dr M. Hamdan (United Arab Emirates). Dr С. Shamlaye (Seychelles) was Rapporteur. Delegates of the following Members were present: Canada, Namibia, Netherlands, Samoa, Seychelles, Tunisia, United Arab Emirates. The Committee examined the formal credentials of the delegates of Afghanistan, Bosnia and Herzegovina, Georgia, Greece, Japan, Kyrghyzstan, Latvia, Malawi, Mauritius, Pakistan, Papua New Guinea, Republic of Moldova and Vanuatu who had been seated provisionally in the World Health Assembly pending the arrival of their formal credentials. These credentials were found to be in conformity with the Rules of Procedure, and the Committee therefore proposes that the World Health Assembly recognize their validity. The Committee also examined the formal credentials of Liberia and Saint Lucia which were found to be in conformity with the Rules of Procedure, and the Committee therefore proposes that the Health Assembly recognize their validity, thus enabling the delegations of Liberia and Saint Lucia to participate with full rights in the World Health Assembly. Lastly, the Committee examined the credentials submitted by Nauru and Niue, whose applications for membership were accepted during the eighth plenary meeting of the World Health Assembly. These credentials were found to be in conformity with the Rules of Procedure. The Committee therefore proposes that the Health Assembly recognize their validity, thus enabling these delegations to participate with full rights in the World Health Assembly as soon as the memberships of Nauru and Niue become effective upon deposit of their instruments of acceptance of the WHO Constitution with the Secretary-General of the United Nations. The PRESIDENT: Thank you, Dr Shamlaye. Are there any comments? In the absence of any comments, I take it that the Assembly accepts the second report of the Committee on Credentials. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

242 A47/VR/12 page FIRST REPORT OF COMMITTEE A 1 PREMIER RAPPORT DE LA COMMISSION A 1 The PRESIDENT: We shall now consider the first report of Committee A, as contained in document A47/48; please disregard the word "Draft" as this report was adopted by the Committee without amendments. This report contains two resolutions which I shall invite the Assembly to adopt one after the other. Is the Assembly willing to adopt the first resolution entitled: "Ninth General Programme of Work covering a specific period ( )"? In the absence of any objections, the resolution is adopted. The second resolution is entitled: "Infant and young chüd nutrition". Is the Assembly willing to adopt this resolution? In the absence of any objections, the resolution is adopted and the Assembly has therefore approved the first report of Committee A. 3. ELECTION OF MEMBERS ENTITLED TO DESIGNATE A PERSON TO SERVE ON THE EXECUTIVE BOARD ELECTION DE MEMBRES HABILITES A DESIGNER UNE PERSONNE DEVANT FAIRE PARTIE DU CONSEIL EXECUTIF The PRESIDENT: The next item on our agenda is item 12: Election of Members entitled to designate a person to serve on the Executive Board contained in document A47/44. I draw your attention to the list of 10 Members, drawn up by the General Committee in accordance with Rule 102 of the Rules of Procedure. 1 In the General Committee's opinion these 10 Members would provide, if elected, a balanced distribution of the Board as a whole. These Members are, in the English alphabetical order: China, Cuba, Finland, France, Kuwait, Pakistan, Russian Federation, Thailand, United States of America, Zambia. Are there any comments or any objections concerning the list of the 10 Members as drawn up by the General Committee? In the absence of any objections, may I conclude that, in accordance with Rule 80 of the Rules of Procedure, the Assembly accepts the list of 10 Members as proposed by the General Committee? I see no objection. I therefore declare the ten Members elected. This election will be duly recorded in the records of the Assembly. May I take this opportunity to invite Members to pay due regard to the provisions of Article 24 of the Constitution when appointing a person to serve on the Executive Board. 4. REPORT BY THE GENERAL CHAIRMAN OF THE TECHNICAL DISCUSSIONS RAPPORT DU PRESIDENT GENERAL DES DISCUSSIONS TECHNIQUES The PRESIDENT: We now come to the report of the Technical Discussions, and I have much pleasure in inviting Mrs Kardinah Soepardjo Roestam, General Chairman of the Technical Discussions, to present the report on the Technical Discussions on "Community Action for Health". Mrs Roestam, you have the floor. Mrs ROESTAM (General Chairman, Technical Discussions): Mr President, Dr Nakajima, your excellencies, ministers of health, distinguished participants, ladies and gentlemen, it has been a great pleasure to have served as the Chairperson of the Technical Discussions at the Forty-seventh World Health Assembly. Those Discussions have now been successfully completed and I am happy to present to you today the report that has been prepared. As you might imagine, the Discussions have covered a range of topics relating to the role that the community can and should play in health development, the role the health sector should play in support 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

243 A47/VR/10 page 228 of the community, and the role that other sectors can play in concert with the health sector and the community. The report which it is my pleasure to present to you deals with the basic principles underlying the concept and the need for community action for health; a discussion of the way in which it works and what it involves; and the consideration of the implications for further action that are now called for. The report recognizes that while community involvement in health is not a new phenomenon, a series of social, demographic and economic factors and conditions have made the subject more relevant and important today than ever before. The increasing availability of modern communications, a better educated public, the spiral in costs of curative care, and the widening gap in many countries between the health care sector and the public, have all contributed to a growing commitment to change and the search for new avenues of health development. The emergence of new social groups, or of groups of which we are more aware today than we have ever been before, has also sensitized us to the need for tailoring health activities to the real and perceived needs of communities, no matter what their form or size. TTie poor, the elderly, the young, refugees, indigenous populations - all these have relatively unique characteristics and special needs. Only by working with them as partners and creating mechanisms that truly reflect these needs and respond to them will we be able to look forward to achieving health for all and greater equity. The need for solidarity between the health sector and the community has never been more obvious, nor indeed has the need for the greater involvement of other sectors in health development. The Discussions highlighted the complexity of the problem as well as the opportunities that present themselves. It is clear, for example, that unless the formal sector and its personnel are able to work closely with the community, listening to them, seeing them as equals, and engaging them in the planning and decision-making process, there will be little real progress. For this to happen calls, on the one hand for new attitudes and approaches on the part of health staff, and on the other, it calls for a better informed and motivated public. The first will only come about when the training of health and other formal sector personnel is itself modified to accommodate and respond to the need for community-based action. The second will only materialize when we learn how to reach all members of the community with information and education with which they can identify and incorporate into their everyday lives. The role and responsibility of other sectors must also be reconsidered. The Technical Discussions last week emphasized, time and time again, that health development is not the prerogative or the responsibility solely of the health sector. Health development is and must be seen as the product of better communications, better education, better environmental conditions, better economic opportunities, regular food availability, and access to clean and plentiful water. If all these conditions are to be met, other sectors will need to participate fully. They too, must also learn to work with and for the community, sharing with the health sector common goals and objectives, as well as a share of the budget resources. Operational approaches must, therefore, be promoted to stimulate the allocation to health development of budgetary resources originating from other sectors. The outline of the technical guidance for the health development programme in other sectors should, however, remain the responsibility of the health sector. Our Discussions also highlighted the important role that women and women's groups have consistently played in promoting and protecting the health and well-being of families and communities. Women must no^v become beneficiaries as well as agents of health change. They must become more clearly involved in responding to this health development challenge and must be recognized as central to the achievement of greater equity in health. The development of a community-based health information system has been encouraged in the Discussions, to permit the building-up of a capacity for decision-making and planning in health and related matters and to allow the community to identify and express particular needs and to negotiate appropriate solutions. Such a system is also important as a way of stimulating decentralization. In all this, the work and the place of nongovernmental and private organizations must receive greater recognition. The task before us is not one that we will ever be able to take up without the organized involvement of public interest groups. Nongovernmental organizations have consistently demonstrated their capacity to reflect the interests of the community and, in so doing, must also become equal partners in the development of new approaches to health. No matter how active communities are, however, their actions can only be sustained when there is a true national commitment to their work and to their role. Community action for health should never be seen as a means of reducing the responsibility of the formal sector, but rather as an initiative designed to complement the work of the health and other sectors. In this regard, the financing of community action for health must become a new focus of attention, and all sectors must learn how to allocate economic as well as technical resources in support of community action for health.

