FORTY-EIGHTH WORLD HEALTH ASSEMBLY

WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTÉ

FORTY-EIGHTH WORLD HEALTH ASSEMBLY

GENEVA, 1-12 MAY 1995

VERBATIM RECORDS OF PLENARY MEETINGS

QUARANTE-HUITIÈME ASSEMBLÉE MONDIALE

DE LA SANTÉ GENÈVE, 1-12 MAI 1995

COMPTES RENDUS IN EXTENSO DES SÉANCES PLÉNIÈRES

GENEVA GENÈVE

1995

WHA48/1995/REC/2

_

PREFACE

The Forty-eighth World Health Assembly was held at the Palais des Nations, Geneva, from 1 to 12 May 1995, in accordance with the decision of the Executive Board at its ninety-fourth session. Its proceedings are published in three volumes, containing, in addition to other relevant material:

Resolutions and decisions, annexes and list of participants - document WHA48/1995/REC/l

Verbatim records of plenary meetings - document WHA48/1995/REC/2

Summary records and reports of committees - document WHA48/1995/REC/3

For a list of abbreviations used in these volumes, 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 WHA48/1995/REC/l.

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. The texts include corrections received up to July 1995, the cut-off date announced in the provisional version, and are thus regarded as final.

AVANT-PROPOS

La Quarante-Huitième Assemblée mondiale de la Santé s'est tenue au Palais des Nations à Genève du 1er au 12 mai 1995, conformément à la décision adoptée par le Conseil exécutif à sa quatre-vingt-quatorzième session. Ses actes sont publiés dans trois volumes contenant notamment :

les résolutions et décisions, les annexes qui s'y rapportent et la liste des participants -document WHA48/1995/REC/l,

les comptes rendus in extenso des séances plénières 一 document WHA48/1995/REC/2,

les procès-verbaux et les rapports des commissions - document WHA48/1995/REC/3.

On trouvera dans les pages préliminaires du document WHA48/1995/REC/l une liste des abréviations employées dans la documentation de l'OMS, l'ordre 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 1995，date limite annoncée dans leur version provisoire, et sont donc considérés comme finals.

ПРЕДИСЛОВИЕ

Сорок восьмая сессия Всемирной ассамблеи здравоохранения проходила во Дворце Наций в Женеве с 1 по 12 мая 1995 г. в соответствии с решением Исполнительного комитета, принятым на его Девяносто четвертой сессии. Материалы сессии публикуются в трех томах, которые, помимо прочих документов, содержат:

Резолюции и решения, а также приложения и список участников - документ

WHA48/1995/REC/1

Стенограммы пленарных заседаний - документ WHА48/1995/REC/2

Протоколы заседаний комитетов и доклады комитетов - WHA48/1995/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 WHA48/1995/REC/1.

В настоящих стенограммах выступлений 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 1995 г. - конечного срока, указанного в предварительном варианте, и, таким образом, они считаются окончательными.

INTRODUCCION

La 48a Asamblea Mundial de la Salud se celebró en el Palais des Nations, Ginebra, del 1 al 12 de mayo de 1995，de acuerdo con la decisión adoptada por el Consejo Ejecutivo en su 94a 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 WHA48/1995/REC/l

Actas taquigráficas de las sesiones plenarias: documento WHA48/1995/REC/2

Actas resumidas e informes de las comisiones: documento WHA48/1995/REC/3

En las páginas preliminares del documento WHA48/1995/REC/l figuran una lista de las siglas emplea-das en estos volúmenes, la composición de la Mesa de la Asamblea y de sus comisiones, el orden del día, y la lista de documentos de la reunión.

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 reprodu-ce la interpretación al francés o al inglés. Las actas contienen las correcciones recibidas hasta julio de 1995， fecha límite anunciada en la versión provisional, y por consiguiente se consideran definitivas.

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全体会议逐字记录一文件W H A 4 8 Z 1 9 9 5 / R E C / 2

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CONTENTS

Opening of the session Address by the representative of the Director-General of the United Nations Office

at Geneva


First plenary meeting

3. Address by the representative of the Conseil d'Etat of the Republic and Canton of Geneva . 4. Address by Professor V. Rajpho, Acting President 5. Appointment of the Committee on Credentials 6. Election of the Committee on Nominations 7. Point of order

Second plenary meeting

1. First report of the Committee on Nominations

2. Second report of the Committee on Nominations

Third plenary meeting

1. Presidential address

2. Adoption of the agenda and allocation of items to the main committees 3. Announcements 4. Review and approval of the reports of the Executive Board on its ninety-fourth and

ninety-fifth sessions 5. Review of The world health report 1995 Fourth plenary meeting

Debate on the reports of the Executive Board on its ninety-fourth and ninety-fifth sessions and review of The world health report 1995 (continued)

Fifth plenary meeting

1. First report of the Committee on Credentials 2. Debate on the reports of the Executive Board on its ninety-fourth and ninety-fifth sessions

and review of The world health report 1995 (continued)

2 3 5 6

6 7

8

9

11 14 14

15 18

23

53

53

Page

Prefflce iii

1 2

Page

Second report of the Committee on Credentials 216 Adoption of the agenda 216 Programme of work 216 First report of Committee A 217 First report of Committee В 217 Election of Members entitled to designate a person to serve on the Executive Board 218

Sixth plenary meeting

Debate on the reports of the Executive Board on its ninety-fourth and ninety-fifth sessions and review of The world health report 1995 (continued) 82

Seventh plenary meeting

1. Transfer of Mongolia to the Western Pacific Region 107 2. Debate on the reports of the Executive Board on its ninety-fourth and ninety-fifth sessions

and review of The world health report 1995 (continued) 108

Eighth plenary meeting

1. Debate on the reports of the Executive Board on its ninety-fourth and ninety-fifth sessions and review of The world health report 1995 (continued) 138

2. Address by Dr Humberto de la Calle Lombana, Vice-President of Colombia 156 3. Awards 159

Presentation of the Léon Bernard Foundation Prize 159 Presentation of the United Arab Emirates Health Foundation Prize 161 Presentation of the Dr A. T. Shousha Foundation Prize 163 Presentation of the Jacques Parisot Foundation Medal 165 Presentation of the Child Health Foundation Prize and Fellowship • 166 Presentation of the Sasakawa Health Prize 166 Presentation of the Dr Comían A. A. Quenum Prize for Public Health in Africa 170

Ninth plenary meeting


Tenth plenary meeting


Eleventh plenary meeting

12 3

4

5

6

- X -

Pages

Twelfth plenary meeting

1. Third report of the Committee on Credentials 219 2. Second report of Committee A 219 3. Second report of Committee В 220 4. Third report of Committee В 221 5. Third report of Committee A 222 6. Review and approval of the reports of the Executive Board on its ninety-fourth and

ninety-fifth sessions 222

7. Selection of the country in which the Forty-ninth World Health Assembly will be held . . . . 223

8. Statement by the Director-General 223

Thirteenth plenary meeting

Closure of the session 225

Indexes (Names of speakers; countries and organizations) 231

TABLE DES MATIERES

Pages

Avant-propos iii

COMPTES RENDUS IN EXTENSO DES SEANCES PLENIERES

Première séance plénière

1. Ouverture de la session 1 2. Allocution du représentant 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 Professeur V. Rajpho, Président par intérim 5 5. Constitution de la Commission de Vérification des Pouvoirs 6 6. Election de la Commission des Désignations 7 7. Motion d'ordre 7

Deuxième séance plénière

1. Premier rapport de la Commission des Désignations 8 2. Deuxième rapport de la Commission des Désignations 9

Troisième séance plénière

1. Discours du Président de l'Assemblée 11 2. Adoption de l'ordre du jour et répartition des points entre les commissions principales . . . 14 3. Communications 14 4. Examen et approbation des rapports du Conseil exécutif sur ses quatre-vingt-quatorzième

et quatre-vingt-quinzième sessions 15 5. Examen du Rapport sur la santé dans le monde, 1995 18

Quatrième séance plénière

Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-quatorzième et quatre-vingt-quinzième sessions et examen du Rapport sur la santé dans le monde, 1995 (suite) : 23

Cinquième séance plénière

1. Premier rapport de la Commission de Vérification des Pouvoirs 53 2. Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-quatorzième et quatre-

vingt-quinzième sessions et examen du Rapport sur la santé dans le monde, 1995 (suite) 53

Pages

Sixième séance plénière

Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-quatorzième et quatre-vingt-quinzième sessions et examen du Rapport sur la santé dans le monde, 1995 (suite) 82

Septième séance plénière

1. Rattachement de la Mongolie à la Région du Pacifique occidental 107 2. Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-quatorzième et quatre-

vingt-quinzième sessions et examen du Rapport sur la santé dans le monde, 1995 (suite) 108

Huitième séance plénière

1. Débat sur les rapports du Conseil exécutif sur ses quatre-vingt-quatorzième et quatre-vingt-quinzième sessions et examen du Rapport sur la santé dans le monde, 1995 (suite) 138

2. Allocution du Dr Humberto de la Calle Lombana, Vice-Président de la Colombie 156 3. Distinctions 159

Remise du Prix de la Fondation Léon Bernard 159 Remise du Prix de la Fondation des Emirats arabes unis pour la Santé 161 Remise du Prix de la Fondation Dr A. T. Shousha 163 Remise de la médaille de la Fondation Jacques Parisot 165 Remise du Prix et de la bourse de la Fondation pour la Santé de l'Enfant 166 Remise du Prix Sasakawa pour la Santé 166 Remise du Prix Dr Comían A. A. Quenum pour la Santé publique en Afrique 170

Neuvième séance plénière


Dixième séance plénière


Onzième séance plénière

1. Deuxième rapport de la Commission de Vérification des Pouvoirs 216 2. Adoption de l'ordre du jour 216 3. Programme de travail 216 4. Premier rapport de la Commission A 217 5. Premier rapport de la Commission В 217 6. Election de membres habilités à désigner une personne devant faire partie du Conseil

exécutif 218

-x iv-

Pages

Douzième séance plénière

1. Troisième rapport de la Commission de Vérification des Pouvoirs 219 2. Deuxième rapport de la Commission A 219 3. Deuxième rapport de la Commission В 220 4. Troisième rapport de la Commission В 221 5. Troisième rapport de la Commission A 222 6. Examen et approbation des rapports du Conseil exécutif sur ses quatre-vingt-quatorzième

et quatre-vingt-quinzième sessions 222 7. Choix du pays où se tiendra la Quarante-Neuvième Assemblée mondiale de la Santé . . . . 223 8. Déclaration du Directeur général 223

Treizième séance plénière

Clôture de la session 225

Index des noms des orateurs 231 Index des pays et organisations 237

A48/VR/1 page 1


COMPTES RENDUS IN EXTENSO DES SEANCES PLENIERES

FIRST PLENARY MEETING

Monday, 1 May 1995，at 9:25

Acting President: Professor V. RAJPHO (Lao People's Democratic Republic)

PREMIERE SEANCE PLENIERE

Lundi 1er mai 1995, 9h25

Président par intérim: Professeur V. RAJPHO (République démocratique populaire lao)

1. OPENING OF THE SESSION OUVERTURE DE LA SESSION

Le PRESIDENT par intérim :

La séance est ouverte.

Excellences, distingués délégués, Mesdames et Messieurs, le Président de la Quarante-Septième Assemblée mondiale de la Santé, M. Temane, se trouve malheureusement dans l'impossibilité d'être présent aujourd'hui, et c'est par conséquent un honneur et un privilège pour moi, en ma qualité de Vice-Président, de présider cette séance d'ouverture jusqu'à l'élection du président de la Quarante-Huitième Assemblée mondiale de la Santé.

J'ai maintenant le plaisir, au nom de l'Assemblée et de l'Organisation mondiale de la Santé, de souhaiter la bienvenue aux personnalités suivantes : M. Bernard de Riedmatten, Représentant permanent de la Suisse auprès des organisations internationales à Genève; M. Guy-Olivier Segond, Conseiller d'Etat, Chef du Département de Prévoyance sociale et de Santé publique de la République et Canton de Genève, représentant les autorités genevoises; M. Yves Berthelot, Secrétaire exécutif de la Commission économique pour l'Europe à Genève, représentant le Directeur général de l'Office des Nations Unies à Genève et le Secrétaire général de l'Organisation des Nations Unies; M. Carlos Fortin, Secrétaire général de la Conférence des Nations Unies sur le Commerce et le Développement; les représentants des institutions spécialisées ainsi que les représentants des divers organismes des Nations Unies; les délégués des Etats Membres 一 et je salue ici tout particulièrement les Palaos qui sont devenus Membre de l'Organisation mondiale de la Santé, le 9 mars 1995，du fait de leur adhésion à l'Organisation des Nations Unies et de leur acceptation de la Constitution de l'OMS, ainsi qu'il est prévu à l'article 4 de la Constitution. Je salue également les observateurs des Etats non Membres, l'Observateur de la Palestine et le Secrétaire du Comité international de la Croix Rouge, les représentants des organisations intergouvernementales et non gouvernementales en relations officielles avec l'OMS. Je salue enfin les représentants du Conseil exécutif qui se trouvent parmi nous.

A48/VR/2 page 2

2. ADDRESS BY THE REPRESENTATIVE OF THE DIRECTOR-GENERAL OF THE UNITED NATIONS OFFICE AT GENEVA ALLOCUTION DU REPRESENTANT DU DIRECTEUR GENERAL DE L'OFFICE DES NATIONS UNIES A GENEVE


Je donne maintenant la parole à M. Berthelot, représentant le Directeur général de l'Office des Nations Unies à Genève et le Secrétaire général de l'Organisation des Nations Unies.

M. BERTHELOT (représentant du Directeur général de l'Office des Nations Unies à Genève):

Monsieur le Président, Monsieur le Directeur général de l'Organisation mondiale de la Santé, Excellences, Mesdames et Messieurs, c'est un grand plaisir et un honneur pour moi de prendre la parole devant cette Quarante-Huitième Assemblée mondiale de la Santé et de vous transmettre les voeux du Secrétaire général de l'Organisation des Nations Unies, M. Boutros Boutros-Ghali, pour le succès de vos travaux. Traditionnellement, le Directeur général de l'Office des Nations Unies à Genève, M. Petrovsky, a cet honneur mais, étant absent de Genève, il m'a demandé de le remplacer.

Cette année est une étape riche en événements historiques dans la vie de l'ONU et des organisations du système des Nations Unies. Elle est marquée, vous le savez tous, par la commémoration du cinquantième anniversaire, qui offre une occasion unique de stimuler la réflexion et l'action afin de donner une nouvelle vigueur aux principes de la Charte et de renforcer l'esprit de solidarité et de cohésion entre les peuples, indispensable au retour et au maintien de la paix dans le monde. Il y a cinquante ans, la Charte des Nations Unies fondait la coopération internationale sur les objectifs de la sécurité collective, du respect des droits de l'homme, du développement économique et social et de la création du droit international. Pendant un demi-siècle, l'ONU a oeuvré à leur réalisation par une action persévérante et concertée. Les succès ont été inégaux, chacun le sait, mais ces objectifs demeurent de grands objectifs pour l'humanité, et l'ONU poursuivra sa tâche.

Dans un monde marqué par une multiplication des conflits locaux et la persistance des inégalités, la fin de la guerre froide a amené des espoirs et des possibilités, et notamment celles qu'apporte un dialogue plus ouvert. Il faut saisir ces occasions et éviter des déceptions qui seraient dramatiques pour la paix. Aussi, le cinquantième anniversaire offre-t-il à l'Organisation l'occasion de réfléchir sur ses missions et la façon de les conduire. Les expériences douloureuses vécues par les membres de la communauté internationale en Somalie, au Rwanda, dans plusieurs des pays issus de Г ex-Yougoslavie doivent être présentes dans cette réflexion.

En cette période de bouleversements importants, et souvent tragiques, l'ONU a besoin de l'engagement constructif de toutes les institutions de la famille des Nations Unies et de chacun de ses Etats Membres. Dans son "Agenda pour la paix"，puis dans son "Agenda pour le développement", le Secrétaire général offre un cadre solide et cohérent pour organiser et mettre en oeuvre cet engagement. Pour sa part, l'OMS est l'institution qui a la responsabilité de l'objectif de la santé pour tous, et elle contribue largement aux efforts humanitaires. La Constitution de l'OMS stipule en effet qu'elle doit agir en tant qu'autorité directrice et coordonnatrice, dans le domaine de la santé, des travaux ayant un caractère international et fournir ou aider à fournir, à la requête des Nations Unies, des services sanitaires et des secours à des groupements de population particuliers. Dans ce cadre, l'aide d'urgence de l'OMS s'adresse aux malades, aux blessés et aux personnes souffrant de malnutrition, qu'il s'agisse de civils, de militaires, de réfugiés. Pour répondre aux besoins de secours d'urgence, l'OMS a lancé près de vingt appels à la coopération entre organismes au cours de l'année 1994. Elle a participé aux activités internationales de reconstruction et de développement du Cambodge et des pays d'Europe centrale et orientale. Au total, l'OMS a organisé des programmes de secours et des activités humanitaires dans vingt-neuf pays différents, touchant plus de trente millions de personnes.

Conformément aux orientations qu'il a arrêtées avec les chefs des grandes agences du système des Nations Unies, le Secrétaire général se réjouit de ce que l'OMS ait l'intention de faire porter ses efforts essentiellement dans les secteurs dans lesquels elle possède des compétences et une expertise remarquables et de collaborer avec d'autres organisations du système des Nations Unies travaillant dans des domaines connexes; cela évitera les doubles emplois et garantira aux opérations entreprises une efficacité maximum. En outre, le développement de la collaboration de l'OMS avec les organisations non gouvernementales en ce qui concerne l'aide médicale d'urgence semble au Secrétaire général particulièrement important car ces

A48/VR/2 page 3

organisations non gouvernementales, de plus en plus présentes dans le domaine des soins de santé d'urgence, ont prouvé leur capacité à mettre en oeuvre des projets sur le terrain.

L'intensification de la coopération entre les organisations de la famille des Nations Unies sera examinée cette année au mois de juillet par le Conseil économique et social sous le thème du "suivi coordonné de la mise en oeuvre par le système des Nations Unies des résultats des grandes conférences internationales organisées par l'ONU dans les domaines économique et social et dans d'autres domaines apparentés". C'est là le titre du point de l'ordre du jour du Conseil économique et social.

La Conférence du Caire sur la population et le développement, puis le Sommet mondial pour le développement social qui s'est tenu récemment à Copenhague, ont été l'occasion pour l'OMS de revoir ses activités dans une perspective plus générale, où fut soulignée l'interaction complexe des dynamiques à l'oeuvre dans les secteurs de la santé, du développement et de la population. Le temps est venu pour nous de reconnaître que le développement et les actions y contribuant ne se réduisent pas à une simple question de solutions techniques et de calculs financiers, de reconnaître que le développement de la santé, comme le développement économique et social, ne se réduit pas à de simples actions sectorielles et techniques.

L'approche en termes de développement durable permet de souligner qu'il est important de valoriser les ressources humaines dans la durée et donc de saisir toute la signification de la place occupée par la santé dans le développement : l'être humain est ainsi placé au centre même de cette approche, et son droit de vivre dans des conditions optimales de santé, de productivité, d'harmonie avec la nature serait de ce fait pleinement reconnu.

Le Secrétaire général se réjouit dans ce contexte des efforts faits en vue d'appliquer les recommandations relatives à la mise à jour de la stratégie de la santé pour tous, qui ont pour objectif de réduire l'écart existant encore entre les solutions préconisées et leur mise en application effective. L'attention prioritaire accordée dans le projet de budget programme pour 1996-1997 aux soins de santé primaires, à la santé des femmes, ainsi qu'à la promotion de l'hygiène du milieu, est à cet égard particulièrement opportune; plus spécifiquement, elle représente une contribution importante au suivi du Sommet mondial pour le développement social. Celui-ci conduira aussi sans aucun doute à la formulation de plans concrets au niveau national afin de mettre en oeuvre les engagements pris.

Sous la réalité encourageante d'un progrès indubitable dans le domaine de la santé, des disparités inacceptables demeurent. Le fossé se creuse entre riches et pauvres, entre groupes de population, entre classes d'âge et entre les sexes. C'est pourquoi, il convient de mettre l'accent sur l'amélioration de la santé des groupes les plus défavorisés et les plus vulnérables et de le faire en ayant à l'esprit une conception élargie de ce qu'est la notion de groupe vulnérable, de ce qu'est la notion de pauvreté, qui ne sauraient en aucun cas être réduites à leur stricte dimension économique.

Une réflexion sur ces points doit remuer les consciences. L'un des défis pour l'avenir consiste à mobiliser la communauté internationale afin qu'elle adopte des politiques et des programmes qui soutiendront l'effort que chacun des pays poursuivra dans ce but.

En conclusion, Monsieur le Directeur général, Monsieur le Président, Mesdames et Messieurs, permettez-moi de vous présenter, en mon nom propre, mais surtout au nom du Directeur général, M. Petrovsky, et au nom du Secrétaire général de l'Organisation des Nations Unies, M. Boutros Boutros-Ghali, mes meilleurs voeux pour une session fructueuse.


Je remercie M. Berthelot.

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


M. Guy-Olivier Segond va maintenant s'adresser à l'Assemblée au nom des autorités fédérales, cantonales et municipales suisses.

A48/VR/2 page 4

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 l'ouverture de la Quarante-Huitième Assemblée mondiale de la Santé, j'ai le plaisir et l'honneur de vous souhaiter, au nom des autorités fédérales, représentées par S. E. M. l'Ambassadeur Bernard de Riedmatten, et des autorités cantonales, la bienvenue dans notre ville et en Suisse.

"Tous les être humains ont un droit égal à la santé". Ce principe politique est un principe fondamental, qui s'exprime sous trois aspects : l'égalité entre hommes et femmes, l'égalité entre les divers groupes sociaux et les différentes classes d'âge, et l'égalité entre les différentes régions d'un Etat, d'un continent et du monde.

Dans le monde occidental, la prospérité a permis le développement de services de santé performants. Un bon système de sécurité sociale a garanti une égalité d'accès aux soins; pourtant, malgré des investissements publics importants, des inégalités face à la santé persistent, en particulier dans certains groupes de population comme les familles monoparentales, les personnes âgées ou les jeunes au chômage. En outre, de nouvelles maladies, dites "de civilisation", ont pris de l'ampleur telles que le SIDA, le tabagisme, les toxicodépendances, les cancers, les maladies cardio-vasculaires, les suicides et les dépressions, trop souvent liées au stress et aux conditions de vie et de travail. Cette situation démontre qu'une société ne doit pas seulement s'occuper de la santé de ses membres en leur fournissant des services de soins efficaces : comme le programme de l'OMS "Santé pour tous" le met en évidence, l'environnement social est en effet un déterminant de la santé aussi fondamental que l'environnement physique ou le bagage génétique.

Dans le monde occidental, où en sommes-nous ？ Habitué à une expansion facile, entraîné par des progrès technologiques spectaculaires et légitimé par la demande de patients toujours plus exigeants, le système de soins a évité les choix et même les questions : l'Etat lui a toujours donné les moyens nécessaires.

Aujourd'hui, les difficultés économiques et budgétaires rendent plus délicat le partage des moyens publics. La compétition entre les grandes fonctions de l'Etat se fait donc plus vive. Le système de soins, longtemps privilégié, se trouve dans une situation qui est nouvelle pour lui : à la logique des besoins, soutenue par les soignants et les soignés, répond dorénavant la logique des moyens, défendue par les contribuables et les assurances-maladie, qui n'arrivent plus à assumer les coûts qui croissent plus rapidement que la capacité collective de les financer.

Pour éviter une société à deux vitesses dans laquelle l'égalité d'accès à la santé deviendrait un slogan, il ne suffit donc pas de rationaliser le système de soins. Il faut développer une approche nouvelle : d'abord, l'accent doit être mis sur la promotion de la santé et la prévention des maladies et des accidents en orientant l'effort vers les catégories de population les plus vulnérables; ensuite, les services de soins doivent évoluer vers une médecine plus communautaire : le développement des soins à domicile, de la médecine ambulatoire et de la médecine de famille est indispensable; enfin, ramélioration de l'environnement social (c'est-à-dire l'emploi, le logement, les relations sociales) doit aller de pair avec l'amélioration de l'environnement physique (la protection de l'eau et de l'air, ou la lutte contre le bruit).

En outre, pour réduire les écarts entre les différentes catégories de populations, il faut passer par un mode de financement plus solidaire du système de santé, fondé sur une assurance-maladie obligatoire, assurant l'égalité entre hommes et femmes, entre jeunes et anciens, entre riches et pauvres et entre malades et bien-portants. De manière plus générale, l'évidence est là : le bon état de santé d'une population dépend de mesures qui ne sont pas toujours d'ordre médical. Protéger l'environnement, bien aménager le territoire, lutter contre le chômage, assurer une bonne formation sont autant de mesures qui peuvent avoir davantage d'effets sur la santé d'une population que des investissements technologiques lourds dans les systèmes hospitaliers.

Tout cela est très intéressant, direz-vous, mais cela ne concerne que le monde occidental. C'est vrai. A l'échelle mondiale, le problème de santé le plus immédiat tient à l'importance des maladies et des décès prématurés provoqués par des pollutions de l'eau, de l'air, des sols et des aliments.

Les problèmes sont particulièrement graves dans cette partie du monde où, chaque année, cinq millions d'enfants meurent de diarrhées causées par les pollutions de l'eau et des aliments, où 267 millions de personnes sont infectées par le paludisme, et où des centaines de millions de personnes souffrent de parasitoses intestinales handicapantes. Ce sont là des fléaux ordinaires qui n'intéressent guère les médias. Toutefois, les chiffres, que vous connaissez bien, sont hallucinants. L'Afrique - où trois personnes sur cinq n'ont pas accès à la médecine - paie un tribut particulièrement lourd : chaque année, le paludisme y tue plus de 750 000 enfants ！ Bien sûr, périodiquement, des progrès décisifs dans la mise au point de vaccins contre

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les maladies tropicales sont annoncés. D'ailleurs, ces prochains jours, nous assisterons à la remise du vaccin contre le paludisme développé par le Dr Manuel Elkin Patarroyo, de Colombie. Toutefois, sur le terrain, ces vaccins n'aboutissent pas encore.

Pourquoi ？ Parce que la recherche, si active dans le domaine de la reproduction et de l'hérédité, se heurte à des

obstacles majeurs ？ Non, je ne le crois pas. La recherche n'aboutit pas parce que les vaccins 一 malgré le volume impressionnant de la demande mondiale 一 n'ont qu'un attrait mineur pour l'industrie : les gains sont faibles. Les contrôles sont astreignants. Le marché se limite aux pays pauvres.

Dans ce contexte, le rôle de l'OMS est clair : il faut trouver des financements à l'échelle internationale permettant d'encourager la recherche jusqu'au passage à la production. Pour développer les dix vaccins essentiels, il faut un milliard de dollars en dix ans. Les pays riches doivent relever ce défi. Ils le peuvent : car, après tout, c'est le produit d'une taxe de 0,01 % sur un jour de transactions financières internationales qui s'élèvent, en 24 heures, à dix mille milliards de dollars ！

Je remercie donc l'OMS des efforts qu'elle déploie pour convaincre les gouvernements, et je vous souhaite d'excellents travaux consacrés à la seule cause qui importe : les progrès de la santé à travers le monde.


Je remercie M. Segond.

4. ADDRESS BY PROFESSOR V. RAJPHO, ACTING PRESIDENT ALLOCUTION DU PROFESSEUR V. RAJPHO，PRESIDENT PAR INTERIM


Monsieur le Directeur général, Excellences, Mesdames et Messieurs les délégués, Mesdames et Messieurs, c'est un honneur pour moi de présider cette séance d'ouverture de la Quarante-Huitième Assemblée mondiale de la Santé en tant que l'un des Vice-Présidents de la Quarante-Septième Assemblée mondiale de la Santé et en vertu de l'ordre de suppléance fixé. Ainsi que vous le savez sûrement, M. Temane, du Botswana, s'est vu confier de nouvelles responsabilités par son Gouvernement à la fin de l'année dernière et a donc été contraint de renoncer à la présidence de la Quarante-Huitième Assemblée mondiale de la Santé.

Mesdames et Messieurs les délégués, Mesdames et Messieurs, deux événements importants ont marqué les délibérations de la Quarante-Septième Assemblée mondiale de la Santé. Tout d'abord, la décision prise par l'Assemblée de restituer à l'Afrique du Sud la totalité de ses droits et privilèges en tant qu'Etat Membre de l'OMS, puis l'adoption par consensus, comme jamais auparavant, d'une résolution sur la situation sanitaire des populations arabes dans les territoires arabes occupés, y compris la Palestine. Ces événements reflètent la maturité dont a fait preuve notre Organisation pour ces questions.

Alors que l'OMS célébrera bientôt ses cinquante années d'existence, je crois opportun d'aborder maintenant le sujet des réformes qu'a lancées notre Conseil exécutif en 1992. Les pays Membres attendent beaucoup de l'adaptation de l'OMS aux changements mondiaux. Je me félicite particulièrement des progrès réguliers accomplis dans la mise en oeuvre du processus de réforme. Je suis certain que les résultats de ces réformes contribueront à renforcer l'efficacité de notre Organisation. Aussi ai-je pris connaissance avec une grande satisfaction des propositions sur une nouvelle stratégie de la santé pour tous. La nouvelle politique d'équité, de solidarité et de santé se situe dans une perspective très ambitieuse et nous devrons nous armer de courage face aux difficultés que nous aurons à surmonter. Pourtant, l'espoir d'instaurer la santé pour tous est tel que l'élaboration de cette nouvelle politique est devenue un impératif moral. La réussite de la mise en oeuvre de cette nouvelle politique dépendra naturellement de la mesure dans laquelle nous, les Etats Membres, avec les autres partenaires dans le domaine de la santé, reconnaîtrons l'urgence qu'il y a à relever le formidable défi de la santé et de l'équité pour tous. Ces deux semaines que va durer l'Assemblée nous donneront l'occasion de débattre les questions non encore résolues du processus de réforme et de faire le point des progrès réalisés à ce jour dans sa mise en oeuvre. Nous pouvons en effet espérer que nous serons ainsi convenablement préparés à satisfaire aux exigences d'un environnement sanitaire en pleine évolution. N'oublions pas que les réformes que nous entreprenons aujourd'hui façonneront notre Organisation pour de nombreuses années.

Nous devons donc faire tout notre possible pour que les réformes que nous engageons suscitent non pas des critiques mais des louanges. Deux facteurs au moins pourront nous aider en cela.

A48/VR/2 page 6

Premièrement, il nous faut réaffirmer notre conception de notre Organisation. Ainsi qu'il est défini dans sa Constitution, le mandat fondamental de l'OMS est d'amener tous les peuples au niveau de santé le plus élevé possible. Notre Directeur général a défini sa vision de la santé comme une dynamique continue et complète de développement, à laquelle participent les pays ainsi que toutes les personnes et les communautés. Ce mandat et cette vision donnent à notre Organisation sa raison d'être et son orientation. Les réformes doivent servir cette vision. Elles doivent aussi s'assortir d'une souplesse suffisante pour demeurer valables et applicables à l'avenir. Elles doivent nous permettre de faire face aux défis constants et changeants.

Le deuxième facteur est le leadership. Nous devons faire en sorte que notre Organisation conserve son leadership dans le domaine de la santé, qu'il s'agisse des politiques ou des questions techniques. Ce leadership doit être ravivé car il est le fondement même du rôle premier de l'OMS, à savoir garantir un état de bien-être à tous les êtres humains. Ce leadership suppose que, dans le domaine de la santé, et par la coopération internationale, l'OMS protège et encourage la justice sociale, l'équité, la solidarité et la dignité humaine. La pratique du leadership nous impose de rester humains. Il importe que les responsables en matière de santé soient au fait des besoins de l'être humain, de ses aspirations et de ses espoirs. Le leadership doit conférer un sens et une valeur à l'ensemble du processus de changement. Les dirigeants doivent montrer le chemin des progrès et du développement humains. Les dirigeants doivent se souvenir que les ressources humaines constituent la base principale de leur soutien. Les dirigeants ont besoin de personnes avec qui travailler et pour qui travailler. Les uns et les autres doivent reconnaître ce besoin réciproque; ils doivent se respecter. Le Conseil exécutif a souligné au mois de janvier qu'il importait de mobiliser un leadership au niveau local et dans les pays pour faciliter le processus de consultation et encourager un nouveau partenariat pour le développement sanitaire. Nous devons accélérer cet effort si nous voulons véritablement contribuer à l'édification d'un système fiable sous la direction de responsables éclairés qui agissent dans l'intérêt de chacun, mais surtout des plus démunis.

Mesdames et Messieurs les délégués, chers amis, j'ai insisté sur ces deux points pour démontrer que la réussite de l'action de l'OMS dépend à la fois de notre vision commune de son activité future et de notre engagement personnel. Chacun d'entre nous doit se consacrer à la réalisation de la santé pour tous. Alors que nous nous réunissons pour examiner l'ordre du jour de la Quarante-Huitième Assemblée mondiale de la Santé, je vous demande d'aider à construire la vision requise pour faire en sorte que notre Organisation soit pleinement reconnue pour sa compétence et la qualité de ses services en faveur d'un monde meilleur et en bonne santé.

Mesdames et Messieurs, avant que se retirent les personnalités qui nous ont fait l'honneur d'assister à la séance d'ouverture, permettez-moi de les remercier de leur présence. Je vais maintenant suspendre la séance pour quelques instants. Veuillez ne pas quitter vos places car nous poursuivrons nos travaux dans un moment. Je vous remercie.

5. APPOINTMENT OF THE COMMITTEE ON CREDENTIALS CONSTITUTION DE LA COMMISSION DE VERIFICATION DES POUVOIRS


Nous passons maintenant à l'examen du point 2 de l'ordre du jour provisoire : "Constitution de la Commission de Vérification des Pouvoirs". L'Assemblée de la Santé doit constituer une Commission de Vérification des Pouvoirs aux termes de l'article 23 de son Règlement intérieur. Conformément à cet article, je soumets à votre approbation la liste suivante des douze Etats Membres qui sont : Bahreïn, Belize, Bulgarie, Comores, Erythrée, Finlande, Malte, Mauritanie, Pakistan, Pérou, Sri Lanka et Tuvalu.

Y a-t-il des objections ？ En l'absence d'objections, je déclare constituée par l'Assemblée la Commission de Vérification des Pouvoirs telle que je vous l'ai proposée. Sous réserve de la décision du Bureau de l'Assemblée, et conformément à la résolution WHA20.2, la Commission tiendra sa première réunion le mardi 2 mai dans l'après-midi.

6. ELECTION OF THE COMMITTEE ON NOMINATIONS ELECTION DE LA COMMISSION DES DESIGNATIONS


Nous allons maintenant passer au point 3 : Election de la Commission des Désignations. Cette question relève de l'article 24 du Règlement intérieur de l'Assemblée de la Santé. Conformément à cet article, il a été

A48/VR/2 page 7

établi une liste de 25 Etats Membres que je soumets à l'examen de l'Assemblée. Je précise que, pour

l'établissement de cette liste, on a appliqué la répartition régionale suivante : Afrique, 6 Membres;

Amériques, 5; Asie du Sud-Est, 2; Europe, 5; Méditerranée orientale, 4; et Pacifique occidental, 3. Voici donc la liste des Etats Membres proposés : Afrique du Sud, Bhoutan, Canada, Chili, Chine,

Chypre, Djibouti, Equateur, Fédération de Russie, France, Ghana, Guinée, Iles Cook, Jamaïque, Liban, Namibie, Nicaragua, Nouvelle-Zélande, Qatar, République populaire démocratique de Corée, Royaume-Uni de Grande-Bretagne et d'Irlande du Nord, Sao Tomé-et-Principe, Slovaquie, Tchad, Turquie. Y a-t-il des objections ？ En l'absence d'objections, je déclare élue la Commission des Désignations.

Comme vous le savez, l'article 25 du Règlement intérieur, qui définit le mandat de cette Commission,

dispose en outre que "les propositions de la Commission des Désignations sont immédiatement communiquées

à l'Assemblée de la Santé".

La Commission des Désignations se réunira à 13 h 15 dans la salle VII. Des rafraîchissements seront

servis immédiatement dans la salle VI (Salon des délégués) aux membres de la Commission des Désignations.

La prochaine séance plénière aura lieu cet après-midi à 16 h 30.

7. POINT OF ORDER MOTION D'ORDRE


Le délégué du Zimbabwe demande la parole pour une motion d'ordre.

Dr STAMPS (Zimbabwe):

This is on a point of order. We are not objecting to the composition of either of these committees but I，representing all African delegations, wish to express our grave concern about the offensive remarks allegedly applied to Africans by the Director-General earlier this year, and we require the Director-General to meet all the delegations together as soon as possible to explain his position and that of his Secretariat. In addition he shall explain the discriminatory composition of the members of his senior staff in that, in 1980， four of 24 director posts were occupied by Africans whereas today, in 1995，only one of 46 such posts is occupied by an African who was appointed before the current Director-General was appointed. I thank you.


Je demande au Dr Piel de répondre à cette question.

Dr PIEL (Cabinet of the Director-General):

Thank you very much, Mr President. I think the Director-General has misunderstood on this subject. However, he feels very deeply about it; it is intended session the geographical balance of the staff in WHO and I understand that the comment on this at that time. Thank you very much, Mr President.

been misquoted and

to discuss later in this

Director-General will

The meeting rose at 12:50. La séance est levée à 12h50.

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SECOND PLENARY MEETING

Monday, 1 May 1995，at 16:30

Acting President: Professor V. RAJPHO (Lao People's Democratic Republic) later: President: Dato Dr Haji Johar NOORDIN (Brunei Darussalam)

DEUXIEME SEANCE PLENIERE

Lundi 1er mai 1995，16h30

Président par intérim: Professeur V. RAJPHO (République démocratique populaire lao) puis Président: Dato Dr Haji Johar NOORDIN (Brunéi Darussalam)

[. FIRST REPORT OF THE COMMITTEE ON NOMINATIONS1

PREMIER RAPPORT DE LA COMMISSION DES DESIGNATIONS1


La séance est ouverte. Le premier point de l'ordre du jour de cet après-midi concerne l'examen du premier rapport de la Commission des Désignations. Ce rapport fait l'objet du document A48/40. J'invite le Président de la Commission des Désignations, le Dr Phillips (Jamaïque), à en donner lecture à la tribune.

Dr PHILLIPS (Chairman of the Committee on Nominations):

The Committee on Nominations, consisting of delegates of the following Member States: Bhutan, Canada, Chad, Chile, China, Cook Islands, Cyprus, Democratic People's Republic of Korea, Djibouti, Ecuador, France, Ghana, Guinea, Jamaica, Lebanon, Namibia, New Zealand, Nicaragua, Qatar, Russian Federation, Sao Tome and Principe, Slovakia, South Africa, Turkey and the United Kingdom of Great Britain and Northern Ireland met on 1 May 1995. Dr P. Phillips (Jamaica) was elected Chairman.

In accordance with Rule 25 of the Rules of Procedure of the Health Assembly and respecting the practice of regional rotation that the Assembly has followed for many years in this regard, the Committee decided to propose to the Assembly the nomination of Dato Dr Haji Johar Noordin (Brunei Darussalam) for the Office of President of the Forty-eighth World Health Assembly.

Election of the President Election du président de l'Assemblée


Merci, Docteur Phillips. Y a-t-il des observations ？ S'il n'y en a pas, et en l'absence d'autres propositions, il n'est pas nécessaire de procéder à un vote puisqu'un seul candidat a été présenté. Conformément à l'article 80 du Règlement intérieur, je propose que l'Assemblée approuve la candidature présentée par la Commission et élise son Président par acclamation.

(Applause/Applaudissements)

Dato Dr Haji Johar Noordin, Ministre de la Santé du Brunéi Darussalam, est élu Président de la Quarante-Huitième Assemblée mondiale de la Santé et je l'invite à venir occuper son siège à la tribune.

1 See reports of committees in document WHA48/1995/REC/3. 1 Voir les rapports des commissions dans le document WHА48/1995/REC/3.

A48/VR/2

page 9

Dato Dr Haji Johar Noordin (Brunei Darussalam) took the presidential chair. Dato Dr Haji Johar Noordin (Brunéi Darussalam) prend place au fauteuil présidentiel.

2. SECOND REPORT OF THE COMMITTEE ON NOMINATIONS1

DEUXIEME RAPPORT DE LA COMMISSION DES DESIGNATIONS1

The PRESIDENT:

Your excellencies, honourable ministers, ambassadors, delegates, Mr Director-General, I would like to thank this august Assembly for the trust it has shown in electing me as the President of the Forty-eighth World Health Assembly. Taking this opportunity, I would like to express my appreciation to Mr Temane, my predecessor, for his contribution to the last World Health Assembly, and to Professor Rajpho for having so ably opened this session. I shall deliver the customary address tomorrow and we will now continue with our work.

I now invite the Assembly to consider the second report of the Committee on Nominations. This report is contained in document A48/41. May I ask the Chairman of the Committee on Nominations, Dr Phillips, to read out the second report of the Committee?

Dr PHILLIPS (Chairman of the Committee on Nominations):

At its first meeting held on 1 May 1995，the Committee on Nominations decided to propose to the Assembly, in accordance with Rule 25 of the Rules of Procedure of the Assembly, the following nominations:

Vice-Presidents of the Assembly: Mr C. Dabiré (Burkina Faso), Dr J.R. de la Fuente Ramírez (Mexico), Dr A. Marandi (Islamic Republic of Iran), Mrs I. Drobyshevskaya (Belarus), Mr Than Nyunt (Myanmar).

Committee A: Chairman - Dr Fatma H. Mrisho, United Republic of Tanzania. Committee B: Chairman - Professor A. Wojtczak, Poland. Concerning the members of the General Committee to be elected under Rule 31 of the Rules of

Procedure of the Assembly, the Committee decided to nominate the delegates of the following 17 countries: Bolivia, Botswana, China, Cuba, France, Indonesia, Japan, Kenya, Malawi, Morocco, Mozambique, Oman, Panama, Russian Federation, United Arab Emirates, United Kingdom of Great Britain and Northern Ireland and the United States of America.

The PRESIDENT:

I invite the Assembly to pronounce, in order, on the nominations proposed for its decision.

Election of the five Vice-Presidents Election des cinq vice-présidents de l'Assemblée

The PRESIDENT:

We shall begin with the election of the five Vice-Presidents of the Assembly. Are there any comments? There being no comments, I 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 be unable to act in between sessions.


A48/VR/2 page 10

The results are as follows and the Vice-Presidents will be requested to act in the following order: Mrs I. Drobyshevskaya of Belarus; Dr A. Marandi of the Islamic Republic of Iran; Mr C. Dabiré of Burkina Faso; Dr J.R. de la Fuente Ramírez of Mexico and Mr Than Nyunt of Myanmar.

I request the Vice-Presidents kindly to come to the rostrum and take their places there.

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. no comments, I invite the Assembly to declare Dr Fatma H. Mrisho Chairman of Committee A by acclamation.


The PRESIDENT:

We have now to elect the Chairman of Committee B. Are there objections, I invite the Assembly to declare Professor A. Wojtczak Committee В by acclamation.


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 like to remind you that the General Committee of the Assembly will be meeting at 17:10 today 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: Bolivia, Botswana, China, Cuba, France, Indonesia, Japan, Kenya, Malawi, Morocco, Mozambique, Oman, Panama, Russian Federation, United Arab Emirates, United Kingdom of Great Britain and Northern Ireland, United States of America.

The next plenary meeting will be held tomorrow at 9:00. The meeting is adjourned.

Are there any comments? There being (United Republic of Tanzania) elected

any comments? There being no (Poland) elected Chairman of


A48/VR/2 page 11

THIRD PLENARY MEETING

Tuesday, 2 May 1995，at 9:25

President: Dato Dr Haji Johar NOORDIN (Brunei Darussalam)

TROISIEME SEANCE PLENIERE

Mardi 2 mai 1995，9h25

Président: Dato Dr Haji Johar NOORDIN (Brunéi Darussalam)

1. PRESIDENTIAL ADDRESS DISCOURS DU PRESIDENT DE L'ASSEMBLEE

The PRESIDENT:

Your excellencies, honourable ministers, ambassadors, distinguished delegates, Director-General, colleagues and friends, as I assume the presidency of the Forty-eighth World Health Assembly I wish first of all to thank you most warmly for your confidence in me and for the tribute you have paid to my country, Brunei Darussalam, and to the Western Pacific Region of the World Health Organization. I assure you that with your support, cooperation and inspiration I shall discharge my responsibilities to the best of my ability. I shall strive to conduct the deliberations of the Forty-eighth World Health Assembly in a spirit of harmony, tolerance and openness and do all I can to bring them to fruitful completion.

The world has witnessed in recent years profound political, economic and social change. New independent States, big and small, have come into being and joined the common endeavour to attain world peace and progress in the face of much turmoil and great difficulties. Everywhere there are rising expectations of a better world. Yet development has faltered, impeded by wars and strife, by natural and man-made disasters and even, it seems, by a reluctance on the part of many of those who are well-off to extend much-needed development assistance to the less fortunate. Other events, unforeseen and not obviously related，have put a brake on development. Financial markets tremble when a bank collapses, international agencies and institutions become uneasy when the United States dollar declines and, as a result, international aid for development is reduced. These challenges and problems related to political and economic instability and diminishing development resources deserve the utmost attention of the United Nations system, including WHO, and call for fresh initiatives, new partnerships and coordinated global action.

WHO has changed in many ways since its creation but at no time has the need for a fundamental adaptation to the environment in which it must function, and which in many ways WHO must help to change, been more pressing than at the present time. A working group of the Executive Board on the WHO response to global change established in May 1992 made 47 recommendations for reform. Aimed at adapting WHO's role and structure to the realities of today, these recommendations are in the course of being implemented.

Does WHO now have new opportunities to play its role as a world health organization? How and where can WHO make a difference? Our Organization has of late received more than its share of sometimes somewhat adverse comments on its effectiveness and relevance.

WHO's mandate as the directing and coordinating agency in health remains as valid today as when the Organization was created almost 50 years ago. But now it needs to emphasize its comparative advantage by increasing its technical strength in the field of competence in which its technical expertise and resources are required - its constantly declining and limited resources, a trend which must be reversed - in order to enable it to make maximum impact on the health of the world's people, particularly the poor and the vulnerable.

Since the beginning of the present decade, new windows of opportunity have opened for WHO to strengthen its directing and coordinating role in international health.

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In 1990, the World Summit for Children adopted a World Declaration and Plan of Action which outlined, not for WHO alone, but for all the organizations represented at the World Summit, what needed to be done in order to give every child a better future. It was an important opportunity for WHO to cooperate further with its partners and cohorts in the United Nations system in achieving its goals in relation to the health of infants, children and mothers. I am particularly pleased that last January the UNICEF/WHO Joint Committee on Health Policy reviewed progress towards those goals. It endorsed the importance of using the review mechanism to strengthen cooperation and collaboration at country level. The healthy growth and development of this partnership has been due in very large measure to the immense contribution of the late Mr James Grant, whose untimely death we so much regret.

The Conference on Environment and Development held in Rio de Janeiro in June 1992, commonly known as the Earth Summit, urged the World Health Organization to assume its role in environmental health as the global United Nations health organization. Our Director-General, Dr Hiroshi Nakajima, had set up two years earlier the Commission on Health and Environment in order to examine the interaction of environment and health in the context of development and to prepare for the Rio Conference a document that would set out the basis of WHO's contribution to sustainable development. The Commission's report described the health consequences of environmental change and highlighted the role of health in environmentally sound and sustainable development. In response to this new challenge, the Forty-fifth World Health Assembly in May 1992 called upon WHO "to formulate a new WHO global strategy for environmental health based on the findings and recommendations of WHO's Commission on Health and Environment and the outcome of the Conference on Environment and Development". The Director-General then established a council on the Earth Summit action programme for health and the environment, which continues to advise on the organizational, institutional and financial issues related to the implementation of Agenda 21 and WHO's global strategy for health and environment. We in the Western Pacific Region are particularly pleased at the Director-General's initiative in taking the necessary action to promote environment and sustainable development as a priority activity of the Organization. The importance which WHO accords to the problems of health and environment, and its rapid and forceful response to the agreement reached at the Rio Conference, indicate once more its resolve to give effect to its mandate. This Earth Summit was the first of a series of United Nations conferences aimed at defining a new people-centred mission for the United Nations, its organs, organizations and specialized agencies. The Rio Conference proclaimed: "Human beings are at the centre of concern for sustainable development. They are entitled to a healthy and productive life in harmony with nature".

The following year, in Vienna, the World Conference on Human Rights issued the Vienna Declaration, proclaiming the principle that development is a right which should be fulfilled in order to meet the health and environmental needs of present and future generations. WHO enshrines in its Constitution the principle of health as a fundamental human right. WHO has repeatedly committed itself to promoting this right for both individuals and communities. It has also emphasized the need for a proper balance of rights and responsibilities. This policy has been particularly exemplified in such WHO programmes as reproductive health and the Global Programme on AIDS. At the summit on AIDS held in Paris last December, the Director-General stressed the ethical obligation of all to respect the rights and the dignity of individuals, whether sick or in good health. He also reminded governments of their duty and responsibility "to take decisions, administrative, economic, health and social measures that will guarantee access to information， education, prevention and care".

As we are all aware, the International Conference on Population and Development took place in Cairo in September, 1994. There, WHO stressed that the concept of population and development is fundamentally about equity, social justice and respect. With its partners in the United Nations system, WHO agreed on a programme of action which affirms the application of universally recognized standards of human rights to all aspects of that programme. WHO's main contribution to the Cairo Conference was, in the words of the Director-General, "helping to reach a consensus and to transcend political and religious differences". Faithful to its constitutional mandate, WHO's strategy for reproductive health addresses the subject through information, promotion of healthy and responsible behaviour, and the provision of the best attainable care and treatment, giving special attention to under-served groups such as the young and the uneducated. The WHO Executive Board in January of this year adopted resolution EB95.R10, which proposed basic principles for the conceptual and strategic framework of its reproductive health programmes and activities. Here, then, is another opportunity for WHO to reaffirm its unique role with respect to the normative research and technical cooperation aspects of reproductive health. We cannot but give our Organization the means and the support to accomplish this role, and we cannot but support fully the strategic framework for WHO's action in reproductive health as outlined in the Executive Board document EB95/28.

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The most recent event in the series of United Nations conferences has been the World Summit for Social Development, which was convened in Copenhagen just two months ago. I should like to invite you to reflect on its main themes: namely, poverty, unemployment and social integration as they relate to WHO's mandate. We know that poverty goes hand in hand with ill-health, and that the alleviation of poverty leads to a healthy and productive life. I believe the main achievement of the World Summit for Social Development was its recognition of the need to address these issues in an integrated way. It drew attention to those indicators of ill-health, poverty and unemployment, hitherto largely ignored. Above all, its conclusions were a recognition on the part of the international community that people should be placed at the centre of economic and social development. What did WHO contribute to the world's social summit? What can WHO offer towards the achievement of its objective? In his statement at the Summit, the Director-General expressed his view of what should be done to break the vicious cycle of poverty and ill-health. He called upon governments, international agencies and all sectors of society to build partnerships in support of integrated policies for human development. He pressed for an agreed plan of action comprising the following elements: first, an assessment of needs and resources; secondly, investments in health, education and agriculture so as to generate economic activity and trade; and thirdly, establishment of mechanisms for managing resources and ensuring solidarity between and within countries. These elements, I believe, must constitute WHO's immediate approaches in its collaboration with other international bodies and national governments towards achieving social development and social justice.

Distinguished delegates, ladies and gentlemen, permit me to mention another level of opportunity where WHO and Member States can work fruitfully together. I speak of the region I come from. In the Western Pacific Region the members discussed at the Regional Committee session last year a common effort to eradicate poliomyelitis. The Member States pledged themselves to its eradication. This is an example of a united, unified regional effort in solving a common problem. As the regional body, we also considered the new direction in health development, as proposed in the Regional Director's paper entitled "New horizons in health". This common approach to solving problems further led to an undertaking by a group of ministers of health from the Pacific Island countries to develop an umbrella theme for collaborative health work. This gave birth to an initiative called "Health promotion and health protection for healthy islands". The lesson derived from this experience is that regional cooperation must be built on common problems, addressed collectively with the commitment and participation of all concerned.

With regard to social mobilization, I am pleased to note that WHO is exploring the support potential of regional institutions. Taking advantage of regional structure, WHO is directing its partnership initiative at the World Bank and the five regional development banks. It is likewise engaged in developing working relations with the five United Nations regional economic commissions and, in the case of the African continent, with the Organization of African Unity and the newly established African Economic Community, as well as the Common Market for Eastern and Southern Africa and the Economic Community of West African States. In direct support of a country-driven agenda for development, and in recognition of the multisectoral basis of health development, the partnership initiative is also directed at government agencies and д wide range of nongovernmental organizations.

There are two other developments we should bear in mind in relation to collaboration with countries, or rather groupings of countries, and to resource mobilization. One is the realignment of regional economies taking place in different parts of the world; Europe, the Americas and the Asia-Pacific region, for example. The other is something that could affect profoundly the nature of WHO's work with the peoples of the world and the concept of community participation and responsibility, namely, the growing role of civil society in governance in giving people the possibility of shaping the environment in which their rights and responsibilities can be exercised.

I am convinced of the need to take advantage of all the opportunities open to WHO to contribute to integrated development. We can assure our partners in development in our Member States that we are committed to upholding the inalienable right to life and the fundamental right to health, to advocating for every country and every human being the right to development, to undertaking programmes that should help people to secure a healthy and productive life and to promoting equity and solidarity in health.

Those are the principles on which we must base our work. Let us therefore plan with countries, work with countries, and together construct partnerships that will lead to a concerted effort at national capacity-building. Let us make the best use of our expertise and resources. Let us strengthen our technical capabilities. Let us translate political will into an operational framework for common action in countries. It is by strengthening WHO's directing and coordinating role in international health, and emphasizing its role

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in development, that we can achieve its vision of health for all. This, after all, is our collective responsibility and raison d'être. I thank you for your kind attention.

(Applause / 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-eighth World Health Assembly (document A48/1), as prepared by the Executive Board and sent to all Member States. The General Committee recommended the following changes to the provisional agenda contained in document A48/1 (these changes are now reflected in document A48/1 Rev.l, which you have before you): delete item 11, that is "Admission of new Members and Associate Members"; delete item 25, that is, "Supplementary budget for 1994-1995"; as for agenda item 26.1, "Assessment of new Members and Associate Members", please delete the words "if any", as the assessment of Palau will be considered; include a supplementary agenda item entitled "Transfer of Mongolia to the Western Pacific Region" - a document on this item will be distributed. Since the General Committee could not reach consensus as to the title of item 31，it is proposed that the Health Assembly include this agenda item but postpone determination of a title for the item until the General Committee reconsiders the issue at its next meeting on Friday, 5 May. Does the Assembly agree with these recommendations? There being no objection, the provisional agenda as amended in document A48/1 Rev.l is approved.

Now we come to 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 the 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, as amended, 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 A48/1 Rev.l.

It is understood that later in the session it may become necessary to transfer items from one committee to another depending on each main committee's workload. I take it that the Assembly agrees with this recommendation. It is so decided.

3. ANNOUNCEMENTS COMMUNICATIONS

The PRESIDENT:

I wish now 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 Friday morning, 5 May, at 10:00 in order to enable the General Committee to meet on the same day at 17:10 to draw up its recommendations to the Assembly regarding these elections.

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We now come to the programme of work. For the remainder of this morning, in accordance with the decision of the General Committee, the plenary will hear introductions to items 9 and 10，review of the Executive Board reports and review of The world health report 1995 incorporating the Director-General's report on the work of WHO. The plenary will adjourn following the introduction of item 10. In the afternoon, debates on items 9 and 10 will commence in plenary and simultaneously the Committee on Credentials and Committee A will each hold its first meeting. The programme of work for tomorrow, Wednesday, and for Thursday, Friday, Saturday and Monday will be as follows: on Wednesday, 3 May, in the 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 continue with the debate on items 9 and 10 and Committee В will meet during the debate. On Thursday, 4 May, in the morning, the plenary will take up the supplementary agenda item and then continue with 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 continue with the debate on items 9 and 10，followed by item 13，that is, "Awards", with its subitems. Committee В will meet during the debate on items 9 and 10 in plenary. On Friday, 5 May, in the morning, the debate on items 9 and 10 will continue in plenary and Committee A will meet during this debate. In the afternoon, the debate on items 9 and 10 will resume in plenary. During this debate, Committee В will meet. At 17:00, the plenary will adjourn so that the General Committee can 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 for the following week and the title of item 31 of the agenda. On Saturday, 6 May, in the morning, Committee A will meet. In view of the fact that item 24, that is, "Appointment of External Auditor" will be considered by Committee В on Monday, 8 May, and in order to enable the candidates to be present, I propose that we consider the programme for that day at this meeting. In the morning, the plenary will not meet but both Committees A and В will meet. Committee A will continue discussions on items 18 and 19, Committee В will first consider items 23 and 24, followed by the continuation of its consideration of item 22. In the afternoon, both Committees A and В will meet until 16:30. At 16:40 the plenary will reconvene to consider item 14, "Approval of reports of main committees", and item 12，"Election of Members entitled to designate a person to serve on the Executive Board". Does the Assembly agree with my proposal concerning this programme of work of the Assembly? It is so decided.