244 A47/VR/10 page 229 Community action for health should also be seen in the light of the scientific and technical contributions which all communities can and do regularly make. And in this regard, we also believe that the work of communities in support of health development must be systematically evaluated in terms of its effectiveness, its cost, and the alternative approaches that can be taken to initiating and sustaining it. The need for health service research that focuses on community action for health was highlighted throughout our Discussions. Our deliberations last week also highlighted the need for WHO to take a leadership role in promoting and in supporting community action for health. The need for guidelines that can be adapted to local and national conditions, as well as the need for a concerted long-term commitment by the Organization was expressed by many participants in the Discussions. In this regard, I am sure that the Executive Board at its session in January 1995 will wish to consider how best WHO should integrate community action for health philosophy in all its activities and programmes. With these few words I would like to thank the Secretariat, moderators and rapporteurs who took part in these Technical Discussions. All of them worked extraordinarily hard, resulting in extremely productive and positive Technical Discussions. It has been a pleasure for me to chair the Technical Discussions at the Forty-seventh World Health Assembly and it is an honour for me today to submit for your consideration the report of those Discussions. Thank you very much. The PRESIDENT: Thank you, Mrs Roestam. I am confident that I am expressing the feeling of each and every member of this Assembly when I thank you most sincerely for presenting this excellent report, which reflects the importance of the subject. The comprehensive background documentation and the video testimonials on selective issues on health within the community clearly set the tone for the Discussions. Participants brought to bear their expertise on the issues under discussion and demonstrated their commitment to seeking concrete actions that would make a difference in the health care system by tackling problems at its lowest level, that is the community level. As one can see, pertinent actions are highlighted in the final report. I would like to take this opportunity on behalf of the Assembly to congratulate all those who have been involved in the preparation for and organization of these Technical Discussions. Before adjourning, I should like to remind you that the General Committee will meet after this meeting, to decide on the programme of work for the remaining duration of the Assembly. I also have two announcements to make. At 13h00 today there will be a briefing on malaria control in Room VIII with interpretation into English and French, and this afternoon the two main committees will meet at 14h30. The next plenary meeting will be held tomorrow, Tuesday, 10 May, at llhlo. The meeting is adjourned. The meeting rose at 12h30. La séance est levée à 12h30.

245 A47/VR/14 page 230 TWELFTH PLENARY MEETING Tuesday, 10 May 1994,at 11Ы0 President: Mr В. K. TEMANE (Botswana) DOUZIEME SEANCE PLENIERE Mardi 10 mai 1994,llhlO Président: M. В. К. TEMANE (Botswana) 1. ANNOUNCEMENTS COMMUNICATIONS The PRESIDENT: The Assembly is called to order. I would like to report to you the decisions of the General Committee which met for the last time yesterday afternoon. The General Committee decided that the main committees should meet simultaneously this afternoon from 14h30 to 17h30. Tomorrow morning the main committees will meet from 09h00 to llh45. The plenary will follow at 12 noon to approve the reports of the main committees. The committees will reconvene at 14h30 to 17h30. On Thursday 12 May the two main committees will meet simultaneously at 09fa00 to finalize their reports. If possible the plenary will meet at llhoo to approve the final reports and this will be followed by the closure which is expected to take place no later than 12 noon. It is understood that the committees may wish to extend their meeting times, and the General Committee has entrusted me with the task of monitoring the progress of work in conjunction with the Chairmen of the two committees in order to be able to decide on the exact time of closure. As indicated, we expect it to be about 12 noon. 2. FIRST REPORT OF COMMITTEE B 1 PREMIER RAPPORT DE LA COMMISSION B 1 The PRESIDENT: We shall now consider the first report of Committee B, as contained in document A47/50; please disregard the word "Draft" as this report was adopted by the Committee without amendments. This report contains three resolutions which I shall invite the Assembly to adopt one after the other. Is the Assembly willing to adopt the first resolution entitled "WHO response to global change: Programme Development Committee"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the second resolution entitled: "Budgetary reform: Administration, Budget and Finance Committee"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the third resolution entitled: "Budgetary reform"? In the absence of any objections, the resolution is adopted and the Assembly has therefore approved the first report of Committee B. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

246 A47/VR/12 page SECOND REPORT OF COMMITTEE A 1 DEUXIEME RAPPORT DE LA COMMISSION A 1 The PRESIDENT: We shall now consider the second report of Committee A, as contained in document A47/49; please disregard the word "Draft" as this report was adopted by the Committee without amendment. This report contains five resolutions which I shall invite the Assembly to adopt one after the other. Is the Assembly willing to adopt the first resolution entitled: "Maternal and child health and family planning: quality of care"? In the absence of any objections the resolution is adopted. Is the Assembly willing to adopt the second resolution entitled: "Maternal and child health and family planning: traditional practices harmful to the health of women and children"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the third resolution entitled: "Implementation of WHO's revised drug strategy: revision and amendment of WHO's Good Manufacturing Practices for Pharmaceutical Products"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the fourth resolution entitled: "Role of the pharmacist in support of the WHO revised drug strategy"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the fifth resolution entitled: "Implementation of WHO's revised drug strategy: rational use of drugs; and WHO's Action Programme on Essential Drugs"? In the absence of Is the Assembly willing to adopt the fifth resolution entitled: "Implementation of WHO's revised drug strategy: rational use of drugs; and WHO's Action Programme on Essential Drugs"? In the absence of any objections, the resolution is adopted and the Assembly has therefore approved the second report of Committee A. I would like to remind you that the main committees will reconvene at 14h30 this afternoon and again tomorrow at 09h00 to llh45. The next plenary meeting will be tomorrow at 12 noon to approve the reports of the main committees. A briefing on WHO's activities in research on reproductive health in francophone Africa will be held in Room X at 13h00 today. Before adjourning the meeting, I should like to request the delegates to remain in their seats to witness a short ceremony concerning the establishment of the Mentor Foundation. The objective of this private foundation is to support activities for substance abuse prevention among children and adolescents worldwide. Many of the founders and members of the Board of Trustees of the Foundation will be with us on the podium for the ceremony. Her Majesty the Queen of Sweden will address the delegates and Her Royal Highness the Hereditary Grand-Duchess of Luxembourg will also be with us. The ceremony will begin at 12 noon, sharp. We shall now adjourn the meeting. The meeting rose at llh35. La séance est levée à llh35. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

247 A47/VR/14 page 232 THIRTEENTH PLENARY MEETING Wednesday, 11 May 1994,at 12h00 Acting President: Dr A. L. PICO (Argentina) TREIZIEME SEANCE PLENIERE Mercredi 11 mai 1994,12 heures Président par intérim: Dr A. L. PICO (Argentine) 1. SECOND REPORT OF COMMITTEE В 1 DEUXIEME RAPPORT DE LA COMMISSION B 1 El PRESIDENTE INTERINO: Se abre la sesión. Examinaremos a continuación el segundo informe de la Comisión B, que figura en el documento A47/52. El informe fue adoptado por la Comisión con una enmienda en la primera resolución. El informe contiene dos resoluciones, e invito a la Asamblea a que las adopte una por una. Desea la Asamblea adoptar, con la enmienda de la que seguidamente dará lectura el Dr. Piel, la primera resolución, titulada: «Respuesta de la OMS a los cambios mundiales: resoluciones de la Asamblea de la Salud»? Dr PIEL (Cabinet of the Director-General): Thank you, Mr President. This is an essentially editorial change which was made in Committee В today when it adopted the draft resolution before you. I am referring to operative paragraph 5(1) and I shall read the text slowly: 5. REQUESTS that when a resolution is first initiated and presented at the Health Assembly without prior review by the Executive Board: (1) the Chairmen of Committees A and В of the Health Assembly will consult their respective officers, supported by the Director-General, and depending upon whether the committee concerned has sufficient information, refer the matter to the General Committee or request the committee concerned to consider the resolution directly. El PRESIDENTE INTERINO: Puesto que no hay objeciones, se adopta la resolución en su forma enmendada. Desea la Asamblea adoptar la segunda resolución, titulada: «Informe financiero y estados de cuentas definitivos sobre el ejercicio 1 de enero de de diciembre de 1993,e informe del Comisario de Cuentas a la Asamblea Mundial de la Salud»? Puesto que no hay objeciones, se adopta la resolución, con lo que la Asamblea ha aprobado el segundo informe de la Comisión B. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

248 A47/VR/14 page THIRD REPORT OF COMMITTEE A 1 TROISIEME RAPPORT DE LA COMMISSION A 1 El PRESIDENTE INTERINO: Examinaremos ahora el tercer informe de la Comisión A, que figura en el documento A47/51; pueden prescindir de la palabra «Proyecto» dado que el informe fue adoptado por la Comisión sin modificación alguna. El informe contiene dos resoluciones, e invitaré a la Asamblea a que las adopte una a una. Desea la Asamblea adoptar la primera resolución, titulada: «Criterios éticos de la OMS para la promoción de medicamentos»? Puesto que no hay objeciones, se adopta la resolución. Desea la Asamblea adoptar la segunda resolución, titulada: «Aplicación de la estrategia revisada de la OMS en materia de medicamentos: inocuidad, eficacia y calidad de los productos farmacéuticos»? Puesto que no hay objeciones, se adopta la resolución, con lo que la Asamblea ha aprobado el tercer informe de la Comisión A. 3. ANNOUNCEMENTS COMMUNICATIONS El PRESIDENTE INTERINO: Esta tarde, entre las y las horas tendrá lugar en la sala A.662 una sesión de información sobre las actividades de la OMS en materia de salud reproductiva en Africa francófona. Asimismo entre las y las 14.00, en la sala VII, tendrá lugar una sesión de información sobre la erradicación de la dracunculosis: qué estrategia adoptar a dos años del objetivo, en la que habrá servicios de interpretación al francés y al inglés. Por fin, también entre las y las horas, se celebrará en la sala A (sede de la OMS) una sesión de información sobre las medidas complementarias de la OMS en relación con la Conferencia Internacional sobre Nutrición, en la que habrá servicios de interpretación al francés y al inglés. Las comisiones principales volverán a reunirse esta tarde a las horas. La próxima sesión plenaria se celebrará mañana a las horas, a ser posible, para examinar los informes finales de las comisiones. Inmediatamente después tendrá lugar la sesión plenaria de clausura. La hora exacta de esas dos sesiones plenarias se anunciará en las reuniones de las comisiones principales y en el Diario. Se levanta la sesión. The meeting rose at 12h30. La séance est levée à 12h30. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

249 A47/VR/14 page 234 FOURTEENTH PLENARY MEETING Thursday, 12 May 1994,at llhoo President: Mr В. K. TEMANE (Botswana) QUATORZIEME SEANCE PLENIERE Jeudi 12 mai 1994,11 heures Président: M. В. К. TEMANE (Botswana) 1. ACCEPTANCE OF CREDENTIALS SUBMITTED BY BOLIVIA ACCEPTATION DES POUVOIRS PRESENTES PAR LA BOLIVIE The PRESIDENT: Your excellencies, distinguished delegates, Mr Director-General, friends, the Assembly is called to order. As our first item of business, I would like to inform the Assembly that the delegation of Bolivia recently submitted formal credentials. The delegation had been seated provisionally in the Health Assembly pending the arrival of this document. However, it was not possible yesterday to convene all members of the bureau of the Committee on Credentials to consider this submission in accordance with Rule 23 of the Rules of Procedure. Nevertheless, along with part of the bureau of the Committee I have examined this document and it was found to be in conformity with the Rules of Procedure. I therefore recommend that the Assembly recognize the validity of these formal credentials. Is this acceptable to the Assembly? It would appear that there are no objections, and it is so decided. 2. THIRD REPORT OF COMMITTEE B 1 TROISIEME RAPPORT DE LA COMMISSION B 1 The PRESIDENT: We shall now consider the third report of Committee B, as contained in document A47/54; please disregard the word "Draft" as this report was adopted by the Committee without amendments. This report contains 14 resolutions and two decisions, which I shau invite the Assembly to adopt one after the other. Is the Assembly willing to adopt the first resolution, entitled: "Consideration of the situation of certain Member States falling under the purview of Article 7 of the Constitution"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the second resolution, entitled: "Status of collection of assessed contributions and status of advances to the Working Capital Fund"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the third resolution, entitled: "Review of the Working Capital Fund"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the fourth resolution, entitled: "Assessments of the Czech Republic and Slovakia"? I call upon the delegate of the Czech Republic. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

250 A47/VR/10 page 235 Mr VENERA (Czech Republic): Thank you, Mr President. We made certain reservations concerning this resolution in Committee B, and I would like to repeat them. The delegation of the Czech Republic would like to place on record its reservations as to the rate and the amount of the contribution of the Czech Republic to the WHO regular budget. The contribution has been assessed on the basis of a figure, 0.42%, approved by the United Nations General Assembly in December The way of establishing that rate was unfortunately in contradiction with international law, and in particular with the principles of equity and non-discrimination, since the rate of the Czech contribution to the United Nations budget was not properly stipulated as applicable for a new United Nations Member State. Therefore the Czech Republic does not consider itself bound by the above-mentioned United Nations General Assembly decision concerning the assessment for the rate of contribution. The Czech Republic is ready to pay its contribution to the budget of the United Nations and other international organizations, based on the United Nations scale of assessment, on a provisional basis only, until this problem is settled within the appropriate United Nations organs. The PRESIDENT: Thank you. This statement will be reflected in the record of the proceedings of the Health Assembly. In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the fifth resolution, entitled: "Assessment of Eritrea"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the sixth resolution, entitled: "Assessment of Niue"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the seventh resolution, entitled: "Assessment of Nauru"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the eighth resolution, entitled: "Real Estate Fund"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the ninth resolution, entitled: "Cooperation Agreement with the African Development Bank and the African Development Fund"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the tenth resolution, entitled: "International Decade of the World's Indigenous People"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the eleventh resolution, entitled: "Collaboration within the United Nations system and with other intergovernmental organizations: health assistance to specific countries"? In the absence of any objections, the resolution is adopted. Is the Assembly willing to adopt the twelfth resolution, entitled: "Rwanda"? I am informed that Egypt wishes to be included as a cosponsor of this resolution. In the absence of any objections, the resolution is adopted. We now come to the thirteenth resolution, entitled: "Health conditions of the Arab populations in the occupied Arab Territories, including Palestine". After adoption of this resolution, I intend to give the floor to two speakers only, Israel and Palestine. Is the Assembly willing to adopt the resolution? Tbe resolution is adopted. I give the floor to the delegate of Israel. Mr LIOR (Israel): Thank you, Mr President. I think it would be superfluous to mention here the background against which this resolution has been adopted by consensus. The cities of Madrid, Washington, Oslo, Cairo are the yardsticks and stones in the process of peace in the Middle East - beginning with the Madrid process, through the handshake in Washington, through the Oslo agreement, and now the implementation, which was decided in Cairo, of the Declaration of Principles between Israel and the PLO. I do not have to emphasize the dimension and the importance of this process, which inspires hope in all of us - not only in Israelis and Palestinians, Jews and Arabs but, I am sure, in every single country represented here. It inspires the hope that we will get away from the vicious circle of suffering and agony and utterly senseless bloodshed. I remind you briefly of all this because everything we do here has some bearing on what is happening in the Middle East. We send messages from here to those who are engaged in the peace process.