I would also like to remind the few delegates who have not yet submitted their credentials that they should hand these over to the secretariat of the Committee on Credentials before 14:30 today.

4. REVIEW AND APPROVAL OF THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-FOURTH AND NINETY-FIFTH SESSIONS EXAMEN ET APPROBATION DES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-QUATORZIEME ET QUATRE-VINGT-QUINZIEME 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-fourth and ninety-fifth 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.

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 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 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 the 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 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 present

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its views, are therefore to be distinguished from statements of delegates expressing the views of their governments.

I now have the pleasure in giving the floor to the representative of the Executive Board, Professor Kumate, Chairman of the Board.

El Profesor KUMATE (representante del Consejo Ejecutivo):

Señor Presidente, señor Director General, ilustres delegadas y delegados, excelentísimos señores: El Consejo Ejecutivo felicita a los señores Presidente y Vicepresidentes por la confianza que en ellos ha depositado la Asamblea al encomendarles la dirección de sus tareas. Me complace, como representante del Consejo Ejecutivo, informar acerca de las deliberaciones y las decisiones del Consejo en sus dos últimas reuniones. El Consejo continuó su labor de seguimiento de la aplicación de las recomendaciones relativas a la respuesta de la Organización Mundial de la Salud a los cambios mundiales que había empezado en su 93a reunión. Procedió a integrar los Comités de Desarrollo del Programa y de Administración, Presupuesto y Finanzas, y decidió que el mandato de los miembros de dichos comités no excediera de dos años. Además, el Consejo estableció los métodos y planes de trabajo de ambos comités. Tanto en la 94a como en la 95a reunión, el Consejo examinó los informes sobre el desarrollo del sistema mundial OMS de información para la gestión y aprobó su plan y su orientación general. Se presentará un plan de ejecución detallado al Consejo en su 96a reunión y el miércoles 3 de mayo se celebrará una sesión de información sobre dicho sistema para los delegados de la Asamblea. En el Diario de la Asamblea se darán detalles sobre esta reunión.

El Consejo ha recomendado a la Asamblea de la Salud que, a partir de la 49a Asamblea, las Discusio-nes Técnicas se sustituyan por sesiones de información, que constituirán un foro menos rígido para el diálogo. El Consejo examinó un informe del Director General sobre la renovación de la estrategia de salud para todos en el que se proponía un método combinado para la aplicación de las recomendaciones relativas a los cambios mundiales, con miras a la actualización de dicha estrategia. El informe recomendaba también que se involucrara en el desarrollo y la aplicación de la nueva política a todos los interesados. El Consejo recomienda a la Asamblea que apruebe este método de consulta y pida al Director General que organice， antes de que finalice 1997, una conferencia mundial en la cumbre encargada de adoptar una Carta de Salud basada en la nueva política sanitaria. El Consejo aprobó la política OMS de comunicación y de relaciones públicas y recomendó su aplicación inmediata. El Consejo examinó el tercer informe sobre la vigilancia de los progresos realizados en la aplicación de las estrategias de salud para todos en el año 2000. El tercer ejercicio de vigilancia muestra que la situación sanitaria mundial ha mejorado en general, aunque con diferencias significativas, según las regiones o grupos de países. El Consejo acordó que la información se utilizara como base para ayudar a los Estados Miembros a establecer sus prioridades, asignar sus recursos en consecuencia y procurar reducir las desigualdades que persisten o van acentuándose entre grupos de países o grupos de población dentro de éstos. Pidió que los resultados del ejercicio de vigilancia se aprovechen para la determinación de las políticas y las prioridades de la OMS. El Consejo encareció la conveniencia de dar amplia difusión a los datos obtenidos y señaló que gran parte de éstos se incorporarán al primer Informe sobre la salud en el mundo, que aparecerá oficialmente mañana. El Consejo se dividió en subgrupos durante tres días para examinar y evaluar programas específicos: nutrición, seguridad alimentaria e inocuidad de los alimentos; equipo y servicios de suministro para los Estados Miembros; evaluación de la situación sanitaria y de sus tendencias; desarrollo y gestión del programa general; información sanitaria y biomédica; Programa de Acción sobre Medicamentos Esenciales; vacunas e inmunización; investigación y control de las enferme-dades tropicales; salud de las personas de edad; higiene del trabajo, y recursos humanos para la salud. Los resultados de los exámenes que realizaron los subgrupos se tuvieron en cuenta durante las deliberaciones sobre el proyecto de presupuesto por programas para el ejercicio 1996-1997.

El presupuesto por programas para el ejercicio 1996-1997 se presentó al Consejo con un nuevo formato, más claro y más sencillo. Una vez incorporadas las enmiendas resultantes de las deliberaciones del Consejo y de la Asamblea de la Salud, se publicará como presupuesto por programas aprobado. El Consejo felicitó al Director General por haber preparado el presupuesto con un nuevo formato y por el nuevo enfoque estratégico. El Consejo recomendó que el proyecto de presupuesto por programas presentado a la Asamblea indicara las reasignaciones de recursos a determinados sectores prioritarios, a saber: prevención y lucha contra determinadas enfermedades transmisibles, en especial el paludismo, la salud reproductiva，la atención primaria de salud y la higiene del medio. Recomendó asimismo al Director General que determinara qué recursos podrían transferirse de los siguientes sectores: órganos deliberantes, adquisiciones y gastos generales de personal, y servicios administrativos. En relación con el examen del proyecto de presupuesto por

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programas, el Consejo adoptó resoluciones sobre los cambios en la enseñanza y en el ejercicio de la medicina en pro de la salud para todos y sobre la prevención de los defectos de audición，resoluciones ambas que se han transmitido a la Asamblea.

El Consejo examinó 12 informes sobre los progresos realizados, presentados en cumplimiento de resoluciones y decisiones anteriores. Adoptó una resolución sobre acción de emergencia y humanitaria, en la que recomienda que la Asamblea de la Salud adopte la estrategia expuesta en el informe del Director General sobre el particular. Adoptó asimismo una resolución sobre cooperación intensificada con los países más necesitados, en la que recomienda a la Asamblea de la Salud que adopte una resolución en la que se exhorte a la comunidad internacional a movilizar recursos adicionales para el desarrollo en los países más necesitados y pide al Director General que conceda la más alta prioridad a estos países. El Consejo tomó nota de los progresos realizados en el cumplimiento de la Declaración Mundial y Plan de Acción que había adoptado la Conferencia Internacional sobre Nutrición en diciembre de 1992. Para fines de 1995 la OMS y la FAO prepararán un informe completo que se presentará por conducto del Consejo a la 49a Asamblea Mundial de la Salud.

Tras examinar el informe del Director General sobre «Tabaco o salud» referente a la marcha de los programas de lucha antitabáquica de los Estados Miembros y al uso del tabaco en los viajes y en los edificios del sistema de las Naciones Unidas, el Consejo adoptó una resolución relativa a una estrategia internacional de lucha antitabáquica, que a su vez contiene una resolución cuya adopción recomienda a la Asamblea Mundial de la Salud.

El Consejo reafirmó el cometido que incumbe a la Organización en el sector de la salud reproductiva y pidió al Director General que presentara a la 48a Asamblea Mundial de la Salud una estrategia de acción e investigación en esta materia.

En el contexto de un informe relativo a la aplicación de las resoluciones sobre la lucha contra las enfermedades diarreicas y las infecciones respiratorias agudas, el Consejo examinó el nuevo criterio de lucha integrada contra la morbilidad infantil y adoptó una resolución en la que se recomienda a la Asamblea que apoye la lucha integrada como método muy eficaz para conseguir la supervivencia y el desarrollo sano de los niños.

Tras examinar el informe sobre los progresos realizados en la aplicación de la estrategia mundial de prevención y lucha contra el SIDA, el Consejo decidió recomendar a la Asamblea de la Salud que adoptara una resolución en la que se acoge con agrado la declaración formulada en la Cumbre de París sobre el SIDA y se invita a los gobiernos que no lo hayan hecho aún a que firmen esa declaración.

Se adoptó una resolución relativa a las enfermedades infecciosas nuevas, emergentes y reemergentes, en la que se recomienda a la Asamblea de la Salud que inste a los Estados Miembros a que fortalezcan la vigilancia y se pide al Director General que establezca estrategias para mejorar el reconocimiento de estas enfermedades y las respuestas correspondientes. Habida cuenta de que el Comité Especial de Ortopoxvirosis no llegó a un consenso, el Consejo decidió aplazar hasta una reunión ulterior el examen de su informe.

El Consejo examinó los informes sobre contratación de personal internacional en la OMS, representa-ción geográfica, y sobre fomento del empleo y de la participación de mujeres en las actividades de la OMS. Se transmite a la Asamblea un proyecto de resolución sobre representación geográfica. El Consejo confirmó las modificaciones del Reglamento de Personal por las que se crea, por un periodo de ensayo de tres años, la categoría de funcionario nacional del cuadro orgánico. Con objeto de contener los gastos de administra-ción de premios y becas de fundaciones, el Consejo decidió otorgar con frecuencia bianual el Premio de la Fundación Léon Bernard; pedir al Comité Regional para el Mediterráneo Oriental que tuviera a bien exami-nar la posibilidad de asumir la responsabilidad administrativa del Premio de la Fundación Dr. A. T. Shousha; y recomendar que se detrajera para gastos de apoyo a programas el 13% de las sumas otorgadas por el Comité del Premio Sasakawa para la Salud y por la Fundación de los Emiratos Arabes Unidos para la Salud. Los demás asuntos de importancia que afectan a la labor de la Organización se mencionan en el documento A48/2 y se tratarán detalladamente en las Comisiones A y B.

Quiero transmitir a la Asamblea el agradecimiento del Consejo por habernos brindado la oportunidad de darles a conocer nuestras reflexiones sobre estos asuntos. Muchas gracias, señor Presidente.

The PRESIDENT:

Thank you Professor Kumate for your excellent statement. I should like to take this opportunity of paying a 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.

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5. REVIEW OF THE WORLD HEALTH REPORT 1995 EXAMEN DU RAPPORT SUR LA SANTE DANS LE MONDE, 1995

The PRESIDENT:

Now I give the floor to Dr Nakajima, Director-General, so that he may present, under item 10 of the agenda, The world health report 1995, incorporating his report on the work of WHO in 1993-1994. Dr Nakajima you have the floor.

The DIRECTOR-GENERAL:

Mr President, excellencies, honourable delegates, ladies and gentlemen, in the course of a year, more than 12 million children die before the age of five, mostly in developing countries and usually from a combination of preventable causes. Sixteen million people die from infectious and parasitic diseases. Among adults, tobacco is responsible for three million deaths. And, with 6000 new cases of HIV infection occurring every day, we can expect the cumulative number of people infected - now close to 20 million - to reach 30 or 40 million by the year 2000.

But alarming figures such as these are only the beginning of the story presented in The world health report 1995, an assessment of the world's health prepared at your request as part of WHO's reforms in response to global change. With its subtitle, "Bridging the gaps", this first issue of The world health report reminds us, once again, that the tragedies of premature death, disease, and disability are not distributed in a random lottery. They reflect inequality: health gaps which could be described as population gaps, poverty gaps, and epidemiological gaps.

Bridging the gaps in health status has always been WHO's main task and the principal focus of its advocacy for health. Access to health for all, including the poorest and most vulnerable countries and population groups, remains the guiding purpose of WHO's programmes and its cooperation with countries. As highlighted in your statements about health and ethics at last year's Assembly, it also remains the overwhelming ethical concern of WHO Member States. In January 1995，the Executive Board strongly reasserted this focus with the criteria it selected for the further prioritization of WHO's health interventions and resource allocations in the 1996-1997 programme budget. The first step is always to establish the facts. We must identify health problems and monitor health interventions and their outcome, with a sharper focus on gaps and priorities. The yearly issue of The world health report will serve this purpose well.

This year's report stresses that some of our major health challenges - the gaps we must bridge - are determined by global population trends. Since 1950, the world's population has doubled. It is now 5.6 billion people, 4 billion of whom live in developing countries. It is estimated that 2.3 billion people -or 40% of the world's population - are under 20 years of age. In the past five years, however, with an overall population growth rate of about 1.7% per year, the increase in people aged over 65 has been about 2.7% (almost double) per year, with a dramatic rise in the numbers of people aged over 80.

These trends show clearly that our efforts and investment must continue to focus on the health of women, children, and adolescents. At the same time, we must prepare for a considerable increase in emphasis on the health and social issues related to care and support for the elderly, including those living in developing countries. For all, we must ensure not only longer but also more fulfilling，productive and disability-free lives.

The most striking and - as I consider it - the most unacceptable gap relates to child survival. It is true that the gap in infant mortality was narrowed by 50% between developed and developing countries within just 33 years, that is between 1960 and 1993. But during the same period the gap between least developed and developing countries actually widened. Infant mortality rates today range enormously: from 5 to 160 per 1000 live births. Unless these figures are improved, there is little chance that the people concerned will choose to practise family planning and thus make it possible to achieve managed population growth. Maternal mortality rates also show wide variations, ranging from 50 to 700 per 100 000 live births. Iii the world today, only half of the women who give birth have a trained health worker nearby who can help them if things go wrong. Currently, 99% of all maternal deaths occur in developing countries.

WHO has made it a high priority to achieve a significant reduction in mortality and morbidity rates among mothers and children by the year 2000. In this respect one of our major targets is to reduce the total number of annual deaths of children under five by more than two million. This surely is an ethical obligation for all of us. Fulfilling it will also help to reduce the total burden of ill-health which developing countries

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are bearing at present. We have demonstrated that we can do this successfully by combining tools and approaches that are used in the Expanded Programme on Immunization, the Children's Vaccine Initiative, nutrition activities, the Safe Motherhood Initiative, the Mother and Baby Package, and the control of diarrhoeal diseases and acute respiratory infections, for example.

The International Conference on Population and Development, held in Cairo in September 1994，was a major breakthrough for us. It endorsed WHO's definition of reproductive health, the principle that reproductive health care should be provided to all as an integral part of primary health care，and our emphasis on the family health approach. In January 1995，the Board confirmed WHO's strategy and its decision to give priority to reproductive health, women's health and family health.

As The world health report so clearly shows, poverty, with all the suffering and social disintegration it brings with it, is another major factor affecting our global health challenges. Today, over one billion people - more than one-fifth of the world's population - live in extreme poverty. They are without adequate food, water and shelter, and are particularly vulnerable to disease. While this absolute poverty deprives people of the essential necessities of life, relative poverty - which affects much larger numbers - severely restricts their access to health, education and other essential services. Poverty also limits people's access to information, so that even where health services are available they may not be used by those who need them most. It is currently estimated that half of the world's population lacks regular access to treatment for common diseases and to the most essential drugs. If we are serious about bridging the gaps in health, we must win the battle against poverty! There is simply no alternative solution.

A major strategic mistake on the part of economists and policy-makers in the past has been their exclusively economic approach to development. It is now widely recognized that economic growth is necessary but not sufficient for overall and sustainable development. In a number of countries today, the economy is growing without any significant reduction in unemployment and poverty. This is a source of major concern for us as we see past achievements and future prospects for health development threatened by the combined shocks of currency devaluations, structural adjustment programmes and economic transition.

Just as poverty is the main obstacle to health development, there can be no sustained economic growth or social development without health. This was WHO's plain message which I conveyed to the World Summit for Social Development in Copenhagen in March 1995. I emphasized that while considerable progress had been made in the control of river-blindness in Africa, such diseases as malaria continued to kill people and hinder human and agricultural development. I stressed that the mere threat of cholera, plague, or diphtheria outbreaks, was enough to disrupt national economic systems and international trade. I also warned that poverty, as a form of violence inflicted upon groups and individuals, always causes violence in retaliation.

Health problems related to substance abuse, commercial sex, family violence, depression, suicide and delinquency, lead us back not only to individual behaviour but also to economic pressures and societal flaws. As we shall document for the World Conference on Women scheduled in Beijing next September, women's specific biological vulnerabilities are greatly increased by their generally lower social and economic status. Often，the health gap is a "gender" gap.

Poverty and unequal development opportunities create tensions between groups and communities and, in extreme cases, can give rise to conflict and complex emergencies. Health and social development policies which are based on justice and equity are among the most powerful instruments for building peace, political consensus and social cohesion. Health has emerged as a leading popular concern in all countries and a major policy issue for all governments, at the highest level of the state. As the Ninth General Programme of Work points outs, health and human development must now be integrated into all public policies.

Finally, The world health report shows that epidemiological trends are decisive in determining the health gaps we must bridge and the challenges we all face. Reliable epidemiological information must command our global health strategies and specific approaches at country level. The total number of cases or general prevalence of a disease is a first indication for action. But an even more significant basis for our judgement and decision on priorities must be the actual burden which any specific disease imposes on people and countries in terms of death, suffering and disability. Our opportunities for action are often limited by insufficient knowledge, technology and resources. But it is our responsibility to find ways to overcome these limitations so that people's suffering can be alleviated and their well-being improved.

Together, infectious and parasitic diseases still account for the largest number of deaths, that is more than 16 million a year, mostly in developing countries. Malaria alone is responsible for about two million deaths，half of which occur in children. With a recorded death toll of about three million in 1993，and some nine million new cases forecast for 1995, tuberculosis has been declared a global emergency by WHO. Tuberculosis, a companion of poverty, is now growing even in industrialized countries.

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Taking the lead to focus efforts and resources on alleviating the global burden of death and ill-health, WHO has set specific targets for the year 2000. We have made immense progress in our fight for the eradication of poliomyelitis. It is mobilizing innumerable dedicated health professionals, voluntary workers, political leaders and private citizens. It has enjoyed outstanding participation from nongovernmental organizations and the continuous support of other United Nations organizations and programmes. Similarly, the eradication of dracunculiasis has received enthusiastic support and is now almost achieved. Leprosy will soon be eliminated as a public health problem. Neonatal tetanus and measles are also targeted for elimination by the year 2000.

These efforts are not only ridding the world of dreaded diseases. They are also helping to extend the infrastructure of sustainable primary health care to the remotest corners of every country. I want to pay public tribute to all those who are helping us to make this part of our dream of "health for all" come true. And I urge everyone else to join in, to ensure that this great undertaking is successfully completed.

In the recent past, we have witnessed some worrying events such as an upsurge of plague, severe outbreaks of meningitis, diphtheria and cholera, and the emergence of new diseases such as AIDS, a new strain of cholera, and multidrug-resistant strains of dysentery and tuberculosis. These occurrences have revealed a general need to update epidemiological surveillance systems and strengthen laboratory capabilities, especially in developing countries. Better coordination of information will make it possible to respond more quickly and effectively to epidemics, and reduce panic. The globalization of tourism, labour and trade also calls for a revision of the International Health Regulations.

The HIV/AIDS pandemic has spread to all regions and countries. In the coming years, we must expect an explosion in the number of AIDS cases worldwide. Wreaking havoc on individual lives and families, the pandemic will be a tremendous drain on all societies, their economic potential and their infrastructure for health care and support. The Joint United Nations Programme on AIDS has been formed to provide against fragmentation and ensure that resources and activities are combined in one common front with unreserved commitment against this universal scourge. During this transition period, WHO's overriding concern is that the continuity of operations in countries should not be jeopardized. I call on all WHO Member States to help us maintain our level of support to countries until the Joint United Nations Programme on AIDS becomes fully operational.

Many noncommunicable diseases such as cancer, cardiovascular diseases and diabetes were thought to reflect the lifestyles of the developed world. It used to be considered that the health gap here was in favour of developing countries. Now, however, it appears that the numbers of people affected in developing countries are becoming as great as those in developed countries, and in some cases far greater. Fatality rates are also higher where access to screening, primary prevention, care and rehabilitation is limited.

In 1993，diseases of the circulatory system caused some 10 million deaths worldwide, 44% of which occurred in developing countries. It is worth noting that here, in terms of heart attacks, men are four or five times more at risk than women. Cancer kills an average of six million people a year and 58% of them are in the developing world. It has been estimated that 20% of all cancer deaths in the world could be prevented if tobacco smoking was eliminated. Worldwide, the increase in noncommunicable diseases can be related to such factors as lifestyles, diet and occupational or environmental health hazards.

As always, the best response is anticipation and prevention. Health education and health promotion are key strategies to reduce the burden of ill-health. This has been clearly demonstrated for sexually transmitted diseases, including HIV/AIDS. The Declaration on AIDS, adopted by the World Summit held in Paris last December at the initiative of the French Government, rightly calls for the establishment of a social, legal and political environment that effectively promotes information and education on AIDS and access to preventive methods and products. Fostering health education at school and within the family is crucial. Moreover, in a world which is experiencing rapid urbanization together with marginalization of the urban poor, specific activities must be planned to deal with adolescent health problems.

Health education is essential to increase the general level of knowledge about health and hygiene, bring about changes in attitudes and lifestyles, and reduce risk-prone behaviour. It fosters individual self-reliance, and gives people a sense of responsibility for their own health and that of their family. Health education for disease prevention is also an investment in the future.

The importance of nutrition cannot be overemphasized, for promoting health in both developing and developed countries. Our decision to make nutrition a priority area was endorsed by the Board last January. Food security and safety must be improved for all and a better diet promoted in all societies. WHO is aiming for the elimination, by the year 2000, of micronutrient deficiencies such as vitamin A and iodine, which cause much physical and mental disability worldwide. By promoting healthy lifestyles and nutritional habits early

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in life we can also ensure a marked reduction in noncommunicable diseases, such as cardiovascular diseases, cancer and diabetes.

Advocacy is not enough. In order to sustain health development, primary health care services must be made accessible to all, close to the people who need them. In January 1995, the Executive Board singled out the promotion of primary health care, including vaccines and essential drugs, as a priority area. In this respect, WHO is doing its utmost to make available to all new vaccines such as the vaccine against malaria developed by researchers in Colombia. Health promotion and primary health care development also imply that some basic infrastructure is in place to ensure people's access to safe water and sanitation. "Africa 2000", an initiative launched by WHO in the African Region, is aimed specifically at achieving this. Here, bridging the gaps between countries and between population groups requires firm commitment on the part of political leaders and all national and international partners concerned. Success will bring invaluable rewards, both in economic and in human terms.

To be able to meet such complex challenges more effectively, WHO has undertaken a far-reaching reform process. It has restructured its programmes to focus more directly on priorities. It has revised its administrative and budgetary procedures and is developing a comprehensive management information system, to enhance coordination and accountability. It is also experimenting with new methods of work, both in the Secretariat and in the governing bodies. Most of the reforms are in place and WHO is now better equipped to respond to global change.

Meanwhile, however, the Organization's activities remain severely restricted by a zero growth budget in real terms. In the past year, budgetary constraints have been compounded by wide fluctuations in currency exchange rates and steep inflation rates affecting costs in countries and regional offices. We have done our best to absorb costs within the proposed programme budget for 1996-1997. But this necessarily reduces our capacity for programme implementation and the flexibility of our response to global and country needs. Our efforts must be matched by a similar exercise in streamlining, self-help and prioritization at all levels in regions and countries. Solidarity requires us to share resources in conformity with evolving needs and priorities. Together we must ensure for the Organization a level of resources which will enable it to carry out programmes and activities which meet the health requirements of the world, especially those of the countries and populations most in need. Your consideration of budgetary matters at this Assembly will be of paramount importance for the viability of our work and the achievement of our common targets and goals.

WHO's reform is a continuous process. Together we must keep track of health issues and opportunities. Resolve, hard work and innovative thinking will ensure that together we can respond to future health challenges successfully and lead international health cooperation. This we will do in coordination with, and with the support of, our United Nations sister agencies and our global network of collaborating centres. We will also seek greater involvement of nongovernmental organizations and other sectors of civil society.

WHO today numbers 190 Member States, the largest membership in the United Nations system. We very warmly welcome the people and Government of Palau among us. It is always heartening to see the WHO family grow and thus become stronger. WHO's mission is to promote health, human development and peace through international cooperation. Our role, first and foremost, is to provide technical support to countries. This may take the form of advocacy, guidelines on strategies and policies, or direct technical cooperation with countries as they themselves build up their infrastructure, train their health workers and implement their health policies and interventions. WHO's technical support may also come as normative guidance to countries. WHO has a constitutional responsibility to propose technical and ethical standards and harmonize them at the global level. This applies to a broad range of areas such as biomedical research and practices, pharmaceuticals, and more generally public health and international cooperation. It includes ensuring equitable partnerships and fair access for developing countries to new information technology and databases as these are developed and applied to health.

Our mission does not stop in the year 2000. WHO's vision of "health for all" remains a generous and much needed ideal, which can be pursued with a strong sense of solidarity by local, national and international communities alike. It implies bridging the gaps between the weak and the strong; between the rich and the poor; between scientific knowledge and actual access to care, information, and technology; and last but not least between what is desirable and what is feasible. It means that at all levels, in all public policies and across all sectors of society, we must mobilize resources and partnerships to meet the health needs of today and tomorrow.

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The PRESIDENT:

Thank you, Dr Nakajima, for your very eloquent words. We have now heard the introductions to items 9 and 10. The next plenary meeting will be held at 14:30, when the debate on these items will commence. The meeting is now adjourned.


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FOURTH PLENARY MEETING

Tuesday, 2 May 1995，at 14:30


QUATRIEME SEANCE PLENIERE

Mardi 2 mai 1995，14h30


DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-FOURTH AND NINETY-FIFTH SESSIONS AND REVIEW OF THE WORLD HEALTH REPORT 1995 (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-QUATORZIEME ET QUATRE-VINGT-QUINZIEME SESSIONS ET EXAMEN DU RAPPORT SUR LA SANTE DANS LE MONDE, 1995 (suite)

The PRESIDENT:

The Assembly is called to order. Before we start the debate on items 9 and 10，I would like to remind you that in accordance with resolution WHA26.1，delegations wishing to take part in the debate on The world health report 1995 and the reports of the Director-General and the Executive Board should concentrate their interventions 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 could make such reports in writing for inclusion in the record as provided in resolution WHA20.2 I would also call delegates' attention to paragraph 2(1) of resolution EB71.R3, in which the Executive Board stresses the desirability of having the debate focus especially on issues or topics deemed to be of particular importance. The delegates addressing the plenary meeting at the Forty-eighth World Health Assembly are invited to give special attention to equity and solidarity in health - bridging the gaps. Delegations wishing to participate in the debate are requested, if they have not done so already, to announce their intention to do so, with the name of the speaker and the language in which the speech is to be delivered, to the officer on the podium responsible for the list of speakers. Should a delegate wish to submit a prepared statement for inclusion in extenso 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 officer responsible for the list of speakers in order to facilitate the interpretation and transcription of the proceedings. Delegates will speak from the rostrum. In order to save time, whenever one delegate is invited to come to the rostrum, the next delegate on the list of speakers will also be called to the rostrum, where he or she will sit until it is time to speak. 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 office of the Assistant to the Secretary of the Assembly, or during plenary to the officer responsible for the list of speakers. The list of speakers will be published in the Journal.

I would like to remind those delegates who have to leave Geneva and are not able to deliver their speeches before they leave that they can ask for their text to be published in the records of the Assembly.

Before starting the discussion on these items, I would like to inform you that the delegate of Kazakhstan wishes to speak today because he has to leave Geneva tomorrow. For this reason I shall give him the floor later this afternoon, before we adjourn.

The debate on items 9 and 10 is now open and I call to the rostrum the first two speakers on my list, the delegates of South Africa and of India. I give the floor to the delegate of South Africa.

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Mrs ZUMA (South Africa):

Honourable President, Director-General, honourable ministers of health, delegates, ladies and gentlemen, it is indeed a great honour for me to address this esteemed gathering, as Minister of Health 30 years after South Africa's departure from the World Health Assembly in 1964.

Firstly, let me congratulate all those who have been elected to various positions during this Health Assembly. I would also like to congratulate the World Health Organization on its efforts to provide a global health status report, set global health priorities, and link resources to identified priorities. This initiative makes WHO the leader in health throughout the world.

The Health Assembly's theme, equity and solidarity in health - bridging the gaps, is obviously very interesting to us because of what we are trying to do in South Africa. Allow me to use South Africa as an example - our experience will surely be relevant elsewhere.

Our country has been truly liberated and our beautiful rainbow nation has been born. The task of liberation has been successfully accomplished and a special word of thanks is due to the international community for the part it played in the liberation of South Africa. We are especially grateful to WHO and its Member States for the support they gave to the liberation movements.

The most difficult task facing us in South Africa now is to try to deracialize and transform our society so as to eliminate the inequalities and make the lives of our people better - thus bridging the gaps.

We see South Africa as a microcosm of the world. It has people of African, European and Asian descent; we find the developed and developing worlds. We also find rich and poor, urban and rural, and male and female disparities in access to resources; all in this southern tip of the African continent. Indeed there are many worlds within our country and we need to bridge the gaps between those worlds.

Diseases of affluence exist side by side with diseases of poverty like malnutrition and kwashiorkor and high rates of tuberculosis and other preventable communicable diseases such as measles. Within the same country we have major disparities in infant mortality rates among people of different races and between urban and rural areas.

The inequalities in South Africa were created deliberately and require the deliberate efforts of the South African Government, its people and the solidarity of the international community to correct them. The speed with which they can be corrected will be limited by human and financial constraints.

The South African Government of National Unity has adopted the reconstruction and development programme as an integrated policy through which it will redress the imbalances and bridge the wide gap that exists between socioeconomic groups. This is in line with the theme of The world health report 1995.

The first step that the Government had to take was, exactly like WHO, to define new priorities according to basic needs as defined in the reconstruction and development programme, and then to begin to shift resources to where they are most needed. Previously the urban and the white areas had been allocated more resources at the expense of the rural and black areas, which meant that those with more resources received more while those who had less resources received even less, widening the gap even further. The Government has only begun the arduous task of shifting resources from the richer to the poorer areas, from urban to rural areas and from less vulnerable groups to more vulnerable groups. The major departments involved in the reconstruction and development programme are all involved in this exercise.

In education, we are phasing in compulsory free education which previously only applied to whites. This will have enormous benefit for child survival and health as the education of women improves.

With regard to water and sanitation, over 60% of our people in the rural areas still have no access to clean water or sanitation. The programmes therefore include the provision of water and sanitation. The housing shortage in South Africa runs into millions. Workers, women and children live in conditions of squalor, and diseases flourish under these conditions. Both rural and urban electrification and bulk infrastructural development are major priorities. This will benefit health and women who are normally the drawers of water and hewers of wood. Job creation is another area we are grappling with. Health is also amongst the priorities of the reconstruction and development programme. As in WHO, we have focused on priorities such as child survival, women's health and safe motherhood, and worker's health. In trying to bridge the gaps regarding the first two priorities we have already introduced free health care for children under six years, for pregnant women and for up to six weeks after delivery. We have embarked on a clinic-building programme to improve access to health facilities. The immunization programme is being strengthened; we are participating in the campaign to eliminate poliomyelitis, and have added hepatitis В for the first time to our immunization schedule.

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Nutrition is a priority, particularly in the under-fives, and we have also introduced a school feeding programme in 8000 schools, feeding more than five million primary schoolchildren every weekday and generating around 10 000 jobs.

We are also investigating national health insurance for primary health care both as a funding mechanism for community health services and a way of shifting human resources from private to the public sector and from urban to rural areas, without detracting from the existing hospital system.

Because, like WHO, we could not significantly increase the Government's spending we have had to shift resources to education, housing, water and health from other areas like defence. Peaceful resolution of conflict and also maintaining democracy is seen as important in creating an atmosphere conducive to human development. When there is war, poverty is accentuated, women and children are usually victims of hunger, ill-health, homelessness, etc.

We are convinced that being part of this family of nations will have enormous benefits for us as a nation in terms of technical expertise, access to information and other resources and solidarity, but we also hope that whatever we are doing in a small way can act as a source of inspiration to the international community, because, as I said, South Africa is a microcosm of the world. The principles outlined above can be applied to the wider world and resources can be shifted from the richer to the poorer nations, from West to East, and from North to South.

Lastly, as a member of WHO, the African continent and the developing world, we would like to see WHO shift resources to where the burden of disease is greatest, and to address public health priorities relevant to the developing world, such as violence. It would also be commendable if the balance of decision-makers could be such that the African continent is represented appropriately. The proportion of women decision-makers and planners in WHO also needs to be increased appropriately as women are important both as consumers and providers of health care.

We as South Africans shall also try to play our part in assisting where we can. Solidarity means we should share the little we have to bridge the gap.

To conclude, I would like to quote our President, Mr Nelson Mandela, who in addressing the Joint Houses of the Congress of the United States in October 1994 said:

"If what I say is true, that manifestly, all the world is one stage and the actions of all its inhabitants are part of the same drama, does it not then follow that each one of us as nations, including yourselves, should begin to define the national interest to include the genuine happiness of others, however distant in time and space their domicile might be."

Dr SILVERA (India):

Mr President, honourable Vice-Presidents, honourable health ministers, honourable Director-General, Dr Nakajima, distinguished delegates, ladies and gentlemen, I congratulate you, Mr President on your election as President of the Forty-eighth World Health Assembly. I also convey my felicitations to the Vice-Presidents and the Chairpersons. I am happy to be with you and I bring with me the greetings of the people and Government of India.

At the outset, allow me to congratulate the Director-General on the launching of The world health

report 1995. We have during the current century witnessed far-reaching improvements in the global health scene. Advances in our knowledge of the causes and effects of diseases, progress in sanitation and nutrition and in the development of vaccines and drugs, along with the expansion of infrastructure for delivery of health care have radically transformed the health scenario the world over. As a result more and more are today enjoying the benefits of good health than ever before. Nevertheless, despite these improvements, millions remain undernourished and are denied fulfilment of the basic needs of shelter, clothing, food, education and even basic health care. Unfortunately, such deprivation exists side by side with overabundance. It is to the health problems of the deprived, living mainly in rural areas and urban slums, that our attention needs to be focused.

This can best be achieved through primary health care, as set out in the Alma-Ata Declaration of 1978， and through sustained economic growth linked with equity and social justice. In respect of the former, I am happy to inform you that India has already set up a network of over 132 000 subcentres, 21 254 primary health centres and 2828 community health centres. As a result, life expectancy at birth has increased from 41.3 years in the period 1951-1961 to 61.15 years in 1991-1995. From the 1950s to 1993, we have reduced the crude birth rate from 41.7 to 28.5 per 1000, the death rate from 27 to 9.2 per 1000 and the infant mortality rate from 146 to 74 per 1000 live births.

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India is also conscious of the importance that economic growth must go hand-in-hand with equity and social justice. In the current scenario of economic restructuring, translating economic development into concrete gains in quality of life, particularly in the area of health, remains a challenge. Poverty, malnutrition, lack of safe drinking-water and unhygienic living conditions are major impediments in our path towards achieving positive health.

It is now conventional wisdom that wherever we have been able to meet basic needs like education, safe drinking-water and gainful employment, the health gains, especially of the vulnerable sections of the population, have been impressive. In this context, I would like to mention that in the Indian State of Kerala, where there has been a tradition of public education and health services with particular focus on women and community involvement, there has been much success in attaining many of the targets of health for all without any massive investment. While on this point I would urge the Assembly to focus also on the importance of bridging regional disparities within a country while providing a better quality of life.

Indigenous systems of medicine, including particularly herbal medicine, which are much more cost-effective, locally acceptable, and with no harmful side-effects, need to be much more widely promoted. In India, for this purpose, we have recently established a separate Department of Indigenous Systems of Medicine and Homeopathy.

There is much truth in the old adage that "prevention is better than cure". We should concentrate on the broader issues of health education and public health and other preventive measures which would be more cost-effective. This assumes particular importance in the context of the burden of traditional diseases, the emergence of new diseases, faulty lifestyles and non-enforcement of health and safety standards in industries.

WHO has played a leading role in the formulation of international policies and strategies to meet the growing challenge posed by the spread of HIV/AIDS. In India, though we have no reliable data on the incidence of HIV infection in the general population and most of the figures are "guesstimates"，we have instituted close surveillance of HIV infection among high-risk-behaviour groups, in whom the infection rate has remained constant during the last three years. ,We have mounted a large public health awareness programme, supplemented with facilities for control and treatment of sexually transmitted diseases and safety of blood transfusion services, in order to prevent transmission of HIV infection. India has also used the technical expertise provided by WHO. It is for that reason that we feel concerned that at the dawning of a new United Nations-wide collaborative effort to combat this pandemic effectively, the involvement of WHO seems to be side-lined. We would like to take this opportunity to stress the critical importance of a continued role and active participation of WHO in the fight against AIDS.

Improvements in health have brought in their wake new problems and challenges. While we are witnessing a dramatic reduction in the incidence of infectious diseases, we are at the same time finding an increase in lifestyle-related diseases, injuries and chronic ailments. The stresses and strains of modern life-styles have added a new dimension to the problems of mental health. Control of fertility is modifying the structure of the population, leading to a rise in the proportion of the elderly. Added to these is the rapid pace of industrialization and urbanization, leading to severe stress on the environment. These are new areas of concern requiring attention and research. In this context we welcome the WHO ad hoc review of health research and development, with its comprehensive approach and look forward to reviewing the final report at the next Health Assembly.

However the challenge before us is to manage the dual burden of disease on the one hand and a growing population on the other. Malaria persists with drug-resistant and insecticide-resistant strains emerging. We are introducing special strategies to bring down morbidity and mortality due to malaria. Tuberculosis resurgence is also a cause for concern and a revised tuberculosis control programme has been launched. Leprosy is on the verge of being controlled and eliminated by the year 2000. The need of the hour is to continue our efforts towards the control of communicable diseases. Our approach has been to encourage the private sector to provide tertiary care and to utilize public resources predominantly for primary health care and strengthening of the district health system.

I would like to take this opportunity to make some observations about the outbreak of bubonic plague in Beed (Maharashtra) and pneumonic plague in a small part of the city of Surat in Gujarat. We mounted an unprecedented effort and succeeded in effectively and quickly controlling it and minimizing morbidity and mortality. While we fully understood and appreciated the travel advisories issued by WHO and some other countries in this regard, we were perplexed at the refusal of some countries to allow flights from India to land even though these originated from plague-free areas, in some cases located more than a thousand kilometres away from the site of the plague outbreak. This was all the more inexplicable when one takes into account that flights emanating from India were in full compliance with International Health Regulations and that stringent measures entailing, inter alia, the checking of passengers before boarding, fumigation of aircraft,

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etc. were being taken by the Indian authorities. The international community would do well to avoid such unwarranted disruption of trade and travel in similar situations no matter where they occur.

The World Health Organization has for the past 47 years been working as a close partner with Member States towards the universal quest for better health for peoples of the world. As a founder Member of WHO, India has greatly benefited from this partnership. I take this opportunity to compliment WHO on its achievements and the Director-General for his stewardship and look forward to their continued involvement in the advancement of health of the people.

Mme VEIL (France):

Monsieur le Président, Monsieur le Directeur général，Mesdames et Messieurs les délégués, Mesdames et Messieurs, c'est pour moi un grand honneur de m'adresser, au nom de la France, aux délégations du monde entier réunies dans cette enceinte, et je voudrais vous féliciter, Monsieur le Président, d'avoir été élu pour conduire les travaux de cette Quarante-Huitième Assemblée mondiale de la Santé qui devrait traiter des questions essentielles auxquelles notre Organisation se trouve aujourd'hui confrontée. Chacun de nous est bien conscient, et le Directeur général, le Dr Nakajima, au premier chef, de l'ampleur des défis qu'il nous appartient de relever, et du rôle tout à fait irremplaçable de l'Organisation mondiale de la Santé pour ce faire.

Les profonds changements politiques et économiques qui ont bouleversé le monde ces dernières années ont eu également pour conséquence l'émergence de nouveaux problèmes sociaux de grande ampleur, parmi lesquels ceux relatifs à la santé occupent une place prioritaire. La communauté internationale en a d'ailleurs largement débattu ces derniers mois, tant à la Conférence du Caire, consacrée à l'évolution démographique de notre planète, qu'au Sommet de Copenhague consacré au développement social. Le prochain rendez-vous de Beijing nous donnera à nouveau l'occasion de revenir sur ces questions, sous l'angle particulier du rôle qui revient aux femmes dans le développement.

Cependant, bien souvent, nos débats peuvent apparaître éloignés des préoccupations réelles, alors que les médias témoignent quotidiennement des drames qui affectent tant d'hommes et de femmes, confrontés aux difficultés dues à la crise économique, aux guerres civiles, ou à la résurgence d'épidémies et de maux que l'on pensait avoir vaincus. Dans ce domaine, certains indicateurs de l'état de santé de la population mondiale sont particulièrement alarmants : la mortalité infantile mondiale ne diminue plus, ce qui signifie qu'elle augmente dans nombre de régions. Ces dernières années, la couverture vaccinale a cessé de s'étendre, régressant même dans de nombreuses régions du monde. Dans le même temps, la tuberculose est redevenue une préoccupation majeure de santé publique et près de la moitié de la population demeure exposée au paludisme.

Le monde en développement paie le prix de la crise économique, mais aussi d'une certaine forme de libéralisme trop systématiquement mis en oeuvre, souvent sans grand discernement, au détriment des programmes sanitaires et sociaux. Dans les pays riches, cette tentation n'est pas absente : l'alourdissement des dépenses sociales conduit parfois à des réformes drastiques qui, sous la pression d'intérêts conjugués ou de la facilité, ne cherchent pas suffisamment à protéger les populations les plus vulnérables en fixant les objectifs prioritaires à préserver. Comment ne pas s'insurger contre l'évolution d'un monde où l'on voit se creuser sans cesse - et le troisième rapport sur la mise en oeuvre de la stratégie mondiale de la santé pour tous vient de le souligner 一 les disparités entre les pays riches et les pays en développement, de même que les écarts au sein d'un même pays entre les riches et les pauvres ？

Nulle part mieux qu'ici, la communauté internationale doit être en mesure de parler d'une seule voix et de se donner les moyens de répondre collectivement, par une coopération renouvelée, aux défis de notre temps. Dans un monde désormais largement ouvert, la santé de chacun de nous dépend largement de celle de tous et je crois illusoire de concevoir une politique de santé publique limitée à son seul pays.

Qu'il me soit permis, à ce titre, de rendre hommage au programme consacré à la coopération intensifiée avec les pays les plus démunis : depuis 1988，ce programme révèle toute l'importance de la solidarité internationale, en s'adressant d'abord aux pays dont les ressources en matière de santé s'avèrent les plus limitées. Sa seule faille, si l'on peut dire，est de n'être pas à même de répondre aux demandes croissantes d'assistance de nombreux pays. Je constate également avec satisfaction le travail accompli par notre Organisation en direction des pays d'Europe orientale dont la situation sanitaire et sociale a fortement empiré ces dernières années.

L'OMS est aujourd'hui bien consciente de la nécessité de s'engager, dans un contexte politique et économique particulièrement difficile, dans la voie des indispensables réformes internes à même de lui permettre de mieux répondre à ces défis. Des premiers pas ont été accomplis ces derniers temps, d'autres

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doivent l'être, et mon pays soutiendra toutes les initiatives qui iront dans le sens souhaité. En termes d'illustration, j'évoquerai un autre domaine où l'Organisation a su faire preuve de sa capacité d'adaptation : celui des secours humanitaires d'urgence. Dans des circonstances particulièrement difficiles 一 je songe notamment au Rwanda -, l'OMS a su en quelques mois se révéler un partenaire essentiel et prendre toute sa place dans ce domaine.

La lutte contre le VIH et le SIDA appelle également de notre part à tous une constante adaptation aux réalités, fort évolutives, de la pandémie. Ces derniers mois, une conscience nouvelle de ces réalités me semble avoir vu le jour. L'organisation d'un premier Sommet mondial consacré au SIDA, le 1er décembre dernier à Paris，a mis en lumière la gravité de la pandémie dans les pays en développement et conclu à la nécessité absolue de faire de ce combat une priorité de nos politiques de coopération ainsi que l'expression de la solidarité des nations de la planète. La Déclaration, signée solennellement par les chefs de gouvernement - ou leurs représentants - de quarante-deux nations, s'y est engagée clairement, en proposant une méthode originale consistant à associer autant que possible à cet effort les organisations non gouvernementales, notamment celles rassemblant des personnes atteintes.

Il appartient désormais à chacun de nous de traduire sans tarder ces engagements par des actions concrètes. C'est pourquoi la France encourage le programme commun coparrainé des Nations Unies sur le VIH et le SIDA, qui entrera officiellement en fonction le 1er janvier 1996，- et elle le soutient avec détermination - à se doter sans tarder des moyens humains et des ressources financières propres à remplir sa mission. Ne nous y trompons pas : le SIDA constitue d'ores et déjà un test majeur de notre aptitude à mettre en oeuvre une réponse commune à un fléau qui affecte l'humanité dans son ensemble. Nous n'avons pas le droit d'échouer, parce que ce virus est un ennemi implacable, mais aussi parce qu'est en jeu une certaine conception de la solidarité entre les nations de ce monde. Que des pesanteurs quelconques, ou les arrière-pensées des uns ou des autres, viennent entraver le développement du programme commun, et c'en sera fini de notre espoir d'un front uni en particulier contre le VIH 一 chacun étant dès lors renvoyé à l'égoïsme de son pré carré - et d'une façon générale contre tout fléau de santé qui menacerait à ce point la collectivité internationale.

A l'heure où s'achève la mission du programme mondial de lutte contre le SIDA, après huit ans d'existence - qu'il me soit permis à cette occasion de féliciter chaleureusement le Dr Merson et son équipe pour le travail accompli durant ces années -, j'ai pour ma part la certitude que la relève est assurée par le Dr Piot et ses collaborateurs, dans un sens qui répond, j'en suis convaincue, aux aspirations de tous et à la nécessité de la plus grande efficacité possible. Mon pays assumera ses responsabilités. Il se félicite des travaux qui ont été menés ces derniers mois avec les responsables du programme commun, dans le cadre du suivi du Sommet. Sur la base des priorités énoncées le 1er décembre, la France est désormais en mesure de mettre des crédits importants à la disposition du programme commun et ce, dès cette année, afin de lui permettre d'engager sans tarder les opérations les plus urgentes. J'appelle solennellement les bailleurs de fonds, qui ont soutenu comme nous-mêmes la constitution de ce programme unique, à joindre le geste à la parole.

Je souhaite qu'avec la mise en place du programme commun, l'OMS continue à jouer le rôle majeur qui est le sien dans la lutte contre le SIDA. La fin du programme mondial dont elle avait la responsabilité ne doit pas conduire à un affaiblissement des actions entreprises jusqu'à ce jour au niveau mondial comme au niveau national, mais au contraire à leur renforcement. Il faudra cependant la coopération et l'effort de tous.

Je sais que cette période de transition est une source d'inquiétude pour un certain nombre de pays, notamment ceux du Sud, qui craignent de voir s'interrompre les concours techniques et financiers dont ils ont bénéficié jusqu'à présent et qui sont vitaux pour leurs programmes nationaux. Pour ma part, j'ai confiance en la capacité des organismes coparrainants d'apporter, chacun dans son domaine, un soutien sans faille au nouveau programme, comme l'OMS elle-même s'y engage. Il appartiendra aux Etats qui contribuent à cet effort d'y veiller précisément, en concertation avec les bénéficiaires de l'aide.

La France assume également, jusqu'au 1er juillet prochain, la présidence de l'Union européenne. Elle souhaite pouvoir donner tout son sens à l'Europe de la santé, issue de la volonté politique des Etats Membres, soucieux de construire une Europe plus proche des citoyens. Le Traité de l'Union européenne institue, en son article 129, la promotion d'un haut niveau de protection de la santé comme objectif des politiques de santé publique mais aussi des autres politiques communautaires.

La prochaine session du Conseil des Ministres de la Santé, réuni chaque semestre et présidé par le ministre de la santé de l'Etat Membre assurant la présidence du Conseil de l'Union européenne, illustrera d'abord la préoccupation de la présidence française d'assurer la continuité et le renouvellement des premières initiatives prises par les Etats Membres dans le domaine de la santé. Il s'agit en effet pour le Conseil, suite

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aux propositions de la Commission et aux avis et aux résolutions du Parlement européen, d'aboutir à une position commune sur les programmes de lutte contre le cancer, contre le SIDA et contre les autres maladies transmissibles, ainsi que sur le programme de promotion de la santé. A ces trois programmes s'ajoutera une discussion d'orientation sur la lutte contre la toxicomanie, qui constitue aujourd'hui un objectif majeur de toute politique de santé publique, et qui est inscrite explicitement par le Traité comme l'un des grands fléaux contre lesquels doit porter l'action de l'Union. Par ailleurs, est prévue, à partir d'une communication de la Commission relative à la sécurité du sang et des produits sanguins, l'adoption d'une résolution sur ce thème.

J'ai également souhaité soumettre au Conseil un mémorandum sur les médicaments orphelins, soulignant la nécessité de prendre, sans tarder dans ce domaine, des dispositions semblables à celles existant aux Etats-Unis d'Amérique et au Japon, pour favoriser le développement de médicaments traitant de pathologies rares, notamment certaines des maladies opportunistes du SIDA ou certaines maladies génétiques. Je forme l'espoir que le débat sur ce sujet, dont les enjeux en termes économiques et plus encore de santé publique sont considérables, pourra produire rapidement des résultats concrets. Je souhaite en outre que le Conseil du 17 mai offre l'occasion de réfléchir lorsque la situation l'impose - je pense notamment aux épidémies qui peuvent éclater ici ou là, à l'apparition de nouveaux virus ou agents pathogènes 一 à des moyens de mobilisation rapide des instances communautaires, et à la mise en place au niveau des ministres eux-mêmes d'une sorte de système d'alerte afin de permettre un échange rapide des informations disponibles et de répondre aux légitimes inquiétudes de l'opinion publique dans ces situations de crise. J'envisage donc de présenter au Conseil de santé une déclaration à ce sujet. Comme vous pouvez le constater, les objectifs de la présidence française pour ce Conseil sont ambitieux : ils me paraissent cependant réalistes, dans la mesure où ils témoignent de l'esprit de coopération exemplaire qui a existé entre Etats Membres, mais aussi avec la Commission et le Parlement européen. Je me suis étendue sur ce projet du Conseil de santé de l'Union européenne car je crois qu'il est temps aussi que des liens plus étroits puissent être tissés entre l'Union européenne et l'OMS, dont non seulement les missions, mais aussi les ambitions, apparaissent à bien des égards complémentaires.

Sachons ouvrir la voie à un partenariat privilégié entre nos deux institutions. Les européens jouent d'ores et déjà un rôle actif au sein de l'OMS, en assurant près du tiers du budget ordinaire de l'Organisation et en fournissant nombre d'experts à ses programmes. Il doit être possible de mettre davantage en commun les réflexions et les travaux menés dans nos enceintes respectives, et de définir ensemble, notamment à l'intention du monde en développement, des actions de coopération en matière de santé publique.

Il s'agit à mes yeux d'une réelle exigence que nous devons tous ensemble être disposés à respecter si nous voulons faire des progrès significatifs en matière de santé publique et atteindre, déjà avec retard nous le savons, les objectifs d'Alma-Ata concernant la santé pour tous. Tous ensemble, nous pourrons progresser.

Mrs THALÉN (Sweden):

Mr President, Mr Director-General, distinguished delegates, the Director-General has asked us to address the subject equity and solidarity in health - bridging the gaps. A relatively coherent picture of global health problems is emerging. The world health report 1995 is an important contribution to making the health problems and challenges more clear to a broad audience.

In this Assembly we have during several years called attention to the widening gaps in health, both within countries and between countries. We all know that health is related to global social, economic and political realities. What is necessary now is to take strategic decisions on action far-reaching as well as concrete. Bridging the gaps in health must be at the top of the international agenda. In this respect it is very encouraging that several United Nations organizations increasingly focus on interventions for health as a way to development.

It is however, a serious problem that the United Nations system does not make optimal use of its resources. By building strong alliances and using complementary expertise and resources, it is possible to proceed more rapidly towards the objectives of health for all. WHO should actively promote such a course of action. Well-functioning division of work and collaboration is the only available avenue to increase resources for health. We, Member States, must ensure productive alliances, and to this end it is our duty to coordinate our positions in the different governing bodies. The creation of the new Joint United Nations Programme on AIDS is in this respect an important step forward. I congratulate WHO on its contribution in this regard.

The WHO response to global change started in 1993 as a matter of urgency, as we all believe that WHO can make a difference In bridging the gaps in health. A broad internal reform process is now taking

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place. Sweden would like to see greater transparency, a strong involvement of Member States in this process and practical results. The Swedish Government has supported the work of WHO since its start. We have also contributed substantial financial and human resources to the development of policies and cost-effective interventions in many programme areas. And we have shared the pride when millions of people all over the world have benefited from the results of the joint efforts. Solidarity in health is solidarity with people in need. Therefore, Sweden has voiced its concern about the effectiveness of WHO. Together with the Secretariat and other Member States, in particular, those who need WHO services the most, we are prepared to work to make it stronger. The challenge is to make the right strategic decisions on how we should work. Sweden believes that WHO must strike a better balance between its normative and technical cooperation functions. Excellence in its normative role must be at the heart of WHO, based on solid research and technology development. This must then be translated into technical and health policy guidance, helping governments to improve their national capacity. It does not preclude the presence of WHO in countries; on the contrary, development of policies and technical guidance can only be carried out in real situations, tried and adapted to a variety of needs.

A weakness in the reform process is that WHO's policy and mission have not been discussed. The results of the monitoring of the health-for-all strategy and the new World health report have not led to clear conclusions on either priorities or on how to restructure the work of the Organization. It is necessary to identify and then concentrate on strategic areas where WHO can make a difference in global health. Its core function has been in the domain of public health; for example, vaccinations, diet and nutrition, tobacco, alcohol and drugs and a safe environment. Here, WHO is in the forefront. Steps have recently been taken to develop the area of reproductive health. In my view, we cannot talk about poverty, equity, women and development, prevention of sexually transmitted diseases and HIV/AIDS, safe motherhood and population issues, unless WHO as a specialized agency accords highest priority to reproductive health in its broadest sense. No other United Nations organization is in a better position than WHO to develop, on a scientific and objective basis, policies and strategies as guidance to its Member States. To claim leadership in public health, WHO, and we ministers of health, must dare to take a lead in reproductive health.

Another crucial issue is the effectiveness of our decentralized organization. From the point of view of governance and cost, much more attention should be paid to the role of WHO at regional and country levels. A major renewal of working methods has been necessary in the European Region. Even if this is far from sufficient to meet the needs of the many new Member States in the Region, I think that the experiences of trying to respond to the needs of collaboration in health care reforms in a large number of low-income countries could be very useful in the global reform process.

Leadership in international health requires a clear vision, high competence and effectiveness. This is the basis for mutually respectful work and collaboration with a variety of partners, not least nongovernmental organizations. Let us set a clear agenda for WHO, carry out the necessary organizational reforms, and ensure full support for future action. WHO has a substantial capital in expertise and experiences. Solidarity in health requires that we put it to better use.

Dr LEE (United States of America):

Mr President, Dr Nakajima, fellow delegates, ladies and gentlemen, it is my pleasure to address you on behalf of the United States. Mr President, I join my colleagues in offering congratulations to you on your election to preside over this Assembly. Our deliberations here occur at a time when many people around the world are living longer and better than ever before, but many are not, as The world health report 1995

describes in such depressing detail. In the good news, we find eight out of ten children in the world have been vaccinated against the five major killer diseases of childhood; since 1980 infant mortality has fallen by 25%; and at the same time overall life expectancy has increased to almost 65 years. For this, the world health community has reason to be proud.

These advances represent much more than an improvement in the quality and availability of health services and the application of research findings to the medical and public health practices of nations throughout the world. They represent the results of economic and community development and a focus on prevention for individuals and communities. These achievements are a result of years of international cooperation towards a common vision of healthy people on a healthy planet.

While our progress over the last century has outpaced the entire history of humankind, millions of men, women and children on this earth still live in abject poverty, struggling for food, clothing, shelter and health. Outbreaks of new infectious diseases, such as HIV/AIDS, and familiar diseases that have evolved to become

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resistant to therapeutic drugs, as in the case of drug-resistant tuberculosis, present challenges to our resourcefulness. Our previous successes are resulting in dramatic demographic changes around the world. As we grow older, the quality of those years must be ensured. As we grow in numbers, the significance of the Declaration of Cairo will be recognized.