251 A47/VR/10 page 236 And what is the message that we are sending this time? It is a mixed one. On one hand, we were engaged in an open, friendly dialogue with the Palestinian delegation; we cleansed the resolution of many of the unnecessary elements which have politicized it in the past; we were moved and touched by the commitment and the devotion of the three sponsors of the peace process, Russia,United States of America, and Norway, who offered all help they could with sensitivity, suggestions and goodwill; and yet unfortunately, on the other hand, the Palestinian delegation could not bring itself to reject outright the remnants of politicization which we still find in this resolution. I suggested to my colleague, the head of the Palestinian delegation, Dr F. Arafat, that we adopt a resolution which is not offensive or confrontational and not provocative to either side - a clean resolution which deals with health and with assistance in this field to the Palestinian people. This time around, we have not been completely successful; we have been promised that next year there will be a healthier resolution. We hope that we will be able to witness the advent of total professionalism to which we will be a party in this Organization, and concentration on the vocation of offering help and assistance to the Palestinian people on the long road that faces them in so many fields as we progress in the peace process in the Middle East. The PRESIDENT: I thank the delegate of Israel. I now give the floor to Palestine. Dr ARAFAT (Palestine): 己 ^ ^ I o.. 々,^^jJ 1 JSJÍ i ^SJ I jlii 1 jlii ^J J^s^l ^-JoL^I ^ jb>\ Ó y, J ^ f-^j:, Ji J :.. U^JU^J "(L^ac Jl^b LJUbl^ I _ о /л ^-ol. ^M^JI '«UjLo e '.L^^Ji ^JU I 0! ^-uc^ L^L I j^ojj djia ^J! ^^sk-aji JJUXJÎ 0 ^ ç-o J-л-А^ у^э^и Lu:! 丄 L I^^J ^ o U J I 产 ^Jî y>z j\ I Jla ^J с Lflwbol ^л-чсл l^'l du J^è) Ua ^ Ul^ UJI JU ' ^^à ^ U^s ^з 0) Uo^J «la.,1 ^ Ji dj J I. LI^LÛ ^jb^/l l^ólo ^JJI 0г._Ц. J^l 广 I ^ Jlk^l ^Ui^JL, J-O-J^j ej^w d^iuji JajJI e 0 l ^l^^ji.. 0) ^JUJI Ji ^lo) J-JjJI^ Ucx^j SàJ i ^jji^ 1 Ua ^ л 二 " o^ с^ь^1 ^ оа с/ 1 ^ 'l^u g L.,..;^ 1 'idols' ^^aji djcj-juo! JLA ^s^ojl ja^o C _.J ^UJI 产 L«JI aji JL***J! Lôw^JLC^. LV :.J J I j^oj l g U ^j^jlso 0 "е.;... 丨 4 " ^i^ji^ I ai^ji ^-o 'LaSLo t ó^ffjl-. V--.-V.JcJJ ^^w^jl 产 jjl ^j) t^-joiujl y L C ^ A-J t JL^JI IJ^J Ji^ 0\ ^J^J JUb c l 3 J-^l^l JUbl UJUbl Ji o V ^ J-^ J^I ^ ^ >n lu)l jjl ^Jl^ IJLíl^ ^^Lu^ ^JL«JI Ji JLibl «... 1 q PbLJ\ The PRESIDENT: Thank you, Palestine. We now continue with the fourteenth resolution, entitled: "Salaries for ungraded posts and the Director-General". Is the Assembly willing to adopt this resolution? In the absence of any objections, the resolution is adopted. There are two decisions taken under item 34: United Nations Joint Staff Pension Fund, namely: Annual report of the United Nations Joint Staff Pension Board for 1993 and Appointment of Representatives to the WHO Staff Pension Committee. The Committee decided to note the annual report of the United Nations Joint Staff Pension Board for 1993 and to recommend the appointment of Professor Béat Andreas Roos, in his personal capacity, as a member of the WHO Staff Pension Committee and the member of the Executive Board designated by the Government of Kuwait as alternate member, the appointments being for a period of three years. Does the Assembly agree? In the absence of any objections, the decisions are adopted and the Assembly has therefore approved the third report of Committee B.

252 A47/VR/14 page FOURTH REPORT OF COMMITTEE A 1 QUATRIEME RAPPORT DE LA COMMISSION A 1 The PRESIDENT: We shall now consider the fourth report of Committee A, as contained in document A47/53; please disregard the word "Draft" as this report was adopted by the Committee without amendments. It contains one resolution, entitled: "Onchocerciasis control through ivermectin distribution". Is the Assembly willing to adopt this resolution? In the absence of any objections, the resolution is adopted and the Assembly has therefore approved the fourth report of Committee A. 4. SELECTION OF THE COUNTRY OR REGION IN WHICH THE FORTY-EIGHTH WORLD HEALTH ASSEMBLY WILL BE HELD CHOIX DU PAYS OU DE LA REGION OU SE TIENDRA LA QUARANTE-HUITIEME ASSEMBLEE MONDIALE DE LA SANTE The PRESIDENT: I should like to draw the Assembly's attention to the fact that, under the provisions of Article 14 of the Constitution, the Health Assembly, at each annual session shall select the country or region in which the next annual session shall be held, the Executive Board subsequently fixing the place. I should also recall that the Thirty-eighth World Health Assembly concluded that it was in the interest of all Member States to maintain the practice of holding Health Assemblies at the site of the headquarters of the Organization. I therefore take it that the Assembly decides that the Forty-eighth World Health Assembly will be held in Switzerland. Are there any observations? In the absence of any observations, it is therefore so decided. Before adjourning the meeting, I have a brief announcement concerning the Executive Board. I understand that the ninety-fourth session of the Board will open at 09h00 tomorrow, Friday, 13 May in the Executive Board Room at WHO headquarters. The closing plenary will be held at llh55. This meeting is now adjourned. The meeting rose at llh35. La séance est levée à llh35. 1 See reports of committees in document WHA47/1994/REC/3. 1 Voir les rapports des commissions dans le document WHA47/1994/REC/3.

253 A47/VR/10 page 238 FIFTEENTH PLENARY MEETING Thursday, 12 May 1994, at llh55 President: Mr В. K. TEMANE (Botswana) QUINZIEME SEANCE PLENIERE Jeudi 12 mai 1994,llh55 Président: M. В. К. TEMANE (Botswana) CLOSURE OF THE SESSION CLOTURE DE LA SESSION The PRESIDENT: Your excellencies, honourable ministers, ambassadors, distinguished delegates, Mr Director-General, colleagues and friends, the meeting is called to order. As the Forty-seventh World Health Assembly comes to a close it is my duty and pleasure to thank all those who made it possible. I thank everyone who participated in the complex machinery of this Assembly. Not only the actors themselves, including your distinguished officers, Vice-Presidents, Chairmen, their deputies and rapporteurs, but also those behind the scenes; the interpreters, ushers, typists, drivers and many other service staff. Before I proceed with my remarks, I will invite Dr Raí, Chairman of Committee A, to address the Assembly and review the work of Committee A. Dr RAI (Indonesia) (Chairman, Committee A): Mr President, Dr Nakajima, fellow delegates, ladies and gentlemen, in accordance with the decision taken at the Forty-fifth World Health Assembly in May 1992,it is with great pleasure that I share with you my impressions of the discussions in Committee A where many important issues were addressed. The first item we looked at on the agenda was the Ninth General Programme of Work. In conformity with Article 28(g) of the WHO Constitution, the Board initiated work on this in 1992 at its eighty-ninth session. Members of Committee A recognize the important contribution by the regional committees and the Programme Committee of the Executive Board to the development of the Ninth General Programme of Work. In all there were 34 speakers on this item, and I think it is fair to say that comments on and reactions to the Ninth General Programme of Work were all very positive and supportive. The Committee recognized that it was clearly a policy document intended to guide all international health action, and that it presented a vision of what could be accomplished by the world health community, including WHO. It also outlined what WHO itself will do in the period The Committee welcomed the fact that details will be developed at the time of the preparation of each programme budget, ensuring both relevance and flexibility in the WHO response. Members of the Committee stressed that with the adoption of the Ninth General Programme of Work we must all collectively focus our energies and attention on implementing it. The second agenda item taken up by the Committee was the implementation of resolutions, under which there were ten subitems. With regard to the first subitem, delegates stressed the importance of technical cooperation among developing countries as a tool for building up and strengthening national capacities and self-reliance, and recognized it as a catalyst for sustainable development. It is also seen as an effective mechanism for countries to share experiences and support each other in addressing common concerns. The importance of generating sufficient resources, and of research in implementing technical cooperation among developing countries were emphasized, and, in addition, the Committee stressed the importance of evaluation of the efficacy of methods for carrying it out.

254 A47/VR/10 page 239 Under the subitem on health and development, delegates discussed the health situation of the most vulnerable groups and the fact that development can lead to a deterioration in their health status and the creation of new situations of vulnerability. Development thus poses both a great opportunity and a great challenge. In this context, the establishment of the task force on health and development policies was welcomed by delegates, who felt that it would have a positive role in evaluating the impact of technical cooperation and development on the health status of vulnerable groups. Women have a crucial role to play in development, and in 1993 the Director-General set up a multidisciplinary independent Global Commission on Women's Health to advise WHO on policies and programmes, and to play an advocacy role on issues related to women's health. The Chairman of the Global Commission reported on the first meeting, held at WHO headquarters in April 1994,and explained how the Commission would be involved in the preparation of the Fourth World Conference on Women. The third subitem related to infant and young child nutrition, including the status of implementation of the International Code on Marketing of Breast-milk Substitutes. It is interesting to note that this was an item that attracted by far the largest number of speakers on any topic in Committee A. A total of 51 delegates took the floor, as well as the representatives of UNICEF, UNHCR, the European Union, and of five nongovernmental organizations. The Director-General's very comprehensive progress report on this item was the eighth of a series of biennial reports on infant and young child nutrition, and reflected the World Declaration on Nutrition and plan of action for nutrition, on which WHO technical support to countries is based. In particular, the report contained information on action taken by WHO Member States, consumer and professional groups, and other technical bodies, to encourage and support breastfeeding, monitoring trends in the prevalence and duration of breast-feeding and, since 1991,measures taken to give effect to the International Code of Marketing of Breast-milk Substitutes in 50 countries and territories. In addition to the technical issues raised by delegates a great deal of the discussion related to the draft resolution on infant and young child nutrition recommended by the Executive Board to the Assembly for adoption. It was clear from all of the interventions that support for the Code and for the ongoing efforts to strengthen it was unambiguous. A number of amendments to the Executive Board draft resolution were proposed. However, in a spirit of harmony and in view of the importance of the subject, all those delegates who proposed changes agreed to withdraw them with a view to adopting the original Executive Board resolution by consensus. This was agreed to in principle and after all the remaining speakers had taken the floor, delegates unanimously adopted the resolution. "Maternal and child health and family planning for health" was the following subitem, under which there were two resolutions, EB93.R10, "Traditional practices harmful to the health of women and children" and EB93.R11, "Quality of care and maternal and child health and family planning". Discussions by members of Committee A underlined the many factors affecting the health of women, children and families particularly the accelerating phase of social, political and economic change. Violence affecting women, children and adolescents is being recognized as a major public health problem. Discussion emphasized the importance of an integrated approach to the health of women and children and the need to address these issues in the context of the health of the family. Both resolutions, with minor amendments, were adopted by consensus. The next subitem the Committee considered was the WHO Ethical Criteria for Medicinal Drug Promotion. In 1992,the Council for International Organizations of Medical Sciences (CIOMS) was requested by the Director-General to convene a meeting of interested parties in collaboration with WHO. One of the main objectives was to intensify efforts to involve government agencies, including drug regulatory authorities, pharmaceutical manufacturers and health personnel concerned with the prescription, dispensing, supply and distribution of drugs. An important focus of this joint CIOMS/WHO meeting was to discuss possible approaches to further advancing the principle embodied in this ethical criteria. Ibis meeting was successfully held in 1993,and Committee members stressed the importance of continuing dialogue and consensus on a quite controversial subject where a great variety of interests was involved. All parties expressed the determination to work together. A draft resolution submitted by numerous delegations to the Committee generated a good deal of discussion and comment and a number of amendments were agreed upon. Again, it was gratifying to note that the resolution was adopted by consensus. Under the next subitem the Executive Board had forwarded two resolutions relating to the implementation of WHO revised drug strategy, revision and amendment of WHO Good Manufacturing Practices for Pharmaceutical Products and the role of the pharmacist in support of the WHO revised drug strategy. These were adopted without any amendments. Two additional resolutions under this subitem were submitted by delegations: safety, efficacy and quality of pharmaceuticals and the rational use of drugs, and WHO's Action Programme on Essential Drugs. Discussion on the first resolution highlighted important areas of WHO's revised drug strategy, since the normative functions of WHO in the area of pharmaceuticals are vital to drug regulatory authorities throughout the world. Amendments were suggested and accepted for both resolutions, following which they were adopted by consensus.

255 A47/VR/10 page 240 During the discussion on the Action Programme on Essential Drugs, a number of delegates expressed their concern that less than 50% of the world's population had access to adequate supplies of safe, essential drugs. The changing global economy was severely affecting developing countries and thus financing had emerged as a major problem. Many countries were seeking new partnerships to meet the challenges, including closer cooperation with the private sector. Such moves will need guidance and support from WHO. The next subitem dealt with the elimination of neonatal tetanus and control of measles. Delegates were reassured that the target set by the Health Assembly in 1989 on the elimination of neonatal tetanus was indeed achievable and that for practical purposes, this meant less than one case per 1000 live births for each district. However, it was realized that while progress had been made, there were still a number of countries where neonatal tetanus was a major problem and concerted action would be needed. It was noted that most progress in the context of measles control had been made in the age group nine months to five years. A number of delegates indicated the need to develop a new measles vaccine to tackle the occurrence of measles before the age of nine months. Delegates from developing countries expressed concern over the cost of vaccines and stressed the implication this had for sustainability of immunization programmes. It was emphasized that immunization activities are an excellent entry point and vehicle for strengthening other elements of primary health care. Turning to the next subitem on dracunculiasis or guinea-worm disease, delegates were pleased that as the eradication of the disease was now very close in Asia, programme activities were being focused on countries in Africa south of the Sahara. Recent data indicates that the total annual incidence of cases has fallen below the two-million mark, making the 1995 target of eradication a possibility. Under the next subitem, the success of multidrug therapy in the treatment of leprosy was welcomed by the Committee. The need to intensify efforts to eliminate leprosy as a public health problem by reducing prevalence to below one case per population was stressed. As the appearance of new disease was less and less of a problem, more and more attention should be focused on disability prevention and management. I am more than pleased to state that soon I expect leprosy will no longer need to be an agenda item before this Health Assembly. Last, under agenda item 19,was the subject of tuberculosis. This disease is a global emergency. Unless urgent and effective action is taken, 30 million deaths and almost 90 million new tuberculosis cases can be expected in the last decade of this century. This Committee noted with concern the high tuberculosis morbidity and mortality among young women - there are more deaths from tuberculosis than maternal deaths. In addition, multidrug resistant strains are becoming more prevalent and HIV/tuberculosis co-infection is rapidly increasing. Speakers emphasized the cost-effectiveness of short course chemotherapy and the impact of rapid and early diagnosis. Delegates welcomed the training activities that were being supported by WHO and nongovernmental organizations and the emphasis on technical support and operational research. The importance of continuing coordination between the tuberculosis control programme and other relevant programmes, particularly that for the control of HIV/AIDS, was emphasized. Committee A welcomed the establishment of a Special Account for Tuberculosis within the Voluntary Fund for Health Promotion. Our next agenda item was onchocerciasis control. The Onchocerciasis Control Programme in West Africa is very well known and celebrated its twentieth anniversary at this Assembly. However, delegates were aware of the persistent needs for the control of this disease in the remaining endemic countries in the regions of Africa, the Americas and the Eastern Mediterranean. A specific donation programme for ivermectin set up by the manufacturer in consultation with WHO opens up the possibility of large-scale disease control. Our Organization has a continuing and important role to play in providing technical leadership and coordination with other interested agencies and nongovernmental organizations. The Committee unanimously adopted the resolution on onchocerciasis control through ivermectin distribution. Committee В took over discussion of the joint and cosponsored United Nations Programme on HIV/AIDS. Our committee therefore, looked only at technical issues relating to the implementation of the global AIDS strategy, stressing the continued leadership role for WHO, and worldwide efforts to control the spread of HIV and AIDS. Delegates expressed deep concern about the pandemic which represents not only such a large number of people ill and dying, but also the enormous emotional and financial impact on individuals, families, communities and countries. While the value of the process indicators developed by WHO is recognized, delegates stressed the need for more attention to assessing outcome since this would help in future understanding and work. To conclude, Mr President, we had a heavy agenda which was made somewhat lighter than originally foreseen because of the transfer of part of the agenda item on the topic of AIDS to Committee B. However, more important to the efficiency and efficacy of Committee A,s work was the spirit of