Urbanization of our world5s population has presented the age-old issues of adequate shelter, water and sanitation with new intensity. And, in addition to meeting the basic needs, the nations of the world must adapt and apply their collective expertise to particularly troublesome social issues - unintended pregnancies, violence, substance abuse, including the use of tobacco, sexually transmitted diseases, and other conditions associated with behaviour - all of which can lead to enormous health burdens for our nations' peoples. The need for a broad-based approach is clear. To address the true determinants of health - behaviour, socioeconomic status, human biology, the environment as well as medical care - a range of individuals, health professionals and institutions, and public and private organizations must work together to protect and improve their population's health.

Priorities must be set, stated, and backed up with action and resources. That is why the Executive Board at its January meeting requested that at least 5% of the 1996-1997 budget, as proposed by the Director-General, be shifted to WHO's highest priority areas including: eradication of specific communicable diseases including poliomyelitis, dracunculiasis, and leprosy; prevention and control of specific communicable diseases; reproductive health, women's health and family health; promotion of primary health care, including especially nutrition and essential drugs; and promotion of environmental health, especially community water supplies and sanitation. The United States welcomes this important beginning to the priority-setting process and to the effort of WHO's governing bodies to become more deeply involved in the decisions on the allocation of resources. Given spending constraints and the competing priorities that each of us faces in our own countries, it will increasingly prove difficult to expand our resources unless national leaders see results and better understand the critical role of good health in assuring successful development in their countries.

There is a need for a stable health services sector that is a major employer in most countries. There is a need for a healthy workforce as it is usually a more productive workforce. There is a need for health education of men and women to assure healthy children and healthy communities. There is a need to consider the health impact of decisions to use financial, human and natural resources in national development efforts.

How can we accomplish these tasks? I believe we must reinvent public health. This means linking public health programmes to the personal health care delivery system and to broader social policies in order to achieve population-based public health goals. By providing a mutually beneficial framework to coordinate population-based services and personal health care services, with broader social policies, we can sustain and continue the improvements in world health.

Solidarity and coordination among nations is the key. It will enable the United States and other nations to share costs, labour, resources and to avoid duplication in our efforts to close the gaps and achieve our goal of health for all by the year 2000. The United States is committed to the pursuit of these goals and values the opportunity to work with and within WHO and with other countries to improve the health status of all.

Mr IDE (Japan) {interpretation from the Japanese)'}

Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, it gives me very great pleasure to outline the basic views of the Japanese Government on the protection and improvement of world health.

Mr President, I would first like to offer you my warmest congratulations on your appointment as President of the Forty-eighth World Health Assembly. My delegation is confident that your outstanding leadership ensures a fruitful outcome for this Assembly.

Permit me to begin by taking this opportunity to express, on behalf of the Government and people of Japan, our most sincere thanks for the warm sympathy and assistance extended, following the earthquake in the Hanshin-Awaji region on 17 January, by so many governments whose representatives are here today, and by people all over the world. The Japanese people, greatly encouraged by that generous sympathy and assistance, are making concerted efforts to restore the affected areas as rapidly as possible. In the midst of such hardship, the people of Kobe are determined to ensure the success of the WHO Kobe Centre, which will be established next year.

1 In accordance with Rule 89 of the Rules of Procedure.

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We are approaching the year 2000, and the beginning of the next millennium. It is not too much to say that the past few years have seen unprecedented change, with very important implications for the health of people all over the world. The Cold War era is over. While this turning point in history was, clearly, greatly to be welcomed, we have recently seen tragedies of vast proportions caused by racial and religious conflicts, for example, in Bosnia and Rwanda. These new conflicts have had a very grave impact on people's lives and health. Also, vast numbers of the world's people continue to suffer from poverty and low health standards, despite worldwide economic development and improvement in overall global wealth. Nor can we ignore the sad fact that millions of children are still dying every day of preventable infectious diseases, notwithstanding continuing progress in reducing worldwide infant mortality.

In addition, rapid population growth, rapid urbanization，the spread of AIDS and the destruction of the global environment must be seen as serious problems on a global scale. These problems expose human beings to critical threats to health. We human beings, who have received the gift of life on this Earth, must join together, consolidating the wisdom of the world, to combat these difficulties in order to preserve and promote health, one of the most important basic human rights. We are confident that, in this vitally important undertaking, WHO will continue to play a leading role, making maximum use of its outstanding expertise.

During the past half century, Japan has implemented important health and medical initiatives, for example, the programme to control communicable diseases and that to improve maternal and child health. As a result of such initiatives, Japan has now attained one of the longest average life expectancies at birth and one of the lowest infant mortality rates in the world. We desire to contribute to the improvement of world health by sharing with other countries the technical know-how and experience which our country has accumulated in the health and medical care fields. I would like to take this opportunity to assure you of Japan's determination to make the greatest possible contribution to promoting WHO's strategy of health for all.

I should like next to refer to several WHO initiatives which we consider of very great importance for world health.

First, I would like to touch upon WHO's reforms. WHO is now actively working for reform, in response to global changes and in accordance with the 47 recommendations approved at the Forty-sixth World Health Assembly. We are pleased to see tangible achievements and progress, such as the establishment of committees to promote closer cooperation and a more effective relationship between WHO headquarters and its regional offices, financial reforms, including the proposed "user-friendly" programme, and efforts to develop a new health strategy for the twenty-first century. We hope that WHO will continue to work for the attainment of these goals, with yet greater energy and with still more rapid progress.

From our own tragic experience of the recent earthquake in the Hanshin-Awaji region, we fully appreciate the ever-growing importance of humanitarian assistance in the health field because of the growing frequency and seriousness of natural and man-made disasters in recent years and other emergency situations with tragic consequences in all parts of the world. WHO has sent many experts to disaster-affected and emergency areas and has provided technical assistance for the prevention of infectious diseases, which are a frequent danger in the case of disasters. We intend to continue to support these WHO humanitarian relief operations.

WHO is currently promoting various programmes directed towards meeting world health needs, such as the joint and cosponsored United Nations programme on HIV/AIDS, the poliomyelitis eradication programme and the food safety control programme. The Japanese Government wishes to pay high tribute to WHO for its very appropriate responses to such world health issues. The Government of Japan hopes most earnestly that WHO, the only United Nations specialized agency in the health field, will continue energetically to introduce and implement initiatives and play the key leadership role among the United Nations organs in promoting the joint and cosponsored United Nations Programme on HIV/AIDS, designed to ensure that those organs can work jointly to control the spread of AIDS. We are of the view that the other United Nations organs concerned should fully share the responsibility by providing financial and technical support for the programme. The Government of Japan here expresses its intention to give this programme the fullest possible support, participating actively in the programme Coordinating Board which is scheduled to be established under the joint and cosponsored United Nations programme.

The theme of this year's World Health Day is "Target 2000 - a world without polio". We are fully conscious that poliomyelitis eradication by the year 2000 is one of the major targets to be achieved. In our Western Pacific Region, eradication of poliomyelitis by the year 1995 has been a major regional goal, and we are close to achieving it. I commend most sincerely Dr S.T. Han, Regional Director for the Western Pacific, and his staff on their remarkable efforts for the attainment of this goal.

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I should like next to refer to the important topic of international food standards regulation. WHO has always played a key role in ensuring food safety, in collaboration with the Food and Agriculture Organization of the United Nations. With the establishment of the World Trade Organization in January of this year, the importance of international food standards has increased very considerably. Now is the time for WHO to bring its great wealth of technical knowledge and expertise in this area to bear for the betterment of health worldwide.

The strategy "Health for All by the Year 2000" was aimed at an important goal towards which we were striving energetically. However, achieving this objective by the year 2000 is now seen to be more difficult than we originally thought, particularly in the light of the massive and rapid global change witnessed in the past decade. It is now clear that we need to update the strategy. The time has come for us, WHO's Member States, to unite under the Organization's banner and make every effort to promote a new health strategy for the twenty-first century. We believe the WHO initiative of convening a high-level world conference is meaningful and essential. The Government of Japan strongly supports this initiative.

We have the greatest possible admiration for the leadership and efforts of Dr Hiroshi Nakajima, Director-General, in addressing the various health issues. We greatly hope that he will continue to exercise the same leadership role in the future.

The Government of Japan has been making every effort as an Executive Board member to address various world health issues, including WHO reforms and other important matters, during the past three years. We take this opportunity to express our readiness to serve again as an Executive Board member from next year, and to stand for election to the Executive Board in May 1996.

I would like to conclude my address by assuring you, once again, Government of Japan to contributing to constructive efforts to fulfil WHO's Organization all possible assistance.

Mme MARLEAU (Canada):

Monsieur le Président, Docteur Nakajima, distingués collègues et délégués, Mesdames et Messieurs, aujourd'hui, l'Organisation mondiale de la Santé se trouve bel et bien à la croisée des chemins, à un tournant de son histoire. Divers facteurs contribuent à cet état de fait, et notamment les principales réformes en cours au sein même de notre Organisation et au sein de l'ensemble des organismes des Nations Unies, les contraintes financières avec lesquelles doivent composer plusieurs des pays qui assurent un soutien important à ces organismes, le besoin de renouveler nos stratégies en matière de santé, enfin, le nouveau contexte géopolitique. Le moment est donc venu de nous demander de quelle manière nous souhaitons que l'OMS continue de répondre à nos besoins collectifs.

Monsieur le Président, le Canada est satisfait du travail réalisé à ce jour sur la réforme de l'OMS visant une meilleure gestion des programmes, une plus grande efficacité administrative et la concordance entre les ressources et les priorités.

Les fortes pressions budgétaires dans de nombreux Etats Membres, dont le Canada, ont nécessité une étude fondamentale de toutes les dépenses de programmes, y compris celles des organisations internationales.

Le Canada continue d'accorder une grande importance aux principes de définition de priorités et d'une limitation maximum des coûts. Toutefois, cela ne signifie pas que l'OMS sera privée des moyens pour réaliser ses tâches essentielles. La simplification administrative et les gains en productivité qui devraient découler du processus de réforme pourraient générer les ressources nécessaires pour que l'OMS puisse rester une organisation dynamique à même de s'adapter aux défis changeants des besoins de santé des populations du monde.

En tant qu'Etats Membres participant à cette Assemblée, nous devons préciser ce que nous attendons de l'OMS, individuellement et collectivement. Pour le Canada, l'Organisation devrait être le premier partenaire pour la définition collective des mesures de santé dans la communauté internationale. Pour ce faire, l'OMS et ses Etats Membres doivent préciser les tâches qui peuvent être le mieux réalisées au niveau international, définir les tâches clés pour l'OMS par rapport aux Etats Membres, spécifier ses responsabilités propres dans la réforme du système des Nations Unies et adopter un programme de travail qui reflète réellement la capacité financière de l'OMS.

Dans ce processus, de nouvelles orientations programmatiques apparaîtront. Elles devraient accorder une plus grande importance à la surveillance ainsi qu'à la coordination des actions de prévention et de lutte contre les maladies au niveau mondial. Elles devraient renforcer le rôle normatif de l'OMS dans les domaines

of the commitment of the noble mission by giving the

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des produits pharmaceutiques, des équipements médicaux et de la réglementation sanitaire, sans oublier la capacité accrue à partager les données sanitaires entre les Etats Membres.

(The speaker continued in English.) (L'orateur poursuit en anglais.)

Several priority activities of the Organization are on this year's agenda and we have before us resolutions that will further global public health. In connection with "Tobacco or health," Canada and other countries have been at the forefront in asking the Director-General to investigate the feasibility of an International Convention on Tobacco Control. I believe that it is now time for such a global regulatory instrument. In this connection, the Government of Canada's Tobacco Demand Reduction Strategy includes an international component which supports WHO's "Tobacco or health" programme.

We also have in front of us for consideration a conceptual framework for reproductive health. This issue is particularly important to Canada and to me as Minister of Health. In the wake of the International Conference on Population and Development, and a few months before the Fourth World Conference on Women, it is extremely important for us to define clearly the role and responsibilities of WHO. WHO proposes to concentrate on the collective, social side of reproductive health through a public health approach. We agree that this utilizes the Organization's comparative advantage. We also believe we must collectively monitor and assess the ethical dimension of new reproductive technologies.

At this Assembly, heads of delegations are focused on equity and solidarity in health - bridging the gaps. The latest report on monitoring of progress in the implementation of strategies for health for all by the year 2000 concludes that globally, life expectancy continues to increase, and infant and maternal mortality is gradually declining. Progress is also being recorded in other specific areas, such as poliomyelitis and leprosy eradication. However, scourges new and old continue to cause death and suffering among the most vulnerable populations of the world, and the gap between the haves and have-nots remains as wide as ever. In order to meet this challenge, WHO is currently advocating a "health futures" approach to help define Member States' health needs of tomorrow.

Canada is also prepared to take on this challenge. A few months ago, my provincial and territorial colleagues and I released a discussion paper entitled "Strategies for population health: investing in the health of Canadians". That document provides a framework for action on the major determinants of health. It gives us a solid basis to set priorities to continue to improve the health of Canadians. The paper recommends strengthening public and government understanding of the determinants of health by demonstrating the links between social status, economic development, income distribution, education and health.

The vast majority of Canadians are solidly behind efforts being made by governments, professional groups and other stakeholders to improve the efficiency of the health system. As Federal Minister of Health, I have fully supported the efforts of provincial and territorial governments in this regard. In Canada, we are committed to an equitable health care system. We recognize and affirm Canadian values relating to health by preserving a universal, comprehensive, accessible, portable and publicly administered health care system Canada has a long history of commitment to these principles in serving a dispersed population in a federal system of government. We will maintain our commitment, notwithstanding some difficult economic realities that we, as many nations of the world, are experiencing at the moment.

Internationally too, Canada's actions are influenced by policies based on equity and solidarity. The Government of Canada has decided that at least 25% of our official development assistance will be devoted to basic human needs such as health, education, water and sanitation. Equity relates not only to income distribution, but also to gender. In this context, the Canadian Government is committed to improving the health of women. The Fourth United Nations World Conference on Women, next fall in Beijing, will draw particular attention to the health needs of women around the world. The specific health concerns of women vary in different parts of the world. But in every country, including my own, the health status of girls and women is related strongly to their economic, social and cultural environment. We must take a multidisciplinary approach to women's health. In Canada, we are working on a women's health strategy, which takes such an approach. We are interested in the major illnesses and diseases which particularly affect women, as exemplified by our work on breast cancer. And we know we must take a gender-specific approach to disease prevention and health promotion. That is why we are establishing centres of excellence for women's health in Canada. The centres will focus on the broad determinants of women's health and on changes in how our health system understands and addresses women's health needs. The health system must respond to these needs by providing women with relevant information, and effective and appropriate

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diagnoses and treatment. We commend the work of the Global Commission on Women's Health and trust that WHO will place a high priority on the health of girls and women.

In conclusion, let me reaffirm Canada's belief that WHO has a unique role to play to further equity and solidarity in health. The world health report 1995 introduced earlier this morning by the Director-General is an excellent example of the work of WHO in collecting and analysing data about the world health situation.

We have set in motion, within the reform process, forces that can close the gap, energies that can redress inequities. Canada is committed to playing its part in that regard and to support WHO in its mission to improve global health.

El Dr. ANTELO PEREZ (Cuba):

Distinguido señor Presidente, distinguido Director General, distinguidos delegados: Mis sinceras felicitaciones a Dato Dr. Haji Johar Noordin por su elección como Presidente de la 48a Asamblea Mundial de la Salud. Deseo comunicarle nuestra decisión de colaborar junto a usted para el desarrollo de esta Asamblea Mundial de la Salud. Se nos ha solicitado que hagamos referencia al tema «Equidad y solidaridad en la salud: reducir las desigualdades»，cuestión que nos agrada mucho pues en materia social en general, y en salud en particular, el pequeño país que represento ha realizado un esfuerzo extraordinario para materia-lizar la equidad social dentro de un desarrollo social sostenido.

Pienso que para tener claridad en este tema, en el orden mundial se requiere analizar la inequidad en materia de salud, pues denota claramente una falta de satisfacción de las necesidades sociales, posiblemente como resultado de una distribución de los servicios de salud que no tiene en cuenta las diferencias en las necesidades de la población, tanto entre los países como en su interior. No obstante, las inequidades no necesariamente se eliminan, ni siquiera se reducen, mediante una distribución igual de los recursos. Tal distribución supondría que las necesidades se distribuyen de manera homogénea, lo cual claramente no es así. En consecuencia, para que la ejecución de la política de salud sea equitativa es fundamental primero conocer la distribución de las necesidades, y éstas se exponen con claridad en el Informe sobre la salud en el mundo, donde se señala la dramática situación existente. Voy a referirme a sólo unos párrafos, que describen la realidad existente en el mundo de hoy.

«El principal factor de mortalidad y causa primera de enfermedad y sufrimiento en todos los pueblos es la pobreza extrema.»

En la pobreza está fundamentalmente la explicación de que los niños no sean vacunados, de que se carezca de agua salubre y de saneamiento, de que no se disponga de medicamentos curativos y otros tratamientos, y de que las madres mueran de parto. Es la causa subyacente de la reducción de la esperanza de vida y de las minusvalías, las discapacidades y la inanición. La pobreza es uno de los principales desencadenantes de la enfermedad mental, el estrés, el suicidio, la desintegración de la familia y el abuso de ciertas sustancias. Cada año mueren en el mundo en desarrollo 12,2 millones de menores de 5 años, en su mayoría por causas que podrían prevenirse con un gasto de sólo unos cuantos centavos de dólar por niño. En buena medida mueren debido a la indiferencia del mundo, pero en su mayor parte mueren porque son pobres.

¿Cómo y de qué manera vamos a enfrentar esta realidad sanitaria de hoy, si no se da solución a las causas reales que generan la pobreza?

No es menos cierto que los países subdesarrollados debemos esforzarnos por llevar hacia delante nuestro desarrollo, pero en materia política, económica y social no podemos admitir que se pretenda equipa-rar los deberes de los países subdesarrollados con los de los desarrollados, pues con ello se intenta borrar la enorme deuda social acumulada, que forma parte de la demanda de nuestros pueblos. Si hablamos de equidad y solidaridad, para que ésta sea efectiva se necesita establecer un flujo real de la cooperación internacional de los países desarrollados a los subdesarrollados que sea equitativa y solidaria, que apoye las acciones de cada país y no las ahogue con sus condicionamientos.

Señores delegados: Al pedírsenos que hablemos de equidad y solidaridad es preciso hacer un alto en esta augusta Asamblea y recordar que jamás se ha atacado de forma tan rigurosa y prolongada en condiciones no bélicas a un país pequeño por otro de enormes proporciones, con armas que nada tienen que ver con la equidad y la solidaridad como son el bloqueo económico y financiero, que a lo largo del tiempo han continuado arreciando para hacerlo más cruel, como la Ley Torricelli y más recientemente personajes como Helms y Burton quieren internacionalizarlo, por lo que considero un deber justo, equitativo y solidario con mi pueblo el de denunciarlo en esta Asamblea. Como es lógico, las presiones, los bloqueos y las pérdidas de nuestros socios comerciales tradicionales nos han traído dificultades, habiendo disminuido los recursos en

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los últimos cinco años a una tercera parte de los utilizados en 1989，con las consecuentes afectaciones en la disponibilidad de medicamentos, material fungible de uso médico, lencería, material de aseo y limpieza, y recursos para el mantenimiento. A pesar de estas insuficiencias de recursos se han sostenido los servicios de salud sin cerrar ninguna unidad, manteniéndose y mejorándose los indicadores de salud, estando presente la voluntad política de nuestro Gobierno a responder oportunamente a las necesidades que se le han ido planteando, la fortaleza del sistema nacional de salud, la equidad de nuestra sociedad y la solidaridad de países amigos y organismos internacionales y otras organizaciones no gubernamentales.

Nuestro sistema de salud es uno de los logros más genuinos en el campo social de la Revolución. Ha contado siempre con la admiración, el respeto y el apoyo de muchas organizaciones y pueblos hermanos, los que sin lugar a dudas coincidirán como nosotros, en que es necesario preservarlos a toda costa, dado su ejemplo y trascendencia, ya que en él se ven materializadas muchas de las estrategias de nuestra Organiza-ción, como son: la garantía de la accesibilidad efectiva en todos sus componentes, la cobertura total de la población, la equidad, el relevante papel de la atención primaria de salud, que logra su mayor expresión en la especialidad de medicina general integral, en el contexto del revolucionario modelo del médico y la enfermera de la familia, que es el centro del sistema, que ha sido la espina dorsal para que mi país haya cumplido desde 1983 con la meta de salud para todos y haberla mantenido a pesar de la crisis económica que hoy atravesamos.

Los cubanos luchamos firmemente para hacer frente a estos tiempos difíciles, no sólo por nuestra voluntad de resistir y vencer, sino también porque hemos creado en estos años los factores propiciatorios del desarrollo que permiten asumir en medio de dificultades, pero con optimismo, los desafíos del presente. Cuba cuenta con recursos humanos y tecnológicos, capacidad y experiencia que han resultado muy útiles a los pueblos del mundo. Siempre hemos estado en disposición de cooperar, y en realidad la colaboración internacional que hemos desarrollado en el campo de la salud la consideramos amplia y beneficiosa para todos. A pesar de la situación actual, mantenemos nuestra voluntad de continuar trabajando en esta línea para contribuir así, como un aporte, a la necesaria integración. Muchas gracias.

Professor CHEN Minzhang (China):

陈敏章部长在第48届世界卫生大会上的讲话

尊敬的主席先生：

中岛宏总干事：

各位代表：

女士们、先生们：

我非常荣幸地代表中国代表团在本届卫生大会上发言。

首先，请允许我对诺尔丁博士当选为本届卫生大会主席和

其它各位副主席表示热烈的祝贺，预祝他们领导本届大会

的工作能取得圓满成功。中国代表团对总干事中岛宏博士

所作的工作彳艮告’对世界卫生组织在促进世界和平与发展，

保护和促进人类健康及世界卫生组织自身改革等方面取得

的成就表示衷心的祝贺。

中国代表团赞赏世界卫生组织根据全球政治、经济、

卫生发展现状正在采取的积板措施制订全球卫生新政策，

并计划修订人人享有卫生保健战略的规则，我们认为这是

一个科学的符合全球卫生发展实际情况的举措，这将更有

利于充分发挥世界卫生组织的作用，与成员国开展更有效

的技术合作，并对全球卫生发展产生积极的影响。

在过去的一年里，为缩小发展中国家和发达国家之间

在经济和卫生服务状况上的差距，世界卫生组织在面临经

济困难的情况下，合理有效地使用卫生资源，积极开展与

各成员国的技术合作。在传染病预防、控制新出现和重现

的传染病、全球艾滋病预防和控制、化学品安全、烟草与

健康、妇幼卫生和生殖健康等方面均取得了一定的进展。

同时，世界卫生组织在处理世界突发事件所采取的紧急及

人道主义行动，在武装冲突地区的卫生和医疗服务以及与

最需要国家的合作方面，作出了积极的努力，为国际和平

与发展，为人类的健康事业做出了应有的贡献。我们认为，

应当全面和客观地对世界卫生组织工作进行评价。考虑到

卫生组织目前存在的经济困难，需要得到各成员国的理解

和支持并履行缴纳会费的义务，同时希望发达国家和捐款

机构继续对世界卫生组织财政困难给予热情的支持和帮助。

主席先生，和平与发展是当今世界各国所关注的焦点。

从的环境与发展大会，到 1 9 9 伴的人口与发展大会，

从今年初的社会发展大会，到即将在中国召开的第4次世

界妇女大会，和平、发展、平等、健康已成为国际社会的

一些中心议题。全球的人们越来越关心他们健康生活的权

力，全世界有识之士都在呼吁和平，促进发展，消灭贫困，

促进健康。中国政府十分赞赏世界卫生组织提出的“卫生

中的公平与团结一消灭差距”的口号，而且正为之进行不

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懈的努力，我们的总目标也是要逐步缩小地区间、人群间

的卫生保健的差距，力求在享有初级卫生保健上做到合理

的公平。

我国政府根据全国卫生事业发展趋势和存在的问题确

定每年或一个历史时期的卫生工作重点。

中国12亿人’有70—80%的人口在农村，因此，做好

农村卫生工作，始终是中国卫生工作头等重要的大事。目

前全国已有670多个县基本达到我国初级卫生保健的指标。

我们将进一步强化各级政府的目标责任制，加强健康教育。

提高群众健康意识及参与意识，在今年底力争有50%的县

即924个县达到初级卫生保健各项指标。

在各级政府的重视和努力下，以及与世界卫生组织联

合国儿童基金会、联合国人口基金、世界银行等组织开展

国际合作，成功地实施了加强中国基层妇幼卫生、计划生

育服务的合作项目，加强了基础妇幼保健网络建设，已经

或正在改善中国近60%贫困地区的妇幼卫生服务能力。妇

女、儿童的健康水平不断有所提高。

加强传染病预防控制一贯是我国卫生工作的重点。在

世界卫生组织及其它国际组织、友好国家政府和一些国际

非政府组织的支持下，近几年在消灭脊灰的活动中取得了

显著的成就，全国报告脊灰发病病例从1992年的1191例降

至 1的 3 6 5 例。我们充分认识到在 1 2亿人口的国土上

实现消灭脊灰的任务需要持续不断的努力，困难还很多。

但是，通过我们最大的努力和友好政府、友好团体的帮助

和支持，我们决心在今年底在中国实现消灭脊灰的目标，

为在西太区以至在全球实现消灭脊灰这一具有重要历史意

义的奋斗总目标做出我们应有的贡献。

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目前，我国政府和人民正在积极准备今年九月的世界

妇女大会，在这个会上，我们将与世界各国的妇女代表广

泛地讨论妇女各方面的问题，其中妇女与健康也是会议的

重要议题，这无疑将对加强全球妇女卫生保健工作，并同

时促进中国妇女的健康发挥重要的作用。

主席先生，我们重视世界卫生组织提出于1997年石开

世界卫生高层会议的倡议，我们认为这将有助于指导本世

纪末至下世纪初的全球卫生战略规划的实现，并创造广泛

交流意见的机会。中国是一个发展中的人口大国，经济还

不发达，但我们在利用有限的卫生资源不断提高全体人民

的健康水平方面取得了一定的成绩，也积累了一些有益的

经臉和教训，很愿意同各国交流合作，共同提高。我们愿

意以积板的姿态参与推动世界卫生发展的进程，如大会决

定石开此会议的话，我愿以中国政府的名义，向主席先生、

世界卫生组织秘书处、总干事申请届时在中国北京石开，

请给予积极的考虑。

女士们、先生们，中国卫生事业的发展一贯得到世界

卫生组织和世界各国朋友的热情支持和帮助，中国也愿意

为全球卫生发展和进步作出积极的努力。让我们共同为创

造一个和平、发展、平等、健康的世界做出应有的贡献。

谢谢大家。

Dr SNEH (Israel):

Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, I deem it a great privilege to address the Forty-eighth World Health Assembly. On behalf of the Israeli delegation, I congratulate you, Mr President on your election to preside over this Assembly. I commend you, Dr Nakajima, on your eloquent report, and for you and your staffs efforts in adapting WHO's work to changing global needs.

One of the major challenges with which policy-makers and health experts grapple in this day and age of tremendous global changes is how to guarantee appropriate health care for all citizens under serious budgetary constraints. How do we create a health care system based on solidarity, equity and human rights? How do we ensure the right of individuals to freedom of choice combined with their obligation to promote and safeguard their own health? How do we bridge inequities in health within and between population groups and, needless to say, within countries and between countries?

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There are many answers which we all know: effective use and allocation of financial and human resources; monitoring and evaluating situations and needs; monitoring and evaluating activities and interventions; and training, research and good management. All these are important tools for use in achieving our target of health for all. Yet, we also know that there is no one magic remedy, and constraints are exacerbated by environmental conditions, by unrest, by wars and terror, and by various political, social and economic upheavals. Each country is left to find the answers to its own special needs. At the same time, facing common challenges gives rise to opportunities for mutual assistance between states. Exchanges of ideas, information and experiences in a forum such as this are most valuable and the catalytic role of the World Health Organization in raising the awareness of all sectors to health issues and their interdependence with developmental processes cannot be surpassed.

From 17 to 22 December 1995 an international conference on governments and health systems will be held in Jerusalem. It will deal with the implications of differing involvements of governments in health systems. Is there a correct balance between involvement/regulation and independent action? Is "managed competition" a reasonable compromise for overseeing delivery systems and costs? I take this opportunity to invite to this conference all of you who may wish to join the deliberations and discussions on these important issues. Members of the Israeli delegation will be happy to provide you with more details and information.

I have recently succeeded in passing the National Health Insurance Law which establishes the fundamental right of every Israeli citizen to health services. Each employed individual pays a progressive fee of 4.8% of his income. Unemployed persons, students and pensioners with no income only pay a symbolic fee. And all citizens, whatever they pay, are entitled to preventive, diagnostic, therapeutic and rehabilitative services at no extra cost.

Even though it is no easy task, our aim is to create a health care system which is equitable, universally accessible and economically viable, while maintaining quality of care for all, something which I know is also a global goal of WHO.

Israel is considered to be a developed country, but it is small, its people come from diverse ethnic and cultural backgrounds, and it still faces serious problems. Yet, in spite of the difficulties, we are willing to share our experiences with others undergoing similar development.

Israel is also reaching out and playing its part in today's world. In the next few days a senior official from the Ministry of Health, Dr Josef Baratz, is flying to Rwanda to review what Israel has already done through the field hospital it provided last year for that tormented country and what more it can do to relieve some of the ongoing suffering. Fifty years after the end of World War II we, as Israelis and Jews, cannot stand idly by in the face of mass killings and human tragedy.

Our bilateral cooperation with countries, far and near, continues to expand and we reiterate our willingness to collaborate with WHO and its Member States in advancing the health and welfare of people everywhere. We already have in Israel a number of WHO collaborating centres and we hope to establish more.

The Middle East is in the process of profound political change. The health sector in every country in the region can be the pioneer in building the bridges for peace through collaborative efforts in the health field. We can initiate without delay regional projects in the field of health, such as: setting up a coordinating transplant organization similar to Eurotransplant in Europe; establishing a monitoring and information centre on communicable and vector-borne diseases; opening a joint research centre on diseases which are characteristic to our region such as familial Mediterranean fever, certain types of anaemia, glucose-6-phosphate dehydrogenase deficiency, etc.; sharing sophisticated and often expensive therapeutic technology, specifically in oncology; initiating a regional coordination and cooperation centre for the management of disaster situations and mass casualty events.

I call upon the health ministers of all countries in our region to join in the implementation of collaborative efforts that will ensure better health for all people and that, hopefully, will advance understanding and peace between our countries. I also call on all countries that can assist the Palestinian Authority to help establish a sustainable medical care system. This is not only a real need of the Palestinian people but is also in the vital interests of peace.

In September 1995 the United Nations will convene, in Beijing, the Fourth World Conference on Women. Regrettably, in many societies women still face discrimination in the fields of health, education, employment and social and legal status. Violence against women exists in all countries. In Israel, health services for women are an integral part of the general health services covered by the National Health Insurance Law. The mother and child health centres spread over the country in both urban and rural areas, which provided health services primarily to women and children, have now become family health centres, providing health services and guidance to all members of the family, including the elderly.

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May all of us who have come together at this important Assembly be granted the wisdom and inspiration to engage in constructive dialogue, in a cooperative spirit and through amicable discussions.

Dr OURAIRAT (Thailand):

Mr President, Mr Director-General, excellencies and distinguished delegates, first of all, allow me to express our sincere congratulations to you, Mr President, and to our five Vice-Presidents on having been elected to take up the important task of this august body. On behalf of the Thai delegation, I would like also to extend our appreciation to the Director-General and his team at headquarters, in the regional offices and at the country level for having worked so hard with our friends the world over to get rid of misery and improve the most important aspect of our quality of life, attaining a higher level of standard of living in a seemingly smaller but ever more fragmented world.

Last year when we gathered here，we had the great joy of hearing the success story of consolidating the foundations of democracy and thus increasing opportunities to improve the quality of life of our friends in South Africa. More efforts were being made to abandon conflicts and bury the bitter experiences of the past in different parts of the world. It gave us high hopes that with the approaching dawn of the next millennium, mankind was about to enter into an era of solidarity, a period of loving and caring for one another, a time beyond health and that is happiness for all. But the world is definitely not yet a sanctuary where peace will reign forever. We learn with great sympathy about the tragedy of ethnic as well as political confrontations in different parts of the world.

We in Thailand firmly believe that nothing exists in isolation and that no good deeds can be achieved alone. Bringing better health to our people is a good example. First and foremost is the need for joint and concerted efforts to control communicable diseases. Different diseases are at different stages of development but all present us with the same challenge, the need for unified commitment and a well coordinated attempt to deal with them. We have been able to eradicate smallpox and we now know that the next virus that may be eradicated is poliomyelitis. Eradicating poliomyelitis definitely needs more efforts than keeping it under control within each individual country. It is not possible for any of the more developed countries to launch their programme and rest assured that they can eradicate the disease when it still plagues other countries, especially their neighbours. Diseases certainly observe no political boundary. With the dynamism of globalization, no geographical barriers exist that could safeguard us against any communicable diseases.

The fight against HIV/AIDS infection offers good evidence to confirm the changing way of thinking. The countermeasures required to deal with this pandemic will become effective only when countries are both open and willing to know and share their real situation with others. The national HIV/AIDS prevention and control policy of Thailand has evolved consistently along this line, thus enabling us to understand the epidemiological transition of the disease, the magnitude of the human suffering involved, and the related socioeconomic implications. At this stage we are quite confident in our own societal endeavours to find a way out of this misery, and we can express some degree of cautious optimism although many challenges are still facing us and demanding an exceptionally high degree of commitment to undertake a continuous series of creative interventions. No matter what diseases we are combating, we must be assured that effective disease control exists equally in different parts of the world, and is not aimed at protecting any country but reflects an undertaking born of our clear vision of how mankind should work and live together in the future as one healthy global community.

We in Thailand have tried to work along this line of thinking, promoting better solidarity among countries in the region in working towards disease control and eradication. Last June, with facilitation and support from the regional offices of the World Health Organization, for South-East Asia and for the Western Pacific, and under the leadership of Dr Uton Rafei and Dr Han, four countries in the neighbourhood of Thailand met and discussed disease control issues of common concern, including poliomyelitis eradication and HIV/AIDS infection and malaria control. We also discussed how to deal more effectively with other common health problems in the region, such as iodine deficiency and substance abuse. The result was quite satisfactory, as it paved the way towards a better understanding of the problems confronting us and has also led to a number of other concrete collaborative projects that will be of mutual benefit to the countries concerned.

The next major challenge for health that requires clear understanding, firm commitment and concerted efforts is better health promotion. We used to believe that health promotion could be achieved by imparting more knowledge to our people, but we all have very good evidence and knowledge to share with our friends in other sectors as to the manner in which better health could be promoted through more healthy public

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policies in domains other than health, and through the provision of a healthier environment for people to live in. Introducing technology into manufacturing processes to reduce the emission of pollutants may add more cost to the production process, but certainly helps to save a great deal of spending on health and to add quality to life. Careful and considerate marketing efforts can contribute significantly to the reduction of unnecessary and even health-hazardous public consumption. The World Health Organization has helped to set good examples with the issue of tobacco, and has also helped towards a more rational use of drugs. We are certain that there will be more issues that will merit debate at the country as well as the international levels to make our global society realize what it can do to contribute to bettering the health of the world population rather than limiting such concern to any specific country's boundary.

In this regard, Thailand has introduced many improvements in the health field, such as the control of tobacco consumption through limiting advertisements of all kinds and the adoption of legislation to make no-smoking areas mandatory in public places. The Thai Government also annually increases taxes on cigarettes -a measure that has been shown to reduce the volume of sales.

The third major challenge to our efforts in creating equity and solidarity for health is that of ensuring access to health services when they are required by people, regardless of their socioeconomic status. All of us know that it is an uphill task for any government to try to meet the demands for health services of any sector of the population. However, in Thailand we are trying to guarantee better access to essential health services for our citizens, especially the underserved rural population. At the same time, through our primary health care system, we are working with the people at the community level to build up a better understanding of how to maintain good health and avoid health-hazardous behaviour and products, as well as to create a healthy environment.

If we are to create a society where good health can be enjoyed by all people alike, it is necessary to ask all parties to actively play their roles rather than leaving it to the government alone or to health service providers to do their best to care for the sick. "All parties" practically means everybody and every sector of society. It means all who deal with public policy formulation and implementation and not just the ministry of public health. It is not just a matter of drugs, but of different types of products that we consume, including the very air that we breathe and the whole environment that we live in. More important is the fact that these concerns should no longer be confined within political or geographical boundaries. We must realize that our health depends on that of our friends in other countries, whether neighbouring or far distant. With such beliefs, I am certain that we all have to work much harder and that the World Health Organization will have a very crucial part to play in the betterment of our global community. Together, I believe we can make a difference that will benefit us 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 vives félicitations de la délégation luxembourgeoise pour votre élection. La mission essentielle de l'Organisation mondiale de la Santé est celle d'amener tous les peuples au niveau de santé le plus élevé possible. En examinant le Rapport sur la santé dans le monde, 1995 一 Réduire les écarts, on constate que, malgré des progrès incontestables, des disparités inacceptables persistent et que les écarts entre riches et pauvres se creusent. Nous commençons à mesurer vraiment le caractère ambitieux et fort complexe du premier objectif de la stratégie de la santé pour tous : l'équité en matière de santé. Cet objectif reste un défi pour beaucoup d'entre nous au niveau de nos pays et un défi certain sur le plan mondial.

Le Luxembourg a fait, depuis 1974 surtout, des efforts délibérés pour garantir l'accès aux soins à toute la population par une série de dispositions, dont une des plus importantes était une mesure d'aide sociale, à savoir l'introduction d'un revenu minimum garanti associé à Г assurance-maladie obligatoire. Comme beaucoup de pays européens, le Luxembourg se voit confronté actuellement à une explosion des dépenses dans le domaine de la santé, qui ne va pas nécessairement de pair avec une amélioration correspondante de la santé de la population. Les prestations de santé obéissent à l'économie de marché et, dans une société de consommation, il n'est pas étonnant d'observer le même type de comportement vis-à-vis des services de santé. La question de la réduction des dépenses nous confronte toutefois directement au problème de l'équité et de la solidarité, puisqu'elle risque de toucher davantage les catégories les plus vulnérables : les personnes économiquement faibles et celles qui sont atteintes de maladies graves de longue durée ou chroniques. La réduction des dépenses de santé nous contraint donc à revoir plus fondamentalement nos politiques de santé. La stratégie de la santé pour tous est un instrument précieux pour nous guider dans cet exercice.

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Je peux rapporter avec satisfaction que le Gouvernement luxembourgeois a inscrit cette approche dans son programme et réalisé des pas importants et prometteurs dans la promotion de la santé en créant un service de la médecine de l'environnement, et en mettant en place une législation et des services de santé au travail conformément à la stratégie formulée par l'Organisation mondiale de la Santé. De plus, un nouveau Ministère de la Promotion féminine vient d'être créé; je suis convaincu que ce nouveau département sera un allié efficace pour promouvoir la santé et le bien-être des femmes et mieux répondre à leurs besoins spécifiques grâce à une meilleure participation des intéressées à l'élaboration et à l'application des mesures qui les concernent.

Il est vrai que nous ne disposons que d'un nombre limité d'instruments pour mesurer les iniquités dans le domaine de la santé et que les données de base mêmes ne sont pas toujours disponibles dans une forme adéquate. L'amélioration de la collecte de l'information, la définition d'indicateurs plus nombreux, plus affinés et comparables, ainsi que la diffusion de cette information devront faire partie de nos premières préoccupations. Les sources des iniquités en matière de santé sont multiples et complexes. Il semble que les déterminantes relevant du domaine de la santé jouent plutôt le rôle de facteurs "adjuvants", alors que les racines profondes se trouvent dans d'autres domaines comme l'éducation, les comportements individuels, les conditions de vie et de travail, le développement social, l'environnement. L'objectif de l'égalité des chances dans le domaine de la santé est donc un argument puissant pour l'approche intersectorielle et l'intégration nécessaire des programmes de santé dans de plus vastes programmes de développement, telles qu'elles sont inscrites dans le neuvième programme général de travail de l'OMS. Notre Organisation joue un rôle éminemment important en valorisant la santé dans les programmes internationaux et en coordonnant son action avec les autres institutions des Nations Unies.

Dans son dernier rapport sur la santé en Europe, le Bureau régional de l'Europe fait le bilan critique des situations engendrées par les développements socio-économiques dans les pays les plus avancés, par l'évolution politique dans les pays d'Europe orientale et par les guerres qui sévissent dans des pays appartenant à la Région. Le bilan actuel serait, hélas, plus décevant encore puisque les guerres non seulement persistent, mais se multiplient. Sur le plan mondial, le bilan est encore plus alarmant. Hormis les catastrophes naturelles qui frappent plus souvent, et en tout cas plus violemment, les pays les plus démunis, ce sont surtout les catastrophes provoquées par l'homme qui ont les conséquences les plus dramatiques et les plus durables. Elles créent de nouveaux groupes de populations totalement démunis : les réfugiés et les personnes déplacées. Même si l'aide humanitaire n'est pas une tâche primordiale de l'OMS, celle-ci ne peut pas refuser de conjuguer son expertise et ses moyens avec ceux d'autres organisations et ceux des pays mêmes pour parer à des situations d'urgence et remettre en place les services de santé.

L'aide aux pays en développement nous est dictée par la raison. Les déplacements de nos populations et les migrations de plus en plus nombreuses des populations fuyant des régions de crise ou des conditions de privation font que les pays industrialisés partagent dans une plus large mesure et de façon plus immédiate les problèmes de santé des pays en développement. Il est certain que ces problèmes demandent une solution dans les pays où ils ont leur origine. La lutte contre les maladies infectieuses, anciennes et nouvelles, reste un des problèmes spécifiques majeurs retenus par l'OMS dans son programme de travail. La situation sur le plan mondial est d'autant moins acceptable que des succès certains peuvent être remportés; l'OMS a une riche expérience dans ce domaine ！ Si la responsabilité et la solidarité guident nos actions sur le plan national, elles doivent être aussi des principes d'action sur le plan international avec le plus grand souci d'équité vis-à-vis des pays les plus démunis et des groupes les plus vulnérables. Depuis 1985, le Gouvernement luxembourgeois a fait des efforts considérables en matière de coopération au développement et il vient de décider d'augmenter encore les crédits qui y sont destinés pour atteindre, en l'an 2000, 0,7 % de son produit national brut. L'orientation sectorielle de l'aide reflète l'intérêt particulier que la coopération luxembourgeoise porte aux projets dans le domaine de la santé. En dehors de la contribution au budget annuel de l'OMS, mon pays s'est associé, avec un montant de US $1,5 million, au financement de sept programmes spéciaux en 1994， contributions qui seront bien sûr maintenues en 1995.

L'OMS accorde à juste titre une très grande priorité à la santé des femmes, des enfants et des adolescents. Dans les programmes pour la santé des enfants et des adolescents, une attention particulière devrait être réservée à ceux qui sont victimes de négligences, de violences, d'exploitation sexuelle ainsi qu'aux enfants des rues. Ces enfants et ces jeunes se trouvent exposés aux maladies sexuellement transmissibles, à des grossesses non désirées, à la drogue, à la criminalité et donc au paroxysme de l'exclusion.

J'oserais dire que les iniquités en matière de santé et les inégalités dans la société en général sont mesurées fidèlement par les indicateurs qui s'appliquent à la santé et à la situation des femmes. Les femmes

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sont exposées à des inégalités en raison de facteurs extrinsèques, non biologiques; elles sont aussi particulièrement vulnérables en raison de leurs besoins spécifiques, qui sont essentiellement en rapport avec la santé génésique. Je souhaiterais que, lors de la Quatrième Conférence mondiale sur les femmes, l'OMS mette enjeu l'autorité dont elle est investie pour agir contre toutes les formes de discrimination à l'égard des femmes et qu'elle consolide ses alliances avec les organisations oeuvrant pour leur promotion, cela en réponse aux priorités retenues dans le rapport du Directeur général.

Pour terminer, permettez-moi de souligner que nous devons persister à revendiquer avec obstination "l'égalité des chances" pour la santé même. Nous sommes bien placés pour savoir que les politiques de santé sont encore loin de faire partie des priorités dans les choix politiques, surtout en période de ralentissement et de récession économiques, et que l'importance de la santé n'est pas admise d'office dans les autres secteurs politiques.

Mr Kyung Shik JOO (Republic of Korea):

Mr President, Director-General Dr Nakajima, distinguished delegates, ladies and gentlemen, on behalf of the Government of the Republic of Korea, I would like to extend our heartfelt congratulations to Dato Dr Haji Johar Noordin on his election as President. It is our great pleasure to assure you that you have all our confidence and support. I would also like to praise Dr Nakajima, Director-General of the World Health Organization, and his devoted staff for their impressive work in organizing this Assembly. In addition, I would like to express my sincere thanks to Dr Han, Regional Director for the Western Pacific for his leadership in implementing a wide range of excellent WHO programmes in the Western Pacific Region. And on the occasion of this Health Assembly, I also would like to express appreciation to WHO for its remarkable achievements in improving the health of mankind. Owing to the efficient help of WHO, many countries including Korea have made an enormous improvement in their nations' health systems. WHO has contributed a great deal to the world community. With almost all the countries in the world participating, the Organization has our confidence for the fulfilment of its unique central role for the coexistence and coprosperity of mankind, now and for the future.

Mr President, at the threshold of the twenty-first century, WHO is now expected to take on a new challenge, effectively helping everybody maintain health at an optimal level on an equal basis, and at least guarantee equal access to the means required for maintaining health. In that context, I wish to give credit to WHO for the most timely and appropriate theme, equity and solidarity in health - bridging the gaps, that will be explored this year. This theme leads us to discuss welfare in its broadest sense. Nowadays equity-related matters in health are receiving greater attention because they are closely linked with social justice by which the optimal environments of physical and mental health free of social and economic discrimination can become manifest.

With the rapid development of medical technology, the economic burden of health care is increasing dramatically, a fact that often appears in stark conflict with social equity. The world now faces a series of problems that are hard to tackle, such as those mainly caused by differences in technological and economic development. The need for the timely introduction of up-to-date medical technology, the newest medical products and equipment, further increases the already costly medical expenditure, widening the gap between the countries that can afford the cost and those that cannot. Moreover, only few countries have free access to the more expensive types of fundamental medical research, genetic engineering, organ transplantation and the sophisticated technology for prolonging human life. All these create a huge gap between nations. The implementation and purchase of medical technology of greater sophistication primarily depends on the economic capacity of each nation or individual. WHO has been tirelessly urging us to see the moral implications of the points I have just made and has been successfully assisting us to develop pertinent policies leading to equity and social harmony. WHO's basic principle, of fulfilling strategies for health for all was based on the concept of equity, and the Organization has constantly delivered useful guidelines regarding social equity problems in health.

Nevertheless, we wish to see WHO take a step further, going beyond its present ideology and advocacy stage to provide us with more specific and realistic means of achieving its well-defined goals. Multilateral cooperation among nations is becoming more and more important to this end. It is time for us together to help the developing countries equip themselves with national medical welfare systems that are compatible with their unique social and economic conditions. To this end, the medically advanced countries should be called upon to make their own medical reform experiences and the valuable findings of their medical research available so that the less advanced can directly benefit from them. Whether or not we will duly meet the

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constantly new challenges before us in such a way that our world becomes a better place to live in will depend on you, the distinguished ladies and gentlemen attending this Health Assembly. In an effort towards this unselfish goal, I would like to set before you, on the Korean Government's behalf, the following few points.

First, as an initial step toward securing cooperation between the advanced and the developing countries in the promotion of greater equity and social harmony, greater exchange of information on medical reform at an international level should be realized. All the benefits of advanced medical technology should be made equally available to people the world over. Above all, WHO should play a more active role in ensuring equal accessibility to health services, which are becoming more and more unequal with the emergence of a new economic order. Korea is ready to share with the world, whenever possible, its own experience of socioeconomic development and its knowledge of social welfare policies.

Secondly, the health policy-makers of WHO and individual governments should be attentive to policies that will affect the overall welfare of ordinary people. At the same time, I would like to recommend that WHO prepare practical methods whereby poor countries will be able to provide their people, especially those suffering from social exclusion, with equal access to health services under the medical system. In this connection, the conventional programme which WHO has run to eradicate disease is a good example.

Thirdly, in the fast-approaching information era, we would advise that WHO assume an important role in enabling the less developed countries to make good use of the information technology that has been progressively developed in the most advanced countries. In so doing, greater equity in health can be achieved at the international level.

Finally, all countries should join together under the leadership of WHO with a view to strengthening research and development activities concerning effective strategies for social equity and solidarity in health; WHO should in turn respond to this collective effort by publicizing international standards of equity in health.

Mr President, I am confident that this Health Assembly will make a great contribution to clarifying many issues about equity and solidarity to the participants who, in due course, will participate in a variety of panel discussions.

In closing, may I take the opportunity to state that the Republic of Korea will continue to support the Members of WHO in their collective effort towards health for all by the year 2000 and beyond, and especially towards enhanced social equity and solidarity in health. Furthermore, let me voice on behalf of the Government of the Republic of Korea, the hope that it will become more involved and play a more intensive and expanded role in a wide range of WHO activities, especially those of the Secretariat and the Executive Board.

Ms TERPSTRA (Netherlands):

Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, first of all I would like to congratulate you, Mr President, and the Members of the Bureau, on your election. I wish you every success in your important tasks. It is a great honour for me to address for the first time this distinguished Assembly on behalf of the Netherlands Government. I will endeavour to keep my intervention as businesslike as possible and concentrate on the theme that the Director-General of WHO has chosen for this year; equity and solidarity in health - bridging the gaps, and I will restrict myself to three concrete recommendations.

The ever-growing health gap between and within countries, which is evident in the reports on the world health situation and the monitoring of progress in implementing health for all by the year 2000, is not an isolated question. It must be dealt with in the context of economic and social development. The appearance of new communicable diseases, such as AIDS, and the re-emergence of known infectious diseases, such as plague, cholera and tuberculosis, have a great worldwide impact, especially on the poor. Dealing with these matters constitutes a real challenge to WHO.

To achieve a sustainable health care system, bridging the gap between rich and poor on a global, regional and national level is a prerequisite. Although the situation with respect to socioeconomic health differences in the Netherlands compares favourably with other countries, such differences nevertheless still persist in my country as well. Our national efforts are aimed at eliminating this gap. We feel that solidarity and equity are the two essential elements which should be built into every health care system. In our country, solidarity means the young caring for the elderly, the rich for the poor, and the healthy for the sick.

Health care should be affordable for, and accessible to, any person who needs it, irrespective of social status, income, "gender" or age. Policy-makers also have to be aware that, in building up a sustainable health care system, choices have to be made - choices for instance, in what is to be covered by collective means and

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what is to be covered by private insurance. The choices are difficult, the problems complex. Sometimes it seems that one is reinventing the wheel. To prevent this, here is my first recommendation. I firmly believe that WHO should play a more prominent role in the area of health care systems and health care reforms.

During the World Summit for Social Development in Copenhagen, the so-called 20/20 concept received broad support. The Netherlands strongly advocates the concept as an important tool for increasing investments in basic social services, including health. We expect WHO to play an active role in the implementation of this concept.

Mr President, the empowerment of women is a very important factor in achieving solidarity and equity. This was acknowledged by the International Conference on Population and Development in Cairo, last September which also concluded that reproductive health is an essential element in sustainable development. WHO must take up the challenge in defining its role in the field of reproductive health. The Netherlands Government is pleased that family health and population issues are among the five priority areas suggested by the Executive Board and the Director-General in their reports to this Assembly. It is evident that this is a priority because the Director-General established, at the request of the Health Assembly, the Global Commission on Women's Health. And here comes my second concrete recommendation, on how emphasis can be given to the activities of the Global Commission on Women's Health by providing more financial resources. We invite the Director-General to do so. It can be done by the reallocation of some of the budgets. Of course WHO should not act in isolation, but in close cooperation with UNFPA and other organizations and bodies of the United Nations system. The need for interagency cooperation cannot be emphasized enough. Duplication of activities and conflicts of competence are always counterproductive. It is in the interest of all of us if international and supranational organizations, operating in the field of health, join forces at the global and regional level. An example at the global level is the Joint United Nations AIDS Programme. However, WHO has to define its own relations with this new programme. In Europe the need for closer cooperation is also recognized. The process, which has come to be called "rapprochement", should bring together the European Union, WHO's Regional Office for Europe and the Council of Europe. Mr President, such close cooperation is also required at the global level. Together with WHO we, the Member States, are responsible for the implementation of this process. The "international health agenda" must be set. Let us return to the Health Assembly theme, equity and solidarity. The empowerment of women, a fundamental right which should be endorsed during the Fourth World Conference on Women in Beijing this September, is an important element. Empowerment of women largely contributes to improving the health of populations and families. As various studies show, women who are educated and earn their own income direct a large part of this income towards improving the health of their families. They are thus contributing to the development of their communities and society at large.

Mr President, in concluding my speech I should wish to reflect briefly upon WHO's response to global change. I have studied WHO's reform process with great interest. In moving WHO's response to global change forward, progress in the work of the several development teams seems to be specially urgent. And that is why I offer you my third concrete recommendation here. That is why we request the Director-General to accelerate the work of the development teams, in particular the development team on the policy and mission of WHO.

Concern about WHO's response to global change is shared by many Members. It is also voiced in several publications, in which WHO is being perceived as lagging behind. This should be taken very seriously by the Organization, as I am sure, Mr Director-General, you do.

Finally, I sincerely hope that, with the problems facing our Organization, the Assembly will have the wisdom to take courageous decisions, for it is our common task and responsibility indeed to provide health for all.

Professor GUZZANTI (Italy):

Mr President, Director-General, distinguished delegates, I wish first of all to congratulate the President and the Vice-President of this Assembly, as well as the Chairmen of the committees on their election and assure you of the Italian delegation's full support.

I would like to begin with some considerations on the theme for this year's World Health Assembly which is equity, and solidarity in health - bridging the gaps. As clearly shown by The World health report

/995, and by the comprehensive third report on monitoring of progress in implementation of strategies for health for all by the year 2000, despite some general improvement, the gap between the "haves" and the "have-nots" is becoming wider and inequities in health persist and perhaps even increase among and within

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regions as well as among and within countries. We must admit that not all have benefited from recent worldwide improvements in health status, coverage and access to health services. Reducing this health gap and overcoming inequities is definitely a very difficult task and a great challenge but we have to increase our efforts towards the attainment by all people of the highest possible level of health - this is the ultimate objective of WHO and its Member States.

Mr President, the Ninth General Programme of Work provides us with the policy framework for worldwide health action until the year 2001. The four policy orientations identified in the General Programme of Work represent a valid focus for action on the part of the international health community in order to reach the aforementioned targets and goals; it is thus mainly a matter of political will and concerted international action. As was not sufficiently acknowledged at the Copenhagen World Summit for Social Development, health is a fundamental factor for social development and therefore should be placed as high as possible on the political agenda. At a time of recession and worldwide financial constraints, the rational, appropriate, extremely careful use of our available resources allocated for health becomes imperative at both the national and international levels.

While on the subject of resources, I would like to refer specifically to one of the major items on our agenda for this Assembly, the programme budget for 1996 and 1997. We share the Director-General's concern about the fact that extrabudgetary resources cannot grow forever, and that relying on extrabudgetary funding may raise the issue of continuity and independence in policy formulation and priority-setting. We are also well aware of the fact that it is not an easy task to maintain a zero-growth budget in real terms while facing growing expectations and requests for assistance from Member States. While recognizing the need to maintain WHO expertise and technical excellence in all aspects of human health, we must stress the fact that cost increases mean increased contributions from our governments and it becomes more and more difficult to meet such increases without incurring a delay or even arrears in payment. Therefore, we would like to stress the urgency of maximizing the best possible use of available resources, aiming at enhancing WHO's operational and technical capacity by revitalizing and strengthening the role of WHO collaborating centres, by avoiding any overlaps and fragmentation of activities, by improving cooperation and coordination with other international agencies, and by reducing bureaucratic burdens in favour of improving the quality of staff performance. We are convinced that WHO has to maintain and strengthen its international leadership in the health field, but to do so requires a great effort in providing technical cooperation with countries and directing and coordinating international health work.

Concerning Italian cooperation in the field of health with countries most in need, I will refer briefly to the emergency interventions by the Italian Government in 1994. The increased request for emergency assistance - mainly due to armed conflicts and civil wars - has meant a significant reorientation of our traditional humanitarian aid activities. These humanitarian and emergency interventions were designed with the ultimate objective of returning as soon as possible to ordinary cooperation and were coordinated with the operation carried out by the United Nations and other international agencies and by the European Union. Of the total amount of funds available, 82% were allocated to organizations and bodies of the United Nations system; it is significant and dramatic that 63% of such funding was allocated to face man-made disasters. Italian cooperation has in fact contributed to limiting the damages and relieving the suffering caused by those dreadful conflicts which have attracted the attention of the international community. The entire Italian population has offered its help in terms of human solidarity as well as supplies, donations and technical cooperation. As for collaboration with this Organization, we can say that Italian cooperation has contributed by responding to the resolution of the Forty-sixth World Health Assembly which asked WHO to play a more active role in coping with urgent health needs in emergency situations. We do hope that the current process of international changes will allow the WHO staff responsible for humanitarian assistance in the regions and at headquarters to provide flexible and adaptable responses, making the best use of financial contributions as well as coordinating a health emergency relief operation.