256 A47/VR/10 page 241 cooperation and consensus which ensured that a number of extremely complex and difficult issues were dealt with in the manner they deserved, namely, with a focus on technical aspects and content. I also want to note that the Committee was careful this year to inform itself of the technical and financial implications of the various resolutions it adopted, as in fact is now required by resolution WHA We all know how easy it is to ask for action to be taken on various matters without taking adequate stock of whether this is feasible in light of the technical, administrative and financial resources available or of the implication that undertaking new work can have on existing activities for which there may be equal or even greater need. Committee A raised an important issue that is of relevance to all of us wherever we work. Specifically, a number of delegates suggested an increased regular budget allocation to several of the WHO programmes discussed. However, I know, as do we all, that to do so would necessarily mean less for other programmes which themselves are also engaged in important work and who are also very concerned to increase their financial, technical and human resources. And we also all know that everywhere, be it WHO, a nongovernmental organization or a community health service, competition for an increased share of existing resources will remain intense. Clearly, one of WHO's major roles is to continue to be a catalyst in guiding the efficient and effective investment of resources for health at both national and international level. I believe I speak for all my distinguished colleagues in Committee A when I say that our work during these past ten days has been undertaken in a spirit of consensus and harmony. We managed very successfully to focus on the technical and public health concerns and steer away from politicizing our debates, even when discussing sensitive issues. In closing, I would like to hope that a similar spirit will endure in the work of future committees. The PRESIDENT: Thank you Dr Rai. I should like to congratulate you very warmly for your excellent presentation and also for the outstanding way in which you presided over Committee A. The next speaker will be the Chairman of Committee B, Dr Asaad whom I now invite to take the floor. Dr Asaad (Saudi Arabia): :( 少,-" ^«Jl 'A^.Lo.ll ) jla^i Jl*^ ^y^jjl i I I djl) I^ьм-^ t ÓJL^JIз CL,! JL***J1 i s-^u^ji ÔJLJI «^UJI 太 JuJI > ṙ JI ^^ej}\, 了 J1 4-s^cJI л., ялу ^ÍILÍOI с Liil J-ox *<Ll>JUI ь cluou LJ LoU U js. ^j..u>.. r, '<Li=JJ! J^s J^lijJI ^^JU 3 juwvl y^l^ ^UJI I Jl^J d-ujuji ^ 一" *<UAJU1 jí^ А^Я.О-0 1 ÓJLA ^JLC ^^JUJI 1^,<?> au ^3-Jl ^JUül сl^-jl jju Lo j-o L^JL»^ ' sl>ji LI^JJL CJ^^I Ju> Jl ^j-ul ^ДЛ A-u^^/l C^l j UUCLD! ^O JJLC A-ÜLUJ-. ^S Ll<x3 JLD^ *<LoLû> CLl Jl^.1 «IS J UCJ 1 U I^JJ ^J^LÍÜ 1 -^pj LG. LW <V_:_,J <LT/ LSJ RTOG л ; CLUKS i ^ j u f S ^ JL-U*V TW. J 1 Lo-. jaji q JJ '<Lc>vtiJ1 Jl j\jla^i dujajuj! ó Jlû> 匕 ^ Lrb ⑷ 6 У^З I б г/; di Vi ^ JI>JI yaloj 丨 ;iiu^y 夕丨 Jil o J ^ jlxl <Laûj>J1 ôsjb JL^^ «' f Lb^ J J I ^^JJ! dili duwjjb ^э Cluols \ Lib jb\ ^Jl '«LUJIAJI '<LU*UV> '«L^ó-S*-, dia-^ ^oji ^ d^i^ji dili v-jl) ^jjlc p Ll. culk 133 LJu j \ 一 ^Js Jl ci-lsij^i) yi13 IjJ 1 doujuü! *<LxaoJ! A :«лу j I ÂJ c LLUJI длл ^JâjJî J^L ^^JLc LJuI ^ 少, 'ajjtk-ui ôjj^wû Ji-L ^J! '«LojJuJl L^vyaJI c^l jlíl^uji ' Sl^ duülio jib! 1 气气 о pu jl^ji ^J-bo^ j^i^jl 丄匕 L 3 J OríJ^ ^ ^^g) 1 '<iili A,..;«all dils dl»w C LJ! djl^j *«LL>UU1 *<Lu>u J1 ja^jl Jj I,.я ^UÜ! \J\ JUi^lj cl^jl^ JU^J! ^ pl^i J^iJ ^^iji 产 ⑴ 1 ^^rí 己己 ^! 0!aJLJI JolyiJ! c^alji JL^o '«LxiaJuJI jsla,^ J^-sJ! ójjb J^*^ ^j! jllji f- Uxcl ^ J! A-^L^^I ^ Jl ^j-* jlcloaji ^-.JÍÚ^ jl^iji _,1 yj

257 A47/VR/10 page 242 ljl Jà AJ^JUI CLJuOsl dj ji^. '«LjI^-uJ! ^JS. '<L>jljJI ^ojl L)j Lw ój^> L<J I lo^jâjuï ^JUJI ^^j. I ^ I5.cc.-U ^^jji JlSaJL. J^Uju.; da^uji ^Лм áu)^j Juí Jj^î J 3ÜCÜI ^J^ jlbl ^eja às 1 ^O^U jll<aco U ^woü^jl IULùiaI c^ltiluji j^í^ji 1 Sà 3 CL» j-íslj' ^os <vjl ^ L»J I jloj I 只 Jk^ LâJLc <Lb I a^oz^ j Ju.^/1 / ^ Í 1! ^c»^ j^-i ju.ju J1 lg*4,1я ^^g '<LJL<JI U 1 j^.v. 11 Q-o jjlc ^ JL>JI " " 'Á-i=Jül ^J 1 ^лгэ^! j LíkJ! ci^ L;* Lu,oJ I 1 yi I VI I ci» L;» L*cu>J 1 1 ^э ^ ÜajJ 1 j^joc ^ I j! vj csl jl j-» ^jmu ^^««J ^ j 1 jx^j^j 1 jj^v LJ> ^JLsCÂ^ L«u) AJ^JZJ, \S Ô>Ju> Lo ^ Icj-«I JJUÛJI A^jlo^CI ^iji j\^sj! ^J "<LbJLJI 己乂 ^ls. J-oUJI «^ЯЫ ⑵ JL> Lu> O.O ;; 1 «. ) 1 jjsclujц> J! ^s ázj^ ^ LAJ 1 太 JLOJI ^ LOIia^Í LA j^sàz ^ûji dbj/l LoJUla:. 一 1 ^ *<3u>JáJuJJ ^-^LJl Г И jji cllu-oji ^ J-J ^-o LJU LA.^ ' ILcuJI 0 >> ^Jl pu ^ d-ujuu! A-, я û.y ^Jl Jü^aJl! JLA 11 J^OJ^ ^^Jl IzjJ I ^S J^jàz ^-.JLSÛ^ dj JU 山 Ü с L /l 1 d-j LJ I Л.g :, " j^jcji ^! jjlc Cl^ ^JaJj 气气 û CI-» Lca^oJ I I j-o d» «i-::;-.» L ü! j-j^^üj j^llu/jj I ^o V J LaJ 1 I l,g l.c AJux.5^ J^jlj^ ^J! " UJLLJI ujllji^ ^J^JI C I, L S I " J U j M _ n V.LJLJI ' ^iju ^ U J I JoJUI ^ U l, ^jmjai^ J^SKIIOJ I ^о)! I ^ÀJb^oJ <9и>Лх UüJ I CL> L LhuxJU d ) 1 JUMOJ I ^ujl>uxj I j^szj LAJU y^s. vjlw^iji J-СЭ ^JJÜ ". «olí ^ J..A '.:«11 ^JAJLSKOJ I ^JAS. 苷二 ; LûS rt 二 Á, ) 气 Л1 $ Le ÀJu» I A_.._, 丄 1! ^Ь I^- LC J-off о IS jji Jbj q 大 " J LA^-.JLSC 1 djl>jui ^jjl3 "l^^jji ÓjiA JÍ3I ó.jg.1 Ш I '«LL^vl 己 :" _ IL J-oC ^^^^h 0 duojâ-juoj! CLuo Lo ^ j^jajuti ^j^-o AJ Lo L-», djuccü I ó ^J^^ I ó j^íl'j] ÓÁgJ *<LJáJuJl '<LL> Lv1 JiS^ ^ jji J«J u«*uj1 ^jb ^jj, ^ JL>w<JI Iлл A-WI j^t^-oj 1 ^y^s^jü àji3 Lio I j djludj^ Lio á^o^z i. V Là J ^ jj I ^ J^JUUÁJ 1 ^^ < JLJU-J 1 ^j^ájb 了 ^ Á J L o J! î 1 j î jsj 1 ^jut d-я--.j I dju>ju 1 I Jx^ jj J I I j <j-jj LoJ I ^^^- JI ^ d-ij I 1 j л j\si I ^wû Lj J^J! j^^sdz «sjl>jl 1 dutxaûj!. _,1j\Jà <LoJaJuiJ I L^J О I «5 V/"^: 1 :: 1 1 -^..ql I ^ LmoX I S Y>yh L*^ 亡 J^Slo j 1 Jó ^ -9 j j á^j, I I ллл ^jji 己 LÜLl^JI cijj US L JL ULúiaI j J \ LuJUJI ^\ j7fjcjj» l^lo^ À S J A M (<UxJaJuü I ^ÍlL^O LUJ \ ^ ^ I yjuü! J^uJ I Í^J^»» jlè^oj I JiJuü 1! Í^jaj^SJJ! ^ JL-C*^ ^-js j^s. I I I ^JJLJ 1 ^ djutk-l) 1 k^u V9yüt ^o (CUAJ^! LA^» jrt-*^ j ^ ^ j^ju^i! ^J 1 ^ js-ü* V-^jX I 1 Jjl 1 L'«J.o.C Цо 产 g 1 ^-o ^J LoJ I dj ISJ Lo 1 ^ J \ ^ Uuï-O LjcJ 产 LaJI ^-.jlaj ^«^JJI I^jJj ^J1 U P Uxil ^ - 一 0-JuÇ C l ^Jl Ij^j^x Lia-. ^ " dju>jul JUxl..jJ J-JuJI 产 L«JI *<LJL«J!^ 产 Ijj ^C^jüuJI 彡