Referring again to the theme of this Assembly I would like to make some brief remarks regarding the Italian health care system. Stemming from recognition of the fact that resources are limited and that health expenditure must therefore be rationalized, a careful analysis is leading to a new model of a health care system that safeguards the principles of equity and solidarity, reconciling them with parameters of effectiveness and efficiency. This process is based on certain fundamental principles: the redefinition of the role of the State, which has the task of financing the system, setting priorities and carrying out regulatory activities, while decentralizing organizational and managerial functions; a revival of the ethics of responsibility, meaning sensitivity to general interests and accountability; and increased quality of care with cost-containment. In this context the present Government takes a positive view of the introduction of a new, market-oriented culture, which, however, must be regulated within the framework of the expenditure ceiling

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and the priorities set by the State. It is also firmly convinced that prevention represents an essential element for equity in health policies as well as a fundamental issue for long-term health improvement and cost-containment. The concept of responsibility leads us to realize that health in the year 2000 will be above all the health of the elderly. Health expenditure for the elderly can in no way be reduced; on the contrary this target group has a high priority in health planning, together with chronic diseases and the most needy sections of the population.

Since hospital care continues to represent the largest part of health care expenditure, Italy began in January 1995 gradually to introduce a new system of remunerating hospital care based on the principle of prospective-cost-per-case payment. The competition thus produced will be a positive innovation since it allows public hospitals, as semi-autonomous enterprises, to compete with one another and with private hospitals. The commitment of the Government is to make certain that the influence of this strong rationalizing element represented by the change in health care financing is subjected to a careful analysis of the results achieved. We are in fact convinced that it would be dangerous to focus only on efficiency as this would be a reversal of the fundamental value of any health care activity which is to make the services effective, enabling them favourably to modify the natural course of disease. The move towards a regulated competition is accompanied by the conviction that the final goal of health care must be more, as well as more generalized, health, and not only cost-containment.

As for relations with WHO, I will just list a number of priority areas in which Italy is very much interested, where there is already excellent cooperation between the competent WHO divisions and units and our Istituto Superiore di Sanità and other institutions. Tropical diseases (particularly in the field of training in malaria control), emergency and humanitarian action, family health, vaccines, human reproduction, essential drugs, tuberculosis, veterinary public health - these are all sectors in which WHO plays a crucial role and which deserve and will continue to receive the support of the Italian Government.

Last, but not least, I wish to dedicate a few words to AIDS, expressing our sincere appreciation for the work carried out by the Global Programme on AIDS and our support for the new Joint United Nations Programme on AIDS. We are convinced that the AIDS pandemic represents a challenge through which it will be possible to measure the real level of the solidarity of the developed world for those countries most in need.

In conclusion, Mr President, I wish to remind you that we are facing challenges for the year 2000 that would become important achievements provided we do not reduce our efforts now that success is at hand, such as the eradication of poliomyelitis. The achievement of these goals will not only improve the future of mankind, it will also strengthen the credibility of this Organization. Thank you for your attention.

The PRESIDENT:

I thank the delegate of Italy and invite to the rostrum the delegate from Central African Republic who is representing 19 African countries.

Le Dr FIO-NGAINDIRO (République centrafricaine):

Monsieur le Président, Mesdames et Messieurs les Ministres, Monsieur le Directeur général, Mesdames et Messieurs, honorables délégués, permettez-moi tout d'abord de m'acquitter d'un agréable devoir, celui de vous adresser, Monsieur le Président, au nom de dix-neuf pays africains, toutes mes félicitations pour votre élection à la présidence de la Quarante-Huitième Assemblée mondiale de la Santé. Nos voeux de succès pour la conduite de cette réunion vous accompagnent.

Monsieur le Président, Mesdames et Messieurs, à la suite de la dévaluation de 50 % du franc CFA, quatorze pays africains de la zone franc s'étaient réunis à Abidjan, en Côte d'Ivoire, pour adopter une politique commune de médicaments et faire face à l'impact de ce réajustement monétaire sur la santé des populations en rapport avec leur accessibilité aux médicaments. Cette initiative a été suivie par six autres pays africains à Evian (France)， à Genève, puis à Bruxelles. Ces dix-neuf pays sont les suivants : Bénin, Burkina Faso, Cameroun, Comores, Congo, Côte d'Ivoire, Gabon, Guinée, Guinée équatoriale, Madagascar, Mali, Mauritanie, Niger, République centrafricaine, Rwanda, Sénégal, Tchad, Togo et Zaïre. C'est au nom de ces pays que j'ai l'insigne honneur de prendre la parole pour m'adresser du haut de cette tribune à l'ensemble de la communauté internationale et évoquer les problèmes liés à la santé de nos populations et au développement de nos pays.

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Monsieur le Président, Mesdames, Messieurs, ces pays africains issus de zones géographiques différentes se sont associés pour aborder à cette tribune des préoccupations qu'ils partagent au-delà de toute considération linguistique ou politique. Depuis notre dernière intervention commune, en mai 1994，à la Quarante-Septième Assemblée mondiale de la Santé, l'environnement de notre secteur s'est enrichi des enseignements tirés de rencontres internationales stratégiques. Je voudrais citer la Conférence internationale du Caire sur la population et le développement, le Sommet mondial de Copenhague pour le développement social et la quarante-huitième session du Comité régional de l'Afrique à Brazzaville. Les problèmes évoqués à ces rencontres stratégiques sont désespérément restés les mêmes qu'à la Quarante-Septième Assemblée mondiale de la Santé et se sont parfois aggravés; je n'en citerai que quelques-uns : premièrement, l'accessibilité aux médicaments essentiels réduite par la dévaluation de la monnaie dans quatorze de nos pays et la baisse du pouvoir d'achat des populations dans tous nos Etats. En effet, le coût prohibitif des produits pharmaceutiques de marque rend difficile l'approvisionnement en médicaments partout où vivent et travaillent les populations. La politique des médicaments essentiels sous nom générique, bien coordonnée par l'OMS, a fait la preuve de son efficacité dans de très nombreux pays par la création de centrales d'achat des médicaments essentiels et des matériels et produits médicaux renouvelables. Pour améliorer les performances dans ce cadre, un accent particulier doit être mis sur le contrôle de qualité de ces médicaments essentiels ainsi que sur leur distribution par les pharmaciens d'officine privée afin de permettre un accès facile. Les activités de soutien, comme la supervision de la formation, la recherche opérationnelle, la décentralisation, la promotion de la médecine traditionnelle et la collaboration intersectorielle, constituent des atouts indiscutables pour promouvoir et améliorer la santé, surtout dans nos pays en développement. Nous souhaiterions l'appui des partenaires au développement pour ces différentes activités afin de réduire les écarts entre les pays du Nord et du Sud. Deuxièmement, la progression du VIH/SIDA et la tuberculose, troisièmement, la morbidité et la mortalité liées aux maladies chez la mère et l'enfant, quatrièmement, le taux de croissance de la population de l'ordre de 3 % pour une croissance moyenne des produits intérieurs bruts nettement inférieure, cinquièmement, la baisse de la couverture sanitaire, sixièmement, l'augmentation de la pauvreté liée, entre autres, à la dégradation des termes de l'échange.

Tous ces problèmes sont aggravés par les conflits armés, les génocides, les épidémies de méningite et de choléra dans plusieurs de nos pays. L'OMS et la communauté internationale sont appelées à soutenir les programmes de réhabilitation des pays qui ont connu, ou connaissent encore, des conflits armés. Dans ce cadre, des programmes de coopération intensive avec ces pays doivent être mis sur pied. Il convient de rappeler ici la résolution AFR/RC44/R17 portant sur le programme spécial de coopération avec la République du Rwanda, adoptée par la quarante-quatrième session du Comité régional de l'Afrique.

Monsieur le Président, Mesdames, Messieurs, à cinq ans du début du troisième millénaire, l'objectif de la santé pour tous, adopté par la communauté internationale en 1978 à Alma-Ata, semble de plus en plus inaccessible pour la majorité des pays africains. Cette crise de la santé n'a pu être surmontée dans le cadre des multiples et successifs programmes d'ajustement structurel arrêtés avec les institutions de Bretton Woods par nos pays respectifs. Ces programmes, malgré la mise en avant de secteurs prioritaires comme l'éducation et la santé, ne favoriseront pas un véritable développement sanitaire tant que des conditions limiteront par exemple le recrutement des personnels nécessaires à une meilleure couverture sanitaire des populations. Ces programmes devraient fortement intégrer l'équité, la solidarité et la justice pour que les couches démunies puissent bénéficier largement de l'éducation et de la santé, seuls leviers d'un développement humain durable à l'horizon le plus proche.

La plupart de nos pays, sinon tous, ont entrepris des réformes de leurs systèmes de santé, des modes de financement des services de soins de santé primaires et de la participation des communautés. Certes, les premiers résultats encouragent à développer la participation des communautés, leur implication véritable dans la détermination des besoins de santé et dans la gestion des services de soins de santé primaires, avec le "paquet minimum santé pour tous". Cependant, ce processus a ses limites, car la crise économique a fait baisser le coût de nos matières premières et, diminuant ainsi le pouvoir d'achat des membres de la communauté, fragilise le système et favorise de plus en plus une marginalisation de certaines couches sociales de nos populations.

A la Quarante-Septième Assemblée mondiale de la Santé, nous avions salué la présence de l'Afrique du Sud parmi nous et sa victoire, ainsi que celle de la communauté internationale, sur le système de l'apartheid. Aujourd'hui, il n'y a plus que regrets et désolation en Afrique au vu de ce qui se passe au Rwanda, au Burundi, au Libéria et en Somalie. La Région africaine, à la quarante-quatrième session de son Comité régional，a adopté une résolution tendant à la création d'un corps de volontaires pour intervenir en cas de sinistre. Nous voulons saisir l'occasion pour appeler l'OMS et les pays nantis à aider à la mise en place et au fonctionnement d'un tel corps.

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Monsieur le Président, honorables délégués, nous osons croire que les objectifs du neuvième programme général de travail，dont le budget programme pour la première période sera approuvé lors des présentes assises, seront atteints. C'est en raison de ce nouveau contexte queje voudrais remercier le Directeur général pour la qualité et la pertinence de son rapport sur la santé dans le monde et le féliciter pour la nouvelle stratégie de la santé pour tous qu'il propose à cette Quarante-Huitième Assemblée mondiale de la Santé. L'an 2000, c'est déjà aujourd'hui; le bilan de ce deuxième millénaire sera celui de l'humanité. C'est pourquoi nous appelons la communauté internationale, et particulièrement les plus nantis, à plus de solidarité dans le développement humain. Les indicateurs sanitaires et sociaux rappelés par le Directeur général de l'OMS, les écarts et les déséquilibres Nord-Sud de plus en plus inacceptables doivent nous amener à un sursaut pour réduire la pauvreté et éliminer toute discrimination. Ainsi, l'objectif de la santé pour tous d'ici l'an 2000 deviendra réalisable dans nos pays.

Le thème de la Quarante-Huitième Assemblée mondiale de la Santé étant "Equité, solidarité, santé 一 Réduire les écarts", l'OMS et la communauté internationale sont appelées à voler au secours des plans nationaux de développement sanitaire de nos pays en transition systémique, caractérisée par des difficultés économiques et financières, des crises sociopolitiques et une véritable explosion du SIDA et des maladies endémo-épidémiques.

Monsieur le Président, Mesdames et Messieurs, honorables délégués, tel est le contenu du message que j'ai eu l'honneur de livrer au nom de dix-neuf pays africains conscients de leurs difficultés.

Dr TYPOLT (Czech Republic):

Mr President, Director-General, distinguished delegates, ladies and gentlemen, let me first congratulate you personally, Mr President, and other officials on your election at this Forty-eighth World Health Assembly. It is a great honour for me to address this Assembly on behalf of the Government of the Czech Republic and His Excellency, Dr Rubas, Minister of Health of the Czech Republic.

The term equity is one of the pillars of a democratic society and any democratic country must ask whether it is providing care on an equitable basis for all its citizens. To give an objective answer, reliable data are needed. For example, the fact that the mean life expectancy of people with lesser education is lower than that of better educated people could be considered as evidence that health care is not equitable, in that the system of health care is not giving the same chance to everyone to develop his or her own health potential. However, that conclusion may not always be justified. Unfortunately, such a way of thinking can result in the creation of a civilization based on group or class demands, which is a perverse caricature of real needs. The central and east European countries suffered a tragic experience with just such a class-demand practice. We often heard about the right to health, to education, and so on, but not so often did we hear about the duty to take care of our own health and education. Citizens prefer asking for their rights to education and all possible health care instead of making an effort to establish a healthy lifestyle.

The Czech Republic has dramatically changed its health care system. The former paternalistic system provided the semblance of a high level of equity, but it resulted in a general deterioration of the health status of the population. Consequently, the new system has to deal with a high frequency of cardiovascular diseases and of malignancies, with a high abortion rate and so on. This unfortunate heritage of the previous undemocratic regime is being methodically eliminated in the new system. In recent years a significant lowering of the infant mortality rate has been recorded in the Czech Republic: from 1% in 1990 to 0.7% in 1994. An increase in the mean life expectancy at birth, a lowering of the cardiovascular mortality and morbidity rates and a 30% lowering of the abortion rate are also significant. In the health service, fundamental changes have been made to the system. There is now a plural system of financing, the main role being played by the general health insurance with a comparatively strong private sector, mainly at the primary care level. Contrary to the former totalitarian regime, the system works in a real economic environment. One of its characteristics is the free choice of one's physician and health care facility, together with competition among health care providers. Equity and solidarity again come into prominence in connection with economic problems. It is obvious that a system based on general health insurance at the higher level of solidarity cannot ensure that all advanced technologies of health care are accessible to everyone; it is necessary to find a balance between the level of solidarity ensuring the right to care on the one hand and the level of personal responsibility of each individual on the other. There is a long-term democratic discussion in my country on the final form of the system which should be achieved during the current reform.

Even the World Health Organization probably cannot avoid discussion on the fundamental reform steps; WHO also has to act in the real world where the general rules are applicable. Only such tasks should be

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accepted as can be achieved under the given conditions, where progress can be evaluated and individual stages are limited in time. Best suited to this concept are practically oriented, not artificially revitalized, programmes.

To conclude my reflections on equity, solidarity, and health care, I would like to express my appreciation of the active involvement of WHO in the humanitarian activities of the international community in emergency areas in Europe in recent years. Humanitarian crises, war, natural disasters, and other catastrophes represent situations where the exhausted capabilities of one group have to be supported by the solidarity of others. With the reintegration of the Czech Republic into a European and global context, there is an increasing feeling of responsibility and solidarity in my country reflected both in governmental and nongovernmental humanitarian aid in emergency areas.

Dr DOUSIKEEV (Kazakhstan):

Д-р ДУЙСЕКЕЕВ (Казахстан):

Г-н Председатель, уважаемый Генеральный директор, уважаемые коллеги,

Позвольте мне поздравить Председателя Ассамблеи, его заместителей с избранием на эти

ответственные должности.

Большое впечатление оставил краткий, но всеобъемлющий доклад о состоянии

здравоохранения в мире. Казахстан целиком одобряет новую форму доклада Генерального

директора, представленную в виде аналитического обзора, в виде оценки глобальной медико-

санитарной ситуации и вклада ВОЗ в улучшение здравоохранения. Вполне закономерно то, что

Девяносто пятая сессия Исполкома предложила данной Ассамблее обратить особое внимание

на тему "Справедливость и солидарность здравоохранения; путь к преодолению различий".

Любая политика, связанная со здоровьем должна строиться на принципах равенства. Следуя

этому, уже в 1991 г. Всемирная организация здравоохранения определила новую задачу:

"Справедливость вопроса охраны здоровья". Эта задача как никогда стала актуальной в новом

мире независимых государств. Стремительно пролетел год после нашей последней встречи в

этом зале. Этот год принес нам те или иные успехи, но успехи кажутся нам незначительными

на фоне продолжающихся негативных процессов социально-экономической жизни республики.

Нашу страну сейчас потрясают явления, которые, казалось, никогда не затронут нас, - те

явления, о которых было сказано в основном докладе, - произошло расслоение общества,

появились новые богатые, средние и бедные, вызывает беспокойство тенденция к росту

безработицы, причем в отсутствие твердых систем социальной защиты наблюдается ранее не

беспокоивший нас кризис социальных нравов.

На Сорок шестой сессии Всемирной ассамблеи д-р Накадзима приводил цитату "на чашу

весов поставлена Земля", - это как никогда тревожит нас, жителей Казахстана. Резко

обострились заболевания, обусловленные экологическими техногенными причинами. Нам

сейчас приходится выражать озабоченность по поводу увеличения уязвимых групп населения,

подверженного влиянию всех негативных социальных факторов, находясь под влиянием

перечисленного выше. Рождаются новые проблемы в здравоохранении, которые требуют

особого подхода, и все это происходит, когда потребности здравоохранения покрыты лишь на

одну треть, и вряд ли эти ресурсы будут увеличены. Мы понимаем, что эти проблемы будет

трудно разрешить в ближайшее время в условиях активных процессов социальной

дифференциации, формирования имущественного неравенства; не решен вопрос социальной

защиты. Одним из реальных путей разрешения этих проблем - утверждение принципа

справедливости - Казахстан видит в совершенствовании и развитии первичной медико-

санитарной помощи, которая была определена как один из приоритетов разработанной в конце

прошлого года Национальной программы мероприятий по совершенствованию служб

здравоохранения республики.

Большую ставку Казахстан делает на глобальную политику в здравоохранении, это весьма

актуально перед лицом начавшегося в республике процесса реформирования здравоохранения

и зарождающейся национальной экономики. Солидарность я бы определил как партнерство 一

это необходимый компонент развития здравоохранения. Примером такого удачного

международного и внутристранового партнерства стала проведенная недавно в Казахстане

операция ВОЗ Мекакар - кампания по массовой вакцинации против полиомиелита. Был запущен

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фундаментальный эффективный механизм, состоящий из цепи различных секторов:

правительство, финансовые органы, транспорт, просвещение, средства массовой информации,

различные религиозные службы и здравоохранение. Эта модель межсекторальной кооперации

завершилась тем, что в течение пяти дней апреля было проиммунизировано 9,5% детей от

новорожденных до пяти лет включительно, и теперь мы твердо уверены в том, что второй тур

этой операции в мае этого года должен быть не менее успешным.

Четвертая всемирная конференция по вопросам женщин, равенства, развития и мира

состоится в Пекине в сентябре 1995 г. Это важная встреча, так как права женщин на здоровье

и доступ к обслуживанию на протяжении всей жизни тесно связаны с вопросами равенства и

развития, и никакое общество не может признать себя справедливо развивающимся, если в нем

не уделено внимание защите интересов охраны здоровья женщин и детей. Проблемы

социально-экономической и медицинской защищенности женщин становятся чрезвычайно

актуальными.

В республике разработаны меры, направленные на предупреждение материнской и

младенческой смертности, - это политические программные инициативы, подготовка кадров,

научные исследования. Примером одной из полити веских инициатив, демонстрирующих

солидарность, явилась проведенная в этом году акция "Бизнес Казахстана - больным детям".

Инициатором ее явился благотворительный фонд "Бубек", в ходе акции было собрано более

1 ООО ООО долл. США, которые были направлены на реконструкцию детских больниц, на

лечение детей, пораженных туберкулезом и онкологическим заболеваниями.

В традиционном международном понимании Казахстан, как и остальные республики

Центральной Азии, часто относят к развивающимся странам. Да, мы отличаемся от стран

Запада по уровню экономики, технологии, развитию демократических процессов, но Казахстан

осознает истинную природу своих проблем и имеет твердую политическую волю решить их,

и в этом мы сильны еще и потому, что действуем совместно с мировым сообществом,совместно

со Всемирной организацией здравоохранения. В свою очередь, Казахстан всегда готов

поддержать ВОЗ для достижения общей цели "здоровья для всех". И, в заключение, мне

хотелось бы напомнить всем один из постулатов Алма-Атинской декларации: "существующее

огромное неравенство в уровне здоровья людей ... является политически и социально-

экономически неприемлемым и поэтому составляет предмет общей заботы для всех стран".

Спасибо за внимание.

The PRESIDENT:

I thank the delegate from Kazakhstan. The meeting is adjourned until tomorrow morning.

The meeting rose at 17:55.

L a séance est levée à 17h55.

A48/VR/5 page 53

F I F T H P L E N A R Y M E E T I N G

Wednesday, 3 May 1995，at 9:15

President: Dato Dr Haji Johar NOORDIN (Brunei Darussalam) later: Acting President: Mrs I. DROBYSHEVSKAYA (Belarus)

C I N Q U I E M E S E A N C E P L E N I E R E

Mercredi 3 mai 1995，9hl5

Président: Dato Dr Haji Johar NOORDIN (Brunéi Darussalam) puis Président par intérim: Mme I. DROBYSHEVSKAYA (Bélarus)

1. FIRST R E P O R T O F T H E C O M M I T T E E O N C R E D E N T I A L S 1

P R E M I E R R A P P O R T D E L A C O M M I S S I O N D E V E R I F I C A T I O N D E S P O U V O I R S 1

The PRESIDENT:

The Assembly is called to order.

The first item on our programme of work today is the adoption of the first report of the Committee on

Credentials, which met yesterday under the chairmanship of Mr Chaudhry of Pakistan. This report is

contained in document A48/47 which you have all received. Are there any comments? I recall that the

delegates should speak from their seats. It would appear that there are no comments. I therefore take it that

the Assembly accepts the first report of the Committee on Credentials. The first report of the Committee on

Credentials is thereby approved.

2. D E B A T E O N T H E R E P O R T S O F T H E E X E C U T I V E B O A R D O N ITS N I N E T Y - F O U R T H A N D N I N E T Y - F I F T H S E S S I O N S A N D R E V I E W O F THE WORLD HEALTH REPORT 1995 (continued)

D E B A T S U R L E S R A P P O R T S D U C O N S E I L E X E C U T I F S U R S E S Q U A T R E - V I N G T -Q U A T O R Z I E M E E T Q U A T R E - V I N G T - Q U I N Z I E M E S E S S I O N S E T E X A M E N D U RAPPORT SUR LA SANTE DANS LE MONDE, 1995 (suite)

The PRESIDENT:

We shall now continue the debate on items 9 and 10. The first speaker on my list this morning is the delegate of Gambia who will speak for the West African Health Community, that is Gambia, Ghana, Liberia and Sierra Leone, as well as Nigeria, whose delegate will make a supplementary statement immediately afterwards. The chief delegates of these countries are seated on the rostrum. I give the floor to the delegate of Gambia.

Mrs CEESAY-MARENAH (Gambia):

Mr President, Vice-Presidents, Director-General, distinguished delegates, on behalf of the Assembly of

Health Ministers of the West African Health Community (WAHC), comprising Gambia, Ghana, Liberia,


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Nigeria and Sierra Leone, I wish to congratulate the President and Vice-Presidents on their election to office and to express, Mr President, our full confidence in your distinguished leadership of the Forty-eighth World Health Assembly. We also wish to congratulate the Director-General and his staff on a comprehensive report and on steering this great Organization successfully in the past year.

The challenges facing the health sector in many developing countries are similar. Formulation of a comprehensive health policy is crucial to the development of the health sector, which has been seeing a gradual decline in investments from governments and donor agencies. Our health policies are based on the essential elements of primary health care, community participation, social mobilization, intersectoral collaboration and the Bamako Initiative. Essential limited expansion and consolidation of existing services, through integration of programmes at the central level, but decentralization of programme implementation at the periphery, have had the necessary impact on our health promotion and protection strategies.

Demands for health services continue to increase without a corresponding increase in the resources available to the health sector. Countries are being called upon to use scarce resources efficiently. Operating costs are high because of the rising cost of inputs for quality health care, as most of these inputs are imported, in the face of scarce foreign exchange in our countries. Individuals and families now have to pay high fees when they fall seriously ill. Our concern in the West African subregión is to find an effective and equitable solution to the problem of health care financing and we welcome the initiative by the WHO African Region to make it the theme for the technical discussions at the next Regional Committee meeting in September 1995.

Human resource development continues to be a major concern for WAHC. Our countries are struggling to develop the necessary capacity to deal with diverse problems in the health sector. The brain-drain has had a deleterious effect on the quality of services being rendered to our peoples. Some of those trained outside the subregión do not return. Preference is now being given in our countries to appropriate in-country or regional training at pre-service and in-service levels. Specialized training for all cadres of health personnel is also being undertaken, to improve the capacity and quality of health care at all levels.

Deforestation, desertification and pollution have become important because of their effect on environmental degradation and consequently on economic development and health promotion and protection. As a result of our concern for environmental degradation, appropriate government actions have been undertaken to promote environmental protection activities. Tree planting and reforestation have been embarked upon to halt the spread of the Sahara desert.

Drought has the effect of a poor harvest and consequently food insecurity and malnutrition. We of WAHC are formulating food and nutrition policies to address some of the issues raised by food insecurity and malnutrition. With the support of some donor agencies, micronutrient deficiency (particularly iodine and vitamin A deficiency) is being tackled. Steps have been taken to ensure that all salt meant for domestic use is iodized. Promotion of breast-feeding has been given priority, as we believe that all children must be given the best possible start in life.

Disease control and prevention continue to be important elements in our health delivery programmes. Control of diseases such as AIDS, malaria, tuberculosis, acute respiratory infections, measles, sexually transmitted diseases and diarrhoea have become important public health concerns and are being addressed appropriately. Steps are being taken to increase the level of awareness of the diseases in the Community, using appropriate health education and social mobilization strategies. To reduce the infant and maternal mortality rates, issues pertaining to maternal and child health are being given the necessary attention at the highest levels. Population control and family planning strategies have begun to have a positive impact on the health of vulnerable groups. Coverage by the Expanded Programme on Immunization is being intensified, with the aim of eliminating neonatal tetanus and poliomyelitis in the not too distant future. We also look forward to the eradication of leprosy and guinea-worm in our countries. The success of onchocerciasis control in the subregión has been maintained, with its desired impact on our communities. However, the management and control of these diseases and the implementation of various programmes will require a lot of resources. We would therefore like to urge WHO to give priority to these areas in allocating its resources.

Once again, WAHC health ministers wish to put before this august body the problem of refugees and displaced persons arising from conflicts and civil strife. Preventive diplomacy and speedy resolution of conflicts would minimize the disastrous effects conflicts have, not only on individuals and their families but also on health service infrastructure and health care delivery systems, which in most cases have been set up at enormous expense in terms of men, money and materials. While efforts are being made by our countries to address the problem in the subregión, the international community is called upon to channel aid to these areas of conflict to assist in the rehabilitation of health facilities and also to address the health needs of displaced persons.

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The problem of urban and adolescent health needs to be addressed and effective programmes developed.

WAHC health ministers wish to put these issues on the global agenda. Health service delivery must come

to terms with these emerging problems, and we would like to appeal to the international community to see

the need for urgent support to countries in greatest need in addressing the twin problems of urban and

adolescent health. More attention should be given to the strengthening of intersectoral collaboration in order

to minimize the unacceptable adverse effects resulting from the neglect of urban and adolescent health.

We in WAHC have confidence in WHO and wish the Organization success in the years ahead.

Dr MADUBUIKE (Nigeria):

Mr President, honourable ministers, Director-General, distinguished delegates, it is with great pleasure and a sense of honour that I stand here to address this august gathering, the Forty-eighth World Health Assembly. I crave your pardon for this addition to the West African regional address already delivered by Gambia. These additions are considered necessary on account of the rather peculiar position of Nigeria, in that region.

May I join others in congratulating you, Mr President, on your election as the President of this Assembly. I congratulate also the Vice-Presidents and other elected officers.

We in Africa are still submerged in and daily concerned with problems of communicable diseases, malnutrition and sub-standard life-styles. These have already been alluded to in some previous reports and addresses. Most countries of Europe and the Americas today suffer from diseases of affluence, since they have, over the years, overcome the many problems of underdevelopment. I venture to suggest that it is time they actively involve those concerned with the latter problems with the conception, initiation and finding of solutions through relevant health programmes. The current seeming imposition of resolutions of these problems from without remains unacceptable.

Underdevelopment is not a racial, ethnic, religious or, even, a sociocultural factor. It is rooted in poverty and illiteracy. Our efforts to overcome some of the problems we have come here to seek solutions for can hardly progress unless we address these fundamental issues. Most developing countries are presently groaning under the heavy load of debt settlement. There is hardly anything else to use for real development as long as this economic burden is not given serious attention, with a view to writing off the debts.

May I now touch on a number of current health-related issues which I am sure are of common concern to most, if not all, developing countries, particularly in Africa. Of great concern to us is the survival of our children and the safety of our women at childbirth. Yearly, UNICEF publishes the document called The progress of nations. Also yearly, we feel sad that we are always listed on the lowest rung in tables showing the various indicators of health. Our vital statistics indicate that we are making progress, albeit slowly, in some areas, but the actual areas of human loss and waste remain static. Whereas our infant mortality rate is gradually declining, our under-five mortality rate and maternal mortality rate seem to remain static. Most of our children die between the ages of one year and the time to go to school. Childbirth is a nightmare to our women, since one out of every 15 pregnant women is likely to die at childbirth. Poverty and illiteracy make this so. The children die of communicable diseases like malaria, diarrhoea, acute respiratory infections, measles and tetanus, most of which have malnutrition as their precipitating factors. Others die of vaccine-preventable diseases like tuberculosis, poliomyelitis, diphtheria and whooping cough. Our wives die at childbirth mostly from haemorrhage, obstructed labour, sepsis, intrapartum hypertension and underlying factors of untreated diabetes, anaemia and septic abortion. These events are less manifest in the literate and affluent citizens in urban areas but afflict the illiterate poor in the rural areas. It seems clear that we know -to a reasonable extent - what to do, but we lack resources to spread our facilities equitably to the rural areas.

Permit me to highlight some of the activities and issues in Nigeria which may be of universal application. Our culture for many years treated women as second-class citizens who could only be seen and not heard. We have presently identified and appreciated that the woman is the pivot around which the rest of the family revolves and on whom they depend. In recent years, positive efforts have been made to empower them. Any woman can now own property and give full expression to herself. Positive steps are being taken to ensure that every female is functionally literate. Women are encouraged to establish small-scale industries and are given access to bank loans. The first lady of Nigeria, Mrs Maryam Abacha, has indeed currently established a programme of family support with great emphasis on education, health care and provision of food, enhancement of widespread supply of safe water and sanitary disposal of human waste, particularly for children, women and families as a whole.

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For a long time, people believed that noncommunicable diseases were of little consequence in the developing countries. This was particularly so in the face of an overwhelming sea of seemingly insurmountable communicable diseases. Current statistics show that the noncommunicable diseases have started to contribute heavily to our morbidity and mortality figures. Few adults now die of communicable diseases. What kills them rather are diabetes, asthma，hypertension, abnormal haemoglobins (notably sickle cell) and cancer. These are presently the killers of our populations between the ages of 40 and 60 years. What makes these diseases more serious in our health system pattern is their chronic and often untreatable nature. The afflicted may have to use drugs for the rest of their lives in some cases, yet these drugs have to be imported at a great cost to our foreign exchange earnings. Many who cannot afford the cost of drugs die unnoticed and often unrecorded. These diseases are systematically drawing on our economic resources.

Let me refer to some of our endemic diseases, not so much as they concern Nigeria in particular, but as they are of wider application in many developing countries. Malaria seems to be becoming an insurmountable problem. Both pests and parasites have developed resistance. There is a growing apathy and unconcern about the disease, yet it continues to take a great toll in terms of the morbidity and mortality of our people. It remains the leading cause of death among our children aged under five years and induces dangerous anaemia among pregnant women, leading to the birth of low-weight babies. We have been experimenting with pesticide impregnated bednets or curtains and this seems to be giving a measure of control. However, there is hardly any Nigerian who does not have some two episodes of malaria in a year. The disease kills many children. A renewed focus and method is being called for and we are happy to notice that this is already being addressed and highlighted by this Assembly.

Permit me to seize the opportunity of this forum to express the appreciation and thanks of the Government and people of Nigeria to President Jimmy Carter, and his Global 2000, for his kind, determined and consistent effort to see guinea-worm eradicated in Nigeria. We are very confident that the scourge of guinea-worm will be a thing of the past in Nigeria by the end of this year. The same cannot be said for river blindness (onchocerciasis), though a stable operational infrastructure has been established and a five-year plan of action has been drawn up. We owe a lot of gratitude to UNICEF, River Blindness Foundation, Sight Savers, WHO itself, Africare and others whose relentless efforts have made us so hopeful that the end of the eradication tunnel will soon be reached. Our consternation is that there are not many well-meaning organizations interested in the control and eradication of schistosomiasis. In spread, it is only second to malaria among those aged under 21 years in Nigeria. It is for this reason that I want to publicly acknowledge our appreciation of the gesture of the Special Programme for Research and Training in Tropical Diseases in recently offering to venture into and assist in this area in Nigeria in the not too distant future.

There are a few other subjects that I know are of universal interest and concern, but time will not allow me to do more than mention them - I refer to HIV/AIDS and emergency preparedness and response. I am sure these will be more than adequately discussed during the course of this Assembly.

Mr THAN NYUNT (Myanmar):

Honourable Mr President, Your Excellency Dr Hiroshi Nakajima, distinguished delegates, ladies and

gentlemen, it is indeed a great honour and privilege for me to be here today at this auspicious World Health

Assembly. At the outset, I would like to thank the organizers of this very important meeting for giving me

the opportunity to deliver an address on this occasion. I sincerely hope that this meeting will result in fruitful

deliberations which would enable us to accomplish the goal of health for all by the year 2000.

Mr President, on behalf of the Government of the Union of Myanmar, the delegation of Myanmar

would like to congratulate you very warmly on your unanimous election as President of the Forty-eighth

World Health Assembly and to assure you of our fullest cooperation and active participation in the

forthcoming discussions. I am confident that under your able leadership, this session of the Assembly will

be productive and extremely beneficial to all Member countries. Allow me to express my compliments to

all the Vice-Presidents who have been elected to assist you during the various meetings of this Assembly.

May I also take the opportunity to extend my sincere appreciation to the outgoing President and to all the

officers of the past session for the exemplary and commendable work they have contributed during their

incumbency. Furthermore I would like to place on record my deep appreciation to Dr Hiroshi Nakajima and

his associates, as well as to all members of the Executive Board for their untiring efforts and notable

accomplishments in promoting the health of the people all over the world.

I would like to emphasize that the Government of the Union of Myanmar reaffirms its commitment to

continue working together with the Member States for undertaking timely actions within the policy framework

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of the Ninth General Programme of Work. It is thus important that the Member countries should follow the policy guidelines of the programme in identifying priorities and in setting up the goals and targets which address the specific problems of the countries. Having set our sights on the policy framework of the Ninth General Programme of Work, it is now opportune for us to plan and develop national health programmes for undertaking specific actions for maximizing and accelerating progress towards health for all by the year 2000.

The National Health Committee has reviewed and revised the national health policy in consonance with the changing political, economic and social situations of Myanmar. One of the elements of the national health policy is: "to raise the level of health of the country and promote the physical and mental well-being of the people with the objective of achieving health for all by the year 2000 goals, using the primary health care approach". This policy element reflects our Government's commitment to health-for-all goals and the primary health care approach. To promote equity and solidarity in health and bridge the gaps in health, health service activities are being expanded not only to rural but also to remote border areas. This has been specifically stated in the national health policy and the Government has been implementing it to the fullest extent, with health centres, dispensaries and hospitals, together with health personnel, being established in these areas. To further support the issue of equity in health, Myanmar is addressing the health needs of women in the context of the women's development agenda for the twenty-first century. It is imperative for women to be healthy in order for them to be able to participate fully in development as workers, mothers, family and community members. Thus, the Government is working together with nongovernmental organizations, both national and international, to develop health strategies which involve women not only as recipients of health care, but also as providers and promoters of health. The health care scheme is an example of such a strategy and is one of the activities in the National Health Plan.

The malaria control strategy in Myanmar focuses on the need for immediate attention in providing treatment for malaria patients. Thus, the improvement of diagnosis and treatment of these patients is the first priority of the strategy. The strategy also emphasizes the importance of involving communities in sustaining selective prevention activities. It calls for the active participation of all sectors, including the nongovernmental sector.

With the present spread of HIV/AIDS, the number of tuberculosis patients is expected to increase, as many AIDS patients develop tuberculosis as a result of their lowered level of resistance. Basic health staff are being given refresher training in case detection, prevention, management and treatment of tuberculosis. To improve treatment compliance, short course chemotherapy recommended by WHO has been introduced. The HIV/AIDS control strategy in Myanmar is to build local capacities at community and national levels to cope with the HIV/AIDS epidemic and to prevent further spread of HIV infection. The strategy also aims to address the social, economic and health needs of those affected through a multisectoral effort involving communities in building enabling environments for behavioural change and support. Malaria, tuberculosis and HIV/AIDS have been designated priority diseases of national concern. Health-related governmental sectors and nongovernmental organizations are collaborating with the Ministry of Health in combating these diseases.

This meeting provides a unique opportunity for exchange of ideas and experiences on important health issues being faced collectively by Member States. It also serves as a useful forum to explore various ways and means to improve the health status of the people, based on the experiences of Member countries. I am confident that these issue-specific discussions by the delegates will provide appropriate and realistic directions to health systems development in the Member States.

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 a spirit of better understanding and close relationship 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 firmly state that we are ready, willing and able to work in close collaboration with WHO and Member countries to implement the goals and targets set in the Ninth General Programme of Work.

Mrs BOTTOMLEY (United Kingdom of Great Britain and Northern Ireland):

Mr President, Director-General, distinguished delegates, let me first congratulate you, Mr President, on your election and assure you of the United Kingdom delegation's full support as you preside over this Forty-eighth World Health Assembly.

I last personally spoke at this Assembly three years ago. I referred then to the consultation in England on our proposals for a health strategy for the year 2000 and beyond. We said we wanted to build on the foundation laid by WHO's health-for-all targets. I also said that the issues on which WHO should concentrate

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its efforts should include strengthening in-country capacity to prioritize health needs, plan and manage health services, and budget and control use of resources. The United Kingdom gave encouragement and support for WHO's efforts to help developing countries to identify their priority health care needs and select cost-effective strategies. We have made much progress in those three years.

Later in 1992，I launched our health strategy, "The health of the nation"，with the objective of promoting good health and preventing ill-health. The strategy identified five key areas responsible for premature death - coronary heart disease and stroke, cancers, mental illness，HIV and AIDS, and accidents. For each key area there are demanding specific targets for reductions in ill-health. An essential part of the strategy is the development of healthy alliances involving central and local government, organizations outside government and individuals. The message is that the health service alone cannot meet the challenge to translate those targets into real improvements in health - we need other organizations in the country committed to those targets also.

Now we are turning our attention to the health of the young nation and in July, to mark our third anniversary, we shall launch a long-term initiative to provide a focus for government and the wider community to join forces in tackling some of the key issues affecting the health of young people. It is vital that they are properly equipped to make responsible informed choices about their health and about their life-style. The initiative creates an opportunity for the National Health Service, for youth and voluntary organizations, for local authorities, for the business sector, for the Health Education Authority and for Government departments - and, of course, for young people themselves - to share their expertise and experience and to trigger new ways of improving the health of young people. At our conference in London at the beginning of July there will be an initial forum for discussing issues such as influencing behaviour in relation to substance misuse and sexual health. We will also be discussing the mental health of young people in its widest sense, ways of boosting their self-esteem and ensuring they feel part of the community, and building on the role the media can play in changing behaviour and encouraging positive life-styles.

Variations in patterns of health occur throughout the developed world. Many of them were identified in The world health report 1995, published this week. We aim, by studying how these variations can be addressed, to ensure that overall standards continue to rise. We are considering ways in which the Health Department and the National Health Service can work to ensure that those with the poorest experience of health can be brought up to the level of the best. There are many practical examples of our commitment to that goal, for example, we allocate additional funds to the family doctors working in deprived areas.

In The world health report 1995, the Director-General particularly identified the importance of health concerns being recognized at the highest political level. Health is an issue of central political, social and economic concern. Our health-of-the-nation strategy recognized that and established a Cabinet subcommittee chaired by a senior government minister to help us take forward the delivery of those health targets. On that subcommittee sit not only myself as Health Minister but also the Environment, Education, Treasury and Employment Ministers - all the key ministers - so that together we focus on how we can improve the health of our nation. I commend that model to other nations as being central to the delivery of improvements in health. Health ministers cannot do it alone. We need the commitment of senior political leaders in all our countries to deliver that change. Not only do we believe we must develop healthy alliances across government departments, but also healthy alliances with organizations outside government who can help improve the nation's health. For example, a close working relationship with employers is fundamental. Developing a commitment to workplace strategies is a significant tool in improving the health status of our populations. This is particularly difficult for the Health Secretary, since the National Health Service is the largest employer in the United Kingdom and we have to be sure that we set an example as an employer before we start exhorting other employers to give priority to these important areas. We take great pride in, and are greatly encouraged by, the progress made as our health-of-the-nation strategy has evolved. We are confident that it will continue.

I have already referred to the importance of prioritizing need and controlling the use of resources. It is equally important that the delivery of health care is systematically based on knowledge. The United Kingdom believes it is essential to bridge the gap between research and practice, to ensure that patients have access to health care of proven quality, and that the greatest benefit can be realized from available resources. We all live with finite resources. We must be sure that we have a knowledge-based strategic approach to maximizing the benefit of those resources for improving the nation's health.

The United Kingdom is one of the first countries to have established a research and development core function within the health service. Our objective is to ensure that the health service is systematically knowledge-based. At a time of rapid scientific and medical advance, we need to promote a more questioning culture so that policy makers and clinicians use sound，up-to-date evidence of effectiveness, coupled with a

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rigorous assessment of outcomes. Simultaneously we are encouraging the adoption and use of clinical guidelines, promoting a wide range of clinical audit initiatives, and assisting in the development of outcome measures to help embed research findings into everyday practice.

Our Department and the health care professions collaborate constructively in many areas of work. Clinical guidelines, based on research evidence, are primarily the responsibility of the professional bodies. We have been working closely with them to deliver appropriate clinical guidelines based on evidence. Our Department has also developed and promoted a wide range of audit initiatives, especially in the development of audit in the professional bodies. In the last few years audit has become an essential component of high standards of practice for all clinicians in the United Kingdom. It is no longer acceptable in any of our countries for the provision of clinical care to be a conspiracy against the laity which excludes the patient. That is why patients have a vital role to play, for example as members of our new Clinical Outcomes Group, a Group chaired by our Chief Medical Officer and Chief Nursing Officer, and bringing in people from professional bodies from the National Health Service and from research.

I have spoken about the value of evidence. Let me now describe briefly a recent practical public health measure in the United Kingdom based on evidence. In June 1994 we were alerted through our regular surveillance activities that a measles epidemic was highly likely in early 1995. On the scale predicted, more than 200 000 children were expected to develop measles and in an epidemic of that size, about 50 children were likely to die. We concluded that we could prevent this epidemic by mounting a measles immunization campaign. This was conducted in schools in November 1994. Nearly 8 million children between the ages of 5 and 16 were immunized with the measles/rubella vaccine, representing an immunization coverage of about 90%. As a result of that successful campaign the predicted measles epidemic has been averted - indeed we have not had a single confirmed case since February.

Similarly, public health measures remain essential in the prevention of HIV and AIDS. The United Kingdom's prevention strategy was preceded by a vigorous open debate in which political and medical leadership was absolutely vital. It was essential that the programme to prevent the spread of HIV included clear information to all sexually active people about how they should modify their behaviour to reduce the risk of HIV infection. In all these areas we recognize and support the important contribution that nurses and midwives have made. I would particularly like to congratulate WHO on its Global Advisory Group on Nursing and Midwifery, and the work being developed to strengthen nursing and midwifery further. In the context of immunization and other areas the United Kingdom greatly values the contribution and leadership of WHO. You will recall that eliminating poliomyelitis by the year 2000 was the theme of World Health Day this year.

We also work very closely, through the Overseas Development Administration, with very substantial grants and my colleague Baroness Chalker, the Minister for Overseas Development has taken a leading role, not least at the International Conference on Population and Development in Cairo.

We value also our good working relations with our Regional Office and have frequent constructive discussions with our Regional Director, Dr Asvall.

Let me finally congratulate the Director-General on the work taking forward the programme of improvement and reform within WHO. This is vital work for the future well-being of the health not of our nations but of our globe.

There is much to be done in reviewing the health-for-all strategy in which the United Kingdom based on its experience wishes to be closely involved. The new strategic budget is vital for effective planning and utilization of resources.

One of our famous British Prime Ministers, Benjamin Disraeli, remarked that the health of the population should be a minister's first concern. I believe that to be true. WHO's first concern is to improve the health of people around the world. There is still much to be done to build on the programme of reform and continuing improvement. We in the United Kingdom are committed, as ever, to assisting in that vital task.

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Professor SUJUDI (Indonesia):

Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, first of all allow me, on behalf of my delegation, to congratulate the President, Vice-Presidents and other members of the Bureau on their election to their respective posts. I am confident that under their able guidance, the Assembly will yield a fruitful outcome.

As the year 2000 draws nearer, it is discouraging to note that the target of health for all by the year 2000 will not be universally attainable. This fact has been clearly stated by the Director-General and is evidenced by the widening gap in the health status between developed and developing countries caused by various changes in the political, demographic, social and economic conditions prevailing globally. In some countries, particularly the developing countries, the health status is unfortunately deteriorating. At last year's Health Assembly, many delegations expressed their concern regarding those changes and consequently discussed it under the topic "WHO response to global change".

The political instability observed in many parts of the world has far-reaching repercussions on development in general and on health in particular. The International Conference on Population and Development convened in Cairo last year is one of the many global efforts devoted to solving the population issues which we all know have such a significant influence on health. Two months ago, the World Summit for Social Development was held in Copenhagen. This summit discussed the issue of poverty eradication and its determining factors such as the economy, education and health. The establishment of the World Trade Organization leading to trade liberalization may jeopardize the economy of developing countries if their health conditions remain stagnant, leading to their inability to compete in a highly competitive world.

The globalization of so many aspects of human activities and circumstances will undoubtedly have positive as well as negative impacts on health. However, only our concerted efforts can overcome its negative impacts. I fully agree with the Director-General that to anticipate those global changes we have to renew our health-for-all strategy.

What kind of reforms are needed to renew our health-for-all strategy? First and foremost comes the political commitment towards health. Although it is universally recognized that health is one of the basic human needs, in practice the budgets allocated for health are all too often far from sufficient. This is often further aggravated by misallocations towards secondary and tertiary care, thus deviating the budget from its main goal which should be to provide better health conditions for the poor. The World Summit for Social Development addressed this issue in a broader horizon under the formula Compact 20/20. It is completely up to the Member countries to adhere to that formula. Implicit in a country's political commitment, however, is the imperative to integrate health into the national development.

Secondly, primary health care should focus on the most cost-effective interventions, known as the basic health package, benefiting mainly the poor. The content of the package may vary from country to country. Health education, a very important component, particularly to curb the spread of AIDS, should be included in this package. So should immunization, the control of diarrhoeal diseases, acute respiratory infections, malaria and tuberculosis, and, of course, maternal and child health. With regard to immunization, I am happy to report here that Indonesia will conduct a national immunization day to eradicate poliomyelitis in September this year. As the geographical spread of Indonesia does not allow us to perform poliomyelitis immunization in one day, we shall extend the campaign to one week, necessitating a change in name to "National Immunization Week".

Thirdly, the community, including the private sector and nongovernmental organizations, should actively participate in these endeavours. No government can cater for the comprehensive health needs of the whole population. In Indonesia, 70% of health expenditure is incurred by the community. Unfortunately this large share is spent mostly on curative measures and 75% of it is out-of-pocket expenditure; only 25% is paid through a third party, namely health insurance. It is a big challenge for Indonesia to reverse this proportion. A community health maintenance assurance developed a few years back has covered around 20% of the population. Vigorous efforts are now under way to extend the coverage as one means of improving the equity, quality and efficiency of the health services.

Fourthly, decentralization of health services offers many benefits. It cuts down bureaucracy, thus increasing efficiency; it enhances community participation, since the community is involved from the planning stage; and, most important, it improves sustainability. The Ministry of Health of Indonesia is quite advanced in the decentralization of its activities to the district level. The Government itself is highly committed to decentralization. Just last month, Indonesia launched a large-scale field test in decentralizing national development involving 26 districts, one in each province.

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Fifthly, health development should play a greater role in poverty alleviation. Giving a high priority to primary health care alone is not sufficient. We should aim at improving the utilization of health services by the poor by improving their access to them. In order to improve this access, geographical, economical and cultural barriers must be overcome. Indonesia has been quite successful in improving the geographical distribution of its health facilities. To overcome the economic barrier, last year we launched the health card, which is a means of exempting the poor from user fees. It replaces the former affidavit of indigence. Special efforts are needed to lift cultural barriers, particularly in a country like Indonesia where there are more than 300 cultural groups.

Aside from the health card, the Government also launched a special assistance scheme to help poor villages, around 22 000 in number, aimed at creating activities which generate income. Each poor village receives around US$ 9000 a year, for use as a revolving fund. The Government of Indonesia is confident that with the issuance of the health card, the health conditions of the poor will be improved, thus leading to higher productivity. Other sectors are also asked to focus their activities on poor villages.

Health, education and the purchasing power of income constitute important factors for the enhancement of the quality of human resources. This has been properly addressed in Indonesia. As of 1994，nine years of primary education are now compulsory throughout the country. Economic growth, improved equity and dynamic national stability have been the basis of Indonesia's national development since the first long-term development period started in 1969. In the field of health, some remarkable results have been achieved in controlling blindness caused by vitamin A deficiency. To date there is no blindness attributable to it. Special efforts have also been made by the Government to control iodine deficiency disorders. Iodization of salt and oral administration of iodine capsules are our mainstay in the control efforts. By the end of 1995, it is anticipated that all consumable salt sold on the market will be properly iodized.

I now come to the end of my statement. To facilitate the renewal of the health-for-all strategy, in my opinion, WHO should maintain its present role, that is to provide advocacy for health, surveillance and to give technical expertise to Member countries as needed, as well as promoting research. What needs to be improved is the way WHO looks at and deals with global health problems, where a more proactive role seems to be indispensable. Other improvements also involve the need to enhance its efficiency perhaps through shortening some of its over-bureaucratic procedures, coupled with an increase in the decentralization of its regional offices and right through to the WHO Representatives.

Finally, I would like to express my heartfelt thanks to the outgoing President of the World Health Assembly. My appreciation also goes to the Director-General and the Regional Director of South-East Asia for their untiring efforts devoted to health development in Indonesia.

Dr KRAMMER (Austria):

Mr President, Mr Director-General, ladies and gentlemen, first of all we should distinguish between inequities in the level and quality of health of human beings and inequities in the provision and distribution of health services. We cannot overlook that variability is an intrinsic characteristic of all creatures, including man. When we, as politicians, criticize inequities, we usually have moral and ethical aspects in mind. That means, we refer to differences that we consider unnecessary and avoidable. Furthermore, if we follow the principle of the universal plea for health for all, we reject unnecessary and avoidable differences as unfair and unjust. Since all of us have a great wealth of information at our disposal, we have to feel responsible for inequities at all levels. We cannot consider ourselves citizens of the world, and at the same time, try to escape global responsibilities.

Politicians should admit that there are inequities, no matter how painful and shameful such recognition may be. We know about differences in health between inhabitants of different geographical regions. Differences in health depending on income and social levels are also well known. Many more examples of inequities could be given.

We welcome The world health report 1995: bridging the gaps as it presents an accurate and comprehensive assessment of the worldwide health situation. In its very first part, the report states that growing disparities in health are evident both among countries and among communities within them. How to bridge these gaps is the first question that arises and that we are called on to tackle in this forum.

The world's most dangerous killer is extreme poverty. At the World Summit for Social Development, this fact was recognized and States have committed themselves to establish national policies to reduce poverty and inequities, and eradicate absolute poverty within a certain time-frame. Social development has been recognized as a main objective of the international community. Access to health facilities is linked to national

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policies, and at the international level, to development cooperation. In this respect WHO has an important role to play. In particular, efforts to achieve health for all through primary health care stand at the centre of the attention of the Organization. The Ninth General Programme of Work focuses on lessening the inequities in health, controlling the rising costs, fully eliminating a number of infectious diseases and promoting healthy behaviour and environment. Austria supports all efforts to coordinate and focus international programmes improving health and bridging the gaps existing in this field. Austria offers a good example in that public health and social security have had an enormous impact not only on the general welfare of its citizens but also on the cohesion of the society as a whole.

Even countries that are proud of a comprehensive health insurance system covering the whole population can, at a closer look, present avoidable differences in health care. In recent times, comprehensive assessments of the quality of social security have provided an important tool towards further equity. Let us all use this Assembly for an efficient and thorough exchange of experience in order to achieve our noble goal of equity in health.

Mr NOONAN (Ireland):

I would like to congratulate Dr Noordin on his election as President of the Forty-eighth World Health Assembly.

Mr President, distinguished colleagues, it is a great honour for me to address the World Health Assembly. I propose, through my address, to share with you some of the most recent developments in relation to health policy in Ireland. I am part of a new partnership Government in Ireland which is committed to meeting the challenge of change. As Minister for Health in that Government, I am conscious of my responsibility where change is concerned.

The theme of this year's meeting, equity and solidarity in health - bridging the gaps, finds an echo in Ireland's national health strategy which was published last year. The Strategy has been endorsed by my Government as the basis for its programme in the health care area. The main theme of the health strategy is the reorientation of the system towards more effectiveness and efficiency by reshaping the way that health services are planned and delivered. It is underpinned by three important principles - equity, quality of service and accountability. It places the concepts of health gain and social gain at the centre of Ireland's health agenda and, in support of these, advocates the identification of the population's health needs, the setting of clear objectives and the attainment of measurable targets in all areas of the health services. The publication of the strategy was accompanied by a four-year action plan which set out specific targets for each of our main health sectors. During my term as Ireland's Minister for Health, I intend to do everything I can to ensure that the health care system described in our health strategy actually becomes a reality.

Ireland's health strategy bases its approach on the identification of the main causes of premature mortality - cardiovascular illnesses, cancers and accidents - and addresses what should be done to tackle these. Particular emphasis is placed on the further development of health promotion strategies which target the life-styles issues which have been identified as at the root of premature mortality. I am now finalizing a health promotion strategy document for publication in the near future which develops further the issues raised in the health strategy. It will focus on the six key areas which are: smoking, alcohol, nutrition, accidents, exercise and cholesterol.

The health strategy also contains a commitment to publish a plan for the development of health services for women. In this context, I am currently finalizing a discussion document on women's health. This document analyses the health of Irish women and pinpoints the main causes of mortality and morbidity among women. Following the principles of the health strategy, it looks at the health services which are particularly important to women and suggests priorities for improvement. This document will form the basis for consultation with all interested parties. Following our consultative process, I intend to draw up a plan for women's health, to be adopted by Government and implemented over a four year period.

On taking office, I set as a priority the development of services to combat cancer. My Department is currently preparing a comprehensive cancer strategy which is due for completion by mid-year. The initiative on cancer was prompted by the perceived need to ensure the provision of an equitable and high quality cancer service throughout the country. The objective is to take all measures possible to reduce the incidence of cancer and to ensure that those who develop cancer receive the most effective treatment and care. This initiative will concentrate on four main areas. These are prevention, treatment, rehabilitation and palliative care. Specific issues being addressed include: the further development of health promotion activities aimed at reducing the incidence of smoking and diet related cancers; the prevention of cancers of the breast and

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cervix through screening and early detection; the integration of the various medical professionals involved in the cancer service towards developing a multiprofessional input into care, management and treatment of persons suffering from the disease; the adequacy of existing general practitioner, diagnostic and hospital services and their distribution; and the development of palliative care services, with particular regard to the hospice movement.

The care of the elderly is one of my top priorities and will be one of the key issues to be addressed by the health services in the next decade. The challenge is to reorganize existing services and develop new services, to ensure that the ill and dependent elderly get the most effective care available. In recent years, services for ill and dependent elderly people have improved in Ireland, both in hospital and in the community. Initiatives such as district care teams for the elderly and the expansion of the home nursing service have enabled more elderly people to be nursed at home. Respite and day care have eased the burden of caring for many relatives. There has been a rapid expansion of specialist departments of medicine of old age attached to general hospitals in recent years. At present, just over 90% of those over 75 years of age live at home and my objective would be to maintain this proportion of those who can live at home. If the same proportion of those over 75 are to be maintained at home in the future, services delivered to the person's home or available locally must be strengthened. This means that there must be a strengthening of the role of the general practitioners, the public health nurse, the home help and other primary care professionals, such as occupational therapists, physiotherapists and social workers, in supporting older people and their carers at home, as one of the priority issues to be addressed over the next four years.