258 A47/VR/10 page 243 The PRESIDENT: Thank you very much, Dr Asaad. Please accept my congratulations for your comprehensive report, and for conducting so well the work of Committee B. It was a job well done. Your excellencies, having thanked the Chairmen of Committees A and B, and all those mentioned in my preambular remarks, I now also wish to thank the Secretariat for all their background work, as well as the Director-General for his leadership throughout the proceedings. This is equally an opportunity for me to thank those members of the Executive Board who now leave their membership to those designated by other countries, for all the valuable experience and expertise they have shared with WHO. In his address to the Health Assembly the Director-General stated that WHO has two major constitutional functions; the direction of international health work with a responsibility for both advocacy and coordination, and the unique obligation to carry out technical cooperation in the field of health with its Member States. Let there be no doubt and no hesitation. In both these major functions, be it at global, regional or national level, WHO has had a distinguished record and an unrivalled reputation for excellence. Countries of the South testify to this fact by cooperating more intensely than ever with our Organization's technical programmes, countries of the North by offering more expertise and more voluntary contributions. In his closing speech last year, my predecessor, Mr OrtendaW, noted that the division between the North-west and the South-east has been all too visible in many parts of our agenda. I must say that to some extent the same observation applies to this Assembly. Yet on many diverse issues Member States have rallied to our common cause. I believe that a unity of purpose,a shared system of values, should weld us all in our common goal. In these difficult times the integrity of this Organization must be preserved. I am confident that all the Member States, without exception, will fulfil their obligations in this respect. We have heard and seen some figures: from US$ 546 million in ,the extrabudgetary funds attracted to WHO have grown to US$ 752 million in This undoubtedly reflects a considerable trust and respect for our Organization, yet the complexity and immensity of world health problems constitutes such a challenge that budgetary data on numbers, however large, can hardly match the real needs, which are infinite. We need to pay tribute here not only to those who generously offered their help to alleviate health problems in the tropics and elsewhere, but also to those who succeeded in sensitizing such donors. It may be paradoxical to think that certain currently under-funded low-priority activities could tomorrow become high-priority issues and succeed in attracting extrabugetary support. Indeed, it was not long ago that the tuberculosis problem was thought to have been solved and that WHO had only a token resourceless unit to deal with that disease. We should be wary of tempting over-simplifications. Nature still holds many secrets despite our daily discoveries and I submit that the mystery of life and disease calls for a little more humility on our part. I often hear that we know all we need to know. If we could only apply our knowledge, yes, but did that knowledge evolve at the same cost and under the same sociocultural constraints as those prevailing currently wherever it has to be applied? Is the transferability of knowledge and technology a straightforward matter? As I said earlier, this Organization has set an exemplary record by setting its goals to very ambitious levels, by constantly searching for new ways of approaching them, by questioning its own role in acquiring the necessary information and expertise. In doing so, our Organization has acquired a precious experience and has identified and developed remarkable talents. Let us make sure we preserve them and nurture them for the benefit of mankind. I wish you all a safe journey back home and a successful accomplishment of your important mission. I now have the pleasure in formally declaring the Forty-seventh World Health Assembly closed. The session closed at 12h45. La session est close à 12h45.

259

260 A47/VR/10 page 245 INDEX OF NAMES This index contains the names of speakers reported in the present volume. A full list of delegates and other participants appears in document WHA47/1994/REC/1. INDEX DES NOMS Cet index contient les noms des orateurs dont les interventions figurent dans le présent volume. On trouvera dans le document WHA47/1994/REC/1 la liste complète des délégués et autres participants à la Quarante-Septième Assemblée mondiale de la Santé. ABAD, P. (Ecuador/Equateur), 177 ABDULLAH, A. (Maldives), 144 ACHESON, D. (Léon Bernard Foundation Prize/Prix de la Fondation Léon Bernard), 161 ADAM, R. (Seychelles), 147 ADAMS, A. I. (Australia/Australie), 88 ALEXANDROVÁ, M. (Slovakia/Slovaquie), 92 ALVARADO SANTANDER, E. J. (Colombia/ Colombie), 182 AMADOR MILLAN, M. A. (Spain/Espagne), 104 ANCONA, H. d' (Netherlands/Pays-Bas), 35 ANGATIA, J. M. (Kenya), 137 ANTELO PÉREZ, J. (Cuba), 169 ARAFAT, F. (Palestine), 214, 236 ARRAYED, J. S. AL- (Bahrain/Bahreïn), 101 ASAAD, M. S. E. (Saudi Arabia/Arabie Saoudite), Chairman of Committee В/ Président de la Commission B, 241 BADI, A. AL- (United Arab Emirates/Emirats arabes unis), 93 BEGANOVIC, M. (Bosnia and Herzegovina/ Bosnie-Herzégovine), 151 BIZIMUNGU, C. (Rwanda), 221 BRAGANCA GOMES, D. F. (Sao Tome and Principe/Sao Tomé-et-Principe), 132 BREDIKIS, J. (Lithuania/Lituanie), 121 CANDUCCI, S. (San Marino/Saint-Marin), 131 CHATTY, M. E. (representative of the Executive Board/représentant du Conseil exécutif), 20 CHHEA, T. (Cambodia/Cambodge), 203 CHRISTIE, W. (Norway/Norvège), 81 CHRISTOPHIDES, M. (Cyprus/Chypre), 175 CIKULI, M. (Albania/AIbanie), 154 CLODUMAR, V. N. (Nauru), 159 CUMBERLEGE, J. F. (United Kingdom of Great Britain and Northern Ireland/ Royaume-Uni de Grande-Bretagne et d'irlande du Nord), 94 DABIRE, C. (Burkina Faso), 113 DAELE, D. VAN (Belgium/Belgique), 190 DASHZEVEG, G. (Mongoüa/Mongoüe), 195 DENG, G. (Sudan/Soudan), 152 DINÇ, К. (Turkey/Turquie), 98 DIOP, A. (Senegal/Sénégal), Chairman of the Committee on Nominations/Président de la Commission des Designations, 9, 14 DIRECTOR-GENERAL/DIRECTEUR GENERAL, 22,206,224 DUJSEKEEV, A. (Kazakhstan), 71 DUMONT, I. (Bahamas), 186 EPALANGA, M. S. (Angola), 212

261 A47/VR/10 page 246 FINETTE, J. R. (Mauritius/Maurice), 171 FOFANA, M. (Guinea/Guinée), 119 FOUZAN, A. AL- (Dr A. T. Shousha Foundation Prize/Prix de la Fondation Dr A. T. Shousha), 163 GARAVAGLIA, M. P. (Italy/ItaUe), 96 GIBRIL, A. A. (Sierra Leone), 154 GODINHO GOMES, H. (Guinea-Bissau/ Guinée-Bissau), 141 GUGALOV, T. (Bulgaria/Bulgarie), 134 GURMAN, B. (United Nations Development Programme/Programme des Nations Unies pour le Développement), 210 HAMADE, M. (Lebanon/Liban), 55 HANSEN-KOENIG, D. (Luxembourg), 208 HEBRANG, A. (Croatia/Croatie), 63 HUUHTANEN, J. (Finland/Finlande), 138 IGREJAS CAMPOS, J. M. (Mozambique), 149 IOANNIDES, F. (Greece/Grèce), 61 IYAMBO, N. (Namibia/Namibie), 188 JACOBSEN, O. T. (Niue/Nioué), 157 JÁVOR, A. (Hungary/Hongrie), 52 KAKOU GUIKAHUE, M. (Côte d'ivoire), 209 KASSIEV, N. (Kyrgyzstan/Kirghizistan), 135 KAUKIMOCE, J. (Fiji/Fidji), 68 KHUDABUX, R. M. (Suriname), 192 KIIKUNI, К. (Sasakawa Health Foundation/ Fondation Sasakawa pour la Santé), 165 KIM, Mo-Im (Sasakawa Health Prize/Prix Sasakawa pour la Santé), 166 KÔNBERG, B. (Sweden/Suède), 49 MAKHZANGI, A. A. F. EL (Egypt/Egypte), Vice-President of the Health Assembly/ Vice-Président de l'assemblée mondiale de la Santé, 12, 27 MALHAS, A. R. (Jordan/Jordanie), 64 MARANDI, A.-R. (Islamic Republic of Iran/ République islamique d'iran), 58 MARLEAU, D. (Canada), 67 MASSAD, C. (Chüe/Chili), 51 MAYAGILY, A. H. (United Republic of Tanzania/République-Unie de Tanzanie), 146 MAZUREK, M. J. (representative of Merck and Company Incorporated/représentant de Merck and Company Incorporated), 211 MAZZA, A. (Argentina/Argentine), 117 MBOYO, E. K. (Zaire/Zaïre), 216 MEHTSUN, H. (Eritrea/Erythrée), 189 MEDINA, J. (Cape Verde/Cap-Vert), 185 MENDO, P. (Portugal), 41 MGIJIMA, R. (South Africa/Afrique du Sud), 12 MINCU, I. (Romania/Roumanie), 85 MONASTERIOS, J. (BoHvia/Bolivie), 187 MONEKOSSO, G. L. (Regional Director for Africa/Directeur régional pour l'afrique), 207 MORENO MORALES, S. I. (Puerto Rico/ Porto Rico), 222 MUBARAK, О. M. (Iraq), 197 MUHAILAN, A.-R. S. AL- (Kuwait/Koweït), 124 NAKAJIMA, H, see/voir DIRECTOR- GENERAL/DIRECTEUR GENERAL NAÑAGAS, J. R. (Philippines), 126 NEÍAEV, E. A. (Russian Federation/ Fédération de Russie), 48 NGEDUP, S. (Bhutan/Bhoutan), 111 NGUYEN VAN THUONG (Viet Nam), 109 NOORDIN, H. J. (Brunei Darussalam/Brunéi Darussalam), 143 LAHURE, J. (Luxembourg), 31 LEE Kim Sai (Malaysia/Malaisie), 99 LIEBESWAR, G. (Austria/Autriche), 133 LIOR, I. (Israël/Israël), 235 LOVELACE, С. (New Zealand/Nouvelle- Zélande), 156, 219 MADANY, M. I. (Algeria/Algérie), 78 MAGANU, E. T. (Botswana), 174 ORTENDAHL, С. (Sweden/Suède), President of the Forty-sixth World Health Assembly/Président de la Quarante- Sixième Assemblée mondiale de la Santé, 4 OUCHI, K. (Japan/Japon), 32 OURAIRAT, A. (Thailand/Thaïlande), Vice-President of the Health Assembly/ Vice-Président de l'assemblée mondiale de la Santé, 40

262 A47/VR/10 page 247 РАК Chang Rim (Democratic People's Republic of Korea/République populaire démocratique de Corée), 193 PETROVSKY, V. (Director-General of the United Nations Office at Geneva/ Directeur général de l'office des Nations Unies à Genève), 2 PIEL, A. L. (Cabinet of the Director-General/ Cabinet du Directeur général), PITA, A. (Tuvalu), 152 PRETRICK, E. K. (Federated States of Micronesia/Etats fédérés de Micronésie), 194 RABBANI, R. I. (Pakistan), 168 RADITAPOLE, К. D. (Lesotho), 66 RAI, N. K. (Indonesia/Indonésie), Chairman of Committee A/Président de la Commission A, 238 RAJPHO, V. (Lao People's Democratic Republic/République démocratique populaire lao), Vice-President of the Health Assembly/Vice-Président de l'assemblée mondiale de la Santé, 172 RANAWEERA, R. H. (Sri Lanka), 122 RIZZO NAUDI, J. (Malta/Malte), 59 ROESTAM, K. S. (General Chairman of the Technical Discussions/Président général des discussions techniques), 227 SALA Vaimili II (Samoa), 11 70,156 SAMARANCH, J. A. (International Olympic Committee/Comité international olympique), 107 SAMAYOA, E. (Honduras), 116 SAMBA, E. (Onchocerciasis Control Programme/Programme de lutte contre l'onchocercose), 211 SANTILLO, H. (Brazü/Brésü), 140 SATA, M. С. (Zambia/Zambie), 6,125 SEGOND, G.-O. (Conseil d'etat of the Republic and Canton of Geneva/Conseil d'etat de la République et Canton de Genève), 3 SHALALA, D. E. (United States of America/ Etats-Unis d'amérique), 30 SHAMLAYE, C. (Seychelles), Rapporteur of Committee on Credentials/Rapporteur de la Commission de Vérification des Pouvoirs, 74,226 SHANKARANAND, B. (India/Inde), 36 SHEMER, Y. (Israël/Israël), 100 SIDIBE, M. (Mali), 218 SONKO, L. J. (Gambia/Gambie), 129 STAMPS, T. J. (Zimbabwe), STEFÁNSSON, G. A. (Iceland/Islande), 110 SUH, Sang-Мок (Republic of Korea/ République de Corée), 34 SUJUDI (Indonesia/Indonésie), 76 SUN Longchun (China/Chine), 44 SWAILAM, A. R. A. A. AL- (Saudi Arabia/ Arabie Saoudite), 84 TAFIDA, S. D. (Nigeria/Nigéria), 11,83 TAMRAT, A. (Ethiopia/Ethiopie), 213 TASEVSKA, B. (The Former Yugoslav Republic of Macedonia/ex-République yougoslave de Macédoine), 204 TEMANE, B. 1С (Botswana), President of the Forty-seventh World Health Assembly/ Président de la Quarante-Septième Assemblée mondiale de la Santé, 16, 243 THAN NYUNT (Myanmar), 80 THANI, H. S. AL- (Qatar), 179 TOFOSKI, J. (The Former Yugoslav Republic of Macedonia/ex-République yougoslave de Macédoine), 201 VEIL, S. (France), 38 VENERA, Z. (Czech Republic/République tchèque), 200,235 VIDOVICH MORALES, A. (Paraguay), 17 VIGNES, C.-H. (Legal Counsel/Conseiller juridique), 6, 7 VOUCÎÎ, B. (Slovenia/Slovénie), Vice-President of the Health Assembly/Vice-Président de l'assemblée mondiale de la Santé, 27 WAENA, N. (Solomon Island/lies Salomon), 156,159, 199 WALKER, С. V. (Barbados/Barbade) 184 WONG, A. К. (Singapore/Singapour), 56 YADAV, R. В. (Népal/Népal), 90 YANTAIS, D. (Greece/Grèce), YUSUF, С. К. I. (Bangladesh), 86 ZOCHOWSKI, R. J. (Poland/Pologne), 54