In these key areas of care and treatment of cancer patients and the elderly, it can be seen from my comments that we believe that a multidisciplinary approach is absolutely vital. This must be based on a programme which determines priorities and delivers services to meet these identified priorities. WHO must continue its valuable work in assisting national governments to plan, in a rational and coherent manner, their health services. Without such planning, services will be fragmented and scarce resources will be wasted.

Funding has been provided for the further development and expansion of services for people with mental and physical disabilities. Major improvements are also in train in the areas of child care, family planning and cancer treatment services.

Equity and solidarity are important goals in the Irish health service. As you will have gathered, Ireland's health strategy is now enabling us to actively pursue these goals and to achieve a more equitable, efficient and effective health service for all our people. This approach by the Government is, in my view, in line with the economic pressure for health sector reform which is being felt worldwide. Countries themselves and WHO are currently considering ways in which the health service - on a national and on a global level - can bring about an improvement in the health of the world's population, particularly in the poorest countries, and in the organization of health services. I am aware that WHO is undergoing its own reform process. For this reform process to succeed, it must have the full commitment of both WHO itself and all the Member States. In this context, I am pleased to inform you of Ireland's contributions from our development assistance programme to a number of WHO initiatives with particular emphasis on aid to developing countries. These will amount to some US$ 750 000 in 1995.

As Minister for Health, I am acutely aware of the difficulties to be faced in determining priorities for health funding. In line with every national administration, WHO must confront this issue. The Organization must continue to be involved in the process of budgetary reform while, at the same time, maintaining its commitment and concentrating on the deteriorating health standards, due to rising poverty, in the least developed countries. Poverty can stem from many sources including natural and man-made disasters. Illness and disease are almost always the first consequences of poverty. But deteriorating health is not the only casualty. Standards of housing, education and the opportunities for economic and social development diminish rapidly. It is my belief that a multisectoral approach is the only one that will succeed in the long term. This approach would involve WHO, along with other international funding agencies, such as UNICEF and the World Bank, in the provision of a coordinated response to the specific needs of each country. I would go further and declare that national governments and international organizations urgently need the active support and participation of the nongovernmental agencies, where Ireland has a strong tradition. Without the support of the wide variety of nongovernmental organizations, particularly at regional and district level, the momentum for progress and change will be seen as one imposed from outside. I know that the participation of the nongovernmental organizations, in successful cooperation with WHO and other international organizations, will eventually improve the prospects for millions of the most deprived people of this world.

In conclusion, Mr President, I wish to point out that, in my short address, I have referred to the measures being undertaken for a new national health strategy in Ireland. This will, I hope, give you and the

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delegates some information on Ireland's real concern and interest in dealing with the issues of equity and solidarity.

Professor ZOCHOWSKI (Poland):

Mr President, Mr Director-General, distinguished delegates, I would like to congratulate you Mr President and the Vice-Presidents, on your election to these highest posts in our Organization and to wish you a successful accomplishment of all the tasks and decisions of our Health Assembly.

I would also like to congratulate Dr Nakajima on The world health report 1995, which gives a much-needed assessment of the health situation and the needs of the world's population. It is a solid basis for the establishment of the programme priorities for the work of our Organization. It can also be seen as a necessary response to the changing socioeconomic situation observed in different regions and countries. The analysis of this report evidently indicates the need for some global programmes, but mostly for decentralized programmes adjusted to regional, or even subregional needs. The report is a good visiting card for WHO as a health information centre for the Member States, collecting, compiling and transferring to them crucial information on health matters. We consider it as one of the most important tasks, which contributes to the image of the Organization as the leading agency in the field of health.

Let me take, as a basis for sharing with you our views on this WHO programme, the process of transformation of the health system which is taking place in Poland. It must be strongly underlined that independent of changes in Government, the direction of reforms stays the same. In the field of health, stress is put on the issue of equality in access to health, the accessibility of primary health care services to all in need, and social support. Also, the regulatory role of governmental agencies in time of transition is seen differently, as the process of change cannot be left to free market forces alone.

A project of a bill on health insurance has been prepared for parliamentary discussion. The internal market mechanisms are being introduced in the health services at the primary health care level, with free choice of doctor and efforts to match the amount and quality of work with the level of salary.

We greatly support and welcome the stress put on the promotion of healthy life-style activities in the work programme of the Organization. These issues are our greatest concern owing to the health situation in our society. We observe negative trends in mortality rates due to cardiovascular diseases, accidents and neoplasms, mainly lung cancer. This is the result of unhealthy nutritional habits. Our national programme of health, based on the philosophy of health for all, whose health priorities have been adjusted to the Polish situation, is considered as a State priority.

We also support the focus given by WHO to the programme of immunization. The problem of communicable diseases, such as cholera or diphtheria, is a serious one, due to the growing migration of people for various reasons, like war or poverty. Therefore we consider that ascertaining the good quality and low price of vaccines, and making them available to all countries in need, is one of the most important tasks of WHO. Here, I would like to inform you, that Poland is close to reaching the WHO target of eradication of poliomyelitis. During the last years only sporadic cases of this disease have been notified.

Once more, we would like to stress the importance of the transfer of valuable experiences of various countries, especially in the field of financing and organization of health systems, as well as managerial practices. Although cultural and social differences as well as traditions preclude an automatic adoption of ready-made methods and solutions, they are important as a source of information which may be adapted to local conditions. Here, we see the role of the Organization as being a top-level consultancy agency in health, giving impartial expert advice on key issues related to investment in health. Sometimes a sober, impartial evaluation of the real needs and the extent of changes, when made by WHO experts who are held in high esteem, is often more convincing and effective than any analysis made by national experts.

We support every effort made for the more efficient use of available WHO resources. This calls for better coordination between various programmes, so as to avoid overlapping. We also need to secure friendly collaboration across the different divisions and sectors. Concluding, I would like to underline that Poland highly values the work of WHO, appreciates its very good and close cooperation, and declares a willingness to contribute actively to its work.

El Dr. MAZZA (Argentina):

Señor Presidente, señor Director General, distinguidos delegados: Permítame felicitarle, señor Presi-

dente, con motivo de su elección y por sus palabras de apertura. Saludamos y agradecemos al Director

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General y a la Secretaría por el constante estímulo y apoyo brindado. Asimismo, queremos destacar la utilidad de las profundas reformas y reestructuración que está llevando a cabo la Organización, con el fin de orientar los programas a las prioridades existentes.

En relación con la equidad y la solidaridad, consideramos que resulta de fundamental importancia lograr en primer término el uso racional de los recursos disponibles para reducir las desigualdades en materia de salud, destacadas por el Director General en la presentación del Informe sobre la salud en el mundo. Esto implica la transformación de los enfoques políticos y de las formas de actuar, introduciendo modificaciones en las estructuras del sistema con el fin de dar respuestas ágiles y eficientes a los problemas que enfrentamos.

Para alcanzar este objetivo es necesario el desarrollo de sistemas de información que permitan conocer mejor la realidad en que nos desenvolvemos, identificando las múltiples variables que interactúan en el escenario de la salud para comprender, explicar y anticipar los problemas del sector. Asimismo, resulta imprescindible mantener nuestros principios éticos en el proceso de toma de decisiones y en la asignación de los recursos.

Señor Presidente, en el marco de las profundas transformaciones económicas y sociales que estamos llevando a cabo en nuestro país, ponemos especial énfasis en lograr la equidad social en el sector de la salud, tratando de incrementar la accesibilidad y la igualdad de cobertura para la población, asegurando un nivel básico de servicios esenciales para todos, respetando la libertad individual. Es por ello que hemos imple-mentado y estamos desarrollando en estos últimos años cambios estructurales con el fin de humanizar y mejorar la solidaridad，eficiencia, eficacia y calidad de los sistemas y de los servicios de salud. A partir de nuestra experiencia práctica, consideramos indispensable seguir tres grandes orientaciones prioritarias.

La primera es mejorar la eficiencia y calidad de los modelos de atención médica con el fin de contener y reorientar el gasto innecesario en salud, y de este modo poder disponer de mayores recursos que aplicar en el mejoramiento del nivel y calidad de vida de la población. Los sistemas de salud son sistemas abiertos, complejos y fuertemente interrelacionados con el contexto, para cuya atención se cuenta con recursos limitados, y por lo tanto resulta imposible lograr la equidad social si no se trabaja con un alto grado de eficiencia. Para efectuar cambios en dichos sistemas es imprescindible contar con el apoyo y la colaboración de todos los protagonistas del sector de la salud, poniendo en práctica el concepto de democracia participati-va. Con el fin de mejorar la eficiencia, en nuestro caso hemos implementado un conjunto de medidas, como la transformación de los establecimientos asistenciales en un nuevo modelo de hospital público de autoges-tión, la puesta en marcha del programa nacional de garantía de calidad de atención médica, la adecuación del proceso de desarrollo de los recursos humanos a la realidad sanitaria nacional, la regulación y transparencia del mercado de los medicamentos, la promoción de la tecnología apropiada, y la creación de la comisión nacional de bioética para asegurar el respeto de la dignidad humana en la actividad sanitaria. Cabe destacar que en este proceso de transformación participan activamente 116 entidades académicas, universitarias, científicas, de profesionales, de técnicos y colaboradores de la medicina, y también, de cámaras y confedera-ciones de prestadores que posibilitan la viabilidad social del cambio perseguido.

La segunda de las orientaciones es disminuir los riesgos evitables de enfermar y morir a través del desarrollo de acciones concertadas y sostenidas de promoción y protección de la salud, y de prevención de las enfermedades, con especial énfasis en los grupos más carenciados por su pobreza estructural y en los de mayor riesgo por su situación biopsicosocial，tales como la madre y el niño, los adolescentes, los ancianos, los discapacitados y los aborígenes. En tal sentido destacamos la prioridad fijada por la OMS de disminuir las tasas de morbi -mortalidad de madres y niños y reiteramos la posición de nuestro país de que el derecho a la vida existe desde la concepción. Como ejemplo, podemos señalar que tenemos en ejecución el Programa Nacional de Maternidad e Infancia, complementado y extendido en sus alcances con el nuevo Programa Maternoinfantil y Nutricional (PROMIN), que además del componente nutricional incorpora el monitoreo operativo y la estimulación precoz del niño. Asimismo, hemos intensificado el Programa Nacional de Inmunizaciones; la Semana Nacional de Vacunación; las campañas de erradicación del sarampión; de vacunación contra la hepatitis В al personal de salud en situación de riesgo; y de vacunación a mujeres en edad fértil para la erradicación del tétanos neonatal. Nos proponemos, con el apoyo de la sociedad en su conjunto, erradicar las enfermedades inmunoprevenibles para repetir el éxito alcanzado en la lucha contra la poliomielitis, que en nuestro país presentó su último caso en 1984.

Dentro de este esquema, consideramos que la educación para la salud es un instrumento muy valioso,

que debe ser tomado en cuenta en la planificación sanitaria. En especial, la educación que puede desarro-

llarse en el ámbito escolar, para lo cual resulta de fundamental transcendencia la articulación de los sectores

de salud y de educación del país. La escuela es el medio ideal para transmitir el mensaje sanitario a la

comunidad educativa, con el fin de lograr cambios de conducta y estilos de vida en la población. En tal

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sentido, en nuestro país funciona una comisión nacional de coordinación intersectorial para el desarrollo de contenidos de educación para la salud y de prevención para la drogadicción en las escuelas. Consideramos que la educación para la salud, así como el desarrollo de la estrategia de atención primaria de salud, deben ser componentes esenciales de todos los programas sanitarios. Esta orientación, integrando esfuerzos y recursos oficiales y de la propia comunidad, nos ha permitido una sensible disminución de la incidencia de enfermedades transmisibles, tales como sarampión, paludismo autóctono, rabia canina, enfermedad de Chagas, fiebre hemorrágica argentina, etc. En el caso del sarampión, podemos destacar que la vacunación de más de nueve millones y medio de niños y jóvenes nos ha permitido alcanzar más del 97% de cobertura.

En materia de medicamentos hemos avanzado sensiblemente en el control de la calidad, así como en la racionalidad de la prescripción y en la implementación del Sistema Nacional de Farmacovigilancia. Similar acción hemos comenzado en el área de la tecnología médica y en particular en el desarrollo de la aplicación de tecnología apropiada. La administración nacional de medicamentos, alimentos y tecnología médicas, que anunciamos en Asambleas anteriores, es hoy una realidad gracias al decidido apoyo técnico recibido de la OMS y de otros organismos internacionales.

La tercera orientación es mejorar la gestión de los organismos de conducción de nivel nacional como instrumentos necesarios para hacer posible la implementación y el desarrollo de las dos orientaciones señaladas precedentemente.

En tal sentido, resulta de fundamental importancia introducir profundas transformaciones en el sector de la salud, orientando las políticas, programas y estrategias operativas a la solución de los problemas prioritarios detectados a nivel local. Transformaciones que deben basarse en principios de centralización normativa, descentralización operativa, programación local, participación social y articulación y comple-mentación intra y extrasectorial, que deben llevarse a cabo contando con una actitud integradora y creativa por parte de las autoridades sanitarias y un trabajo conjunto de todos los protagonistas, para hacer realidad la ambiciosa meta de salud para todos. Estimamos necesario motivar a la sociedad, para que todos trabaje-mos en forma conjunta para el bien de la comunidad. La participación social es un mecanismo indispensable para asegurar el logro de los objetivos propuestos y para retroalimentar al proceso de toma de decisiones.

Señor Presidente, por último queremos referirnos al SIDA y a la pobreza, temas que constituyen un grave problema social que desborda en muchos casos los límites del sector, pero que a su vez inciden fuertemente sobre el sistema de salud.

En cuanto al SIDA, reiteramos lo expresado en este mismo foro en Asambleas anteriores, en el sentido de destacar la competencia primordial, en los aspectos técnicos del programa, de la OMS a nivel mundial, de la OPS a nivel regional, y de los respectivos ministerios de salud en cada país. Seguimos considerando imprescindible que se defina un mensaje único, común para todos nuestros pueblos, sobre prevención del SIDA frente a la globalización conceptual y operativa ya comentada en este foro. Ello otorgaría coherencia a las campañas a desarrollar, evitaría falsas interpretaciones a nivel de la comunidad, que pueden generar confusión y conflictos que dificulten el logro de los objetivos de los programas nacionales de lucha contra el SIDA. En tal sentido, solicitamos nuevamente la realización de una reunión internacional de expertos destinada a establecer un mensaje homogéneo de educación para la salud en materia de SIDA, a cuyos efectos tenemos intención de presentar un proyecto de resolución ante esta Asamblea.

En nuestro país, como consecuencia del compromiso político asumido en la Cumbre de París, hemos convocado a sumarse a esta estrategia a las ONG que actúan en la materia y hemos firmado convenios con sindicatos y universidades.

Señor Presidente, también nos preocupa el problema de la pobreza, dado que más de una quinta parte de la población mundial vive en esas condiciones, tal como lo señalara el Director General en su informe. Al respecto recordamos que el 20 de diciembre pasado la Asamblea General de las Naciones Unidas aprobó, con el apoyo de 65 países copatrocinantes, la iniciativa del señor Presidente de la Argentina, Dr. Carlos Saúl Menem, para la creación de los «cascos blancos»，cuerpo de voluntarios que participarán en actividades de ayuda humanitaria, alivio, rehabilitación y cooperación técnica para el desarrollo. En el marco de la iniciativa, el sector de la salud tiene una participación relevante, motivo por el cual queremos convocar a los distinguidos delegados y a la Organización Mundial de la Salud a que sumen sus esfuerzos a esta propuesta social.

Compartimos lo expresado por el señor Presidente de esta honorable Asamblea en el sentido de que combatir la pobreza es un desafío ineludible que debemos enfrentar para promover el acceso a una vida sana y productiva. Los cambios estructurales adecuados a las realidades regionales y nacionales, llevados a cabo mediante el trabajo multidisciplinario y el apoyo de la OMS, permitirán mejorar la eficiencia del sector y la calidad de vida de la población, reducir las desigualdades y prever un mañana mejor con equidad y solidari-dad social. Muchas gracias.

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The PRESIDENT:

As I am obliged to leave the meeting for a few hours, I would now like to invite the first Vice-President, the Honourable Minister from Belarus, to take over the presidency.

Mrs I. Drobyshevskaya (Belarus), Vice-President, took the presidential chair. Mme I. Drobyshevskaya (Bélarus), Vice-Président, assume la présidence.

The ACTING PRESIDENT:

ИСПОЛНЯЮЩАЯ ОБЯЗАННОСТИ ПРЕДСЕДАТЕЛЯ:

Глубокоуважаемые коллеги,

Я благодарю всех вас за ту честь, которую оказали вы мне, избрав вице-президентом

Сорок восьмой Ассамблеи здравоохранения. Кроме того, я хочу поздравить г-на Генерального

директора д-ра Накадзиму, г-на Президента, всех региональных директоров с теми успехами,

которых мы достигли, и надеюсь, что наша работа даст нам надежду на то, что Всемирная

организация здравоохранения сыграет и в дальнейшем свою роль в улучшении развития

здравоохранения мира.

Благодарю. И продолжим дальше нашу дискуссию.

Итак, было объявлено выступление представителя Испании. Приготовиться

представителю Ирана (Исламской Республики).

La Sra. AMADOR (España):

Señor Presidente, señoras y señores ministros, distinguidos delegados, señoras y señores: Es un honor para mí dirigirme en nombre de España a los delegados de todo el mundo reunidos aquí. Deseo en primer lugar felicitar al Presidente y a los Vicepresidentes por su elección para dirigir esta 48a Asamblea Mundial de la Salud y asegurarles el apoyo de la delegación española para culminar con éxito su importante tarea.

Señor Presidente, España tiene en la más alta estima a la Organización Mundial de la Salud y tenemos el firme compromiso de contribuir, en la medida de nuestras posibilidades, a hacer realidad los objetivos de paz, solidaridad y salud mundial que persigue. El Gobierno de España está firmemente convencido de la importancia de las tareas desarrolladas por la OMS, y por ello desea apoyar activamente el proceso de reformas en curso, que deben contribuir a prepararla para los desafíos de los próximos años.

Los nuevos y viejos problemas de salud a los que se enfrenta la humanidad requieren indudablemente la cooperación entre todos los Estados y hacen, por lo tanto, imprescindible que la OMS mantenga su liderazgo y su prestigio. Como toda organización que ha de hacer frente a un proceso de cambios en un mundo en rápida evolución, la OMS necesita el estímulo externo y el apoyo de los Estados Miembros y de sus representantes, reunidos en esta Asamblea. Tenemos el deber de asumir esta responsabilidad y de adoptar las decisiones que garanticen que la OMS del futuro responderá eficazmente a las necesidades de salud de la humanidad y a las demandas de solidaridad y de cooperación internacional, para lograr un mundo más justo y humano.

Señor Presidente, este año hemos sido invitados a centrar nuestra atención en las desigualdades ante la salud. Difícilmente hubiera podido ningún otro tema incidir mejor en la raíz de los problemas de la humanidad. El Informe sobre la salud en el mundo, 1995: reducir las desigualdades, presentado a esta Asamblea, nos recuerda a todos los hechos más trágicos del sufrimiento humano en nuestro mundo, junto a algunos datos que demuestran que, a pesar de todo, el esfuerzo siempre merece la pena, porque permite ir avanzando. Todos los países afrontamos el reto de hacer permanente la paz y asegurar que el nuevo proceso de desarrollo refuerce la democracia. Nivel de salud y equidad están íntimamente relacionados en todas las sociedades y por ello la lucha contra la pobreza, en todas sus formas y manifestaciones, es la tarea funda-mental para lograr un nivel aceptable de salud en el mundo. La salud es un elemento básico del desarrollo socioeconómico y por ello debe constituir, a su vez, la piedra angular de las políticas de desarrollo.

En la Región de Europa, la OMS ha venido insistiendo durante todos estos años en la importancia de la equidad y la salud, temas sobre los que se han publicado excelentes trabajos que son ya textos de referen-cia. Considero necesario seguir trabajando en esta dirección porque, incluso en los países europeos más avanzados, las disparidades económicas tienen su manifestación más injusta en desigualdades de salud. Hay

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que recordar, una vez más, que la aparición de situaciones contrarias a la equidad no sólo afecta a nuestra conciencia individual, sino que constituye un problema de enormes consecuencias sociales y económicas que no podemos ignorar. La promoción de una mayor igualdad en materia de salud ha sido considerada tan importante para la política sanitaria europea que ha constituido el contenido del primer objetivo de la política de salud para todos y el lema de su estrategia de conjunto. Este objetivo fijaba que las desigualdades del estado de salud entre países y entre grupos en el mismo país debían reducirse al menos en un 25% antes del año 2000，mediante la mejora del nivel de salud en los países y en los grupos desfavorecidos. La falta de acceso a los servicios médicos, el desequilibrio entre los diferentes tipos de cuidados y la mala calidad de la atención son claros ejemplos de situaciones que pueden tener repercusiones negativas sobre la salud de las poblaciones o de ciertos sectores de las mismas. La mejora de la estructura y organización del sistema sanitario puede, por lo tanto, generar una mejora considerable de la salud.

La salud depende no sólo de factores ligados a la prestación de cuidados sanitarios, sino también de factores unidos a los recursos económicos, a las condiciones físicas y sociales de vida y de trabajo，además de a factores vinculados a los estilos de vida. En este sentido, las estrategias para disminuir las desigualda-des deben basarse tanto en estrategias intersectoriales, que conduzcan a una participación y corresponsabilidad de los ciudadanos respecto a su propia salud, como en estrategias propias de los sistemas sanitarios, en las cuales se ve claramente que ciertas prestaciones sanitarias permiten la mejora efectiva del nivel de salud de la población y una importante reducción de la morbimortalidad en muchos países. La política sanitaria tiene un papel importante en la promoción de la igualdad ante la salud, disminuyendo las desigualdades de acceso a los servicios sanitarios y ayudando a atenuar las consecuencias para la salud de otros factores de riesgo, ajenos al propio sistema sanitario.

Señor Presidente, no quiero dejar de comentar brevemente la tragedia que representa el SIDA para todos los países y, especialmente, para los Estados Miembros de la Región de Africa. Algunos datos son demasiado significativos para no mencionarlos. Por ejemplo, en el Africa subsahariana，donde vive el 10% de la población mundial, se encuentran dos tercios de los infectados del planeta, y ello hará que la esperanza de vida no se eleve en los próximos años. Este año finaliza el Programa Mundial sobre el SIDA y toma el relevo el Programa conjunto de las Naciones Unidas sobre el SIDA. Es el momento de felicitar a los responsables y a todos los que han participado en el Programa Mundial, pero también de llamar la atención para que el nuevo programa responda a las expectativas y necesidades mundiales, sin perder la continuidad de lo que hasta ahora se ha venido realizando.

Afortunadamente también se están produciendo signos esperanzadores para un mundo más humano y solidario. En muchos países las ONG están contribuyendo a fomentar el interés social por el desarrollo y, por otro lado, los gobiernos e instituciones internacionales dedican cada vez más atención al problema mundial de la pobreza y a la estrecha relación existente entre salud y desarrollo. En marzo de este año se reunía en Copenhague la Cumbre Mundial sobre el Desarrollo Social y adoptaba un Programa de Acción que representa una esperanza para el progreso de la humanidad. Entre los objetivos para el año 2000 se incluyen contenidos del Noveno Programa General de Trabajo de la Organización Mundial de la Salud para el periodo 1996-2001，relativos a lograr en todos los países un mínimo de 60 años de esperanza de vida, que la mortalidad infantil no sobrepase los 50 por 1000 nacidos vivos y la reducción de la mortalidad materna en un 50%, entre otros aspectos.

Señor Presidente, permítame una breve referencia a España. El esfuerzo del Gobierno español por seguir perfeccionando nuestro sistema de protección social, del que estamos legítimamente orgullosos y que ofrece a todos los españoles la cobertura del Sistema Nacional de Salud, no impide que seamos conscientes de que las desigualdades sociales son un reto permanente y de que la lucha contra las mismas - y particular-mente las desigualdades en salud - es y debe seguir siendo para nosotros una prioridad. Conocer en profundidad la magnitud de este problema, su extensión y sus consecuencias es un primer paso imprescin-dible para tomar las medidas que permiten alcanzar altas cotas de equidad y solidaridad. La última Encuesta Nacional de Salud realizada en España ha estado especialmente orientada en este sentido, de forma que la investigación epidemiológica sobre desigualdades recibe un apoyo prioritario.

Señor Presidente, no quisiera terminar mi intervención sin antes recordarles mi referencia, en la última Asamblea Mundial de la Salud, a la defensa del uso del español como lengua cooficial de la OMS. Somos conscientes de las dificultades financieras existentes, pero en ningún caso ello puede suponer una limitación de la pluralidad lingüística consustancial con el propio sistema de las Naciones Unidas.

Por último, permítame reiterar mi deseo de que los debates que van a tener lugar durante esta Asam-blea Mundial contribuyan a conseguir grandes avances en los ámbitos de la salud y de la paz mundial. Muchas gracias.

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Dr MARANDI (Islamic Republic of Iran):

Madam Vice-President, Mr Director-General, distinguished delegates, ladies and gentlemen, at the outset, I would like to express my sincere congratulations to the President and other Vice-Presidents on their election. I also appreciate the vote of confidence that I received from the Assembly. I would also like to thank the Director-General for his illuminating and comprehensive introductory address. I am certain that this meeting will produce, as it always has, positive results for the promotion of health in the world.

As we approach the fiftieth anniversary of the establishment of WHO, an assessment of the past performance of this Organization indicates that it has been successful in reducing mortality and physical disability related to communicable diseases. However, changes in life-styles and behaviour of people have contributed to the increase of noncommunicable diseases, including cardiovascular diseases and cancer. Various accidents in modern life, specially road accidents, have also become one of the leading causes of death in today's world. Moreover, man continues to be exposed to environmental degradation caused by rapid industrialization of certain corners of the world.

Despite the outstanding achievements of WHO in many aspects of physical health, it seems that the Organization has not been as successful in improving mental and social health status. Noting the mental and social dimensions of health, the inappropriate usage of new communication technology can have negative impacts on these two aspects. Nowadays, television programmes in some countries encourage violence and disorderly conduct, specially among children and adolescents. Unfortunately, the harmful impacts are seen far beyond the boundaries of the broadcasting countries.

The spiritual component as the fourth dimension of health is a major contributor to the three previously mentioned dimensions. It is encouraging to notice that human society is paying greater attention to this aspect of health.

In keeping with the noble Islamic teachings, with trust in Almighty God, and in accordance with our constitution, the Islamic Republic of Iran is pledged to give priority to health as a way to achieve social justice and equity. Iran is also fully committed to its international undertakings in health-related issues and has close cooperation with other countries. In this regard, such cooperation includes awarding scholarships, receiving and treating seriously ill and injured patients from other countries, giving health care to millions of refugees, and extending health services to some other countries in the region. Our participation in the implementation of the national poliomyelitis immunization days in the Islamic State of Afghanistan in 1994 and 1995 is a paramount example of such activity.

Family planning has been a successful programme in our country after the Islamic Revolution. We managed to reduce our population growth rate from 3.2% to 1.8% within six years. We have also continued to play a constructive role in the efforts undertaken by the international community in population-related issues. This role was so recognized during the International Conference on Population and Development in which international negotiations on the sensitive issues led to satisfactory conclusions.

Pursuant to the International Conference on Nutrition, we have further expanded our food and nutrition programmes. The implementation of an extensive programme on promotion of breast-feeding in recent years has increased the rate of breast-feeding. The survey carried out in 1994 indicated that 82% of urban and 88% of rural mothers continue to breast-feed their children beyond 12 months of age. A growth monitoring study in 1994 revealed that the rate of malnutrition in children under five has decreased by 50% compared with that of 1986. Combating micronutrient deficiency disorders is one of our health priorities. A study conducted last year showed that 85% of urban families and 61% of villagers consumed iodized salt, which is locally produced.

The Islamic Republic of Iran enjoys having one of the most efficient primary health care networks, which have been further strengthened following involvement of the universities of medical sciences. Quantitative and qualitative development of health services in peri-urban areas of large cities is one of the priorities of our Second Five Year Development Plan. For this purpose, a new type of health facility has been set up in the deprived areas of the cities.

In line with current programmes for health for all by the year 2000, the Islamic Republic of Iran is paying special attention to the two fundamental principles of primary health care; that is, community involvement and intersectoral collaboration. During the national immunization days for poliomyelitis, which started last year, we benefited from the extensive engagement of volunteers in the implementation of the programme. In the first round of the second year of national immunization days, carried out two weeks ago,

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500 000 volunteers and 100 000 health workers undertook house-to-house immunization of over eight million under-fives, covering 100% of the target group in one day. In the early part of this year, 2000 health units were established through active participation of women health volunteers in order to promote breast-feeding and family health. In addition, some 15 000 other women health volunteers are involved in health care delivery in 230 cities throughout the country. Healthy Cities projects are good examples of intersectoral collaboration. These projects, which initially started in the southern part of Teheran as a pilot project, are now being implemented in 11 cities.

After 10 years of the integration of medical education and health services in our country, the positive impacts have become more and more evident. As a result of this integration and the increase in the number of universities, we have managed to overcome the shortage of health manpower as well. Special attention is being paid to the expansion of community-oriented medical education in the universities of medical sciences all over the country. I believe this experience would be interesting for Member States and WHO as a practical and successful health development programme. Furthermore, to promote equity in health, the national health insurance policy recently became law, and the Government is preparing for its execution, giving priority to rural areas and vulnerable groups of the population.

Improvement of global health status requires our joint efforts and mobilization of our resources. We should bear in mind that, in an interdependent world, more developed countries have a greater responsibility toward the international community and should actively participate in assisting needy countries to resolve their health problems. We must be aware of the fact that the responsibility for the suffering and death of innocent mothers and children who lose their lives due to poverty and lack of basic social services in developing countries lies with us all, but particularly with developed countries. Bearing in mind the deteriorating effects of discrimination and oppression on health, it is our obligation to put an end to all inhumane activities that are taking place in Bosnia and Herzegovina and other places.

In conclusion, I would like to suggest that an intergovernmental panel of experts be set up to. discuss ways and means of bridging the existing gap between countries regarding equity and solidarity in health throughout the world. It is recommended that the report of this panel be examined by the Executive Board and placed on the agenda of the next Health Assembly.

Dr DEGUARA (Malta):

Madam President, Mr Director-General, distinguished delegates, it is a great pleasure and honour for

me to be addressing this Assembly for the first time as Parliamentary Secretary for Health in our Ministry

for Social Development. On my behalf, and that of my delegation, may I offer you, the President and the

other Vice-Presidents my congratulations on your election to office, wish you every success, and assure you

of the full cooperation of my delegation in the onerous task that you will have to perform during and beyond

this year's Assembly. I would also like to thank the Director-General and the Chairman of the Executive

Board for their reports, and congratulate Dr Asvall on his reappointment as Regional Director for Europe,

and Dr Samba and Sir George Alleyne on their respective appointments as Regional Directors for Africa and

the Americas.

In the invitation we received to attend this Assembly we were asked to concentrate on two important

aspects which have become major determinants in our efforts to build a more humane, just, and healthier

society. Equity and solidarity have become two of the most frequently used words in our everyday language,

but they are not new to this Organization. Indeed, equity is the essence and embodiment of our global health-

for-all policy.

One of the main challenges for health policy in the 1990s is to reduce inequities in health. Among the

health outcomes that we have sought through the application of the health-for-all strategy is that of ensuring

equity in health by reducing gaps in health status between countries and between groups within countries.

These are the objectives and values to which we all aspire. Yet data on health status as reflected in The world health report 1995 indicate that large differences remain both within and between countries, and that

these are more severe in the least developed countries. Differences in socioeconomic development in both

developed and developing countries translate into disturbing inequities in health status. These are issues

which will have to be addressed in the elaboration of a new global health policy.

A major task in any national policy-making, if it is to be consonant with health-for-all values, must be

the establishment of a consistent and long-term strategy capable of attacking the causes of social inequity.

While the objectives of a social policy must be to promote social justice and respect for human rights, and

to bias public spending on health toward the poor and disadvantaged members of our communities, those of

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a health system must be to improve outcomes, control costs, satisfy users and, above all, to increase equity. Only by concentrating our efforts on achieving these goals can we hope to create a more humane and just society. The pressure to contain costs in the health sector is an experience common to all health ministries. New modalities of financing health care are being researched or implemented across most countries to ensure the sustainability and operational viability of the health sector. My country is in the process of formulating a new financing strategy which besides taking into account cost parameters will also address the issues of solidarity and equity. We firmly believe that health is a prerequisite to social development and sustained economic growth, and unless development and financial policies incorporate sound social policies, people's vulnerability will increase and new pockets of deprivation and marginalization will emerge.

We also speak of solidarity, but solidarity must not be selective or parochial. In the words of our Prime Minister when addressing the World Summit for Social Development earlier this year in Denmark, "the building of a secure world for future generations requires solidarity at the national and international level". At the international level Malta has, both at the United Nations and elsewhere, launched and piloted initiatives aimed at securing international solidarity. Two such examples are the United Nations Convention of the Law of the Sea and its provisions designed to generate funds which are to go towards social development purposes; and secondly, in the context of a regional initiative, Malta's recent proposal, in the purview of the Mediterranean Action Plan, to establish a regional commission for sustainable development.

At the international health level Malta is providing, through bilateral arrangements, sponsored training facilities in our University and the Institute of Health Care for health personnel from developing countries. Our voluntary organizations have established and are implementing social and primary health programmes, especially directed at the care of children and the poor, in countries in Africa and central Europe.

In The world health report 1995 just published, mental health is described as being at the bottom of the medical pecking order. During the course of the current year, the Department of Health Policy and Planning in Malta has formulated a national policy on mental health services which has been endorsed by Cabinet. The thrust of the policy is to improve patient care through multidisciplinary programmes aimed at the rehabilitation and social reintegration of mentally ill patients. The new mental health services will be reoriented towards mental health promotion, prevention and community care. Community services will be developed by reallocating resources from the hospital sector to the community sector. Innovative ideas in health care management and financing schemes form part of the policy. It is my Government's aim to develop Malta as a centre of excellence in mental health care for the benefit of both Malta and other countries, especially our Mediterranean neighbours. I am pleased to report that our efforts in mental health reform have been endorsed by the European Union, and have attracted the interest of other neighbouring countries including Israel and Morocco.

Attention is also drawn in the report to the increase in the number of old people which will be one of the factors most profoundly affecting health and social services in the next century. Malta was one of the first countries to take a number of important steps towards tackling the challenges of an aging society. We set up a Secretariat headed by a Parliamentary Secretary specifically for the care of the elderly and have built up dedicated organizational structures and services. The challenge we met was to revolutionize the traditional concept of formal support for the elderly. Our policy has been to provide psychosocial support and specialized rehabilitative care for the elderly in their own environment, thus delaying, if not averting, the need for admission into residential homes.

We have read with interest the proposal in the biennial programme budget for 1996-1997 for the convening of an expert committee to prepare guidelines for framing policies on aging and health for the twenty-first century. Malta would be happy to contribute its experience and expertise to the work of that committee.

I am also pleased to announce that we have finalized our national health policy document and would like to acknowledge the very valuable assistance we received from the Regional Office for Europe in that task. Many of the ideas and approaches proposed in the policy document, which we have called "Health vision 2000", have been inspired by the WHO health-for-all policy in Europe.

I would like to end my intervention by raising one final point which has caused me some concern as I am sure it has done other members of this Assembly. I am referring to the portrayal of this Organization in certain quarters as an organization in crisis. Our delegation rejects that contention. Like many other organizations, our Organization has had to face challenges in the past few years that have severely strained its resources and yet, despite this, we can ail take pride in what it has achieved across the broad front of its activities and endeavours. While much still remains to be done, the third monitoring report clearly shows that there has been a commendable improvement in the health status of the world's population. Many millions of men, women, and children are alive today because of the efforts of WHO.

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At the global level, the recommendations of the Executive Board's Working Group on the WHO response to global change are being implemented with commendable urgency and thoroughness. These, when completed, will form a platform for launching a revitalized WHO into the twenty-first century. Speaking as a member of the European Region, I can also say that we are proud of the progress and achievements that the Region has made under the leadership of Dr Asvall in shaping European health policy, in addressing the problems of equity throughout the Region, in providing humanitarian assistance, and in fostering a spirit of solidarity among all its Members.

WHO is not the Secretariat, or the regional offices. It is not the Assembly or the Executive Board. WHO is all of these working together for the common good of mankind. That solidarity which we have demonstrated in the past, and will continue to demonstrate in the future, is the most effective means of overcoming the challenges this Organization has to face today and ensuring its continued successes in the years ahead.

Dr ADAMS (Australia):

Madam Acting President, Dr Nakajima and colleagues, WHO is a unique organization within the United Nations system, and with the massive changes currently being experienced throughout the world its importance has not diminished but has increased. These social, political and economic changes have brought new challenges, and indeed have demonstrated that many of the health battles which we believed had been almost resolved have in fact yet to be won. Poverty and international conflict remain central factors in the challenges which face us and we no longer need to be reminded that health is at the heart of justice and equity. WHO must remain relevant and effective by ensuring it can adapt and respond to the demands of these changes and challenges.

Australia remains a strong advocate of reform in WHO. We believe that it is only through the reform process that the Organization will be able to meet the challenges of the twenty-first century. Last year we stressed the need for timely and complete responses by WHO to the agreed global change recommendations. We have been very pleased to note the progress reported by the Director-General in implementing these recommendations, but we reiterate Australia's view that much more remains to be done - and more quickly. WHO must be able to demonstrate positive outcomes to the global change recommendations, not simply provide assurances that steps are being taken in the right direction. Real reform must be vigorously pursued.

Australia congratulates the Director-General on presenting a clearer and simplified proposed budget document and notes his assurances that further detail at the sub-programme level, the establishment of realistic and measurable targets and transparent, consistent and accountable financial systems, in accordance with prevailing common accounting standards set by the United Nations, will be provided to the Executive Board. In the context of budget reform, it is timely to reiterate Australia's commitment to the principle of zero real growth in the regular budget of WHO. To that end we are concerned with the cost increase figure in the proposed 1996/1997 budget, which in our view is unacceptably high. We continue to maintain that real programme growth is possible within zero real growth through the pursuit of efficiency and productivity gains.

The above issues, of course, relate to one of the key areas of reform for the Organization and that is prioritization of its work. In this context, we welcome the Director-General's implementation of the Executive Board's recommendation that 5% of the regular budget be reallocated to priority areas. Australia recognizes, however, that the current number of Member States in arrears for financial contributions is having a serious effect on the work programme and financial situation of the Organization. It is clear that the incentive scheme to promote timely payment of assessed contributions is not working. Given the magnitude of the problem, imaginative ways need to be found to urgently address this issue.

Australia is pleased with the new Executive Board initiative to review the individual programmes. We are pleased to announce that our contributions to many of the extrabudgetary programmes have been increased this year. We look forward to improvements in the integration of regular budget and extrabudgetary funding and in the overall management of the joint funds.

Within our region, the Western Pacific, we are looking to develop closer ties with countries in relation to public health and medical research, and in that context we are looking to create real networking between regional WHO collaborating centres.

We are approaching a landmark in WHO's history, that of the Organization's fiftieth anniversary in 1998. What better time for the Organization to look at its Constitution, a Constitution which has served us well for the past 50 years but which in our view needs to be revised to ensure that WHO is relevant to the

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international health challenges of the late twentieth century and beyond. Now is the time for the Assembly to start thinking about how it will approach this task.

A number of public health challenges warrant mention. Smoking tobacco products remains worldwide the most preventable cause of morbidity and mortality from noncommunicable diseases in all countries. WHO's "tobacco or health" programme deserves our fullest support. We note the work of WHO to date and urge the Director-General and all national governments to maintain pressure to achieve smoke-free working and recreational environments throughout the world.

The second major public health issue we wish to discuss is one which represents a great achievement by WHO - perhaps one of WHO's greatest achievements - the eradication of smallpox. To bring this achievement to finality, one step remains - the destruction of the remaining stocks of smallpox virus. Apart from the obvious health and moral arguments for the destruction of variola virus stock, Australia believes that destruction would be consistent with our disarmament objectives in the biological weapons area - in particular, compliance verification under the Biological Weapons Convention.

In the context of health challenges into the twenty-first century, there remains the ever present and growing challenge of the continuing spread of HIV/AIDS. In response to this major international health issue, Australia strongly supports and is committed to the establishment of the joint and cosponsored programme, UNAIDS, in January 1996. Australia has contributed significantly to its development and our own record demonstrates that we have much to offer. However, it is also our desire to ensure that the specific needs of the countries of our region - the Asia Pacific region - are also addressed through UNAIDS inter-country and in-country activities.

Another major health issue which has been placed squarely on the international agenda relates to improvement in the status of women. Through the explicit recognition of women's status as integral to development, the International Conference on Population and Development held in Cairo in 1994 clearly identified improvements in women's health as a key factor in achieving improvements in the status of women. It is clear that the United Nations Fourth World Conference on Women, to be held in Beijing in September this year, will reiterate the central importance of women's health in improving the status of women. The Australian Government has contributed significantly to the pursuit of issues related to women's health at the international level and in April of this year the Australian Government had the pleasure of hosting the third meeting of the WHO Global Commission on Women's Health. At the recent Commission on the Status of Women meeting held in New York, Australia's initiative that the Beijing Conference be a conference of commitments was endorsed.

Another major challenge to which Australia is no stranger is that of improving the health status of indigenous people. Australia recognizes that many indigenous Australians live in communities where unconscionable standards of health have long defied the efforts of governments to improve them. It is our belief that attempts to improve the standards of living and status of aboriginal Australians must start from the concept of empowerment. The provision of adequate health and education must be consistent with this principle.

The world remains a far too dangerous place and while we can do little more than prepare for natural disasters such as that which befell our friends in Kobe, Japan, at the beginning of the year, in this International Year of Tolerance Australia believes that much can be done to prevent the disasters created by humanity itself. In this context, Australia urges the development of a common approach for organizations of the United Nations system in response to violations of humanitarian law in conflicts.

In conclusion, Madam Acting President, we wish to assure you all of Australia's strong commitment to this Organization whose continued existence remains as essential as ever. Its future beyond the twentieth century depends on its capacity to remain relevant and efficient to meet current and new challenges, yet at the same time to retain an idealism based on a real concern for the well-being of humanity. We wish it well.

M. MENDO (Portugal) (interprétation du portugais) ：1

Madame le Président de séance, Monsieur le Directeur général, Messieurs les délégués, Mesdames et Messieurs, je tiens tout d'abord à féliciter notre Président pour son élection, ainsi que tous les autres membres du bureau, et à adresser mes salutations au Directeur général. Connaissant leurs qualités et leur expérience, je suis sûr qu'ils s'acquitteront avec succès de leur tâche.

Conformément à Г article 89 du Règlement intérieur.

A48/VR/4 page 75

Tous les Etats-providence, nés après la guerre de 39-45, se sont basés sur des principes d'égalité et d'universalité : égalité de tous les citoyens par rapport aux bénéfices sociaux et non-sélection (universalité) des bénéficiaires. L'égalité et l'universalité ont ainsi constitué les principes essentiels des services publics de la santé, ce qui a permis un développement très important des politiques sociales pendant toute la période de croissance soutenue de l'économie de l'après-guerre.

A partir des années 70，plusieurs facteurs, dont la récession mondiale, les difficultés liées à l'évolution des grands équilibres économiques, le besoin de maîtriser l'accroissement des dépenses des Etats, la prise de conscience de l'agression contre l'environnement due à un développement désordonné, ont mis en cause cet Etat-providence et l'interprétation limitative et sans discernement, quoique apparemment progressiste, de ces principes d'égalité et d'universalité. Une notion plus élaborée de ces principes, plus conforme aussi à l'objectif de justice sociale qui est le nôtre, est en train de se développer : dans la formulation de politiques sociales, notamment les politiques de santé, la justice impose des critères de sélectivité qui seuls assurent véritablement l'égalité et la solidarité.

Les sociétés sont de plus en plus diversifiées et constituées de personnes - dans un large éventail de contextes distincts - dont les intérêts, les besoins et les aspirations ne sont pas les mêmes. Face aux inégalités de ce monde，malheureusement illustrées par l'existence de démunis, de marginaux, de pauvres et d'exclus, de malades et de laissés-pour-compte, qui, avec les puissants, les riches et les bien-portants, se partagent les grandes sociétés humaines, seules des mesures adéquates, adaptées à chaque cas différent, peuvent créer l'équité et la justice dans les systèmes de protection sociale. La société du bien-être que nous sommes censés créer, pour qu'elle devienne la société de l'avenir, doit se fonder sur l'aide apportée et la solidarité manifestée par ceux qui en ont les moyens.

C'est uniquement de cette façon que nous serons capables de développer des politiques sociales équitables, où les services de santé seront ouverts à tous, mais où une aide sera donnée à ceux qui en ont réellement besoin. Sera ainsi évitée l'énorme injustice sociale qu'est la distribution généralisée et sans discernement de l'assistance, dans les mêmes conditions et avec les mêmes charges comme si les besoins étaient les mêmes pour tous.

Je félicite ainsi l'OMS pour avoir pris l'initiative de proposer à notre réflexion commune le thème "Equité, solidarité, santé", puisque, n'en doutons pas, c'est seulement en nous fondant sur ces principes qu'il sera possible de lutter contre la maladie, de défendre la santé, de soigner ceux qui en ont besoin, de combattre l'inégalité et l'injustice. Le Portugal, qui est en train d'entreprendre une réforme de son service national de santé en conformité avec ces principes, est conscient, d'après sa propre expérience, de la valeur de la solidarité et de la cohésion sociale pour le développement de la politique sociale. En outre, par son histoire, son appartenance à l'Union européenne et son lien affectif avec les pays de langue officielle portugaise, le Portugal sait également que la solidarité est nécessaire dans les relations entre les nations.

Nous pensons ainsi que les pays de langue officielle portugaise, l'Angola, le Brésil, le Cap-Vert, la Guinée-Bissau, le Mozambique, le Portugal et Sao Tomé-et-Principe - qui représentent plus de deux cents millions de personnes parlant le portugais à travers le monde - ont tout intérêt à maintenir et à renforcer leur politique de coopération dans le cadre des principes d'équité et de solidarité proposés par l'OMS comme thème pour cette session. Ils donneront ainsi au monde un exemple, de plus en plus nécessaire, de collaboration et d'entente véritables entre pays, souverains, mais fraternels et solidaires.

Au nom du Portugal, je tiens à remercier l'Organisation mondiale de la Santé et son Directeur général, le Dr Nakajima, pour tout le soutien qui nous a été donné afin que cette politique de coopération se développe selon ces principes.

Je saisis cette occasion pour saluer tous les pays présents à cette quarante-huitième session de l'Assemblée mondiale de la Santé en formulant le voeu que l'humanité puisse être témoin de la concrétisation d'un réseau universel de solidarité entre les nations qui permettra l'exécution de projets conjoints, différents, sélectifs et chaque fois plus efficaces, contre la maladie, l'exclusion et la pauvreté.

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Mr ABDULLAH (Maldives):

Madam President, Mr Director-General, distinguished Ministers and delegates, at the outset, I wish to warmly convey to you, Madam President, warm congratulations and good wishes for the success of this Assembly. While expressing greetings and good wishes to the distinguished delegates, I also wish to convey our sincere appreciation to the Director-General, Dr Nakajima, the members of the Executive Board, and the Regional Director for South-East Asia, Dr Uton Rafae.

In a rapidly changing world confronted with new challenges, social inequalities, disparities among communities，classes and gender, and emerging and re-emerging diseases, it is indeed very encouraging that WHO is going through a process of reform, in response to global changes.

This is certainly a subject of great importance which calls for urgent action: action demonstrating our political will and readiness to mobilize available resources to effectively implement our policies; and action that will also help develop and sustain a system that will ensure greater equality and better health for all.

We are gratified by the tremendous achievements made towards our health-for-all objectives. The primary health care approach has proved to be highly relevant and effective in attaining these goals. As a result of this, we are witnessing unprecedented developments in world health, which have led to the control and elimination of several diseases, provision of improved health care, and promotion of healthy life-styles. Vaccination of children, safe motherhood, provision of safe water and sanitation, emancipation and empowerment of women, and community participation in health have been important contributing factors.

We recognize that these achievements have been the result of the pivotal role and leadership of WHO, with the assistance of other international agencies, together with the political will and perseverance of Member States. Therefore there is a moral imperative for us now to reaffirm our commitment to a renewed health-for-all policy within the framework of a revitalized WHO.

Population explosion, poverty, social tensions and disorder, escalating incidents of violence and accidents have, however, greatly undermined our efforts for a healthier world, thereby draining a large portion of our valuable resources. These problems must be carefully addressed. Our traditionally rich social and family values, discipline and order must also be preserved as an essential vehicle for driving us towards greater social harmony and justice. These would help us to accelerate our health policies and also bridge the gaps between various communities and classes of people.

At this crucial juncture, we have to bear in mind that today's world has changed so much that the renewed global health policy should be formulated in such a way that it will cater to our broader health needs not only for the present, but also for many years in the future. It should also be broad and flexible enough to address new and emerging challenges. We should make it a catalyst in providing effective leadership and guidance for the attainment of a sustainable health system by all countries, irrespective of their size and economic status.

We realize that these are formidable goals. It is paramount that the international community should extend its full support to achieve them as diseases respect no boundaries.

It is very heartening that a vaccine for malaria is being developed. I sincerely hope that the search for vaccines for other deadly diseases such as AIDS will be continued with renewed vigour. These efforts also merit more generous international assistance. Unless and until we join together in our fight against diseases, they will plague our development and aspirations to achieve our health objectives.

Environmental degradation due to human abuses, and its adverse effect on the health of people remain major concerns for all of us. It is imperative to ensure for now and the future a world free of pollution and harmful effects of chemical wastes. The use of tobacco which causes grave dangers to human health, also calls for urgent action. In this respect, we are happy to mention that we have joined several other Member States in banning tobacco advertising and enforcing other measures for the control of tobacco use.

The health-for-all policy will remain our fundamental goal. Educating our people and a closer mix of the community, the private sector and the public sector are paramount to the achievement of our renewed goals towards sustainable health. Trained health personnel, health promotion, management, and monitoring and supervision of the delivery of health services play a vital role in this process. It is therefore imperative for us to exert more efforts to train and sustain our human resources for health.

In conclusion, I would like to convey our deep appreciation to the Director-General, Dr Nakajima, for his vision and leadership. I also convey my appreciation for WHO's special initiative for intensified

A48/VR/4 page 78

cooperation with countries and peoples in greatest need, and its contribution towards the development of our health services. The initiative has played a major role in organizing a donors' meeting for the Maldives in pursuit of sustainable health. We sincerely hope that our partners in development, donors and friends will extend their best support in our pursuit of better health for all.

Dr CHRISTIE (Norway):

Madam President, WHO's objective is to attain the highest possible level of health for all peoples. Better health for all is also a means of achieving social and economic development and a better quality of life. This is a momentous task for our Organization. But WHO, like other international organizations, faces a growing gap between the increasing scope of global tasks and the decreasing availability of financial resources. This is a situation which can only be met by a more careful screening of priorities and a better allocation of resources. We, the Members of WHO, have a responsibility to continuously ensure that available resources are distributed according to the priorities we have established.

My Government fully supports the Executive Board's list of priorities from January: the eradication of specific communicable diseases; the prevention and control of specific communicable diseases; reproductive health, women's health and family health; promotion of primary health care and other areas that contribute to primary health care, such as essential drugs and vaccines, and nutrition; and finally the promotion of environmental health, especially community water supply and sanitation. Priorities not only imply agreed formulations, they must also be reflected in the budget. The reallocation of 5% of the budget as suggested by the Executive Board is highly commendable.

Communicable diseases constitute a serious health problem in all countries. During the recent World Summit for Social Development in Copenhagen, communicable diseases were regarded as being intimately linked to poverty and therefore a hindrance to social development. WHO has been involved for many years in the eradication, prevention and control of these diseases, which affect not only the individual human being, but society as a whole. A forceful follow-up by WHO of the health recommendations of the Copenhagen Summit will therefore be an important contribution to world social development.

We are now trying to eradicate poliomyelitis the same way as we fought smallpox. A close cooperation between the different United Nations bodies, the nongovernmental organizations and the national health agencies such as the United States Centers for Disease Control and Prevention has proved successful in such efforts. To strengthen our efforts to fight targeted diseases, we must improve cooperation among governments and between international agencies. I trust that the establishing of the joint and cosponsored United Nations Programme on AIDS will be successful. The AIDS pandemic, because of its magnitude and complexity, calls for a comprehensive and concerted effort involving most sectors of society - also at the international level.

Women's health is another priority area to which Norway would like to pay special attention. This issue has been on the agenda for the International Conference on Population and Development in Cairo, on the agenda of the World Summit for Social Development in Copenhagen and will certainly be in focus in the forthcoming United Nations Fourth World Conference on Women in Beijing. The female population has more health problems than men, especially among the poor. On the other hand, more research is targeted towards men's than towards women's health. We need gender-specific statistics on diseases in order to allocate our resources where they are most needed and to improve health services for women. By investing in women's education and health, the family and society at large will benefit. A first priority is to improve women's access to health services. The concept of reproductive health, which implies inter alia that people have the capability to reproduce and the freedom to decide if and when to do so, is essential. It also includes sexual health and behaviour, as well as counselling and care related to reproduction and sexually transmitted diseases.

Let me turn to the new world health report. We have read the summary with great interest. I would like to urge the Secretariat to release the next complete report well before the 1996 Health Assembly. This will be necessary to enable delegations to use the document in their preparations for the Assembly. In the next edition, more emphasis should be placed upon changes in the world health situation and on the impact of WHO on efforts to improve health. Our aim must be to make The world health report a key tool in setting global priorities and in updating planning strategies. The monitoring of the implementation of health-for-all strategies should be the basis for The world health report. We are concerned about the slow progress in monitoring and reporting on health for all. Only 69% of the Member States have responded to the WHO questionnaire, and only 17 out of 69 indicators have been reported in a way useful for comparison. This is

A48/VR/4 page 79

an insufficient basis for a reliable world health report. Monitoring of a system based on carefully chosen indicators should be improved and simplified for the next world health report. We welcome the ad hoc review on research for global gains in health in the twenty-first century and support its comprehensive approach. We look forward to its completion and hope there will be a possibility for the next Health Assembly to discuss this report.

Finally, I would like to address the subject of the budget and finances in this Organization. Like many other countries, my Government is concerned about the growth rate of the proposed programme budget for 1996-1997. In almost all WHO programmes there is a complex mix of regular and extrabudgetary funds. In the current financial situation it is of utmost importance for WHO to demonstrate efficient use of all resources. In particular, Member States contributing to extrabudgetary funds need to be assured that these investments represent good value. Norway has, together with the United Kingdom and Australia, conducted a study on how our extrabudgetary funds have been used in this Organization. The report will be made available during this Assembly. Our impression is that the funds contribute significantly to global health, and that they are targeting important health issues and disease burdens. But there are critical concerns regarding the lack of ability to concentrate resources coherently from regular budget and extrabudgetary funds to areas of high priority. There are also inefficiencies in the cooperation between the programmes. Multiple and confusing management of all the programmes makes it almost impossible to get an overview of the total financial flows.

In my statement to this audience two years ago, I expressed concern about the lack of direction in WHO, and stressed the urgent need for improved leadership and governance. We feel that progress since 1993 has been too slow. Existing management practices limit the effectiveness and efficiency of many programmes receiving funds from our countries. Without stronger overall leadership these programmes will continue to go their own way. This Assembly and the Executive Board have sufficient formal control over these funds, but I do not think we have exercised this authority sufficiently to date. According to the study on the extrabudgetary funds, the main issue is not the effects of extrabudgetary funds on the Organization, it is rather the lack of authority and leadership exerted by the World Health Assembly, the Executive Board and the Director-General over the whole Organization, including the use, distribution and accountability for all funds, including extrabudgetary funds. In my opinion, the Executive Board has shown an increased willingness to utilize its authority in giving advice to the Organization. Hopefully, the evaluation report will be of assistance to this Assembly and the Executive Board in advising on the use of extrabudgetary funds.

The World Health Organization has been exposed to heavy criticism lately. We in this Assembly must take this criticism seriously and use it to transform WHO into a better organization. This Assembly, in cooperation with the Executive Board and the Secretariat, should work together to improve and to strengthen governance over budgets and programmes. Only in this way will we move forward towards the goal of attaining health for all.

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Mrs MEGHJI (United Republic of Tanzania):

Madam President, Director-General, honourable ministers, distinguished delegates, ladies and gentlemen, it gives me great pleasure to address this august Assembly. I bring you greetings from the President of the United Republic of Tanzania, His Excellency Ali Hassan Mwinyi and the people of Tanzania. The Tanzanian delegation wishes to congratulate the President and Vice-Presidents on their election. I also thank the Director-General for his excellent world health report for 1995.

Since the last World Health Assembly in May 1994，Tanzania has made significant strides in promoting health for its people. At the height of this are the health sector reforms which include strengthening of district health care by establishment of district health boards, reviving public health training of health managers, and decentralization of responsibilities, as well as finances and logistic support. Financial reforms are beginning to show positive results. A health service fund has been established using a cost-sharing initiative. We are now finalizing modalities for health insurance. It is expected that the public/private mix in health care will increase accessibility of health care and, to a certain degree, alleviate the public sector burden.

Despite some progress, Tanzania continues to have a very high burden of disease. Malaria continues to be the leading cause of morbidity and mortality in all age groups from 0 to 65 years. It is gratifying to see that WHO has for the years 1996-1997 pledged increased support in the area of clinical management of malaria.

Tanzania participated in the malaria vaccine trial using the vaccine that was invented and developed by Dr Manuel Patarroyo of Bogotá, Colombia. The trial, which exemplified South-South and North-South collaboration involved Tanzanian, Swiss, Spanish and British institutions. The study was mainly funded by the Special Programme for Research and Training in Tropical Diseases, as well as the participating institutions. The trial started mid-1992 and was completed in August 1994. Early phases showed that the

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vaccine (SPf66) was safe and immunogenic. The phase III trial, which involved 600 children aged 1-5 years, showed again that there were no side-effects and, above all, that the risk of developing malaria was lowered by 31% in the vaccinated group.

We in Tanzania are proud that we hosted and participated in the first ever successful malaria vaccine trial undertaken anywhere in Africa. We are grateful to the Colombian Government for providing the vaccine for the trial, and WHO for funding. This study raises the hope that a new era in malaria control may soon dawn. My Government will, more than ever before, maintain its commitment and dedication to participation in the development and eventual deployment of malaria vaccines and other interventions so as to ultimately stem the tide of malaria morbidity and mortality in Tanzania, and the world at large.

Early in 1995, WHO field tested a protocol on training in management of the sick child aged 1 week to 5 years at primary health care level. Tanzania sees this as another important development. The course aims at reducing childhood deaths by targeting common endemic diseases such as diarrhoea, acute respiratory infections, malaria, fevers, measles, malnutrition, ear problems, anaemia and childhood immunizable diseases. Together, these diseases account for 70% of all childhood deaths. The pretest of the teaching/learning materials was carried out in Arusha, Tanzania being the first country. This intervention has a large potential for improving health workers' skills in providing care of the child as stipulated in resolutions WH040.34 and WHA44.7.

Plague has been endemic in Tanzania for over two decades now in three districts. We experienced an epidemic of 900 cases from December 1994 to February 1995 with 48 deaths, i.e. 19% mortality. Tanzania is hopeful that the recent African Region's strategy to assist Member countries to develop country-specific control measures will benefit the districts where plague is currently endemic.

Cholera affected 5013 people during 1994 with a mortality of 7%; dysentery on the other hand affected 27 927 people with 0.3% mortality. Tanzania continues to register resistant strains of Shigella.

As of now, Tanzania continues to host 600 000 refugees mainly from Rwanda and some from Burundi. The effects of these refugees cannot be over-emphasized. In the two districts where there are more refugees than Tanzanians there is deforestation, shortages of water, food and shelter, and increasing disease occurrence. While Tanzania is grateful to the agencies that are providing support to the refugees, I would like to take this opportunity to register my concern that not enough is being done for the host population who have had to share their own resources, including land, with the refugees.

Tanzania, like other developing countries, has been struggling to improve its economy through promotion of agricultural activities and industrialization. In this transition period, a gradual increase in the use of industrial, chemical, pesticide and radioactive materials has been experienced. Workers in the formal and informal sectors are affected. In order to improve occupational health, my Ministry has developed an occupational health policy guide and a programme of action covering the period 1994-1998. Among the activities planned are advocacy for employers, employees and self-employed people, monitoring of occupational heath and industrial guidelines, as well as training in occupational health.

The situation of HIV and AIDS continues to be alarming. During the period from January to December 1994, 52 247 cases were registered, an increase of 5% over the previous year. Increasingly, the younger population is becoming affected, particularly young females. My Government, together with a number of nongovernmental organizations, continues expanding educational services targeted on the most vulnerable groups and aiming at positive change of behaviour. AIDS continues to take its toll on Tanzanian society and there is not a single sector that has not been affected.

Tuberculosis cases have likewise increased from 21 773 cases in 1993 to 33 000 in 1994. In line with resolution WHA47.9 on quality of care in maternal and child health and family planning,

Tanzania has been able to increase its contraceptive prevalence rate from 6.5% in 1991-1992 to 14% in 1994. Tanzania plans to continue promoting reproductive health by improving access and quality of care.

Lastly, I would like to thank WHO, other United Nations organizations, bilateral friendly countries as well as nongovernmental organizations which have been lending support to Tanzania. Without them, the struggle would have been even more difficult. On behalf of the United Republic of Tanzania, thank you all.


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SIXTH PLENARY MEETING

Wednesday, 3 May 1995，at 14:30

Acting President: Dr A. MARANDI (Islamic Republic of Iran) later: President: Dato Dr Haji Johar NOORDIN (Brunei Darussalam)

SIXIEME SEANCE PLENIERE

Mercredi 3 mai 1995，14h30

Président par intérim: Dr A. MARANDI (République islamique d'Iran) puis Président: Dato Dr Haji Johar NOORDIN (Brunéi Darussalam)

DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-FOURTH AND NINETY-FIFTH SESSIONS AND REVIEW OF THE WORLD HEALTH REPORT 1995 (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-QUATORZIEME ET QUATRE-VINGT-QUINZIEME SESSIONS ET EXAMEN DU RAPPORT SUR LA SANTE DANS LE MONDE, 1995 (suite)


I call the Assembly to order and if I may I would like, again, to thank the Assembly for the vote of confidence that I received and also say that it is a great pleasure and honour to be able to take over the Presidency of the Assembly for a few hours while his Excellency the President is absent. And now if we can resume the debate on items 9 and 10, our first speaker of the afternoon is the delegate of Germany. If he and the delegate of Mexico will come to the rostrum, the delegate of Germany will have the floor as the first speaker.

Mr VOIGTLÀNDER (Germany):

Mr President, Mr Director-General, excellencies, distinguished delegates, one of the major topics of this World Health Assembly is The world health report 1995: bridging the gaps. It is a discomforting report, and at the same time it should be a stimulating one. The challenges the people all over our world are facing become explicit. Something can be done to bridge the gaps. WHO is not a bystander. Though it cannot, by itself, remedy this situation, it has developed plans addressing some of the major scourges and their causes. WHO is adapting, albeit still too slowly, to these challenges. Let me mention the UNAIDS programme. It must be established fully, and without further delay. It will be important that regional divergences and regional sensitivities are fully taken into account.

Two major world conferences, the International Conference on Population and Development in Cairo and the forthcoming Fourth World Conference on Women in Beijing, focus on adequate answers to the health problems of mother and child. Beijing will address the "mainstreaming" of the human rights of women. We must make progress in these fields. The world health report is very clear in this respect.

Two other problems are of growing concern to mankind: environmental health and health care for the elderly. Both concern the developing world as well as developed countries. Although Germany is particularly affected by the challenge of an aging society, the report predicts wide-ranging changes also in the developing world within the foreseeable future. The two respective departments are headed by directors with an outstanding experience in development. It gives me pleasure and satisfaction to hear from all sides how widely recognized their competence and dedication are.

Distinguished delegates, Germany does not limit its commitment to assisting developing countries in their struggle for an affordable and effective health system. The European Region of WHO now stretches

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far into the heart o f central Asia. That is an enormous challenge. Germany is assisting with technical cooperation in order to help in health reform and in introducing - step by step - health insurance systems. One of the messages of this Health Assembly could therefore be - in accordance with what was said by the Director-General yesterday when he introduced The world health report - that governments should put a higher priority on health as being probably the best investment in the future. This appeal is addressed not only to developing countries but to industrialized countries as well.

As is well known, medical services in Germany are of a very high standard. Where we face problems is how to manage the economic side o f health, how to contain the costs. We wi l l have to continue to rethink basic principles which we may have cherished for too long. No country can avoid continuously adapting its health system to the changing needs of the medical and the economic environment.

Let me finally say a word about WHO's recruitment policy. Over the years I have had the opportunity of meeting many of WHO's staff. WHO has always maintained high professional qualification as the primary criterion for appointments. Every country in the world has highly qualified professionals. I have therefore difficulty in understanding why so many countries are not adequately represented among the staff. Germany is one of them. The number o f German nationals is less than half the midpoint target figure, according to WHO's rules. WHO should make every effort to provide for adequate personnel representation. It is a question of equity and equality o f participation in the life o f the Organization.

El Dr. de la FUENTE RAMIREZ (México):

Señoras, señores: México ha recorrido en las últimas décadas un arduo camino para proteger y mejorar la salud de sus habitantes. El esfuerzo realizado ha dado resultados positivos en diversas áreas.

La esperanza de vida de la población ha alcanzado ya los 70,3 años, lo que significa un incremento de 1,2 años durante los últimos cinco años. Los programas de salud reproductiva tienen cada vez mayor aceptación: la tasa global de fecundidad se redujo de 3,6 hijos por mujer a 3,0 en el mismo periodo.

Gracias a las medidas de salud adoptadas, el perfil de la morbilidad y de la mortalidad se ha modifica-do a nivel nacional de manera significativa. Desde octubre de 1990 no se han notificado casos de poliomieli-tis. El sarampión y la tos ferina también se encuentran en avanzado proceso de eliminación y hoy podemos afirmar que casi el 95% de los niños mexicanos menores de cinco años han sido objeto de programas de vacunación completos. México asesora a 24 países en la ejecución de programas de inmunización similares y en reconocimiento a los éxitos alcanzados recibió el Premio Alleyne «Día Mundial de la Salud 1995» el pasado 7 de abril, en la ciudad de Washington.

El programa de prevención de enfermedades diarreicas logró, entre 1992 y 1994，reducir a la mitad el número de muertes por enfermedades infecciosas intestinales entre niños menores de cinco años, pasando de 15 490 a 7900 casos. La mortalidad infantil y preescolar muestran una tendencia descendente y es así como en los últimos cinco años las tasas por 100 000 nacidos vivos se redujeron un 31% y 33%，respectivamente. Estos avances en materia de salud se han logrado en un contexto de mejoramiento creciente de la infraestruc-tura urbana y de la educación. La política de salud se inscribe claramente en la política de desarrollo social del Gobierno mexicano.

Hace apenas unos años las causas de muerte más frecuentes en México eran enfermedades infecciosas y parasitarias. Hoy en día lo son las enfermedades del corazón, los tumores malignos, las lesiones y los accidentes. Sin embargo, los avances innegables en la salud de los mexicanos no han sido uniformes. Una proporción todavía estimable de la población mexicana padece un alto grado de marginación. Esta condición representa riesgos adicionales para su salud y contribuye a perpetuar enfermedades propias de la pobreza. Este tipo de enfermedades todavía significan en México cerca del 30% del peso de la enfermedad, definido éste por los años de vida saludables perdidos, ya sea por incapacidad o por mortalidad.

Por otro lado, el sedentarismo, la dieta inadecuada, el tabaquismo, el consumo excesivo de alcohol, la falta de prevención efectiva de accidentes viales y laborales y las prácticas sexuales poco seguras son los factores de riesgo que explican la mayor parte de las muertes evitables por enfermedades no infecciosas, con excepción del SIDA. La presencia creciente de estos factores de riesgo junto con la disminución de las enfermedades de la pobreza, condicionan la transición epidemiológica de nuestro país. Así, cerca del 70% del peso de la enfermedad, definido en los mismos términos, se debe a las enfermedades emergentes.

Está claro que nuestro sistema de salud muestra signos de agotamiento, bajo su esquema actual, como resultado de una organización centralista y los vacíos de cobertura que hasta la fecha han sido insuperables. Por ello, el Gobierno de México, encabezado, a partir del 1 de diciembre de 1994，por el Dr. Ernesto Zedillo, ha decidido iniciar un proceso de reforma de nuestro sistema de salud con el propósito de hacer frente a los

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retos que plantea la transición epidemiológica que vivimos, a la cual se suma señaladamente la transición demográfica, y de hacer de los programas de salud instrumentos eficaces de equidad y combate contra la pobreza.

Los principales objetivos de la reforma son: mejorar el nivel de salud de la población; distribuir equitativamente los beneficios y la carga de los servicios; satisfacer a los usuarios y a los prestadores de servicios; evitar dispendios; y anticipar problemas. Para lograrlos, se han diseñado estrategias a corto y largo plazo y se han definido claramente dos fases. La primera tiende a dar respuestas eficaces a la necesidad de superar los retrasos acumulados y hacer frente a los problemas emergentes, mientras que la segunda está orientada a mejorar las condiciones de trabajo del personal de las instituciones públicas y el estado de los inmuebles y el equipo y a incrementar los flujos de fînanciamiento público gracias a criterios de mayor eficiencia.

Se trabaja ya en la descentralización y regionalización de los servicios a la población que no tiene acceso a los de la seguridad social, así como en la estructuración de un paquete de servicios esenciales para los grupos de más alta marginación, llenando así el vacío en la cobertura de servicios ordinarios.

Conviene reiterar que la reforma de la salud en México forma parte de la nueva estrategia de desarrollo social y sostenible del Gobierno de la República. Es así como las comunidades, a través de sus comités de salud, y la sociedad en su conjunto, por conducto de sus diversas organizaciones, están participando de manera activa en el diseño y la ejecución de las diversas acciones que comprende la reforma.

Consideramos de la mayor importancia la cooperación técnica y científica con los países que han iniciado procesos similares. Sabemos que las iniciativas de reforma de los sistemas de salud han adquirido una importancia creciente en países con los más diversos niveles de desarrollo económico y con los más diferentes sistemas políticos. Resulta por ello conveniente conocer y analizar los elementos comunes a dichas reformas, tendientes a formular políticas modernas e integrales de salud en el ámbito internacional. La buena cooperación que ha existido con nuestros países vecinos, hacia el norte y hacia el sur, habrá de incrementarse en el futuro cercano con nuevos acuerdos de trabajo, programas conjuntos de investigación y formación de recursos humanos y elaboración de estrategias comunes ante problemas de salud compartidos.

México camina hacia la organización de un nuevo sistema de salud que sea capaz de satisfacer de modo completo y eficaz las necesidades esenciales de salud de todos los mexicanos. Lo hará en forma abierta y democrática, y continuará participando activamente en los programas de la Organización Mundial de la Salud, procurando enriquecer sus perspectivas mediante el intercambio y la cooperación internacionales.

Professor NECAEV (Russian Federation):

Проф. НЕЧАЕВ (Российская Федерация):

Уважаемый г-н Председатель, г-н Накадзима, уважаемые делегаты, дамы и господа!

Позвольте мне прежде всего поздравить Председателя Ассамблеи и его заместителей с

избранием. Я убежден, что подготовленный Исполкомом проект резолюции по важнейшим

вопросам повестки дня Ассамблеи отличается четкостью и реалистичностью, что, безусловно,

облегчает работу нашего форума. С большим вниманием мы выслушали выступление

Генерального директора и ознакомились с новым по форме документом, который объединяет

доклад о состоянии здравоохранения в мире и отчет Генерального директора о работе ВОЗ за

1994 г. Первый опыт выпуска такого объединенного документа достаточно удачен и

позволяет составить конкретное представление об усилиях и мерах, предпринимаемых ВОЗ для

решения актуальных проблем здравоохранения, и их влияния на здоровье населения мира.

На протяжении нескольких последних лет ВОЗ постоянно испытывает серьезные

финансовые трудности. Они существенно затрудняли работу и в отчетном году. Но, к чести

нашей Организации, следует признать, что и на этот раз она сумела противостоять их

негативному влиянию и настойчиво проводит в жизнь коллективные решения своих государств-

членов, направленные на охрану и укрепление здоровья населения планеты. Поэтому

необходимо признать работу Всемирной организации здравоохранения за отчетный период

положительной, а усилия самого Генерального директора Хироси Накадзимы заслуживают

самой высокой оценки. Правительство нашей страны продолжает погашение задолженности

по обязательным взносам ВОЗ. В 1994 г. нами переведено на счет этой Организации 34,3 млн.

долл. США. В этом году уже переведено 10 млн. Мы будем и впредь планомерно погашать

свою задолженность, и я уверен, что в этом году избавимся от нее.

A48/VR/4 page 85

Успешность работы и высокий авторитет ВОЗ в мире во многом связаны с тем, что ее

деятельность неизменно основывается на принципах международной солидарности и

справедливости. На начальном этапе деятельности Всемирной организации после окончания

второй мировой войны разрыв в показателях состояния здоровья и здравоохранения между

странами был чрезвычайно велик. Сконцентрировав усилия на приоритетных проблемах, ВОЗ

смогла эффективно содействовать залечиванию ран тяжелейшей второй мировой войны. Этот

исторический опыт внушает оптимизм в отношении выравнивания ситуации в мировом

здравоохранении и в настоящее время. Основой успехов, которыми отмечена история ВОЗ,

является глобальная стратегия достижения здоровья для всех, что может быть достигнуто

только при полной солидарности государств - членов Организации, единстве их устремлений,

согласованности действий и взаимной поддержке. Особенности современных условий, на наш

взгляд, требуют проведения гибкой политики Организации. При этом необходимо еще упорнее

крепить нашу солидарность и решительно проводить начатую работу по дальнейшей

модернизации и совершенствованию организационных форм деятельности ВОЗ. Прежде всего

следует особо усилить роль Исполкома Всемирной организации здравоохранения.

В проекте Программного бюджета ВОЗ на период 1996-1997 гг. много внимания уделено

проблемам развивающихся стран, Центральной и Восточной Европы, новым независимым

государствам. Подобно всем государствам - членам ВОЗ, заявившим о своей приверженности

цели достижения здоровья для всех, Российская Федерация в процессе реформирования своей

системы здравоохранения стремится к возможно более полному воплощению принципа

справедливости в национальных масштабах. Серьезное внимание мы уделяем разработке

законодательных актов, направленных на обеспечение прав граждан Российской Федерации на

получение необходимого объема бесплатной и качественной медицинской помощи. Ряд законов

принят нашим парламентом. Другие находятся на этапе разработки или обсуждения в нем.

Заметную помощь в этой работе нам, как всегда, оказывает Всемирная организация.

Приоритетное внимание продолжаем уделять службе охраны материнства и детства. Нам

удалось снизить общую летальность в акушерских и детских стационарах, и, прежде всего,

детчкую смертность до одного года жизни.

В нашей стране принята и эффективно реализуется президентская программа "Дети

России", в рамках которой продолжается работа по оснащению современной медицинской

техникой областных, районных больниц, центров планирования семьи, перинатальных центров,

детских реанимационных отделений, центров реабилитации детей-инвалидов.

Завершается работа по подготовке Национального плана действий в интересах детей

Российской Федерации до 2000 г., содержащего, в частности, разделы "Безопасное материнство

и охрана здоровья детей", а также "Питание детей".

Серьезные изменения происходят в системе организации лечебно-профилактической

помощи. Реорганизация первичной медико-санитарной и стационарной помощи осуществляется

на основе творческого развития отечественного опыта с учетом лучших достижений мирового

здравоохранения и непременно - рекомендаций ВОЗ. Предусматривается постепенный переход

к системе врача общей практики и бюджетно-страховым формам финансирования медицинского

обслуживания граждан. Вместо устаревших, неэффективных лечебно-профилактических

учреждений только в 1994 г. открыто более 600 новых клиник и специализированных центров.

Продолжается работа по развитию сетей дневных стационаров, диагностических центров,

дифференцированию стационаров по уровню оказанию медицинской помощи.

Особое внимание уделяется медицинскому контролю за состоянием здоровья населения,

проживающего на территориях, пострадавших в результате аварии на Чернобыльской атомной

станции. Помощь ВОЗ здесь весьма ощутима и эффективна.

Серьезную обеспокоенность вызывает сложившееся в России положение с инфекционной

заболеваемостью. Министерством разработана и утверждена правительственная программа

неотложных мер по обеспечению санитарно-эпидемиологического благополучия, профилактике

эпидемий и снижению уровня преждевременной смертности населения. Необходимость

усиления внимания развитию отечественной фармацевтической и медицинской промышленности

обусловила преобразование в 1994 г. Министерства здравоохранения в Министерство

здравоохранения и медицинской промышленности. Несмотря на сложность экономической

ситуации в стране, отечественная медицинская промышленность продолжает функционировать

A48/VR/4 page 86

в активном режиме. В России сейчас производится 386 отечественных лекарственных средств.

На фоне кризиса отмечается увеличение выпуска медицинской промышленности на 5% по

сравнению с 1993 г.

Государственной программой России по улучшению лекарственного обеспечения и

развития фармацевтической промышленности предусмотрено увеличить производство

лекарственных средств в 1995 г. по сравнению с 1991 г. в 2,9 раза, в том числе жизненно

необходимых препаратов - более чем в 3 раза. Мы упростили в России систему регистрации

зарубежных лекарственных средств, производимых в странах с хорошо развитой

фармацевтической промышленностью. Эффективно функционирует государственная система

контроля качества лекарственных препаратов. Серьезное внимание уделяется привлечению

иностранных инвестиций на основе создания кооперативных производств и совместных

предприятий. Мы уверены, что намеченный путь к достижению здоровья для всех вселяет

надежду на успех проводимой стратегии, обеспечивающей доступность, бесплатность и

эффективность медицинской помощи каждому члену общества.

Благодарю за внимание.

Mr BUTALE (Botswana):

Mr President, honourable ministers and heads of delegations, Director-General of WHO, ladies and gentlemen, please accept the sincere congratulations of the delegation of Botswana on the election of the President and Vice-Presidents to their important offices. We promise you our support during the whole of your tenure of office.

My delegation wishes to thank both the Executive Board and the Secretariat for the two reports that are under discussion. Both the documents are of a high standard and raise issues that should generate lively discussion during this Assembly. The Executive Board, in its wisdom, has proposed that those addressing the Assembly discuss the important subjects of equity and solidarity in health - bridging the gaps. This is an extremely important topic, all the more so for those of us in developing countries. The only problem is that it is such a frustrating one to consider, because equity in a grossly underresourced situation is almost impossible. That is the situation we face in Botswana and other developing countries: distributing equitably health resources that are not enough to go round except in the most thinly spread form.

Our countries have since independence tried to fulfil the social responsibility of the State of providing basic health care to as great a proportion of their citizens as possible. This I can confidently say we have achieved to a large extent in Botswana, despite a population that is rather sparse in the greater part of the country. However, like other developing countries, our governmental expenditure is starting to outstrip the revenues. In the face of the international recession and the poor prices we get for the commodities that constitute our main exports, we face the unpleasant prospect of having to slow down the growth in governmental health expenditure before our targets of coverage are fully attained. We also fear that quality may also be compromised.

What we are not sure about, Mr President, is whether the solutions that are being prescribed as universal solutions are the best course to take. When the economic recession hit the developing world, certain drastic measures commonly referred to as structural adjustment programmes were put forward as the remedy to put the economies back into sustainable growth. Up to now most countries that have undertaken structural adjustment programmes are not sure whether these actions have worked or not. Certainly, they have not promoted equity. In the field of health, the universal remedy being prescribed now is health care reform. The features are an extension of structural adjustment - liberalization, more private services and less government expenditure, more cost recovery: these are measures meant to bring more efficiency, but it is doubtful whether they can really promote equity. Is it really possible that there can be equity when the poor are asked to pay more for services, or to contribute to health insurance when they have no formal income?

I am not saying these policies are wrong. If they are the only course of action that can make health services sustainable, so be it. Let them be implemented. But let us not delude ourselves and say that they will bring more equity or bridge the gap. The rich will continue to have access to the highly technological private facilities while the poor are likely to have access only to the most basic care. It is therefore important that as many models of health care financing as possible be tried, including a more efficient application of the older models.

The developing countries need to act together to solve their problems. It is quite obvious that the development assistance provided by the developed countries is not producing the expected outcome. This

A48/VR/4 page 87

may not be so surprising, because the assistance is generally not very rational. If a country is performing

fairly well economically because it has managed its economy well, the assistance is curtailed. It would appear

that aid starts really to flow into a country when the economy is already in serious trouble, and the aid comes

with all sorts of prescriptions. The result is that initiatives like health sector reform tend to be donor-driven.

Those countries, like Botswana, that prefer to do things their own way do not attract much development

assistance. It is always being said that the gap between the industrialized countries and the developing

countries is widening, and that the same phenomenon is occurring between the rich and the poor inside the

developing countries. Yet one cannot see this gap being reduced by the new international economic policies.

It remains for us in the developing countries to work together, to develop joint programmes in the health

field, and to promote trade among ourselves in order to pull our peoples out of poverty and bring about health

development. We should strengthen our regional trading blocks like the Southern African Development

Community (SADC) and make them active also in the field of health, not just trade, so that proper regional

integration is achieved.

The developed countries should continue to provide us in Africa with development assistance. While

advice and guidance are welcome, the assistance should not be subject to prescriptions to the extent that if

a recipient does not want to follow the prescriptions then the aid is cut. We cannot all follow the same

model.

Dr VITKOVA (Bulgaria)：

Д-р ВИТКОВА (Болгария)：

Г-н Президент, г-да заместители Председателя, г-н Генеральный директор, уважаемые делегаты и гости!

Позвольте мне от имени болгарской делегации и от себя лично поздравить вас,

г-н Председатель и г-да заместители Председателя, с избранием на высокие посты в

руководстве Сорок восьмой сессии Всемирной ассамблеи здравоохранения и пожелать вам

успеха в исполнении ваших ответственных функций на этом высоком международном форуме.

Пользуюсь случаем, чтобы выразить удовлетворение предоставленным резюме годового

доклада и, поблагодарив Секретариат Организации за хорошую совместную работу в течение

прошедшего года, выразить надежду, что медленное распространение полного текста доклада

среди государств-членов не отразится существенно на качестве дискуссий. Считаю, что объем

и качество деятельности ВОЗ за отчетный период нашли адекватное отражение как в

представленном резюме доклада, так и в рабочих документах Сорок восьмой Всемирной

ассамблеи здравоохранения.

Дамы и господа, в современном мире здоровье как фундаментальное право человека

является существенным фактором благополучия человечества. Благодаря своему

универсальному характеру оно становится основным элементом политики каждого

правительства. Право на здоровье имеет много аспектов - экономические, социальные,

этические и другие, но самый важный из них - обеспечение равноправия всех граждан в рамках

национальной системы здравоохранения. Здоровье и здравоохранение являются социальными

категориями, которые должны найти свое отражение в демократической, политической

доктрине здравоохранения, демократических принципах и структурах. Все это дает нам

основание поддержать изложенные в докладе Генерального директора положения и новые

приоритетные направления деятельности Организации. Обеспечение права на здоровье для

каждого жителя планеты немыслимо без устранения экономических различий как между

странами, так и между отдельными людьми. Лишь преодоление экономической поляризации

в глобальном и национальном масштабах могло бы гарантировать равные права на здоровье.

В этом смысле одной из основных политических задач в здравоохранении на национальном и

международном уровнях до конца текущего десятилетия должно стать сокращение неравенства

и проявлений несправедливости в этой области.

Уважаемые делегаты, в странах Центральной и Восточной Европы в последние годы

произошли колоссальные политические и экономические перемены. Их экономическое

положение в той или иной степени ухудшилось, а большинство из них испытывает серьезный

экономический кризис. В результате этого резко снизились показатели здоровья, а система

A48/VR/6 page 88

здравоохранения оказалась перед серьезными испытаниями. В Болгарии, как и в некоторых других странах, наблюдается наибольший спад объема производства и валового национального продукта, что непосредственно отражается и на возможности инвестирования средств в здравоохранение. Несмотря на прогнозируемые финансовые затруднения, система подверглась серьезным переменам, необходимость которых в большей степени обосновывалась политическими, а не экономическими мотивами. Эта политика в области здравоохранения привела к значительной дезинтеграции системы, в результате чего каждое учреждение работает только на себя при отсутствии руководящих органов на региональном и общинном уровнях. Цены на лекарственные средства были либерализованы до полной потери государственного контроля над их формированием, что делает их непосильными как для больных, так и для государства, которое, в свою очередь, является основным потребителем лекарственных средств. Неконтролируемая частная практика была разрешена всем врачам, работающим в сфере общественного здравоохранения, что сильно деформировало взаимоотношения между государственной и частной практикой и между пациентом и лечащим его врачом.

В настоящий момент усилия Министерства здравоохранения Республики Болгарии направлены на спасение национальной системы здравоохранения путем эффективного использования национальных финансовых, кадровых и технических ресурсов, а также поддержки и помощи со стороны международных, правительственных и неправительственных организаций. При реализации этого подхода мы стремимся к достижению баланса между быстрыми и ощутимыми результатами в определенных критических областях здравоохранения, с одной стороны, и мерами по долгосрочному развитию системы здравоохранения, с другой.

Процесс поиска адекватных решений для существующих в болгарском здравоохранении проблем ориентирован на максимальное использование опыта развитых стран и международных организаций в области здравоохранения. Разработка новых законодательных и нормативных актов, которые гарантируют цель реформы - создание системы здравоохранения, обеспечивающей гражданам доступную медицинскую помощь и равенство при ее получении, является приоритетной задачей Министерства здравоохранения. Недавно Парламентом был принят новый, современный закон о лекарственных средствах и аптеках, который создает стабильную, правовую основу для развития лекарственной политики у нас и регламентирует производство и торговлю лекарственными средствами.

С целью создания общей концепции развития сектора здравоохранения в сотрудничестве с Европейским региональным бюро ВОЗ разрабатывается национальная стратегия "Здоровье для всех". К концу года стратегия будет готова и представлена общественности.

Следуя по пути масштабных перемен, страны Центральной и Восточной Европы могут либо улучшить свои показатели здоровья и приблизиться к уровню развитых стран, либо вернуться в прошлое, когда существовали те болезни, о которых они давно забыли. На этом перепутье ВОЗ при помощи своих экспертов могла бы существенно повлиять на направление хода перемен в этих странах в области здравоохранения, предостерегая их от ошибок и предоставляя им анализы и оценки возможных решений по глобальным проблемам. В ином случае, наши системы здравоохранения явятся жертвами ряда безуспешных экспериментов, что приведет к серьезным общественным последствиям. Опыт последних нескольких лет дает достаточно материала для размышлений. Было бы желательно, чтобы специальный форум ВОЗ провел углубленный анализ развития здравоохранения в Восточно-Европейском регионе и предложил меры по устранению различий в региональном и национальном планах, в результате чего мы смогли бы направить нашу деятельность на их преодоление.

Г-н Генеральный директор, хотелось бы обратить внимание Ассамблеи на проблемы, связанные с последствиями вооруженных конфликтов, а также санкций Совета Безопасности ООН для здоровья населения тех стран, где происходят такие конфликты или против которых применяются такие санкции. К примеру, в бывшей Югославии дети, женщины и пожилые люди погибают в результате вооруженных действий, а также из-за нехватки лекарств и т.д. Соблюдая санкции, но не получая нужного содействия в виде компенсаций со стороны международного сообщества, соседняя Болгария в условиях проводимых болезненных реформ несет потери, которые в несколько раз превышают годовой бюджет на здравоохранение. Последствиями этого неблагоприятного для нас течения обстоятельств является

A48/VR/6 page 89

катастрофическое обеднение большой части населения, ухудшение его питания и угрожающая

нехватка средств на цели здравоохранения.

Вместе с группой других стран Болгария призвала к активизации усилий международного

сообщества в целях достижения мирного, справедливого и прочного решения кризиса

параллельно с приостановкой и снятием санкций. В связи с этим хотелось бы попросить

д-ра Накадзиму подготовить информацию для Сорок девятой сессии Ассамблеи о мерах,

предпринятых ВОЗ в целях преодоления негативных последствий на здоровье, а также

социальных и гуманитарных последствий для стран, пострадавших в результате осуществления

резолюции Совета Безопасности о введении санкций против Союзной Республики Югославии

(Сербия и Черногория) во исполнение пунктов 4 и 6 постановляющей части резолюции 49/21

Генеральной Ассамблеи ООН от 13 декабря 1994 г.

В заключение позвольте, г-н Президент, выразить поддержку и убежденность болгарской

делегации в идеях, политике и практике ВОЗ, отраженных в глобальной стратегии "Здоровье

для всех". Учитывая важность обсуждаемых на пленарных заседаниях проблем равенства,

общественной солидарности в области здравоохранения и устранения существующих

экономических, социальных и региональных различий при оказании медицинской помощи,

предлагаю утвердить эту тему для обсуждения на одной из следующих тематических дискуссий

Ассамблеи.

Спасибо за внимание.


I thank the delegate of Bulgaria, and I give the floor to the delegate from Finland, who will speak in Finnish. As all delegates know, when delegates choose to speak in a native language or in any language other than those used in the Assembly, they assign an interpreter who does the initial interpretation into one of the languages used in the Assembly, and that is the case with Finland. May I also invite the delegate of Zimbabwe to the rostrum, please.

Mrs HUTTU (Finland) {interpretation from the Finnish)'}

Mr President, honourable delegates, ladies and gentlemen, may I begin by congratulating the President and the Vice-Presidents for their elections at this Forty-eighth World Health Assembly. You have all my support for the demanding task which lies before you.

Both in the global and European perspective, inequity in health has increased as outlined in the summary of The world health report 1995. The East-West public health gap in Europe has been widening at least since the early 1980s. Similarly, the public health gap between the richest nations in the North and the poorest nations in the South is growing. I find these trends alarming. Consequently we must ask ourselves does WHO have the most effective strategy and action to turn the adverse developments into a reduction of the public health gaps worldwide? Have we been effective enough in raising the consciousness of the world community about the increasing inequities? Particularly, I must ask myself, have we been effective enough in pointing out that increasing inequity is not a natural law, but rather a result of choices made by politicians, as well as economic and other powers in the international scene? Do we have today the potential required to develop the global and regional partnerships for reaching equity in health?

In my view WHO has had and will have a key role in the health development of the world. Its achievements are significant and numerous. This gives us confidence that our Organization can successfully also meet the challenges before us.

Let me use this opportunity to extend my delegation's appreciation to the Director-General and his staff for their determined efforts in carrying out the implementation of the 47 recommendations of the Executive Board's Working Group on the WHO Response to Global Change. The global changes must be seen as challenges and the WHO responses to these changes as a continuous process, not ending with the implementation of the Board's recommendations. This requires determination, hard work, commitment, unprejudiced action and full support by all Member States. In this context, I feel it important to acknowledge that raising global awareness and developing global alliances and partnerships for health development should

1 In accordance with Article 89 of the Rules of Procedure.

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receive a high priority in the activities of WHO. A concerted effort by all relevant international and national actors was also called for by the World Summit for Social Development in Copenhagen last March. WHO should do its best to support the programme launched by the Summit to transform the commitments of the Summit into concrete action in global social and economic development.

Renewing the health-for-all policy as proposed by the Director-General will give us an opportunity to refocus WHO's policy and mission on the issues that give most benefit, in particular, for the countries with greatest needs. In this process of implementation of the health-for-all policy, equity should receive more attention and emphasis and be given a distinct role as a goal.

Finland looks forward to the renewing of the WHO health-for-all strategy. We support the idea of probing high-level discussions with all necessary political weight on the issues related to the revision of this strategy at the Fiftieth World Health Assembly.

Let me now turn to the proposed programme budget for 1996-1997. In my view, the programme budget cannot be assessed in isolation from WHO's reform and response to global change. Neither can the programme budget proposals be detached from the parameters set out in the Ninth General Programme of Work.

Finland welcomes the new budget structure and format, the so-called new strategic approach. The strategic nature of the programme budget document and the reduction from 59 programmes to 19 major headings is a welcome change in efforts the better to prioritize WHO's work. Overall, it is very positive that the priorities of the Organization's activities have been spelled out more clearly than previously. We encourage the Director-General to pursue the prioritization of WHO's work yet further with the initial preparation of the next budget cycle following 1996-1997. Also, proper attention must be given to putting the current resource reallocations of the programme budget into practice. I am optimistic that the new strategic nature of the programme budget will enhance the work of WHO so that it can better meet the needs of its Member States.

While welcoming the new strategic approach, we should remind ourselves of the fact that the regular budget we are dealing with now covers less than 50% of the total costs of WHO. A major part of WHO activities is financed by voluntary contributions. In order to increase transparency and the comprehensiveness of the work of WHO, the programmes and activities financed from extrabudgetary sources should somehow be incorporated into the new strategic approach, and exposed to better control of the governing bodies of this Organization.

Finally, Mr President, next autumn the Fourth World Conference on Women will be held in Beijing. In our view, good health of women is closely associated with equal opportunities for education, with a view to eliminating female illiteracy, with equality before the law, with the right of women to work on equal terms, and with equal remuneration for equivalent tasks. In attempts to enhance women's health cooperation with different groups, governmental and nongovernmental organizations, it is of vital importance that balanced and effective strategies be set forth. Especially, we need a strong social component alongside the health determinants in enhancing women's health. That is why WHO should play a more comprehensive and cooperative role in this area. We are convinced that the results from this cooperation would benefit all Member States.

Dr STAMPS (Zimbabwe):

Mr President, Director-General, honourable ministers, delegates, ladies and gentlemen, today health technology expands at an unprecedented rate. The development of sophisticated equipment such as in medical imaging, new generations of drugs, genetic and fertility scientific applications in reproductive health, and fragmentation of health disciplines into subspecialties are but a few examples. All these new technologies are expensive; and this is a time, when，globally, the issue of high health-care costs is of concern to all our countries, including the rich developed countries. We all face very serious public health problems which, though differing in type, have the same fundamental causes, resulting in both an unacceptable level of morbidity and mortality as well as unacceptable rates of unwanted pregnancies leading to abortions and abandoned children. Furthermore both developed and developing countries are experiencing deteriorating dependency ratios, albeit at different ends of the human life-span.

The paradox is that these developments occur at a time when both the knowledge and the technology to reverse these trends is available. Oral vaccine has been available universally for more than three decades to eliminate the scourge of poliomyelitis, and yet we continue to see new cases of the disease in several countries today. Vaccination rates are falling, even in sophisticated societies. Simple technology is available

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to ensure protected water sources and the safe disposal of human excreta, yet most countries continue to face a heavy burden of morbidity and mortality resulting from waterborne diseases. We observe that WHO, which should take a leading role in health development, is delegating these responsibilities to others, who have commercial and other non-health priorities. Yet at the same time WHO takes on new scientific adventures on behalf of the global community. Sometimes one thinks that established public health principles are either forgotten or deliberately not followed; perhaps some never knew them. The realization of our health goals can be achieved. Basic public health principles, however, must return to centre stage in dealing with the many health issues we face today.

The AIDS epidemic continues and every country in the world is affected. Unfortunately, most AIDS prevention initiatives forget primordial prevention, which is seen as threatening to the global sex industry, which has responded to the challenge of AIDS by aggressively promoting promiscuous and deviant sex behaviour through the print and electronic media targeted specifically at the young. Today popular media believe that freedom of expression is more sacred than the truth. Each of our countries, especially the developed countries whence these corrupt and irresponsible activities emanate, must find a way of using the print and electronic media appropriately and aggressively to promote AIDS control activities and curb destructive hedonism. Behaviourial change is the only answer. Drastic action, even to the extent of curbing human freedom, is not out of place where we have an epidemic destroying the whole fabric and future of our world. The handle of the Broad Street Pump has to be removed. Cholera in London in the nineteenth century and AIDS in the world in the twentieth century both need the leadership and moral fibre of a John Snow. The belief that humans can and should be free of fear and anxiety is one of the distinguishing illusions in Western thought in this century.

While we have questioned some of the statistics quoted and forming the basis on which the priority health problems facing our countries have been formulated in the World Bank document entitled "Better health in Africa", we had welcomed this document as an important first step towards discussion on health sector reform in our countries. However, the process being used to carry out this agenda through private citizens, who are identified with no consultation or reference to our governments, is not likely to lead to the sort of progress we had hoped for. How does a private individual dedicated to the sector of commercial medicine initiate the type of reforms envisaged in "Better health in Africa" short of government involvement? I urge the World Health Organization and the World Bank to reconsider this issue and use the tested, tried and acceptable methods of communicating with us and our people. Private individuals and nongovernmental organizations, no matter how well intentioned they may appear, cannot assume the role of government in development of policy or planning.

The status of women in Zimbabwe is a central plank of our post-independence development policy. My Government has introduced several legal instruments entrenching the rights of women to equal treatment. The Age of Majority Act gives equal rights to both males and females from the age of 18. The Labour Relations Act protects women in the workplace by especially protecting their rights during pregnancy and the breast-feeding period and their right to continue to receive an income during that period. The Matrimonial Causes Act gives women proprietary rights which they were deprived of during colonial times when they were regarded as minors from cradle to grave. The Succession Amendment Act provides for equal rights to property compared with their male counterparts after the death of a parent or guardian.

The Children's Protection and Adoption Act is being expanded to develop a children's act, which will include public health issues such as the control of sale of tobacco and alcohol products to children and compulsory immunization and hospitalization where necessary, where some religious groups deprive their families of that right. All these legal changes have immeasurable public health benefits for a very small investment in political and financial terms.

During the last few Health Assemblies, I have given examples of how the life of a Third World person is given less value than that of a person in the developed world. Indeed, the Director-General's report indicates that 100 African children must die to compensate equivalently for the death of one Japanese child. This is the implication for the world's non-renewable resources of the differences in geographical and ethnic origin of the mouths which we are called upon to feed. Other than the economic disparities between North and South, ethnic conflicts affecting some of our countries continue to lead to loss of tens of thousands of lives and the displacement of millions of people. Other than those nationals directly affected by the carnage in Rwanda, for example, all the neighbouring countries are adversely affected. All this is happening while the whole world sits and watches. This is morally unacceptable, politically destabilizing and, in public health terms, permanently disabling. We have a duty to promote and protect the lives of all people especially those who are suffering in situations of ethnic conflict.

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The first and important step is to put equal value to each human life, from wheresoever it may originate. Europe and North America appear from our position to have adopted the apartheid view, condemned for so long in our neighbour South Africa, in the spread of xenophobia and restrictions on freedom of association, work and travel based on domicile and ethnic origin.

As we now welcome the dawn of reason in our subcontinent, we hope it will not be long before this reason returns to the countries of the developed North.

Mr FOWZIE (Sri Lanka):

Mr President, Director-General of the World Health Organization, honourable ministers, your excellencies, distinguished delegates, ladies and gentlemen, on behalf of the Government and people of the Democratic Socialist Republic of Sri Lanka let me congratulate the President on his election. I am confident that under his guidance the deliberations of this Assembly will be productive and be beneficial to all Member countries. Our collective endeavours towards promoting health development would shape the destinies of the peoples of all nations. Let me also congratulate you, Dr Nakajima, for an excellent report to this Health Assembly. We look forward to your continued leadership as the head of this Organization. I also wish to congratulate the Chairman of the Executive Board for the excellent reports.

The People's Alliance Government of Sri Lanka under the leadership of Her Excellency the President has embarked on a programme of health development with an emphasis on preventive and promotive health, and the provision of better services to the underprivileged and the disadvantaged. The budgetary allocation for health has remained at around 3% for a decade. For 1995, my Government has increased the allocation to 9%; this is a great leap forward. Our guiding principles in health development have been based on respect for the dignity of the user, equitable and accessible services afforded free of cost to the entire population, and the recognition that health and other sectoral development are mutually dependent. We are also taking steps to strengthen intersectoral and community participation in the planning, implementing and evaluating of the health services at grass-roots level.

The provision of universally accessible free health services and the institution of other social welfare measures has enabled the people of our country to enjoy a health status which is relatively better than that of most developing countries and probably that of some developed countries as well. The health care delivery system has developed over the years bringing the health services closer to the people through a well distributed peripheral network, affording easy access to both curative and preventive services. With a per capita income of around US$ 500 we have been able to bring down our infant mortality rate to 19 per 1000 live births and the maternal mortality rate to 0.4 per 1000 live births. The expectation of life at birth has increased to 71 years in males and 74 years in females. Despite these commendable achievements there are still categories of people within our country who have been deprived of adequate access to health arid other social welfare services. These groups include the urban poor, workers on the plantations, and those affected by the civil strife which has plagued our country for over a decade. There are also a large number of people who are extremely poor and are unable to maintain a satisfactory state of health. Improving the health status of these disadvantaged groups is a challenge which we will face in the coming years.

Our Government has already embarked on several programmes to help these disadvantaged groups. A programme known as Samurdhi (prosperity) has been initiated to assist the poorest people in our country by giving them support to improve themselves through their own efforts. We believe that the poor have the potential to do so if support and guidance are provided to make use of their inherent abilities. We have also formulated several special programmes for the estate and urban sectors with assistance from WHO, UNICEF and other United Nations bodies. A phenomenon that has not received adequate attention is the reluctance of technically qualified staff to work in peripheral institutions, depriving the more disadvantaged groups of the benefit of their services. There is thus a maldistribution of these categories of staff, with congregation in the larger urban centres. This has resulted in the underutilization of smaller institutions and overcrowding of secondary and tertiary care institutions. We propose to take steps to correct this anomaly and ensure equitable distribution of staff, giving priority consideration to the optimum staffing of the more peripheral institutions.

To ensure that health personnel will have the necessary capabilities to meet the current health sector demands, their training curricula will be revised. Equitable opportunities for career development will be provided to all categories of health personnel by making facilities available to them for higher education, both within the country and abroad. We are also taking steps to provide more facilities to our primary curative care institutions. For this purpose we intend upgrading one primary level institution in each of the 25 districts

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every year for the next five years. Each such institution will be provided with all basic facilities inclusive of an emergency treatment unit, a health education unit, a laboratory for basic investigations and ambulance facilities. The plantation sector, which makes a major contribution to the national economy, was provided with better access to health facilities than other parts of the country during colonial rule through the provision of a large number of governmental medical institutions in plantation areas. Encouragement was also given to management companies to provide their own services within the estates by granting them special incentives. Despite this seemingly favoured treatment the desired impact on the health status of the population in the plantation sector has not been achieved. It has, over the years, remained well below that of the general population. Commencing next year, it is our intention to integrate the existing plantation health services with the Government health services. Plans are afoot to integrate all health facilities and staff in the plantation sector with the rest of the Government health programmes in a phased manner. We will appoint qualified personnel to man these stations and bring them in line with the Government health facilities. We are hopeful that through these efforts we will be able to produce a healthier population in the plantation sector.

Undernutrition is recognized as a serious and longstanding problem, affecting preschool children and pregnant mothers, especially among the underprivileged groups. We realize that there are no easy solutions to the problem of undernutrition. We are in the process of developing effective strategies to combat undernutrition, realizing that it requires a multisectoral approach with a strong coordinating mechanism.

Among the communicable diseases, malaria continues to be the most important public health problem. About four million people live in areas where there is a risk of malaria. Since the adoption of the global strategy for the control of malaria recommended by the World Health Organization in 1993, the annual incidence of malaria has declined by 30% while the expenditure on insecticides has been reduced by a third. This has been accomplished by establishing mobile malaria clinics for early detection and treatment of cases, and limiting spraying operations to selected areas. We are also carrying out trials with alternative insecticides with promising results.

Sri Lanka is still a low-prevalence country for HIV/AIDS, with a cumulative total of only 156 HIV antibody-positive cases, inclusive of 51 cases of AIDS. However, there is a significant degree of risk behaviour among Sri Lankans as reflected in a high incidence of other sexually transmitted diseases. We are convinced that a concerted effort could contain and modify the epidemic. Unfortunately, because Sri Lanka is a low-prevalence country, we have experienced difficulty in mobilizing international support for our programmes. We trust that WHO would be able to assist us in mobilizing such support.

In 1989，Sri Lanka had the unique distinction of becoming one of the first developing countries to achieve universal child immunization. Recent reports indicate that the coverage for all Expanded Programme on Immunization vaccines exceeds 85%, and special surveys carried out suggest a much higher coverage in fact. The target diseases have continued to decline, and the Government has embarked on a programme to eradicate poliomyelitis and eliminate neonatal tetanus. No cases of poliomyelitis were detected in 1994. Starting in October this year, we propose to adopt the strategy of conducting national immunization days during the next three years. WHO, UNICEF and Rotary International have already committed themselves to ensure the successful implementation of this programme. We are confident of being able to declare a polio-free Sri Lanka by 1998.

Another area of great significance is the effect of the environment on the health of our people. Environmental effects caused by population growth, changes in ecological systems, environmental degradation, and natural and man-made disasters can have a profound effect on health. Decisions on environmental issues are often taken with little consideration of their health impacts. This deficiency has been recognized and the health sector is now recognized as the focal point for all environmental health activities.

Our country is facing a period of transition. Noncommunicable diseases are on the increase. Lifestyles are changing - alcohol consumption and substance abuse are on the increase. The aged population and the workforce are increasing. The health needs of the population and, therefore, the demands on the health services will consequently change. We need to prepare ourselves to care for the elderly and meet the health needs of an expanding workforce. I am confident that under the guidance of the World Health Organization we will be able to meet these demands.

I wish the Forty-eighth World Health Assembly all success in its deliberations.

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Dr BARAN (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 and all the other distinguished officers of the Assembly on their election to their important respective offices of the Forty-eighth World Health Assembly. I am confident that under the able guidance of the President this Assembly will achieve its goals. I also wish to thank the outgoing President, Mr B.K. Temane, for having successfully presided over the Forty-seventh World Health Assembly. I take this opportunity to express my pleasure in welcoming the new Member State.

It is a basic duty of the State to ensure a healthy life for every individual in society. This obligation is clearly embodied in our Constitution. Consequently, health services are given high priority in our policies and strategies. Modern societies are aware that the health sector is not only related to the health requirements of individuals, but also to the other aspects of society such as the economy, social stability and internal peace. In the light of this reality, the question of health either already enjoys or will enjoy in the near future the priority it deserves on the agenda of all countries. Every individual has a right to equity in health services. This right can only be realized by providing equal opportunity to all to protect and improve their health.

As regards the health situation and services, we observe pronounced disparities between States and between various strata of a given society. Inequity in health is a common feature even in the developed world. In countries facing this problem, the health indicators - such as life expectancy in different income groups, and infant and child mortality rates - show marked differences. Similar disparities could also be detected between age groups and geographic regions. It is therefore of the utmost importance that the Member States should strive to develop consistent long-term health policies in order to reduce these inequities. The relation between population and sustainable development, both of which closely concern mankind, is becoming more evident today. Countries are working hard to reach decisions on the common targets and strategies to strengthen the relationship between population, environment and development. At the International Conference on Population and Development, held in Cairo last year, this issue was addressed and an action plan, together with the principles and targets of implementation, were adopted so as to serve as guidelines for the next two decades. The Cairo Conference, emphasizing the importance of reproductive health in human life, proposed to incorporate related programmes in the primary health care services. Implementation of the action plan adopted at the Cairo Conference requires urgent technical support from the World Health Organization. We are making every effort in Turkey to implement the conclusions of the Conference successfully.

As a representative of a country which has pioneered in the recognition of the equality of women in political, legal and social life, I must express our appreciation for the valuable contributions of the World Health Organization to the improvement of the status of women as a key element in achieving sustainable development and in solving population problems.

We have noted with satisfaction The world health report 1995 of the Director-General, submitted to the Assembly for the first time this year. We agree with the findings and the analyses of the Director-General. We feel that his vision and his priorities for the future are right. We firmly believe that by the adoption by Member States of this vision and the priorities we shall be able to bridge the gaps of inequity in health.

We are pleased to see that the agenda of this year's Health Assembly covers a wide variety of important topics. We feel that the inclusion of emerging, re-emerging and new infectious diseases in the agenda together with the control and prevention of communicable diseases will provide guidance in the formulation of future national health policies. We believe that it is important to draw the attention of the health community to tuberculosis, AIDS, malaria, diarrhoeal diseases and acute respiratory infections in a shrinking world of intensified transport and communication links.

In Turkey, one of the major activities in health is the Expanded Programme on Immunization, which is carried out within the framework of child health and control of infectious diseases. Thanks to important achievements made within this programme, we have reached a high level of vaccination coverage in 1994. We continue our efforts in line with the fifth target of the Global Strategy for Health for All by the Year 2000, in order to eliminate and eradicate certain diseases. I should mention in this context that the elimination of neonatal tetanus, control of measles and eradication of poliomyelitis have been targeted as priority policy areas.


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We follow with great satisfaction the activities undertaken by the countries with a view to implementing comprehensive immunization and disease control programmes. The Region of the Americas, where poliomyelitis is virtually eradicated, deserves particular praise in this respect. With the same aim, we participate in a comprehensive programme implemented by 18 countries in our region. We are confident that national immunization days, which are an excellent example of international solidarity and multisectoral cooperation, will be successfully concluded. Nevertheless, we need political determination, technical cooperation, support, and the contribution and participation of various actors of society to reach our targets. I wish to express our appreciation and our gratitude to all individuals and organizations who have contributed to this activity.

We believe that this Assembly will provide a good opportunity to assess our achievements so far and to give fresh impetus to our work towards health for all by the year 2000. Turkey has enthusiastically supported this programme and its targets since its inception. We also support the work undertaken to update the targets of this programme.

Although considerable progress has been made in the implementation of the health-for-all strategies, we feel that we still have some distance to cover before universally attaining these targets. Internal conflicts, wars and the economic difficulties that many Member States face obviously constitute major stumbling-blocks in this respect. Conflicts and wars in Bosnia and Herzegovina, Azerbaijan, Rwanda and Burundi, whose long-term effects will be felt by the generations to come, are major concerns for mankind. This is equally true of the victims of terrorism. Humanity is duty-bound to extend every assistance to these victims and to fight with determination against forces of aggression and terrorism.

We appreciate that WHO, which is facing financial restraints, cannot attain all its targets in a manner that will fully meet the expectations of its Member States. We are confident, however, that the budget reform process and the proposals made by the Director-General to shift resources from areas of lesser urgency to those with high priority are steps in the right direction.

I once again wish the Assembly successful deliberations and thank you, Mr President, for having given me the opportunity to address it.

Mr TULADHAR (Nepal):

Mr President, Mr Director-General, excellencies, distinguished delegates, ladies and gentlemen, I would like to offer my most sincere congratulations to the President, on his unanimous election to the presidency of the Forty-eighth World Health Assembly. Congratulations are extended also to the Vice-Presidents, chairpersons of the main committees and other officers who have been elected to lead this Assembly.

Although the meeting in Alma-Ata two decades ago rang with the slogan of Health for All by the Year 2000，we delude ourselves if we think that we are any closer to the goal now than at that time. What was needed then, as now, was a major change in thinking and strategy in the whole approach to health, which had to be at once personal, professional, local, national and global. Instead, much of the subsequent policy and action has actually aggravated the global health situation rather than helped it. There has been little questioning of whether our basic approach might contain built-in limitations and itself be part of the problem rather than the solution. Consequently, as the year 2000 approaches, we are on the brink of a major health disaster of global proportions, which furthermore, is intimately interlinked with growing political and ecological crises.

There is a great and growing gap between general health situations of different social groups. We remain encumbered with the problems of unsafe water, insufficient nutrition, and lack of ample and meaningful work and opportunity for the bulk of the world's population. Furthermore, we are faced not just with AIDS and a return of supposedly vanquished diseases such as malaria and tuberculosis, but with the spectre of an epidemic resurgence of antibiotic-resistant microbes, which pose a far greater health crisis than the current AIDS one. In the previous decade, we have come to face for the first time in history with generally decreasing levels of agricultural productivity and seafood catches worldwide. There is destruction of our forests, rivers and pasture lands, which is eroding the ability of communities to care for themselves. We are poisoning our air and soil with petrochemicals. We have seen the resurgence of international, ethnic and communal strife which mock our attempts to raise people's health. In the last quarter century we have experienced greater centralization of finance, planning, control of people and control of nature, and the erosion of the social and natural variability and autonomy that are essential to a healthy, dynamic and democratic world society.

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Despite claims to the contrary, the present paradigm of health has generally restricted health to technical intervention focused on the individual. It has excluded the environmental, social and political economic context, not only of health services but of those imposed by the powerful interests which determine policy, research, finance and availability. Although this paradigm bases itself on a version of science which is a product of society according to prevalent values, this so-called science has cut itself off from appraising the effect of these values or taking social responsibility for the results. Powerful interests in society and the state determine and shape this paradigm, and they encourage the mystification of health care planning, research and application. They make health care knowledge inaccessible to all except professionals and experts. Sharing of knowledge is largely restricted to the domain of seminars in five-star hotels and professional journals, which shut out the common people. The decisions are made in agency and government offices and corporate board-rooms. And the implementation is designed in university and corporate laboratories. This separation of the generation of knowledge and decision-making from application prevents the health care professionals from gaining sympathy and insight into the actual health conditions, needs and capabilities of the rural peoples and urban poor. People are precluded from participating in decision-making and developing health care according to their perceptions, capabilities and needs, and health care professionals are prevented from having a substantial positive effect on people's lives or on the general health condition of the world.

International health policy has subordinated health to multinational alcoholic beverages, the weapons trade, nuclear power, petroleum, fertilizers and pesticides, international finance, and pharmaceuticals. These have subjugated people's thinking and actions to their own interests, and they seduce health care practitioners away from serving human and community interests with rewards of status, consumption of status goods, undue comforts and other shares in the spoils. Multilateral and bilateral financial agencies, furthermore, in the interests of efficiency, the service industry, and promotion of a technocentric orientation, are using their financial force to suppress other more decentralized and locally generated alternatives. Though these financial agencies have recently laid stress on human development and human resource development as a part of a new paradigm, they are still forcing a monolithic, top-down approach across the world. This centralization is destroying the variety of human alternatives and plurality necessary for creating viable and appropriate alternatives, leading to environmental destruction, social breakdown and ultimately widespread violence.

What is required is a shift of international support and political commitment of national governments away from the immoral, top-down approach that currently dominates health and medicine to a holistic one that aims to deal with and adjust to the entire set of conditions that shape people's health: ecological, political, economic, social and moral. It must recognize the manner of medicine's own participation in these conditions and work to transform itself in the process. The overall local conditions of good health must be emphasized, including more equitable distribution of control over land and capital, literacy, and removal of parasitic groups which feed off the people, such as landlords, moneylenders, profiteering middlemen, government and corporate bureaucrats, and agents. Health care must stop serving as a lackey for powerful international and local interests, and it must refrain from providing widespread tacit approval to socially and environmentally destructive systems of relations purely for the purpose of expediency, and instead aim for substantial long-term solutions that genuinely transform the conditions underlying and perpetuating poor health.

Local people must be encouraged to take the initiative in developing their own health care programmes

according to their conditions and to develop local alternatives. The whole realm of health and medicine must

be demystified and made accessible in forms pioneered by the approaches and books such as Where there is no doctor, so people are no longer victimized by the health enterprise. The development of local

organizational frameworks in which people can jointly reflect upon and tackle their health needs must be

encouraged. The relationship of the medical profession to the people it serves, instead of its current top-down

form, must be placed alongside, and "on tap" to the community to assist in its self determination. Research

must be shaped and determined by the needs, interests, knowledge and conditions of local communities rather

than the corporate and bureaucratic interests, and they must serve to extend local knowledge and resources.

The whole process of health care and development must be made people-intensive rather than capital-

intensive.

As Nepal and other Member States seek to devise effective strategies to achieve equity in health,

considerations of how the concept of access is operational ized assume a central role in our deliberations. The

goal of increased access - a goal that is reflected in the health development strategy of Nepal - must be: to

assure that the poor and most vulnerable groups are able to use services at rates proportional and appropriate

to their existing need for care.

Finally, on behalf of His Majesty's Government of Nepal and on my own behalf, I would like to

express our appreciation to WHO for its active support and effective technical cooperation.

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I hope that this meeting will provide a forum in which people can sincerely and critically reflect upon

their own roles, values and practice, upon the role of the health system, and begin to make some meaningful

and positive impact in the world.

Le Professeur LE VAN TRUYEN (Viet Nam):

Monsieur le Président, Mesdames et Messieurs les Ministres, Monsieur le Directeur général, Messieurs les Directeurs régionaux, Mesdames et Messieurs, je voudrais, au nom du Gouvernement de la République socialiste du Viet Nam, adresser mes félicitations les plus sincères au Président et Vice-Présidents, Rapporteurs et Présidents des différentes commissions à l'occasion de leur élection. La délégation du Viet Nam tient à exprimer sa haute appréciation au Directeur général et aux Directeurs régionaux, et notamment au Directeur régional pour le Pacifique occidental, pour la mise en oeuvre des résolutions et décisions de l'Assemblée mondiale de la Santé et pour l'appui prêté aux Etats Membres afin qu'ils se rapprochent de l'objectif de la santé pour tous d'ici l'an 2000.

C'est au seuil de la célébration du cinquantenaire de la création de l'Organisation des Nations Unies et du cinquantenaire de la victoire des forces démocratiques qui a mis fin à la Seconde Guerre mondiale que la communauté internationale se réunit ces jours-ci à l'occasion de la Quarante-Huitième Assemblée mondiale de la Santé pour étudier le thème "Equité, solidarité, santé - Réduire les écarts".

Au cours de ce demi-siècle, le Viet Nam est sorti de deux guerres; il a aussi été victime de toutes sortes de pressions venues de l'extérieur pour empêcher son développement. C'est pour cela que nous comprenons très bien ce thème, car nous sommes parmi les plus touchés; nous nous demandons si, dans les conditions de l'après-guerre froide, la communauté internationale pourrait faire quelque chose de mieux; en effet, mieux vaut tard que jamais ！

Le Viet Nam a pratiqué la politique d'ouverture, de coopération, de sécurité commune et d'amitié avec tous les pays. Il poursuivra le processus de rénovation afin d'atteindre le but qu'il s'est fixé, à savoir que le peuple soit riche, le pays fort, la société égalitaire et civilisée.

A l'échelle internationale, nous constatons que le développement prospère de certains pays va de pair avec l'augmentation de la misère des autres, alors qu'à l'intérieur d'autres pays, les processus de réforme et de régulation intensive entraînent l'accroissement de la pauvreté, du chômage et de la désunion sociale. Or ces faits sont inacceptables et sont pour la communauté internationale un défi consistant à réparer pour en tirer des avantages et réduire au minimum les incidences négatives pour chaque société, chaque individu.

Grâce à la globalisation, elle-même conséquence des innovations technologiques et de l'action des grandes entreprises internationales, les Etats pourraient bénéficier des bonnes expériences acquises et éviter les erreurs que les autres ont faites ou les difficultés qu'ils ont rencontrées.

Nous devrions focaliser notre effort et nos politiques pour résoudre les causes radicales de la pauvreté et satisfaire les besoins fondamentaux de chaque société et de chaque individu considéré comme le point central de nos préoccupations. Parmi ces besoins, ceux de la santé sont considérés comme prioritaires : il faudrait d'abord chercher à atteindre le but stratégique de la santé pour tous, y compris une hygiène satisfaisante, un approvisionnement adéquat en eau saine et potable, une bonne nutrition et une médecine préventive efficace. Nous devrions ensuite prendre toutes les mesures nécessaires - sans oublier de bien coordonner les activités à l'échelle mondiale - pour réduire la morbidité et la mortalité causées par les maladies infectieuses telles que le paludisme, la tuberculose et le VIH/SIDA, afin qu'elles ne puissent empêcher ou repousser les progrès réalisés dans le développement socio-économique parce qu'elles sont souvent les causes de la pauvreté et de la marginalisation sociale. Il faudrait enfin chercher à atteindre les objectifs de santé pour les mères et les enfants, particulièrement ceux de la réduction de la mortalité des mères et des enfants fixés par le Sommet mondial pour les enfants de 1990，la Conférence des Nations Unies sur l'environnement et le développement de 1992 et la Conférence internationale sur la population et le développement de 1994. Bien sûr, il faudrait porter une attention particulière aux besoins et aux droits des femmes et des enfants qui sont les plus touchés par la misère, et à ceux des individus et des couches déshérités et vulnérables.

En fait, le développement social est la responsabilité de chaque Etat, mais cette responsabilité ne saurait être assumée avec succès sans l'engagement et l'effort collectif de la communauté internationale. Le défi est aujourd'hui d'unir les déterminations nationale et internationale pour établir un cadre de coopération continue, efficace et durable.

En nous fondant sur ces constats, nous voudrions suggérer que notre prestigieux forum se penche sur le développement et les façons de distribuer au mieux les ressources économiques, en tenant compte des cinq

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propositions principales suivantes : a) alléger et annuler les dettes des pays pauvres conformément à l'accord du Club de Paris en décembre 1994; b) reconsidérer les aspects négatifs des dépenses militaires colossales et stupéfiantes, même dans l'après-guerre froide; c) mobiliser les nouvelles sources de financement multilatérales, bilatérales à des conditions privilégiées, et sous forme de dons; d) réaliser l'accord de réserver 0,7 % du produit national brut des Etats riches à l'aide publique au développement des pays pauvres; et e) demander aux différentes instances de l'ONU, à l'OMS et à d'autres organisations internationales de porter plus d'attention aux objectifs communs de premier rang pour la réduction des écarts.

Le grand défi de cette fin de siècle est d'infléchir cette évolution des pays pauvres par un effort conjugué de tous. Nous sommes sûrs de pouvoir compter sur l'OMS vibrante et dynamique que le monde attend. Il nous faut une ambition pour notre Organisation ！

Pour conclure, j'aimerais vous assurer, Monsieur le Président et Monsieur le Directeur général, que le Viet Nam continuera à travailler en étroite collaboration avec l'Organisation mondiale de la Santé, comme il l'a toujours fait.

Je vous remercie de m'avoir donné l'occasion de m'exprimer aujourd'hui devant cette Assemblée et d'adresser, au nom du Gouvernement vietnamien, des sincères remerciements aux gouvernements et organisations non gouvernementales pour leur coopération et l'assistance qu'ils ont apportée aux services de santé du Viet Nam. Je termine en vous transmettant les meilleurs voeux de la délégation vietnamienne. Je 。 forme des voeux de succès pour la réussite des travaux de l'Assemblée de la Santé.

Dato D r Haji Johar Noordin (Brunei Darussalam)，President, resumed the presidential chair. Dato D r Haji Johar Noordin (Brunéi Darussalam), Président de l'Assemblée, reprend la présidence.

Mr MUTISO (Kenya):

Mr President, Director-General, distinguished delegates, ladies and gentlemen, first of all, on behalf of the Kenyan delegation, I would like to congratulate you, Mr President, on your election. Please accept our best wishes as you steer the deliberations of this Assembly, and during your term as President of the Forty-eighth World Health Assembly. I also take this opportunity to express our appreciation of the work of the Executive Board as contained in the reports on its ninety-fourth and ninety-fifth sessions.

Allow me also to congratulate the Director-General and his entire staff for their good work, and for producing The world health report 1995: bridging the gaps. This report, which is the first publication to be prepared in response to the Executive Board's recommendations, is a concise and comprehensive report which gives an analytical overview of the global health situation, and WHO's contributions for improving health, and outlines priorities for international health action.

The world health report 1995 identifies poverty as the main reason why babies are not vaccinated, why safe water and sanitation are not provided, why drugs and other medical supplies are not available, and why mothers die during childbirth. Poverty is also a major contributor to mental illness, stress, and drug abuse. Hence, it is imperative that all efforts should be geared to poverty alleviation. During the past year, Kenya has initiated steps aimed at focusing on the plight of the poor. A national leaders meeting on social dimensions was held towards the end of last year, chaired by none other than His Excellency, the President of the Republic of Kenya. This day-long meeting came up with recommendations on actions to be taken in order to address the needs of the poor people in our society.

During the same year, a new health policy framework for Kenya was adopted and launched on 15 December 1994. This new policy framework document is the blueprint for health sector reform in our country, it identifies the ways in which we can invest in health in order to obtain the optimal benefits, through working out the minimum health-for-all package for every district. Further decentralization of health services, with emphasis on community-based health care, has been undertaken in an effort to renew the health-for-all strategy. Health financing, with an emphasis on community co-financing, should continue to be encouraged, particularly in developing countries, with a view to providing sustainable health care services. This will go a long way towards enhancing the participation of communities in their own health.

Kenya, like the rest of the world health community, continues to face new challenges in the health sector. The AIDS pandemic has not spared us, and to date over 56 000 cases of AIDS have been reported with an estimated one million infected people out of a total population of about 27 million. We are seeing close to 8000 new cases per year. Efforts on prevention and control of this scourge continue to be intensified. We commend and support the joint and cosponsored United Nations Programme on HIV/AIDS, which is due to start and take over the initiatives started under the Global Programme on AIDS. This should lead to a

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well-coordinated effort in the fight against this dreaded disease. Research efforts should continue to be supported on all relevant aspects of AIDS and HIV.

On a brighter note, Mr President, Kenya joined other countries in observing this year's World Health Day on 7 April 1995. The theme this year was "A World without Polio by the Year 2000". I am happy to report to this Assembly that Kenya is well on course towards achieving this goal, as no single case has been detected in the country for the last three years. Similarly, the guinea-worm eradication programme in Kenya continues with a lot of success except for a few cross-border cases in the common border with our neighbours. We commend the efforts by former United States President, Jimmy Carter, and his centre in supporting guinea-worm eradication, and his intervention in the recent peace initiative in Khartoum. This will go a long way in achieving the set goals on guinea-worm eradication.

In an effort to improve the health of our people, Kenya has made great strides in economic and political reforms. The inflation rate has declined to single-digit figures, and multiparty democracy has taken root. The political stability of our country has made Kenya a haven of peace in our region. However, the situation in neighbouring Somalia and a number of other countries in the region has resulted in a lot of effort and resources being put to emergency programmes. We wish to thank the international communities and donors who have come to our assistance. We view health programmes, particularly those geared towards maternal and child health care, as being crucial to the attainment of health for all our people. Hence, donor support to these programmes should continually be geared towards assisting our countries to sustain the on-going activities particularly in the supply of vaccines, essential drugs and other basic medical supplies. At the same time, political conditionalities should not be seen to be of such great importance when it comes to child survival and development programmes.

As we continue to intensify our fight against malaria, diarrhoeal diseases, acute respiratory infections and other communicable diseases, our attention is turning towards prevention of road traffic accidents and drug abuse, which are causing premature deaths, suffering and disability. This is so, not just in Kenya, but in other developing countries, and we hope these emerging problems will be discussed during this year's Health Assembly, and that ways of combating them will be mapped out. Intercountry exchanges on experiences and prevention programmes could be very useful in these areas.

Finally, Mr President, ladies and gentlemen, the Kenyan delegation appreciates the role of the World Health Organization in providing technical support to our countries as the lead agency in the health sector, a role that we should all continue to support.

Professor LJUBIC (Bosnia and Herzegovina):

Mr Director-General, Mr President, distinguished colleagues, ladies and gentlemen, at the outset allow me, on behalf of the people of Bosnia and Herzegovina, to say how honoured I am to have the opportunity to be together with so many representatives of the countries which have been collaborating closely with us and helping us to uphold our common faith in health and human development.

At present, the aggression is still continuing against our country. The cruellest violence has caused enormous suffering of civilians, more than has ever been the case in Europe since the Second World War. As we speak here today, almost at the end of the twentieth century, the original deadline for achieving health for all, many of the health indicators of my country have deteriorated over the past three years. The incidence and prevalence of some communicable diseases have risen dramatically, especially hepatitis A, diarrhoeal diseases and tuberculosis, even among the young generation. Rodent-borne diseases such as haemorrhagic fever have increased. Tularaemia has also appeared. It has been difficult to maintain consistently high levels of immunization coverage although our coverage was among the highest in Europe before this war. Waste treatment and disposal constitute a potential environmental health hazard due to the rising number of rodents.

Deaths and morbidity among all age groups due to shelling, especially of the civilians, continue to mount on a daily basis. The overall figures of victims in the Federation of Bosnia and Herzegovina are awesome; estimations speak of over 150 000 killed and missing, 240 000 injured and 12 000 disabled persons. The rehabilitation of the war-disabled is on the list of our top priorities. Our health system nevertheless continues to function on a more or less regular basis and we are able, one way or another, to provide care to all who need it, and we are moving ahead with health care reforms which will further improve our capacity to provide health for all. We are faced with the serious problem of the salaries for the health professionals, which is causing a continuous brain-drain.

Mr President, dear colleagues, let us remind ourselves once again of WHO's definition of health, which says that health is not only the absence of disease and speaks of mental and social well-being as an integral

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part of health. Let us also remind ourselves of the human rights resolutions of the United Nations: the right to health, the right to water, the right to food, the right to shelter, the right to life itself. Yet today, on the eve of the twenty-first century, and almost 20 years after Alma-Ata, no more than two hours away from Geneva or London, an entire population is being denied those most basic rights.

I ask myself what is the right to health when our hospitals, health centres and primary care facilities are being systematically targeted. At least 25% of our regional hospitals, 30% of our health centres, 50% of our primary health care facilities have been destroyed or damaged to such an extent that they are no longer able to function. During this past winter some of our major hospitals registered temperatures of 10°C in the intensive-care rooms and operating theatres because our access to heating fuel had been cut off. Old people were dying of hypothermia, the newborn and young infants have been forced to suffer inexcusably. We have even been denied the right to move our sick and dying to other cities and health facilities where their lives could have been saved. I would like the representatives of WHO, as well as the Member States，to use their influence in order to provide permanent humanitarian assistance in the form of food and pharmaceuticals to the besieged enclaves and the replacement of health professional teams in the enclaves.

What is the right to water, when water supplies to entire cities are systematically cut off, and when 50% of our households were denied clean water for over three months at a time?

What is the right to food, when most of our population has been forced to subsist for the past three years on humanitarian food aid even though our cities are surrounded by good arable land to which we are denied access by snipers and tanks? What does the right to food mean when even UNHCR convoys are regularly denied access to our cities and when food stocks are made to sit for months at a time spoiling in the open, in the rain and snow at Sarajevo airport, because not even the United Nations is allowed to take them into the city for distribution? What does the right to food mean when in May 1995, ladies and gentlemen, the nutritional condition of thousands of people in Gorazde, Srebrenica, Bihac and Sarajevo is being calculated in terms of weeks' and days' supply?

What does the right to education and human development mean, when our children are being shot and shelled while going to school?

What is the right to free movement and shelter, when for over a thousand days three of our main cities -Sarajevo, Srebrenica and Gorazde - have been besieged and cut off from the outside world? There is no movement of civilians in or out of these cities, and the psychosocial impact of this imprisonment is now taking a severe toll on our children.

What is the right to shelter when two million people have been forcibly displaced from their villages and towns, and many of them are condemned to live in overcrowded camps and poorly equipped collective centres that cannot offer any real opportunity for family life and human development?

Many health institutions, which only four years ago were still organizing health care research and training activities for WHO, are now in ruins, a shadow of what they were. We are nevertheless engaged in training and research activities which will help us to adapt the primary health care concept to the needs of tomorrow's Bosnia and Herzegovina. Later this year we will organize a congress on war surgery, which will allow us to share our knowledge and experience gathered for the last three years.

This year Bosnia and Herzegovina celebrated World Health Day together with you. Poliomyelitis was eradicated in our country 20 years ago, so this year we decided to dedicate part of World Health Day to disability prevention. For us, disability prevention has come to mean trying to keep with the needs of over 12 000 disabled persons and to setting up psychosocial centres to help women cope with the aftermath of systematic mass rape.

Permit me again to thank so many of you for helping us. Our thanks go to all countries, nongovernmental organizations, and bilateral assistance programmes for donating food and medicines, for helping us to reconstruct our health facilities, for helping us to set up programmes for vulnerable groups. I hope the day will soon come when we will not need this type of assistance. For now, however, I look forward to your continued support. Permit me to thank Dr Asvall, Regional Director for Europe, for the support his office and his staff in Sarajevo have been giving us, even under the most difficult conditions.

Mr President, could we not unify ourselves as a health body, as the United Nations specialized agency for health, to stand up and take the lead in denouncing aggression against civilian populations? Let us take the lead in stating that the systematic attacks on health and health institutions are a gross violation of the basic rights which we all must defend. I hope that this Forty-eighth World Assembly will stand high and speak loudly on the need to respect human rights as a fundamental and indivisible part of health.

Finally, I can declare that the most significant improvement in the health sector in my country will be the result of the cessation of this cruel war and further investments in economy and education, restoration of

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an equitable supply of water, electricity and fuel, housing and sewerage system repairs, and the return of refugees and displaced persons to their homes. Participation of the international organizations, including WHO, in these efforts is unavoidable.

Le Professeur MINCU (Roumanie):

Monsieur le Président, Monsieur le Directeur général, chers collègues, Mesdames et Messieurs, c'est un grand honneur et un plaisir pour moi de vous féliciter, Monsieur le Président, pour votre unanime élection en tant que Président de la Quarante-Huitième Assemblée mondiale de la Santé et de vous transmettre nos voeux sincères de succès dans l'accomplissement de votre haute responsabilité. Je tiens aussi à féliciter les distingués Vice-Présidents de l'Assemblée et les Présidents des deux commissions. Je voudrais remercier M. le Directeur général, le Dr Hiroshi Nakajima, et ses collaborateurs d'avoir si bien organisé cette Assemblée qui nous réunit chaque année pour faire un tour d'horizon de l'état de santé dans le monde et identifier les grandes lignes d'action pour l'avenir.

La délégation de la Roumanie a examiné avec un très grand intérêt et apprécie hautement le Rapport présenté par M. le Dr Nakajima. Ce Rapport fait une analyse approfondie de la situation si complexe où l'on se trouve à présent et des efforts déployés pour mieux adapter le système des Nations Unies en général et l'Organisation mondiale de la Santé en particulier aux changements économiques et politiques rapides qui se produisent dans le monde.

Les efforts de l'OMS pour améliorer la santé sont toujours présents et positifs dans notre pays, qu'il s'agisse aussi bien d'actions à caractère général que d'activités visant à résoudre des problèmes prioritaires. Ainsi, la réforme du système de santé en Roumanie, en cours d'application expérimentale dans huit des quarante et un départements administratifs du pays，s'inspire des idées de la stratégie de la santé pour tous d'ici l'an 2000 et du programme EUROSANTE. Le programme à moyen terme conclu entre la Roumanie et le Bureau régional OMS de l'Europe représente, lui aussi，un cadre de référence pour l'approche des problèmes prioritaires. La transition économique nous fait ressentir plus que jamais la nécessité de bien utiliser les ressources limitées dont nous disposons.

A présent, en Roumanie, la réforme du système de santé met l'accent sur l'amélioration des soins de santé primaires. Suite à la réforme, le médecin généraliste a reçu une formation pour agir en tant que médecin de famille, et la population a le droit et la possibilité de choisir le médecin qu'elle considère le plus capable de défendre ses intérêts en matière de santé. De nouveaux services ont été organisés, qui doivent mieux permettre d'assurer des soins d'urgence aussi dans les zones rurales. La réforme a conduit de façon évidente l'individu et les communautés à participer directement à la solution des problèmes de santé. Quant aux services de santé, on a commencé à reconnaître leur réelle valeur sociale. Il faut aussi noter que, pour mettre en place un système de santé harmonieux, capable de répondre dans des conditions satisfaisantes aux besoins d'amélioration de la santé de la population, on ne peut pas ignorer les secteurs des soins secondaires et tertiaires. C'est dans ce but, par exemple, que le Gouvernement roumain a alloué des fonds importants à l'équipement, à un niveau adéquat, de plusieurs centres de cardiologie et chirurgie cardiaque, en vue de réduire le taux élevé de mortalité par maladies cardio-vasculaires. De même, un programme national intersectoriel de lutte contre le SIDA a été établi, conduisant à la disparition des contaminations nosocomiales du type de celles qui ont déclenché l'accident épidémiologique des années 88-89.

Le concours de composantes du système de santé et d'autres secteurs de la vie sociale s'est matérialisé avec l'élaboration récente d'un certain nombre de programmes de santé concernant, entre autres, la tuberculose, le cancer, la mortalité infantile et la promotion de la santé. Vu leur importance, la réforme et les programmes de santé ont été récemment évalués lors d'une réunion nationale des principaux décideurs à laquelle le Président, le Premier Ministre et plusieurs membres du Parlement ont été conviés. La loi sur l'assurance de santé, celle sur le droit d'exercer et sur les collèges de médecins vont compléter le cadre législatif spécifique, facilitant l'exercice du droit à la santé garanti par la Constitution.

La visite en Roumanie de M. le Directeur général, le Dr Nakajima, nous a permis, d'une part, de faire une évaluation précise des domaines où l'OMS nous avait donné son appui et, d'autre part, de montrer aux hommes politiques roumains la capacité technique de l'Organisation et du système des Nations Unies. Certes, les problèmes auxquels la Roumanie est confrontée ne sont pas isolés. Ils se retrouvent dans plusieurs pays ou régions, et c'est pour cette raison queje voudrais souligner aussi le rôle positif que le Bureau régional de l'Europe a joué et continue de jouer. Dans ce contexte, je pense que le développement permanent des actions de coopération entre deux Etats Membres ou plus serait bénéfique pour tous. Au nom du Gouvernement roumain, j'exprime la volonté de mon pays de participer à de tels programmes et d'apporter son concours

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pour que les meilleurs moyens de résoudre les problèmes de santé soient trouvés, et je déclare qu'il est disponible à cet égard. Je tiens aussi à exprimer notre appréciation en ce qui concerne la récente réunion des ministres de la santé de certains pays d'Europe centrale, au cours de laquelle nous sommes convenus que chaque pays élabore un programme multinational sur des problèmes de santé majeurs. La Roumanie est responsable du programme sur Г épidémiologie des maladies chroniques et infectieuses. Dans ce processus, le Gouvernement roumain a élaboré avec succès un programme d'amélioration de la santé avec la Banque mondiale. En tant que pays associé, nous comptons toujours sur l'appui renforcé de l'Union européenne.

Pour conclure, j'aimerais indiquer que mon pays conçoit la santé en tant qu'expression des droits de l'homme et élément fondamental pour l'édification d'une société civile en Roumanie. Nous sommes conscients des difficultés de nos démarches et de la responsabilité que nous avons prise. L'amélioration de l'état de santé de la population dépend largement de notre coopération, d'un partenariat réel entre nous tous, les Etats Membres et l'OMS. De nos jours, il n'y aura pas de développement social et économique soutenu sans une bonne santé pour tous.

M. MOLIERE (Haïti):

Monsieur le Président de l'Assemblée, Monsieur le Directeur général, Mesdames et Messieurs les délégués, Haïti traverse depuis quelques années une crise aiguë dont elle n'arrive pas encore à se relever. Les structures en place ne permettent pas de répondre aux attentes d'une population aspirant à la liberté, la paix et l'édification d'un Etat de droit et de justice sociale.

La population haïtienne a atteint près de sept millions d'habitants en 1995; elle continue à croître à un rythme annuel de 2 %. Environ 40 % de la population a moins de quinze ans. Les femmes en âge de procréer représentent quelque 25 % de la population générale.

La situation économique est précaire. Le produit national brut par tête, estimé en 1991 à US $380, est revenu au niveau de I960. Le chômage et le sous-emploi sont endémiques. Les problèmes d'environnement, d'assainissement et d'eau potable sont sérieux. Le réseau d'eau potable aurait diminué de 30 % entre 1991 et 1994, pendant la période du coup d'Etat.

La conséquence en est une situation sanitaire critique. Les indicateurs suivants le prouvent aisément. L'espérance de vie est de 55 ans. Sur 1000 naissances vivantes, 94 enfants meurent avant l'âge d'un an. Sur ces mêmes 1000 nouveau-nés, 133 n'arriveront pas à l'âge de cinq ans. La moitié de ces décès sont dus à la diarrhée et aux infections respiratoires. Le taux de mortalité maternelle est estimé à 4,6 pour 1000 naissances vivantes. Le taux d'incidence de la tuberculose est estimé à 5 pour 1000. La moitié des sidéens sont tuberculeux. La séroprévalence du VIH varie entre 8 et 10 % en milieu urbain. En milieu rural, elle a augmenté de 1 à 4 %，hausse liée à la migration interne, conséquence de la répression politique de 1991 à 1994. Les femmes sont presque aussi touchées que les hommes. Le paludisme est endémique sur 80 % du territoire national.

Au milieu de tous ces problèmes, une note positive : les efforts entrepris en 1986 ont porté des fruits. Actuellement, le pays est indemne de poliomyélite. Cette importante victoire contre la poliomyélite verrait ses effets anéantis si rien n'est fait pour améliorer les conditions environnementales dans lesquelles évolue le peuple haïtien. Tant que nous cohabiterons aussi étroitement avec les détritus, tant que notre eau sera dispensée, collectée et emmagasinée dans les conditions actuelles, tant que notre couverture sanitaire restera aussi basse et que plus de 40 % de la population ne bénéficie d'aucun accès aux soins de santé primaires, tant que les conditions socio-économiques de l'Haïtien ne s'amélioreront pas de façon sensible - et j'en passe -, nous ne pouvons espérer de victoires réelles et pérennes contre les maladies. De plus, nous constatons que des pathologies dites "de développement", mais tout aussi liées aux conditions de l'environnement, nous agressent. Nous souffrons et mourons de plus en plus d'accidents, de cancers et de maladies cardio-vasculaires. Il est donc important qu'à ces maux nous trouvions des solutions rapides, sinon la santé pour tous d'ici l'an 2000 restera un slogan vide de sens en Haïti.

Ainsi, nous devons rappeler à votre attention que le combat n'est et ne peut être exclusivement mené par nous tout seuls et avec nos maigres ressources. Nous profitons donc de cette tribune et de l'importance de ces assises pour féliciter et surtout remercier, au nom de tous les Haïtiens, tous ceux qui nous ont aidés et qui continuent à le faire. Cependant, ce n'est point suffisant. C'est l'occasion souhaitée pour lancer à tous un appel de solidarité, solidarité entre pays qui pourrait se manifester par une sollicitude plus évidente des plus nantis à l'égard des moins favorisés, solidarité entre des peuples menant un même combat, solidarité garante d'un meilleur équilibre socio-économique puisque, après tout, sur bien des tableaux, nous sommes tous aussi concernés par l'évolution de la planète qui nous contient, grands et petits, développés et

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sous-développés, avancés et moins avancés. Je voudrais ici exprimer le voeu du peuple haïtien de maintenir les acquis et de travailler à obtenir un environnement meilleur, où il puisse vivre et évoluer dans des conditions humaines et apporter sa contribution à l'humanité tout entière.

Après Alma-Ata en 1978，la stratégie des soins de santé primaires proposée par l'Organisation mondiale de la Santé a été appliquée en Haïti par le biais de multiples programmes prioritaires de santé imposés, auxquels l'Etat accordait une importance relative suivant le moment et la disponibilité des fonds, et par l'action non coordonnée de nombreuses organisations non gouvernementales toujours très bien financées. Les résultats n'ont pas répondu à l'attente de la population. La couverture en personnel de santé est estimée à 1,6 médecin, 1,3 infirmier et 0,4 dentiste pour 10 000 habitants; ce personnel est de plus très inégalement réparti. La couverture vaccinale est restée basse, aux alentours de 30 %. Environ 80 % des accouchements ont lieu à domicile, dans des conditions infra-humaines. Moins de la moitié des tuberculeux commencent un traitement que plus de 40 % d'entre eux vont abandonner avant la fin. Les services d'eau potable couvrent seulement 37 % de la population de la capitale, 41 % des villes secondaires et 23 % seulement en milieu rural. L'assainissement de base est assuré à 30 % en milieu urbain et à 15 % dans les zones rurales. Par ailleurs, les moyens financiers dont dispose l'Etat sont insuffisants pour répondre aux besoins de la population et inadéquatement utilisés. Le système de santé représentait donc l'aboutissement d'une approche sectorielle de la santé qui a, jusqu'à présent, favorisé des actions et des programmes cloisonnés, ponctuels et verticaux, non intégrés à une stratégie globale de santé et de développement.

La lutte du peuple haïtien contre la pauvreté et contre toute forme d'oppression a pris un tournant décisif avec le choix politique du 16 décembre 1990. Ce choix reflète le rejet collectif d'un système incapable de satisfaire les besoins fondamentaux de la population, notamment dans le domaine de la santé. Malheureusement, les événements de septembre 1991 sont venus arrêter ce processus. Ne pouvant collaborer avec le secteur étatique, les bailleurs de fonds, pour apaiser les souffrances, ont travaillé en étroite collaboration avec les organisations non gouvernementales. On a assisté alors à la multiplication de ces organisations, dont l'importance de l'action reste à évaluer.

Pour apporter à tous des services de qualité et en quantité optimales, le Gouvernement travaille activement à l'établissement d'un véritable partenariat avec la société civile. Il est incontestable pour cela qu'il lui faut renforcer ses structures, l'effort des agences internationales et des organisations non gouvernementales ne pouvant être positif et entraîner des changements profonds que si le secteur public est fort et bien organisé.

Le potentiel existe cependant pour une amélioration sensible du rendement. Pour cela, nous avons réfléchi et redéfini nos politiques en prenant comme point de repère le principe selon lequel la responsabilité de la santé incombe en tout premier lieu à l'individu, aux familles et aux collectivités. Intégrée dans la politique générale du Gouvernement, la politique de santé servira de cadre de référence pour aider les individus et les collectivités à prendre des décisions rationnelles. Cette politique est donc nettement opposée aux pratiques antérieures, caractérisées par le centralisme et le caporalisme d'Etat tournant le dos à la population.

Dans le cadre de cette nouvelle politique, l'Etat haïtien admet que la santé est plus que l'absence de maladie; c'est aussi une capacité d'adaptation physique, mentale et sociale à l'environnement dans lequel 且，individu évolue. Les axes stratégiques de cette nouvelle politique incluent une affirmation de l'autorité de l'Etat. L'Etat se doit de garantir le droit à la vie et à la santé de tous les citoyens. Il doit, en partenariat avec la communauté, définir les priorités de santé, établir les normes, veiller à leur application et coordonner l'action des différents acteurs du système de santé tant nationaux qu'internationaux. La participation de la communauté est une stratégie en même temps qu'un aboutissement. La décentralisation sera un moyen de favoriser la participation de la population et d'améliorer l'accessibilité aux services. L'unité communale de santé représente l'unité de base de la décentralisation. Elle a la responsabilité de planifier et de gérer tout ce qui concerne la santé de la population locale, et elle est appuyée par les niveaux départemental et central. Les niveaux locaux disposeront d'un budget à exécution autonome composé tant d'une dotation du budget étatique que des recettes provenant de la contribution financière des populations à la santé. La population participera à la gestion des budgets. Il faut en outre mentionner la rationalisation de la carte sanitaire. Un plan quinquennal est proposé visant à doter les 133 communes d'Haïti d'unités communales de santé fonctionnelles. Il faudrait un meilleur partage des coûts de la santé. A cet égard, seront soutenues, dans le cadre de la décentralisation, les expériences mettant en place progressivement des systèmes locaux de partage des risques et de plus grande solidarité, basés sur les réalités de la culture haïtienne. Il faudrait aussi assurer la coordination des activités du secteur de la santé avec celles des autres secteurs, une coordination intrasectorielle et l'intégration des services et la mise en place du "paquet minimum de santé" allant de

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l'assainissement du milieu, y compris I'approvisionnement en eau potable, jusqu'aux soins curatifs. Il faudrait également une amélioration des moyens matériels de fonctionnement pour les services de santé, une amélioration de l'accès aux médicaments et, surtout, une politique de ressources humaines adaptée. La formation médicale et paramédicale sera redéfinie. L'accent sera placé sur une formation adaptée aux conditions sociales, géographiques et épidémiologiques du pays plutôt que sur une formation de pointe, qui est tournée vers l'exportation vers des pays plus nantis que le nôtre. La recherche, quant à elle, devrait être au service de la population. La recherche sera encouragée, à la condition de présenter des retombées pratiques pour la santé de la population haïtienne. En particulier, la protection des intérêts de toute personne volontaire doit être garantie. Il faudrait, enfin, une législation défendant les intérêts de la population et un partenariat avec les agences et les pays amis. La lutte contre certaines pathologies et contre les problèmes environnementaux ne peut être conçue en dehors d'un partenariat avec les pays voisins. La Déclaration conjointe de Jimani, signée en décembre 1994 entre la République d'Haïti et la République dominicaine, en est un exemple.

La mise en commun des ressources peut grandement contribuer à potentialiser l'action de tous. A cet égard, le rôle joué par l'OMS est d'une importance capitale; il se doit d'être de plus en plus évident et de moins en moins équivoque. A ce titre, permettez-moi d'exprimer nos plus vives satisfactions vis-à-vis de la représentation actuelle de l'OPS/OMS en Haïti. Il faudra continuer à renforcer cette action, qui nous permet d'accéder à bien des services, éviter la dispersion et la duplication des efforts.

En guise de conclusion, nous vous dirions que notre politique, si belle qu'elle soit, ne soulagerait pas, dans un délai acceptable, les misères trop longtemps endurées par le peuple haïtien si nous n'obtenions pas votre appui à tous. Votre soutien moral et matériel nous est indispensable dans cet effort de reconstruction nationale.

The PRESIDENT:

I thank the delegate of Haiti, and I give the floor to the delegate of Nicaragua, who is speaking on behalf of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua and Panama.

La Sra. PALACIO (Nicaragua):

Honorable señor Presidente de la 48a Asamblea Mundial de la Salud, honorable señor Director General de la Organización Mundial de la Salud, honorables delegados ante esta magna Asamblea Mundial de la Salud, queridos amigos y ministros de salud de Centroamérica y Belice: En nombre de mis colegas de la región centroamericana me permito presentar a ustedes un breve informe de la salud en nuestra región. En la histórica Cumbre de las Américas, realizada en Miami en diciembre de 1994, los presidentes acordaron como meta para todo el continente la integración de nuestras economías para el año 2005, dentro del marco de un mundo en proceso de globalización. Centroamérica tiene sólo diez años para enfrentar la integración a un mercado americano de 750 millones de personas. En el corto plazo, nuestros gobiernos tienen el reto de alcanzar primero la integración efectiva de Centroamérica.

El 12 de octubre de 1994, en la ciudad de Managua, los centroamericanos adoptamos la Alianza para el Desarrollo Sostenible como estrategia nacional y regional orientada a hacer del istmo centroamericano una región de paz, libertad, democracia y desarrollo. Reunidos en El Salvador en marzo de 1995, nuestros presidentes se comprometieron a concentrar sus esfuerzos de inversión en el ser humano mediante la ampliación, creación y acceso a mayores oportunidades de educación, capacitación, cultura, alimentación y nutrición, salud, agua, saneamiento, seguridad social y empleo productivo para toda la población centroameri-cana. Para viabilizar este compromiso aprobaron el Tratado de Integración Social Centroamericano, cuyos principios retoman al ser humano como centro y sujeto del desarrollo y, en su artículo 11，ordenan formular la política social y regional que permitirá coordinar los esfuerzos del desarrollo social de la región. Todos estos compromisos evidencian los pasos que los centroamericanos hemos dado para iniciar la lucha de la erradicación de la pobreza y la discriminación en nuestra región. Todos los países del área centroamericana estamos invirtiendo progresivamente mayores recursos en lo social. Hemos retomado la salud y la educación como prioridad política, estamos conscientes de que invirtiendo en salud y educación invertimos en el ser humano, que es nuestro principal elemento de ventaja competitiva que nos permitirá entrar a la integración del continente americano con mayor productividad y eficiencia. Solamente con hombres y mujeres saluda-bles y adecuadamente educados y capacitados, podremos enfrentar los retos que demanda el nuevo orden económico mundial.

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Señor Presidente: Los ministros de salud de Centroamérica, con el apoyo de la Organización Paname-ricana de la Salud, iniciamos desde 1983 esfuerzos integracionistas en salud muy importantes. Bajo el lema «La salud, un puente para la paz», los centroamericanos dimos respuesta a necesidades urgentes de salud de grupos vulnerables por su condición de marginalidad geográfica y de contexto bélico. Este esfuerzo constitu-yó la primera fase de la iniciativa integracionista de salud conocida como ISCA. En 1990 suscribimos la segunda fase de la Iniciativa de Salud de Centroamérica bajo el lema «Salud y paz para el desarrollo y la democracia». Se contó con el respaldo decidido de la comunidad internacional, la cual contribuyó a consoli-dar la paz y la reconciliación de la familia centroamericana, sobre todo en los países que pusieron fin a guerras civiles que se prolongaron por más de una década, como es el caso de Nicaragua y de El Salvador. La segunda fase de la Iniciativa de Salud de Centroamérica priorizó la atención a grupos especiales de refugiados y desplazados de guerra, mujeres y niños, logrando dirigir la preocupación de nuestros presidentes a temas generales y específicos de salud relacionados con las condiciones de vida de nuestros pueblos e impulsar el marco de un desarrollo humano y local. Salud y paz para el desarrollo y la democracia permitió a Centroamérica y Belice abrirse a un proceso de modernización del sector de la salud, acompañando los esfuerzos de los ministerios de salud para impulsar procesos amplios de reformas en un marco de equidad en el derecho a la vida.

Señor Presidente: Los avances de la democracia en nuestros países continúan con firmeza. Estamos culminando una transición dolorosa, y su consolidación requiere la incorporación de prácticas democráticas de negociación a través de la participación responsable de todas las fuerzas vivas de la sociedad. En la actualidad vivimos cambios en el perfil epidemiológico que está afectando a la población, con patrones de morbi -mortalidad coexistentes de enfermedades infecciosas y degenerativas. Dentro de nuestra región, más de 10 millones de personas no tienen acceso permanente a servicios de salud. Han resurgido el dengue, la malaria y la tuberculosis. El cólera avanza en nuestras comunidades, la enfermedad del SIDA amenaza a nuestras familias al igual que en otras regiones del mundo. La malnutrición persiste y las enfermedades infecciosas y transmisibles afectan sobre todo a los grupos más vulnerables y desprotegidos, donde las condiciones higienicosanitarias están más deterioradas. Nuestra región tiene en estos momentos las condicio-nes propicias para que se presente en cualquier momento una epidemia de dengue hemorrágico. El Programa sobre enfermedades tropicales de la Organización Mundial de la Salud representa para nosotros un apoyo fundamental y solicitamos al Director General mantenerlo entre los programas prioritarios para nuestra región. El cólera es la expresión más evidente de la falta de inversión en agua y saneamiento y de la persis-tencia de la pobreza. Estas inequidades representan claramente el mayor obstáculo que tiene Centroamérica para el avance de un desarrollo social y económico sostenido. Nuestra región, a pesar de sus condiciones de subdesarrollo, ha logrado en los últimos años reducir las tasas de mortalidad infantil, sobre todo en las enfermedades que se previenen con vacunas. Al igual que el resto de América, nuestra región ha sido declarada territorio libre de la poliomielitis y tenemos como meta la erradicación del sarampión y del tétanos neonatal para 1997. Hemos dado pasos firmes en la modernización del sector salud. Iniciamos reformas que nos están permitiendo mejorar la gestión de la salud mediante la descentralización administrativa y presu-puestaria y la contratación de servicios privados, sin limitar el acceso de la población a los servicios de salud. La atención primaria de salud ha tomado un nuevo impulso, frenando la absorción de cuantiosos recursos hacia los hospitales y orientándolos hacia medidas preventivas para toda la colectividad.

La participación de la mujer en posiciones de poder ha sido determinante en el impulso del enfoque de género en las políticas públicas, y específicamente en las políticas sanitarias. En Centroamérica tenemos el honor de tener una mujer como presidenta de Nicaragua y dos mujeres como vicepresidentas en Costa Rica y en Honduras. Esta situación ha contribuido a fortalecer la definición de políticas de salud relaciona-das con la salud reproductiva y con la maternidad sin riesgo. Estamos avanzando en los análisis de situación de salud, utilizando el género como instrumento analítico que nos permite formular políticas y acciones para promover una mejor atención de salud y calidad de vida para nuestros hombres y para nuestras mujeres. Nuestros países están dando pasos para que la educación sanitaria de nuestra población sea una prioridad en la definición de las estrategias a implementar para avanzar en la meta de salud para todos en el año 2000. Los ministerios de salud y de educación de Centroamérica tenemos el compromiso con nuestros gobiernos de presentar en el mes de noviembre de este año un plan de educación en salud para toda la región centro-americana. Los centroamericanos también hemos aprendido que el impacto deseado en la situación de salud lo lograremos centrando nuestros esfuerzos en los factores que condicionan la aparición de las enfermedades. Por ello, hemos de proseguir el camino que ya iniciamos de compartir la responsabilidad con otros sectores de la sociedad y declarar que las comunidades son las verdaderas protagonistas en la determinación de las acciones a seguir.

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Los ministerios de salud de Centroamérica y Belice hemos aprobado una tercera fase de la Iniciativa de Salud de Centroamérica, basada en principios que enmarcan los contenidos programáticos y prioridades que ratifican, como estrategia básica del desarrollo, la atención primaria de salud y el desarrollo de los sistemas locales de salud, y que deberán estar incorporados al proceso de integración social que vive la región. La agenda de salud de la tercera fase de esta Iniciativa está orientada por los siguientes principios. Primero, la búsqueda de la equidad mediante la universalización del acceso a una canasta básica de servicios. Segundo, la focalización de acciones a través del establecimiento de prioridades geográficas, poblacionales y estratégicas. Tercero, la descentralización de la gestión de la salud y el desarrollo de los sistemas locales de salud. Cuarto, la búsqueda de la calidad en la provisión de los servicios. Quinto, la garantía de la participación social en el desarrollo de la Iniciativa de Salud. Sexto, la promoción y prevención de la salud como base de los nuevos modelos de atención. Séptimo, la incorporación del enfoque de género en las políticas, planes y programas del sector salud, y octavo, el fortalecimiento de la cooperación técnica entre nuestros países, como modalidad de acción que propicie el intercambio solidario de experiencias y lograr impulsar intervenciones simultáneas que nos permitan alcanzar mayores impactos en la salud de la región. La agenda común de salud de Centroamérica es en sus principios coherente con las guías establecidas por la institucionalidad centroamericana, los mandatos emanados de las cumbres presidenciales y los acuerdos de los países en otros foros internacionales. Confiamos en que la Organización Mundial de la Salud, así como las agencias de cooperación y la comunidad internacional continúen comprometiéndose con Centroamérica para apoyarla en el afianzamiento de la paz, la democracia, el desarrollo con equidad y la integración.

Señor Presidente: Para finalizar, los centroamericanos queremos dejar manifestada nuestra preocupa-ción por el posible incremento de las cuotas de los Estados Miembros, ya que el crecimiento económico alcanzado hasta ahora no nos ha permitido reducir la gran deuda social que tenemos acumulada. También deseamos manifestarle nuestra solidaridad con los países de habla hispana ante la amenaza que se cierne respecto al uso de la lengua española como idioma oficial y de trabajo dentro de la Organización Mundial de la Salud. Muchísimas gracias.

The PRESIDENT:

I thank the delegate from Nicaragua and her colleagues. The meeting is adjourned.


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SEVENTH PLENARY MEETING

Thursday, 4 May 1995，at 9:20

President: Dato Dr Haji Johar NOORDIN (Brunei Darussalam) later: Acting President: Mr C. DABIRÉ (Burkina Faso)

SEPTIEME SEANCE PLENIERE

Jeudi 4 mai 1995，9h20

Président: Dato Dr Haji Johar NOORDIN (Brunéi Darussalam) puis Président par intérim: M. C. DABIRÉ (Burkina Faso)

1. TRANSFER OF MONGOLIA TO THE WESTERN PACIFIC REGION RATTACHEMENT DE LA MONGOLIE A LA REGION DU PACIFIQUE OCCIDENTAL

The PRESIDENT:

Good morning, distinguished delegates, the meeting is now called to order. This morning, we shall take up Supplementary agenda item 1 : Transfer of Mongolia to the Western Pacific Region. The Director-General received a communication from the Government of Mongolia indicating its decision to join the Western Pacific Region of WHO. Document A48/45 contains the text of the communication.

To facilitate the Assembly's consideration of this item, I shall read out a draft resolution which corresponds to the resolutions that have habitually been adopted by the Assembly in response to such requests. It reads:

The Forty-eighth World Health Assembly, Having considered the request from the Government of Mongolia for the inclusion of that country

in the Western Pacific Region;

RESOLVES that Mongolia shall form part of the Western Pacific Region.

Are there any comments? The delegate of the Democratic People's Republic of Korea has requested the floor and I give him the floor.

Mr РАК Chang Rim (Democratic People's Republic of Korea):

Mr President, my delegation became aware of the confidential letter from the Ministry of Health of Mongolia addressed to the Director-General only through the Assembly document circulated just yesterday, and we are very surprised at the sudden departure of Mongolia which has had close cooperation and solidarity with the Member countries in the South-East Asia Region for more than 30 years. We respect the decision taken by the Government of Mongolia and we will try to understand their reasons which are explained in the letter. It is with much regret that Mongolia leaves our Region today, but we do hope that they will continue cooperation with us in future.

The success of our Organization depends on the activities of all the individual regions of the Organization. We are of the view that the headquarters of the Organization should pay more attention to the strengthening of its individual regional organizations. In this regard, I would like to suggest that the Director-General take the necessary measures to maintain an appropriate balance between regions and explore a procedure for the transfer of Member countries from one region to another. The lack of such a procedure and a hasty decision by the Health Assembly may cause confusion in the work of the region to some extent.

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In my view, the subject of the transfer of a Member country from one region to another should be discussed first in the respective regional committee meeting and then by the Health Assembly for a final endorsement.

The PRESIDENT:

I thank the delegate of the Democratic People's Republic of Korea. Are there any more comments? The proposal put forward by the Democratic People's Republic of Korea will be noted and will be recorded in the verbatim reports of the proceedings. I see no other request from the floor and I therefore suggest that we adopt this resolution. The resolution is therefore adopted. I note that there is now a request from the floor from the delegate of Mongolia. Sir, you have the floor.

Mr YUMJAV (Mongolia):

Mr President, honourable Director-General, distinguished delegates, at the outset allow me to congratulate you warmly, Mr President, on your well-deserved election as President of the Forty-eighth World Health Assembly and to wish you every success in your noble endeavour.

The Mongolian delegation would like to express thanks to the delegates of the Forty-eighth World Health Assembly for the assignment of Mongolia to the Western Pacific Region of WHO. As is indicated in the letter addressed to the Director-General, the Government of Mongolia has taken the decision on this issue in view of its geographical location, as well as the similarity of health problems between Mongolia and the Member States of the Western Pacific Region. Mr President, it is our duty to inform this august Assembly that we have been most satisfied with the cooperation that we have had with the Regional Office for South-East Asia and its Member countries for the past more than 30 years. Taking this opportunity on behalf of the Government of Mongolia, I would like to express our full recognition and our profound gratitude to Dr Uton Rafei, Regional Director, his entire team, his predecessor, Dr U Ko Ko, and all members of the South-East Asia Region for their support, and for the close and fruitful cooperation that Mongolia has enjoyed during the past. We are convinced that the cooperation in different areas of health development that has so happily existed between Mongolia and the South-East Asia Region and its Member States will be continued in the future bilaterally and multilaterally in order to achieve the universal goal of health for all by 2000.

The PRESIDENT:

I thank the delegate of Mongolia.

2. DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-FOURTH AND

NINETY-FIFTH SESSIONS AND REVIEW OF THE WORLD HEALTH REPORT 1995 (continued)

DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-

QUATORZIEME ET QUATRE-VINGT-QUINZIEME SESSIONS ET EXAMEN DU

RAPPORT SUR LA SANTE DANS LE MONDE，1995 (suite)

The PRESIDENT:

We shall now continue the debate on items 9 and 10，and before I call the first two speakers to the rostrum I would like to inform the floor that I intend to close the list of speakers at the end of our meeting today. I now call to the rostrum the delegates of the Democratic People's Republic of Korea, and of Slovenia.

I give the floor to the delegate of the Democratic People's Republic of Korea, who will speak in Korean.

A48/VR/7

page 109

Mr KIM Su Hak (Democratic People's Republic of Korea) (interpretation from the Korean): 1

Mr President, dear delegates, first of all, the delegation of the Democratic People's Republic of Korea would like to congratulate you, Mr President, and the Vice-Presidents on unanimous election to your respective positions. My delegation would also like to express its appreciation to Dr Hiroshi Nakajima, the Director-General, for his energetic devotion to the activities of the Organization and for his comprehensive annual report to this Assembly.

It is already several years since the decision was adopted to ensure that all peoples of the world lead a productive life in the social and economic spheres by the year 2000, and since public health and other social activities started on a global basis to provide equal medical services to all peoples under the ideal of the Global Strategy for Health for All, based on social justice and impartiality. We highly appreciate the efforts made by WHO for this noble work and the results achieved in this area.

However, notwithstanding these efforts, the issue of public health still remains a serious one in the present world, and mankind continues to face a certain challenge in this field. My delegation expresses its deep concern over the fact that striking differences persist in the health services and health conditions between the developed countries and the developing countries, particularly the least developed countries, and also among the different strata of people even in one country, including developed countries. These differences grow further, affected by changing international situations.

The average span of life is 79 in the developed countries, whereas it is only 42 in the developing countries, and the mortality rate of infants under the age of five years is 6 per 1000 in the developed countries, whereas it is 200 or even 320 per 1000 in the developing countries. It is particularly tragic that in the developing countries, three million infants under the age of five who can be saved if 7 US cents is provided per infant, die of diarrhoea. My delegation is of the view that these tragic situations should not be tolerated any longer in the light of social justice and impartiality.

One of the major grave concerns to mankind today is poverty. Poverty is the main hindrance to development of public health and it becomes one of the main factors that produce inequality in social development, including public health, between countries as well as among the different strata of peoples in one country.

A total of 1.3 billion people, one-fifth of the world population, are suffering from poverty, which results in the death of innumerable people from hunger or diseases every year, and 40 000 children are dying of malnutrition every day. This requires a decisive measure on the part of the international community. It is the view of my delegation that in order to develop health services in conformity with the present requirement, it is important to establish the public health policy to serve the people. It is also important that all countries strengthen mutual cooperation and exchange on the basis of equality and solidarity in the field of health services for just development of public health on a global scale.

Mutual cooperation among the developing countries will be one of the significant ways for development of public health in these countries. Assistance by the developed countries to the developing countries, in particular to the least developed countries, is the prerequisite for fair development of public health in the world, and this assistance should be sincere and not serve as a means of political pressure or interference.

It is important to enhance the role and function of WHO in order to solve public health problems faced by the world. WHO will have to proceed with relevant measures for coping with the changed climate, including the renewed strategy of health for all, to the advantage of the developing countries. It will also have to direct more resources and efforts of the international community to help the Member States, particularly developing countries, in their efforts to develop public health. At the same time, my delegation wishes to underline that the technical cooperation activities of the Organization should be oriented towards meeting the actual demands of Member States.

We are pleased to note that the World Summit for Social Development held in Copenhagen took up the issue of public health as a priority. We hold the view that the Fourth World Conference on Women to be held in Beijing in September should also give priority to the issue of women's health.

In the Democratic People's Republic of Korea, under the wise leadership of the Great Leader Comrade Kim Jong II, public health policy and systems for the people are established and the State pays great attention and resources to the promotion of health and welfare of the people. In my country, basic conditions for and rights to healthy life are equally secured for all people through universal free medical care, preventive medical treatment, introduction of the district doctor system, upbringing of all children at State and social expense,


A48/VR" page 110

a social security system for all working people, a special protection and treatment system for women, a free education system, and other relevant measures. The State pays close attention to ensuring a high quality of medical services to all people and to removing differences between urban and rural areas in terms of medical service standards. In doing so, the Government further consolidates the successes achieved in equipping hospitals and clinics with technical equipment, ensuring safe drinking water for the rural inhabitants, and upgrading clinics as hospitals. The Democratic People's Republic of Korea will, as ever, make every effort to realize the noble cause of health for all through further strengthening of cooperation with WHO and other Member countries.

Dr VOLJC (Slovenia):

Mr President, on behalf of the delegation from the Republic of Slovenia, I would like to congratulate you on the confidence the Assembly demonstrated in you and your country when it appointed you this year's President. I share your wish that you will contribute with your leadership to useful joint conclusions of this year's meeting.

Mr President, Mr Director-General, excellencies, WHO ascertains that, despite all internationally accepted principles of equity in health and numerous forms of aid, the differences in the organization and quality of health care between rich and poor countries are becoming greater. It is understandable that questions arise about why this is so, as well as questions about the type of aid given, which should be more effective than up to now.

It is evident that these differences are growing for political reasons on a national and global level. It is hardly worthwhile discussing the numerous social and economic causes of poverty in the frame of this year's theme of the Assembly. We know that the growing differences between poor and rich countries are intensifying global and political tensions. We also know that all the social results of poverty make the poverty even greater if no suitable action is taken. And we know particularly well what the medical consequences of poverty are: we know the typical diseases, conditions and medical risks and the ensuing losses of individual as well as collective human potential. At the same time, we realize that much of this could be avoided with suitable action.

These circumstances are being explained and analysed from different aspects, including, in the area of health care, the big general questions: What is wrong? What are we missing? What must we still learn, so that we may influence the circumstances more effectively?

When looking for answers to these questions, we first of all consider the aid which is given by the richer countries, whose health care is more developed, to the poorer countries with less developed health care. This aid comes in many shapes and sizes, its effectiveness varies from country to country. And if we look at poverty, with all its effects, as though it were a sickness, then we as doctors and health politicians must be interested in examples where aid does not bring the expected results. In medicine, mistakes are what doctors learn most from, if they admit and analyse them in a proper manner. There is probably no reason why the same rule should not apply in cases of less successful collaboration between the rich and the poor in the field of health assistance, which is after all, an attempt to cure the existing conditions. This is why it is important that the actions to be taken are prepared and executed in a manner that later enables us to analyse and examine them regardless of the results. The analyses of successful and less successful occurrences may help us find a better way.

If we stick to the comparison of sickness and its cure, we can say that each treatment should take into account the conditions in which the patient lives. The analyses of less successful collaboration are therefore particularly valuable, when they embrace all the specific features of the countries involved, the features which vary from one environment to another and which may be either complementary to, or at variance with, each other. A country's health cannot be dealt with separately from its other sociological, political and economical circumstances. That is why there are no universal answers resolving the strategy of a successful collaboration between the rich and the poor countries in the area of health care.

Any collaboration is a mutual affair. It is therefore particularly interesting to know how to trigger the appropriate activities and reactions on both sides. The experiences in this area are once again diverse, largely because they involve diverse notions about what the collaboration should look like and how it should be carried on. My country would therefore like to emphasize that the aid-provider should try to get a clear picture of the aid-receiver's expectations before the collaboration is even started. What aid should do is to introduce active and long-lasting responses and organizational changes in the environment to which it is sent. If it fails to do so, it is a gratuity rather than aid.

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As we seek to bridge the ever-widening gap between the rich and the poor and ensure equity in health, we are forced to acknowledge the existence of such a gap within the rich and well-developed countries themselves - and this gap is no easier to bridge than the former. Here, too, we encounter numerous cases of aid failing to bring about the expected results. A particularly persevering inequity in health is brought about by risky behavioural patterns, when it is bred by health-endangering habits such as smoking, alcohol, drug addiction and the like.

Finally we always run into the question of money. The usual complaint is that there is too little money and that more means would yield more achievement. This is undoubtedly true, but it is also true that money is not the only yardstick with which to measure success in reducing inequity in health. If we are to bridge gaps, then the abutments of the bridge should be firmly anchored in each of the banks. On the one bank there must be a will to give help, on the other bank there must be a will to receive it fittingly. Allow me, then, to re-state that without proper cooperation there can be no hope of genuine success.

The Health Assembly is attended by representatives of all nations. In a way this auditorium epitomizes the structure of the entire planet. Among us there are representatives of the richest and the poorest countries, and each of them represents also the complications of their environment. Thus we all, as representatives of our States, represent also their mutual relationships, including the questions that this year's session is addressing. And all the answers, including those we have not yet arrived at, are thus also with us, in this very auditorium.

The theme of this year's Assembly was surely not chosen in the expectation of an overall solution to the problems of inequity in health. What is important, however, is that we discuss them and that in our home countries as well as internationally we have them discussed by as many responsible and eager individuals as possible. By constantly calling to mind the differences that we are discussing here, and their consequences, we cannot change human nature, but we can generate the necessary alertness and thereby better and more effective measures. We can never do away with differences between nations and individuals, but we have to be concerned by the differences increasing in a way that ties inequality in health to inequity. Health in its broadest sense may be viewed as a signpost showing the way out of the modern world's dilemmas. Health politics should, of all politics, particularly ensure that inequality in health is not the outcome of any form of discrimination and egoism. This, however, is a theme that already touches upon the ethics of health politics and was discussed by this Assembly last year, resulting in appropriate resolutions.

Mr President, let me use this opportunity to assure you that Slovenia is willing to participate in all WHO endeavours directed towards the best possible realization of this year's motto "Bridging the gaps".

Dr FATIMIE (Afghanistan):

‘ I T 力 . “ 力 ^íUp r!>LJi

Mr President, Mr Director-General, honourable Regional Directors, distinguished delegates, ladies and gentlemen,

First of all, please allow me to congratulate you, Dato Dr Haji Johar Noordin, on your election as the President of the Forty-eighth World Health Assembly. We are confident that under your esteemed leadership this session will be very fruitful. We also extend our congratulations to the five Vice-Presidents elected and other members of the bureau.

Mr President, it is our pleasure to be attending this august meeting, the goal of which is health equity and health for all. Before presenting a brief statement on suggestions for global cooperation to bridge the gap of health equity, on behalf of the Islamic State of Afghanistan allow me to express our heartfelt appreciation for the close working relations of WHO with the Ministry of Public Health of Afghanistan, which has provided an efficient and effective approach to the rehabilitation of our health programmes and the control of communicable diseases.

Today, we would like to present four recommendations for global strategies to help poor and developing nations such as Afghanistan catch up to the level of health of the richer and developed nations. The first recommendation is that control of communicable diseases should be approached from a geographical point of view. The incidence of diseases in neighbouring countries and the routes of spread of disease should be fully considered, and campaigns to prevent or control disease should be fully coordinated among the countries most affected, regardless of national, ethnical, ideological, or religious boundaries.

For example, from a global perspective, three out of four cases of poliomyelitis in the world come from the Indian subcontinent, and large numbers of cases have been reported this year from among the Afghan refugees in Pakistan and the displaced Afghans in camps around Jalalabad inside Afghanistan. The

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coordinated poliomyelitis eradication campaign in April and May this year in Afghanistan, Bangladesh, Islamic Republic of Iran and Pakistan is an excellent example of fighting infectious diseases on a geographical basis.

The Ministry of Health of Afghanistan is grateful to WHO and specifically to the WHO Regional Office for the Eastern Mediterranean led by Dr Hussein Gezairy and to the WHO Representative in Afghanistan, Dr A.О. Gebreel, for initiating and supporting the mass immunization campaign in Afghanistan, for the assistance provided by the Islamic Republic of Iran's generous donation of eight million doses of oral polio vaccine to our campaign, for the cooperation of Pakistan in the storage and transport of vaccines, and for the participation of an experienced UNICEF campaign worker from Bangladesh. We would like to support similar efforts to coordinate the fight against other communicable diseases and emphasize that cooperation should be determined by the extent of the diseases rather than by national or international boundaries of nations or regions. Other examples of cross-border communicable diseases which may be amenable to cooperative strategies include malaria shared with Pakistan, diphtheria shared with Tajikistan, and cutaneous leishmaniasis shared with Uzbekistan as well as Pakistan and the Islamic Republic of Iran.

The second global strategy we are recommending is intersectoral cooperation both nationally and globally. For instance, to combat iodine deficiency diseases within a nation, cooperation of the mining and industrial sectors is needed to produce iodized salt, and the cooperation of the economic, legislative and education sectors and the media is needed to promote the use of iodized salt. Through intersectoral cooperation the national government can support the cost of iodization, inform the populace about its advantages, and prohibit the production, sale, and import or export of non-iodized salt. At an international level intersectoral cooperation is also needed. At health conferences, nations have agreed not to import or export non-iodized salt, but there is no international body actively ensuring that these resolutions are being carried out. We would support international incentives or credits to be offered to those nations fulfilling their role in promotion of health-related activities and international censure for nations who evade their promises. This would require cooperation of the United Nations General Assembly or the International Monetary Fund, for example.

The third global strategy is simply the sharing of information and ideas on a regional and global level to help poorer nations in their struggle to find cost-effective approaches to achieving health for all. For example, in Mexico we heard about the idea of combining other health activities with an immunization campaign. We have adopted this idea in the three rounds of our campaign and are providing health messages about diarrhoeal disease, vitamin A to prevent respiratory infections and blindness, and oral iodine oil to prevent iodine deficiency diseases along with immunization against five childhood diseases.

Finally, we would like to emphasize that for the attainment of global health equity, it is very important for WHO consistently to uphold the ideals of humanity, neutrality, and impartiality.

The meaning of these three ideals has been revealed in WHO's cooperation with the Ministry of Public Health of Afghanistan during the tense political situation in Afghanistan over the past year. We have worked side-by-side solely for the humanitarian benefit of Afghan families, making a concerted effort to uphold a policy of neutrality and to avoid taking sides in the conflict. At the same time, there has been an overriding effort to provide services and assistance under a policy of impartiality so that every party, region or ethnic group receives a share of the available resources according to their needs. In return, the people of Afghanistan have welcomed the programmes and services of WHO and have cooperated to the fullest extent.

Upholding the ideals of humanity, neutrality, and impartiality is a very complex issue, but is based on the simple idea that WHO is responsible for the health of the people of the world. Somehow, national, ethnical, ideological, and religious barriers must be crossed to conduct surveys of health needs and to provide resources to answer those needs.

Sometimes the barriers are within national boundaries. WHO needs international support to challenge nations who insist that health, whether equitable or not, is their internal affair. Sometimes the barriers are between nations. The international community must continually strive to overcome discrimination and alliances when matters of public health are concerned, so that all people of every social status, ethnic background, and religious or ideological belief can share the greatest gift on earth: health for themselves and their families.

Now, while I am addressing this august gathering, the peace efforts which started recently, have been spreading their wings and gaining rapid momentum not only in the capital Kabul, but all over Afghanistan. As a result, the second round of the mass immunization campaign, which started with support of WHO and UNICEF on 29 April, is proceeding successfully without any obstacle in every corner of the country. We are sure this immunization campaign will have significant impact on the health status of our people, as well as on the whole region.

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Finally, on behalf of the Afghan nation, we would like to take this opportunity to express our thanks once again to Dr Hussein Gezairy, the Regional Director for the Eastern Mediterranean, and to Dr A.O. Gebreel, WHO Representative in Afghanistan, for their untiring and selfless services to the benefit and to the health of the Afghan people. We would also like to thank the many other agencies and organizations that have contributed in cash or in kind to the mass immunization campaign, including UNICEF, many nongovernmental organizations, and the Ministry of Health and Medical Education of the Islamic Republic of Iran for their brotherly donation of eight million doses of oral polio vaccine for the mass immunization campaign in Afghanistan.

El Dr. SOLARI (Uruguay):

Señor Presidente, señores Vicepresidentes, distinguidos delegados: En primer término, deseo felicitar al señor Presidente por su merecida designación y comprometer el apoyo de la delegación del Uruguay en el feliz desempeño de sus funciones y en el fructífero desarrollo de esta Asamblea. En segundo término, deseo congratular al Director General, Dr. Nakajima, y al personal de la OMS por el trabajo desempeñado en favor del bienestar de los pueblos del mundo. El Informe sobre la salud en el mundo, 1995: reducir las desigualdades contiene una buena síntesis de ese trabajo de la OMS.

Señor Presidente: Por resolución del Consejo Ejecutivo se nos invita a los delegados a que centremos nuestros debates en los aspectos críticos de política, estrategia y programa más que en la situación particular de cada uno de nuestros países. Asimismo se propone que en las discusiones de los puntos 9 y 10 del orden del día nos refiramos especialmente al tema «Equidad y solidaridad en la salud: reducir las desigualdades». Sin perjuicio de que muchos delegados entiendan conveniente ejemplificar con referencias a sus propios países el tratamiento de este tema, es conveniente cumplir la recomendación formulada por el Consejo Ejecutivo. En consecuencia, es necesario reflexionar sobre qué podemos aportar nosotros en un foro tan distinguido, en la consideración de un tema tan complejo como trascendente. No son, ciertamente, los aspectos técnicos o empíricos observables en las distintas regiones del mundo. De ellos tienen mayor conocimiento los funcionarios de esta y otras organizaciones internacionales, que dedican su vida profesional al estudio y análisis de estos temas. Las delegaciones están integradas por quienes tenemos responsabilidades de conducción política del sector salud en cada uno de los países que forman parte de la OMS. En conse-cuencia, es probable que se espere que compartamos nuestras experiencias en materia de políticas, estrategias y programas desde el punto de vista de las potencialidades y limitaciones que el proceso político y de gobierno plantea en la conducción del sector salud. Me propongo pues, señor Presidente, hacer ciertas reflexiones en esta dirección, tomando como base algunos ejemplos de la evolución de la salud y de los servicios de salud en mi país, el Uruguay.

En primer lugar, analicemos el título de «Equidad y solidaridad en la salud》. La equidad en la salud requiere que todas las personas alcancen un buen nivel de salud relativamente similar, que no dependa de factores sociales, ambientales o económicos ajenos a la voluntad de la persona. La pobreza, la marginación social, la falta de acceso a la educación y a la cultura, a veces el lugar de residencia, determinan niveles de salud muy inferiores a los de otros miembros de la comunidad nacional. Ello se expresa en indicadores de morbilidad y mortalidad diferentes según el nivel socioeconómico, el nivel de ingreso medio del hogar, el nivel de educación de la madre, etc. Las mismas o mayores diferencias a las encontradas entre los países se observan en el interior de muchos de éstos. Entre las primeras se destacan, en el informe de la OMS ya señalado, las diferencias en la esperanza de vida al nacer, de 78 años en los países más desarrollados frente a tan sólo 42 en los menos desarrollados. Entre las segundas, es decir las nacionales, en el Uruguay la mortalidad infantil en los hogares por debajo de la línea de pobreza es casi tres veces superior a la que se observa en el resto de los hogares.

Ciertamente, señor Presidente, con esto no estoy expresando nada nuevo, ni a nivel nacional ni a nivel internacional; no hay equidad en un valor tan fundamental como la salud. Eso lo sabemos. Lo que no sabemos es si nuestros esfuerzos, en el gobierno y en la sociedad civil, son los más adecuados para reducir esa falta de equidad. No sabemos cómo enfrentar las fuerzas sociales del egoísmo que tienden a aumentar las desigualdades. No sabemos cómo conciliar el deseo general de equidad con la expectativa individual de obtener la mejor tecnología posible, aun a costa de incrementar las desigualdades. La contribución de cada uno de nuestros programas y proyectos de salud a la reducción de las desigualdades debe ser un criterio fundamental de valoración previa y de análisis posterior. Ciertamente que la equidad no debe constituir el único parámetro de medición de nuestras políticas y programas, pero debe ser, conjuntamente con la efectivi-dad y la eficiencia, uno de los criterios fundamentales. En el análisis de mi experiencia personal como

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Ministro de Salud, en mis conversaciones informales con colegas y con gobernantes del área económica y social de varios países de las Américas, puedo asegurar que el tema de la equidad en la salud y en sus servicios está permanentemente en nuestro pensamiento. En la medida en que el estado de salud está vinculado a la pobreza y a los factores que la rodean, la lucha por la equidad en la salud está íntimamente ligada al combate contra la pobreza.

Señor Presidente: La lucha contra la pobreza ha sido un tema de permanente preocupación en los foros nacionales e internacionales durante los 50 años de existencia de las Naciones Unidas que celebramos este año de 1995. En este periodo se han logrado avances en la reducción de la pobreza en el Uruguay y en muchos otros países de la Región de las Américas y del mundo. Pero así como el crecimiento económico no necesariamente significa una disminución de las desigualdades, tampoco el mejoramiento de los indicado-res de salud refleja necesariamente una disminución de las inequidades en salud. Tomemos como ejemplo la aplicación de la estrategia de atención primaria y el uso de las sales de rehidratación oral, probablemente el mayor avance de la salud pública en la segunda mitad del siglo XX. Ciertamente provocó la disminución de las diferencias en la tasa de mortalidad infantil entre sectores pobres y no pobres de una misma sociedad. Pero no disminuyó la inequidad de base, por cuanto se sigue produciendo mayor cantidad de episodios de diarrea entre los sectores más pobres. El mejoramiento de la equidad y la reducción de las desigualdades requieren esfuerzos solidarios de la sociedad. El Uruguay constituye, señor Presidente, lo digo con mucho respeto hacia las demás naciones aquí presentes, aunque también con mucho orgullo como uruguayo, un ejemplo de un país en vías de desarrollo que ha procurado insistentemente la solidaridad en sus políticas y programas. A tal punto se buscó reducir la inequidad que los propios instrumentos del «estado de bienestar», desarrollados por la sociedad uruguaya, dificultaron el sostenimiento y desarrollo de su economía. País pequeño, homogéneo, educado y culto, sin diferencias étnicas, con buenos niveles de bienestar humano, el Uruguay ha procurado insistentemente la solidaridad, ha logrado cierta equidad (aunque incompleta) entre sus mayores, pero ha dejado de ser un centro laboral atractivo para sus jóvenes, cuyo deseo mayoritario es emigrar a otros países，menos solidarios pero con mayores oportunidades de desarrollo personal..

A modo de ejemplo, permítaseme señalar que el sistema de seguridad social en mi país representa un gasto equivalente al 18,5% del PIB. Solamente el sistema de pensiones y jubilaciones representa casi un 15% del PIB, la cifra más elevada en el mundo. La deuda implícita del sistema de pensiones representa el equivalente a tres veces el tamaño de la economía PIB. Este enorme esfuerzo provocado por el sistema de seguridad social deprime la inversión productiva y deteriora el mercado de trabajo, con menor generación de empleos y con puestos laborales de inferior calidad. En consecuencia, el Uruguay se ve enfrentado al desafío político y económico de recomponer el equilibrio entre el sistema de seguridad social, que tiende a mejorar la equidad, y el sistema productivo, que sirve de base al bienestar personal, incluyendo en éste el aporte solidario a la propia seguridad social. La búsqueda continua de este equilibrio entre las demandas del desarrollo económico y las del bienestar social, en un mundo globalizado aunque imperfectamente competiti-vo, debe constituir seguramente una de las preocupaciones centrales de los delegados aquí presentes. Entendemos en el Uruguay que el Estado debe desempeñar un papel fundamental en la búsqueda de este equilibrio. La recaudación de impuestos destinada a programas sociales en las áreas de la salud, la educa-ción, la seguridad social y la reducción de la pobreza constituyen el resultado visible, aunque siempre insuficiente, de esa vocación social del Estado uruguayo. Pero el esfuerzo del Estado no es ni debe ser el único en la reducción de las desigualdades, incluidas las sanitarias. La solidaridad privada, expresada a través del funcionamiento de organizaciones de la sociedad civil, constituye un complemento indispensable. Desde ONG destinadas a la prevención de la difusión del virus del SIDA entre las prostitutas, hasta la participación de drogadictos rehabilitados en la rehabilitación de otros adictos y en la prevención de este mal, existe una amplísima gama de instituciones que canalizan el espíritu solidario de la mayoría de la sociedad uruguaya.

Me gustaría, señor Presidente, presentar en forma muy resumida los cuatro principales mecanismos de solidaridad existentes en el sistema de servicios de salud del Uruguay y la principal dificultad que éstos encuentran para continuar contribuyendo a la equidad, ante la incorporación indiscriminada de tecnología médica.

Un 30% de la población del país, aquella con menores ingresos, accede a un conjunto integral de servicios de salud en una red de establecimientos dependientes del Ministerio de Salud, que se financia a través de impuestos. Los integrantes de los hogares en situación de pobreza obtienen atención médica subsidiada plenamente a través de esta red. Este gasto público representa una contribución importante a la equidad en el acceso a los servicios de salud. Sin perjuicio de lo anterior，el esfuerzo público no es suficien-te para corregir las desigualdades derivadas de una menor cantidad de recursos por persona cubierta y de mayores necesidades de quienes, por su condición de pobres, se atienden en este componente del sistema.

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El segundo elemento de solidaridad en los servicios de salud radica en el seguro de enfermedad para los trabajadores en actividad, elemento componente del sistema de seguridad social. Las contribuciones obligatorias y proporcionales al sueldo de empleadores y empleados, financian el acceso de los beneficiarios del seguro a instituciones privadas de prepago, prestadoras de asistencia médica. Aproximadamente un 20% de la población tiene acceso a un paquete integral de servicios de salud por medio de este sistema. En tanto el aporte se hace de acuerdo con el sueldo y el beneficio se obtiene en función de las necesidades individua-les, sobre la base de un paquete común de beneficios, el seguro por enfermedad constituye un aporte inequívoco a la solidaridad del sistema.

Un 35% adicional de la población se adhiere voluntariamente a las organizaciones privadas de prepago ya mencionadas, a través de un sistema de seguro privado. El valor de la contribución mensual es similar entre todos los asegurados, independientemente de sus necesidades y de su consumo de servicios. Estas organizaciones privadas anteceden a la seguridad social en el Uruguay; se organizaron como entidades solidarias basadas en grupos de inmigrantes y constituyen un elemento natural del esquema de disminución de las desigualdades en el acceso a un conjunto muy amplio de servicios de salud.

Finalmente existe un seguro nacional de salud que cubre el costo de los procedimientos de muy alta tecnología para la totalidad de la población del país. Este seguro se constituye sobre la base de pagos de cada uno de los afiliados a las instituciones de prepago y de aportes por el Estado para cubrir los gastos de la población en situación de pobreza y de otros grupos a su cargo. Los servicios cubiertos, de alta compleji-dad y costo, son brindados por organizaciones privadas y se financian por el seguro nacional mediante el pago por acto. Dentro de este esquema están comprendidos los procedimientos de cirugía cardiaca, implanta-cî 'ii de prótesis articulares, trasplantes de órganos, diálisis renal y otros. El seguro hace que estos servicios estén igualmente disponibles para toda la población, exclusivamente en función de su necesidad; constituye por lo tanto, un aporte importante en favor de la equidad.

Los cuatro mecanismos descritos no solucionan las desigualdades de situación de salud de los diferentes sectores de la población, aunque contribuyen a igualar sus posibilidades de acceso a los servicios de salud. El aumento de los costos de atención de salud derivado de la incorporación de tecnología médica sin guías ni normas clínicas para su utilización, sin información adecuada sobre el costo y el beneficio de la misma, importada indiscriminadamente, empujada a través de la venta de equipamientos tecnológicos más destacados, conspira contra la igualdad y en definitiva contra la solidaridad que el pueblo uruguayo quiere mantener en sus servicios de salud.

Señor Presidente: Para finalizar, y en función de lo anterior, solicito que esta Asamblea considere, como un aporte concreto a la reducción de las desigualdades, el apoyo de la OMS a la formulación a nivel internacional de estrategias de desarrollo e incorporación de tecnología médica, con especial atención a la capacitación del cuerpo médico y a la difusión de los beneficios y costos de su uso, para que sea compatible con la equidad y la solidaridad en la salud. Muchas gracias.

Mr POLITOPOULOS (Greece):

Mr President, Mr Director-General, distinguished ladies and gentlemen, Dr Kremastinos, the Minister of Health, Welfare and Social Security is unable to be with us today in Geneva, due to pressing parliamentary issues. He has nevertheless asked me to convey to you his best wishes for a successful and productive work and to address you on his behalf. I would like to start by offering my warmest congratulations to the President, the Vice-Presidents and other officers on their election. I am confident that their large experience is a guarantee for the progress of our work.

The reports of the Director-General and of the Chairman of the Executive Board give a thorough analysis of the key factors bound to shape health conditions and suggest that new health action is essential. My delegation hopes that fruitful discussions will be held on various health problems thus leading to practical, down-to-earth solutions, for the benefit of health for all, a fundamental condition for social and economic development.

The main point for discussion this year is, as requested by the Director-General, equity and solidarity in health, with suggestions on how to bridge the existing gaps in health care. Equity in health can be promoted through a carefully planned health-care policy, aimed at reducing inequalities in health care; each country needs to carry out an assessment of the nature and magnitude of differences in access to health care between different social groups in the population.

Health is a central political, social and economic issue worldwide. The term applies to all persons, without exception, each one taken individually: this is the meaning of health for all. This goal cannot be

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achieved and maintained without equity and social justice. Of course it has to be added that financial resources are also required, which however is insufficient in itself without purposeful management. For it is true that many countries are facing the problem of increasing demand for health care and, at the same time, of the cost of financing it. Because spending more on health care does not necessarily mean better health for the individual. Now, this is precisely what happens in many developed countries: they spend a significant proportion of their gross domestic product on health care but this has not resulted in equity or real access to health care for all their people.

Monitoring progress in the implementation of strategies for health for all by the year 2000 means that Member States of WHO must prepare for new public health action to meet the challenges of the incoming century. The report raises important questions and I would like to point out some of them. One is the fact that the gap between richer and poorer countries tends to grow instead of diminish; and that despite tremendous efforts made both at national and at international levels, the health status of a large proportion of the world population remains precarious. For this reason priorities have to be set carefully. Another is the situation of the health workforce, which is characterized by imbalances. Last but not least, growing emphasis should be placed on training for general practitioners, in order to strengthen primary health care systems.

It is obvious that the world is going through a critical period，with dramatic social changes due to rapid urbanization and mass migration. In the late twentieth century, migration is emerging as one of the main factors affecting social well-being and health of people.

All of us are very well aware of the various problems that many of the disadvantaged countries are facing today. We know that health systems in most developing countries are not at present able to deliver the kind of services expected from them. To improve this situation, WHO should focus its efforts on cooperation with governments, in such a way as to ensure that health services go to people in need. This can be done by: improving country capacity to prioritize the health needs; providing support to combat AIDS, HIV and sexually transmitted diseases; strengthening control of major communicable and noncommunicable diseases; taking better care of women's health and family planning; and paying due respect to environmental matters related to health.

Our modern societies have to be based at least on a code of values that gives pride of place to respect for the human being, dignity of the individual and human rights. Access to health care and progress in medicine imply a respect for ethical principles; and ethics has always been a fundamental concern of the medical profession.

We have carefully examined the proposed programme budget for 1996-1997 which will be the subject of detailed discussion during this Assembly. We consider that document as a promise to initiate some changes within WHO itself and as a reaction by the latter to some new challenges we are faced with. Still, we are not completely sure whether what is proposed in it will be sufficient. WHO has a heavy burden on its shoulders.

Mr President, we in Greece have given top priority to the conception and role of prevention; we also consider that a health care system is a dynamic factor in promoting health. We recently took the necessary steps to review our national health scheme, precisely by making health care equally available to the population. The main target of all our changes in the management of our public health care system is to increase the patients' freedom of choice and to give incentives to hospitals, health centres and family doctors to adapt their activities to the patients' needs and preferences. This new health plan is to be submitted to the Parliament for approval. We are trying to make the best possible use of existing resources and to ensure that services provided are effective and suitable for those who need them most.

My delegation is a great believer in the ideals and objectives of this Organization. WHO has an excellent performance record to be proud of, for its past. We firmly believe that it also has a tremendous potential, for its future. In conclusion let me say that WHO must remain the central driving force behind health development, working in concert and harmony with Member States, other international agencies, and nongovernmental organizations.

Dr ROXAS (Philippines):

Mr President, the Director-General, your excellencies, honoured delegates and guests, ladies and gentlemen, I extend to you the warmest greetings from the President and the people of the Republic of the Philippines. I join my colleagues in congratulating the President and the officers of the Forty-eighth World Health Assembly on their election.

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The right to health is a basic principle which is permanently enshrined in no less than the Constitution of the World Health Organization. The attainment of health which is the state of complete well-being, is the fundamental human right of every man, woman and child. The same document likewise entrusts to Governments the responsibility for the health of their people and for the adequate provision of health and other social services.

Unfortunately, and because of social, political, and economic realities, the actions taken by individual governments regarding these provisions of the WHO Constitution have been of varying quality and quantity. Most governments have adopted the goal of health for all by the year 2000 through primary health care. But after two decades of worldwide primary health care experience, and amidst many major gains and dramatic improvements in the world health situation, there remains a persistently widening gap in health and health development between countries, regions and groups.

Today, it is but timely for the Health Assembly to focus on equity and solidarity in health, and on bridging these gaps. It is relevant for this world body to discuss pertinent issues and to provide governments with guidelines to realize the full potential for health, especially where the basic health infrastructures are already in place. The realization of our common goal of health for all people everywhere will forever lie beyond our grasp if we do not immediately and adequately address these urgent issues.

What are the underlying factors? The rapid socioeconomic progress of rich countries, vis-a-vis the persistent poverty in the Third World, has further widened the gap in health development. The lack of resources and technology, coupled with high population growth rates, has resulted in the very slow pace of economic and health development in the developing countries. These countries, because of their slow pace of development, are more often exposed to obsolete technology, banned commodities and to the exploitation of their natural resources.

The major gaps and inequities in health are clearly reflected in the wide variations in critical health indicators among the developed and the developing countries, and between the privileged and not-so-privileged groups within the same countries. These include disparities in life expectancy, infant and child mortalities, deaths due to preventable diseases, disability-adjusted life years, population growth rates, health budgets and the adequacy of human health resources.

What are the actions to be taken? Reforms are necessary in socioeconomic development policies particularly on health issues，to ensure equity in health and to attain our health-for-all goals by the year 2000. The developing countries have struggled to keep pace with health development. The experiences of these countries show that health initiatives and development strategies, when supported by a strong political and popular commitment, could successfully lead to a more equitable health care system, even in a Third World setting.

Most governments have espoused the attainment of health goals as part of their mandate. These are reflected in efforts to increase health allocation in the national budget, more balanced development policies and a variety of measures for health and socioeconomic development through legislation. Organization streamlining and health programmes repackaging are among the reforms that have been instituted to correct maldistribution of health resources. But particularly for the least developed countries, where health must compete with other developmental needs for limited public resources, policy-makers should be made to realize the enormous potential returns from their countries' investment in health. They must be persuaded to invest more in health by showing them that improvements in health will enhance productivity and promote development.

The decentralized organization, wherein power and authority are devolved to the lowest administrative level is the best setting for us to realize our health-for-all goals. The smallest administrative unit should be given the authority over its own health delivery system. It is under a decentralized system that decision-making on health matters becomes most appropriate to the local health needs, since this is brought as close as possible to those who are most affected by it. The integration of health services at all administrative levels of government is a cost-effective measure. The provision of a wide range of health services in one accessible, lower-level facility like the health centre, allows the cost of health care to remain at affordable levels. For countries with the least resources, a critical issue is mobilization of the population in the struggle to improve its own status. Health for all must be transformed into a national crusade, involving as many people and groups as possible. The multidisciplinary and multisectoral approach to planning health development and delivery of health services must be supported. Accelerated health development is generally facilitated through participation of various disciplines and sectors to expand coverage of the health system. Community-based health programmes always lead to more accessible health services. They facilitate the participation of the individual, family and community in programme planning and implementation. The community has to feel strongly regarding its right to health. In this regard, there must be an equally strong commitment towards

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education for all, particularly for girls and women. Appropriate health education materials should serve to create awareness and help people identify their health risks and problems. Empowerment is possible only if people first become aware of issues affecting their health and safety.

Most of the developing countries have implemented programmes with a strong bias to the most vulnerable sectors. These include the poor and the marginalized, women and their children, the aged and the disabled, the indigenous and cultural minorities, and workers in the small-scale industries and agriculture. The successful implementation of programmes for their health and well-being has made them more productive and lessened the burden to the Government's scarce resources.

Capable planners and managers are essential elements in every successful effort to achieve equity in health. Therefore, capacity-building in the health sector must be promoted, particularly managerial capability for optimizing the utilization of scarce resources.

Technical cooperation among and between developed and developing countries is essential to further accelerate health development by facilitating the transfer of needed technology. Existing agreements must be improved to assure the transfer of efficient and effective technology. The WHO Regional Office for the Western Pacific has facilitated and supported our development projects along these lines.

To ensure equity and solidarity in health, we must adhere to a global health plan of action with short-term and long-term dimensions. This global action should, among other things, specifically target the least developed countries, as well as the unserved and underserved areas and groups within the same countries. To achieve this, information technology through networking and international data banking must be shared among countries. Let us share our collective skills and technology to identify objectively and respond appropriately to the health needs of those countries who are most in need. Let us urge all members of the United Nations to adhere to this agreement which should include a mandate to extend appropriate assistance according to country needs. Let us call on the international donor community and push for more humane and liberal health financing schemes to be granted to those countries in need so as to ensure that assistance will have maximum impact in bridging the gaps in health and development.

In conclusion, let us pursue the health-for-all goals ever more relentlessly, so that when we come together again, we shall be doing so in a world where people, no matter where they may be, will have a much better chance for a better quality of life for everybody.

Dr JAVORSKY (Slovakia) {interpretation from the Slovak)-}

Mr President, Mr Director-General, distinguished delegates, it is a great honour for me to address this Assembly on behalf of the Government of the Slovak Republic. I would like to congratulate the President and all Vice-Presidents of the World Health Assembly on their election and wish them every success in their work.

The results of the annual assessment of the world health status and needs, as presented by Dr Nakajima in The world health report 1995, require urgent application of principles of equity and solidarity in all sectors of the life of society. These principles are particularly important in the health sector. Thanks to their implementation, WHO has succeeded in coping with many health problems threatening mankind. We highly appreciate the efforts of WHO in immunization and activities connected with this year's World Health Day, "Target 2000 - A world without polio".

Many countries are trying to implement the principles of equity and solidarity in their national health policies. According to the Constitution of the Slovak Republic, "every person shall have the right to protect his or her health. Based on health insurance, individuals have the right to free-of-charge health care and medical aids under the terms to be provided by law". This fundamental principle has been further developed in four basic laws in the field of health. According to these laws everybody has the right to equal access to health care services, to free choice of physician, to protection of his or her patients' rights, and to health protection, which comprises healthy environment, healthy working and living conditions and primary health prevention.

In April 1995, the Government of the Slovak Republic approved the updating of the national health promotion programme based on WHO's strategy, health for all by the year 2000. The programme is oriented to six priority areas: first, enhancement of physical activity; second, healthy nutrition; third, reduction of tobacco consumption; fourth, drug abuse prevention, fifth, education towards partnership, parenthood and family together with prevention of sexually transmitted diseases including HIV/AIDS; and sixth, control of


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hypertension, promoting healthy lifestyles. The objective of the national health promotion programme is to reduce differences in the health status of people living in various regions of Slovakia by 25% within the period of -six years.

The health insurance system in Slovakia is based on the principle of solidarity. The task of paying health insurance that covers children, retired people, refugees and other vulnerable groups of population has been undertaken by the State. By embodying the above-mentioned principle into national health legislation, the Government of the Slovak Republic has taken great responsibilities. However, the principles of equity and solidarity will hardly be implemented or sustained in a country where gross national product per capita is less than US$ 2000, and health care expenditures per capita per year are less than US$ 200. In such case an effective and timely assistance from external resources, mainly from abroad, is necessary. The efforts of international organizations to provide the countries in need with such projects should result in rapid and visible effects, but often without taking into account a country's specific needs, historical and cultural background and actual social situation. It often results in failure of these projects, which not only drain international financial resources, but are interpreted as political and social unwillingness to solve basic health and health care problems in targeted countries. I think that WHO plays an important role in resolving these misinterpretations by advocating the interests of countries which need health assistance. The excellent example of the efficient cooperation between WHO, donors and recipient countries in targeting external assistance is the support provided by the Canadian Government's programme in the central and eastern European countries. This timely and very well-targeted assistance has launched a large movement for prevention of noncommunicable diseases in these countries. The same applies to the support of the Government of the Netherlands to national integrated programmes on environment and health in these countries.

Embodying the principles of equity and solidarity into the national health legal system has resulted in nearly 100% immunization coverage of the population in Slovakia. Under State supervision are the quality of water, soil, air, food and other hygienic standards. The Slovak Republic does not face serious problems with infectious diseases. On the other hand, ensuring equal access to health care services has not reduced the gaps in the health status of the population. Despite the equal conditions in providing health care services, significant differences in mortality and morbidity caused mainly by noncommunicable diseases exist among various districts in Slovakia, morbidity due to noncommunicable diseases such as cardiovascular diseases, cancer, chronic diseases of the respiratory system, mental disorders, and diabetes has been increasing significantly. The main causes of increased incidence of these diseases are, particularly, low interest of the individual in his or her health and unhealthy lifestyles. It means that without the consistent implementation of the health-for-all strategy targeted especially on individual behaviour, working and living conditions, the health legislation mentioned above could result in an enormous burden on the State budget. In this context, I consider the first and the third priorities laid down in The world health report 1995 very important.

In conclusion, I would like to stress that peace is a fundamental precondition for every humanitarian activity. Only in peaceful times can principles of equity and solidarity and adequate health care be implemented. Unfortunately, nowadays we see war, conflicts and violence in many parts of the world. These conflicts threaten development and worsen the living conditions of the population, consequently leading to a rapid deterioration of its health. I believe that next year at this forum we shall be able to see improvements also in this respect.

M. DE COSTER (Belgique) ：1

Monsieur le Président, Monsieur le Directeur général, distingués collègues et délégués, Mesdames et Messieurs, la délégation belge tient à remercier le Conseil exécutif de sa décision de voir les débats de la Quarante-Huitième Assemblée mondiale de la Santé axés sur le thème "Equité, solidarité, santé - Réduire les écarts". Les termes "équité" et "solidarité" nous paraissent particulièrement bien choisis : le premier implique le respect des droits de chacun et l'impartialité; le second exprime le devoir de s'entraider. Et "réduire les écarts" signifie diminuer les intervalles, les distances. Nous ne pouvons certes pas couvrir dans cette intervention tous les problèmes sous-jacents au thème retenu, mais nous estimons utile d'insister sur certains d'entre eux.

Afin de mener une bonne politique de santé, il est absolument nécessaire de disposer de bonnes données de santé en tenant compte de la situation sociale des malades. C'est dans ce cadre que le

1 L e tex te q u i su i t est la ve rs i on in tég ra le d u d iscours p r o n o n c é par M . D e Cos te r sous f o r m e abrégée.

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Gouvernement belge a mis sur pied un système d'enregistrement informatisé de la santé et des données sociales.

Parmi les mesures prises par le Gouvernement, je voudrais souligner l'importance qui a été attachée à trois groupes cibles : les nouveau-nés, les toxicomanes et les personnes atteintes par le VIH/SIDA. La mortalité néonatale a été fortement réduite et des efforts supplémentaires ont été faits pour renforcer encore cette politique. Le Gouvernement a établi une note sur la toxicomanie qui vise tous les aspects y afférents. Notre pays a fait des efforts considérables pour lutter contre le SIDA. A ce propos, nous tenons à exprimer notre ferme soutien au nouveau programme commun coparrainé des Nations Unies sur le VIH et le SIDA, sous la direction du Dr Piot. Nous sommes convaincus que l'OMS donnera tout l'appui nécessaire pour la réussite de cette mission difficile.

La comparaison entre les inégalités socio-économiques et leurs effets sur la morbidité et sur la mortalité doit aboutir à des conclusions importantes. Il reste néanmoins des problèmes méthodologiques à résoudre, en particulier le choix des indicateurs pour assurer une approche aussi objective et globale que possible. Il faut également évaluer les facteurs qui peuvent influencer la morbidité et la mortalité tels que l'usage du tabac, de l'alcool et de certains médicaments, les habitudes alimentaires, l'exercice physique, les conditions d'habitat et de travail, le climat, les actions en médecine préventive et en médecine curative. Nous estimons que dans les études sur la morbidité et la mortalité doivent être envisagées les relations éventuelles avec les ressources économiques, la situation sociale, la diffusion de l'information, les activités non professionnelles telles que les activités sportives, sans négliger les drames de certaines situations d'urgence et les questions conflictuelles qui restent malheureusement d'actualité.

Nous signalons aussi que dans la Communauté flamande l'Institut flamand pour la Promotion de la Santé a été chargé d'assurer le soutien et la coordination nécessaires dans ce domaine. A cette fin, un plan stratégique global en faveur de la santé a été mis au point. L'approche retenue s'inscrit dans les recommandations formulées par l'OMS en matière de "promotion de la santé". Le plan stratégique couvre les différents aspects de cette matière, décrit les grandes lignes et définit les objectifs à atteindre dans un proche avenir. Le plan sert en outre de cadre global à la définition des options politiques en matière d'affectation prioritaire des subsides publics. Quatre options politiques prioritaires ont été retenues : prévention du cancer, prévention du SIDA, lutte contre l'alcool et la drogue, et pratique des sports médicalement justifiée en ce qui concerne l'utilisation des produits de stimulation. Le plan stratégique s'appuie en premier lieu sur les concepts d'intersectorialité et de participation. Il est aussi fondé sur le principe de l'égalité. C'est dans cet esprit que la Communauté flamande a lancé en 1991 un projet de médiation interculturelle en matière de santé. Ce projet découle d'une initiative du Centre pour les Minorités ethniques et la Santé. Plusieurs enquêtes et la pratique sur le terrain avaient en effet démontré que la population immigrée se trouve confrontée à des problèmes spécifiques en matière de soins de santé. Au cours des prochaines années, la Communauté flamande poursuivra ses recherches dans le domaine de l'état de santé des allochtones (immigrés provenant du bassin méditerranéen, groupes plus petits d'immigrés nouveaux, demandeurs d'asile, etc.) ainsi que sur les problèmes qu'ils rencontrent dans leurs contacts avec nos organismes d'aide.

Une autre initiative importante dans le secteur des soins de santé s'est traduite par la mise sur pied de réseaux de soins palliatifs régionaux dans le cadre d'une politique fédérale. Ces réseaux ont pour objectif une répartition plus équilibrée entre les prestations hospitalières et les soins à domicile par une approche multidisciplinaire. Ils visent à permettre à chacun de mourir dans l'environnement de son choix, dans des conditions plus humaines et plus dignes.

Au plan fédéral, le Gouvernement belge a élaboré un rapport sur la pauvreté, traitant entre autres des liens avec les problèmes de santé et de sécurité sociale. Le rapport contient des propositions qui sont en voie d'exécution sur le plan fédéral et dans les Communautés.

En ce qui concerne la Communauté française, des enquêtes ont été menées afin de détecter les situations de pauvreté et d'exclusion, et des initiatives ont été lancées pour y remédier. A titre d'exemple on peut citer, en Communauté française, le projet de mise sur pied d'un Observatoire des politiques de l'enfance, celle-ci étant un groupe cible de la politique de santé de cette Communauté; la création de réseaux susceptibles de soutenir des personnes en difficulté et de créer des solidarités, telle une expérience de coordination de réseaux de soutien aux futures mères; des actions de santé communautaire dans le but d'aider les personnes à devenir acteurs et partenaires dans leur démarche santé; le soutien à des projets médiateurs en matière de santé pour les populations immigrées; une attention particulière concernant l'enseignement en cas de non-maîtrise de la langue maternelle ainsi que la rupture socioculturelle, phénomène lié à la pauvreté.

Un des aspects particuliers de la morbidité et de la mortalité dans le monde entier est celui qui est lié aux personnes âgées. Le vieillissement représente un problème en termes de morbidité et de mortalité tant

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sur le plan individuel que sur le plan familial et social. Ce problème doit être abordé globalement sans négliger certaines affections particulières qui, à notre avis, méritent davantage l'attention, telle la maladie d'Alzheimer. Dans les pays industrialisés, cette affection est déjà un problème de santé publique à l'heure actuelle et le sera plus encore à l'avenir. Chez les plus de 60 ans, la fréquence de la démence sénile double tous les cinq ans et on estime que la maladie frappe le quart de ceux qui atteignent l'âge de 85 ans. Cette maladie est un problème à la fois social et économique, et notre société moderne n'est ni préparée ni équipée pour y faire face. Il s'agit de malades dépendants pour lesquels la présence d'une tierce personne est le plus souvent nécessaire. Il n'est pas possible d'exiger des familles qu'elles supportent intégralement le coût de la prise en charge de ces malades; la plupart ne le peuvent d'ailleurs pas. La maladie d'Alzheimer est aussi un problème médical car il n'y a pas de traitement étiologique，la maladie évoluant jusqu'à la mort. Cependant, des actions peuvent être entreprises afin de réduire le poids insupportable qu'elle fait peser sur les individus et les familles. C'est pour cela que le Ministre de la Santé publique a créé, dans le cadre du Centre collaborateur OMS pour les facteurs psychosociaux, un centre d'information concernant cette affection. Mettre les meilleurs renseignements disponibles et les meilleurs exemples de bonne pratique à la disposition de chacun est le but de cette initiative, surveillée par un conseil scientifique et éthique. L'approche suivie pour cette maladie est d'ailleurs un modèle pour d'autres affections.

La délégation belge estime également qu'une attention accrue doit être accordée au programme international sur la sécurité chimique en vue d'une participation de tous les pays aux travaux du forum intergouvememental. Simultanément, les moyens doivent être trouvés pour couvrir les aspects scientifiques et techniques de ce programme. La Belgique, qui a eu l'honneur d'accueillir la première réunion intersessions de Bruges, souhaite qu'une telle initiative se répète régulièrement, comme cela sera le cas en Australie en 1996. Il est apparu, lors des discussions de Bruges, que les pays en développement sont confrontés à des problèmes de gestion des risques chimiques et qu'ils devraient pouvoir compter sur l'appui scientifique et technique des pays industrialisés dans un contexte de partenariat international.

Le même principe d'équité et de solidarité doit s'appliquer également au contrôle et à la prévention des maladies infectieuses en voie d'extension et de réapparition comme la tuberculose, dont le retentissement sur la morbidité et la mortalité reste évident. Restant attentifs au principe proposé, nous espérons que les actions envisagées visent en priorité les pays ayant le plus besoin d'assistance sanitaire et de secours.

Il est clair qu'on ne peut parler d'équité et de solidarité sans mentionner l'aspect de la coopération internationale, et plus spécifiquement celui de l'assistance aux pays les plus démunis. Mon pays, par le biais de son Département de la Coopération au Développement, soutient particulièrement les efforts de l'OMS en faveur des pays les moins favorisés. Il apprécie vivement, à ce titre, les efforts accomplis par l'OMS au travers de sa Division de la Coopération intensifiée avec les Pays. La Belgique recommande à l'OMS de trouver, dans son budget ordinaire, les moyens nécessaires pour soutenir davantage ce programme.

Nous nous arrêterons ici, convaincus de ne pas avoir couvert tous les problèmes impliqués par le thème choisi, mais nous souhaitons que les principes de l'équité et de la solidarité restent la préoccupation majeure de l'OMS dans toutes ses activités.

The PRESIDENT:

Distinguished delegates, as I am obliged to leave the meeting for a few hours, I would now like to request the third Vice-President, Mr Dabiré from Burkina Faso, to take over the Presidency.

M r Dabiré (Burkina Faso), Vice-President, took the presidential chair. M . Dabiré (Burkina Faso), Vice-Président, assume la présidence.


Excellences, Mesdames et Messieurs les Ministres, honorables délégués, c'est pour moi un plaisir et un grand honneur de présider cette Assemblée. Nous allons maintenant poursuivre le débat sur les points 9 et 10 de l'ordre du jour. Je passe donc aux prochains orateurs inscrits sur ma liste. Je donne la parole au délégué de l'Egypte et invite le délégué de la Jamaïque à prendre place à la tribune.

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Dr PHILLIPS (Jamaica):

Mr President, Vice-Presidents of the Forty-eighth World Health Assembly, distinguished delegates, ladies and gentlemen, I deem it a privilege and certainly a pleasure to be able to address this distinguished Assembly on behalf of the Jamaican delegation. Firstly, let me offer our congratulations to the President, the Vice-Presidents and all other delegates who have been elected to the various offices at this Assembly. Secondly, I wish to congratulate the Director-General on his excellent world health report. It certainly highlights several aspects of health development, the challenges, as well as some achievements, in this our changing world.

The structural adjustment programmes of the 1980s, while designed to help developing countries to improve their macroeconomic management and fiscal performance, also resulted in some harmful social effects, in the short term. Fiscal constraints forced the reduction of budgetary outlays for social services, as well as subsidies for food and other basic items. As a result, the ranks of the poor swelled and they became more vulnerable. More recently, on the international scene, terrorism and armed conflicts are factors contributing to poverty, due to the accompanying destruction of infrastructure and displacement of populations. The combined effect of these changes in the global community has been the intensification of

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poverty, social dislocation and turbulence, and a widening gap between the rich and the poor, both within and between countries.

There are alarming disparities in income, nutrition, health, education and housing between rich and poor, and between rural and urban populations. The lot of the poor is typified by ill-health, lack of education and undernutrition. Trapped in a vicious cycle, ill-health robs these individuals of the energy they need to produce, leading in turn, to reduced incomes. Undernutrition inhibits their children from receiving the full benefits of education and also compromises their natural defence against disease.

Poor populations are generally characterized by a lack of access to basic health services as manifested by long waiting times to receive care, deferred elective interventions, inadequate staffing and equipment at the health facilities they use, and the unavailability or inadequacy of basic services such as potable, running water and sanitation. In so-called midlevel countries, such as Jamaica, we are faced with a double burden. On the one hand, despite the significant gains that have been made, there is a persistence of infectious diseases such as diarrhoeal diseases. Simultaneously, however, the so-called lifestyle related diseases and chronic illnesses are constituting an ever-increasing share of the total disease burden, for example, complicated cases of diabetes mellitus can account for as much as 75% of patients on the adult medical wards; and limb amputations form a constant feature on every surgical list.

These inequities in health are critical, especially for developing countries, since research shows that socioeconomic development is in large measure determined by the health of the population and by investments in health. Better health will therefore increase the well-being of the population, resulting in increased productivity and social progress. There is therefore an urgent need to take action to ensure that public policy does not focus so exclusively on economic efficiency as to eliminate from view the linkage between health services, social equity and economic development.

WHO's global objective, health for all, implies equity and sets out an appropriate context for health policies in particular, and development strategies, more generally. Success in achieving this goal will require clear political commitment, as well as clarity of analysis and competence in policy implementation.

Faced with severe fiscal constraints, as we are, the pursuit of these objectives implies first of all the intensification of efforts, aimed particularly at health promotion, and the prevention of illness generally. We must redouble our efforts to eliminate preventable communicable diseases through effective, sustained and intensive prevention strategies and immunization. At the same time, however, we must be alive to the increasing threat posed by the chronic so-called "lifestyle" illnesses, which are making mounting claims on the limited resources of countries such as my own. This suggests that greater attention must be paid to the promotion of healthy lifestyles and the prevention and control of these chronic ailments.

Beyond that, the major emphasis must be on the twofold challenge of greater efficiency in resource use and the development of more effective systems of social resource mobilization, in order to ensure the existence of a health system that is both efficacious and equitable. In pursuit of this reform agenda, activities to be pursued would include decentralization of services, the reorganization and rationalization of services, identification of new sources and methods of financing health care, identification and implementation of a public and private mix, improvement of the management systems, upgrading of legislation, establishment of quality assurance strategies, strengthening of epidemiological capabilities, and research and development.

Ultimately, we need to recognize, however, that our responsibilities extend beyond the task of caring for the ill and should involve the creation of conditions for healthy living. Traditionally, in the health sector, risk analysis has predominantly been oriented towards consideration of pathophysiology and thus has tended to neglect social and economic factors which are crucial in identifying appropriate interventions. Technical cooperation is therefore needed to assist developing countries to measure existing health gaps and to consider all the critical variables involved in the establishment of good health.

Obviously, effective intersectoral collaboration will be necessary, since the promotion of health, prevention and control of illness, and rehabilitation of those who have been ill must be achieved with the broad context of the sectors allied to health. Public and private sector organizations must consider the implications of their policies and activities on the health of the population. There is also a need to establish and maintain the necessary linkages between organizations that provide related services in order to plan these services in a manner that effectively utilizes resources and prevents fragmentation in the delivery of health care.

Strong community participation is also necessary to promote equity and solidarity in health and must therefore be facilitated, especially in the planning and implementation of promotive and preventive care programmes.

Such a holistic vision of the challenges of providing health for all should also sensitize us to new definitions of health issues. In closing, I would like to single out one of these which is, unfortunately, of

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increasing relevance to all of us. Violence not only abuses human rights and threatens peace, it is also fundamentally a threat to good health. Invariably, the outcomes necessitate emergency care in the hospital setting, involving usually costly and lengthy interventions, driving up the cost of care generally. Additionally, the victims, especially children, need care to ensure that promotive, preventive, emotional and physical health is not jeopardized. The international community needs to unite to develop strategies that will not only assist with the understanding of the social and psychological underpinnings of violence, but will also aid with efforts to prevent and reduce violence and its effects. We must act now to confront this growing epidemic that is sweeping some of our countries.

While ultimately our efforts to meet our objective of health for all will depend fundamentally on our individual efforts within our several countries, our objective will remain elusive if we fail to undertake the necessary and indispensable collaborative efforts critical to the achievement of equity and solidarity. Only by combining our energies will we facilitate more effective management of health systems, and health reform proposals; only mutual support in training and staffing and research, at both regional and global levels, will provide us with the effective impetus to achieve our goal. In this regard, we all continue to look to WHO and its regional offices to provide the essential leadership upon which our people depend for the realization of their aspirations.

Mr RABBANI (Pakistan):

In the name of Allah, the Beneficent and Merciful. Mr President, Vice-Presidents, Mr Director-General, distinguished delegates, ladies and gentlemen, it

is a great pleasure for me to represent Pakistan at this important session of the World Health Assembly and of course an honour to address this august meeting. On behalf of the Pakistan delegation, and on my own behalf, I would like to congratulate Dato Dr Haji Johar Noordin on his unanimous election to the Presidency of this Assembly. He represents a fraternal country, a country which is playing an increasingly important role in regional and global affairs. I am confident that under his wise guidance this Assembly will achieve encouraging results.

This Assembly is taking place at a very important juncture in world history. The era of ideological confrontation is over. Nearly all nations subscribe to the principles of democracy, human rights and free markets. With growing interdependence and the development of communications, the world is fast becoming a "global village". Today, we are equipped with enormous technological and human resources for investment and growth. The international community has an unprecedented opportunity to initiate peace and cooperation for the welfare of all mankind. And yet there is disease and immense human suffering. The growing number of people who inhabit this planet are more unequal than in the past. Poverty is widespread and The world health report has aptly described it as the "world's biggest killer". The world health report points out that over 12 million children die each year owing to poverty. Poverty is the major cause of infant mortality, physical and mental disabilities, shorter life expectancy and, above all, illiteracy. The report indicates some sombre facts: life expectancy is growing in the richest countries, while it is declining in some of the poorest. A healthy man in a rich country can expect to live twice as long as a man in the least developed part of the world. Pakistan has been one of the countries which has always held the opinion that poverty breeds most of the evils in our society. Be it in the field of health, or education, or human rights, the international community will never be able to achieve its goal of collective progress unless the wide gap between the rich and poor, both at national and international levels, is reduced. WHO, through the present report, has once again reminded us of this harsh reality of bridging the gap between "haves" and "have-nots". The time calls for our urgent and sincerest efforts to address this core issue - lest our endeavours for health for all by the year 2000 remain a dream.

It is not a coincidence that the most heavily populated areas of the world are also among the poorest. A global policy to bring down population growth rate and to promote the implementation of a large-scale primary health care programme must therefore be brought to the top of the world agenda. Governments and donors should be motivated to allocate additional resources to this sector. A primary aim in development strategy in these countries should be towards improving the quality of life. The challenge for us all is to use available resources effectively to reduce and eliminate avoidable deaths and communicable diseases.

In Pakistan the Government of Prime Minister Benazir Bhutto is determined to succeed in the battle against disease in order to provide a life of dignity and well-being for the people of Pakistan by the year 2000. The Government has embarked on a comprehensive programme which aims to generate rapid economic growth - and to improve the social and living conditions of its citizens through more education

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facilities and better health care. I may stress that it is protection of the mother and child which is a cornerstone of our policies in the health sector.

As Prime Minister Bhutto stated in her address to the International Conference on Population and Development, "It is imperative that every pregnancy is planned and every child conceived is nurtured, loved, educated and supported". The Prime Minister of Pakistan called for a global partnership for social action promoting the objective of planned parenthood for population control. We need now to translate that into action. A key feature of Pakistan's policy in this respect is the initiation of the Prime Minister's programme for family planning and primary health care. This programme aims to extend health services in the rural areas and urban slums to the doorsteps of all through the initial deployment of 33 000 locally based female national health workers. These workers, after receiving three months' initial training, are responsible for delivering family planning and primary health care services in their communities. Their duties include the provision of immunization, family planning, first aid, prevention of diseases, maternal and child health services, treatment for minor ailments, and public education in health matters. About 9000 national health workers have already been trained and the remaining 24 000 are expected to be in the field by the end of 1996.

A major part of Pakistan's investment in human development has been through the Social Action Programme which commits the Government to certain minimal additional expenditure each year for primary education, nutrition, primary health care, family planning, rural water supply and sanitation. The programme was launched over a year ago and positive results have already begun to materialize.

Other priority health programmes in Pakistan include the launching of national poliomyelitis days, with the aim of its eradication before the year 2000; renewed efforts to control malaria and the spread of tuberculosis; and initiation of a programme to contain the spread of AIDS.

In our fight against disease, WHO has remained an active partner. We are.grateful for its technical and financial assistance and hope that this will grow in the coming years. In Pakistan we have been quick in responding to WHO's calls for AIDS prevention, poliomyelitis eradication, the provision of safe and effective drugs, and control of infectious diseases. WHO continues to be in the front line of the global endeavour to create a healthy world population. It has some outstanding achievements to its credit - the eradication of smallpox is one of those. WHO is also the premier international agency which monitors the prevalence of communicable and noncommunicable diseases in the world. However, since better health will be contingent on greater economic well-being, in future WHO will need to work even more closely than before with other multilateral and bilateral donors.

In concluding, I would like to look ahead and offer some suggestions for the future. Two points stand out very clearly. First, that the challenges in the health sector in the next decade are going to be considerable as some new diseases require additional resources, while a few re-emerging ones need effective control. The second point is that donor contributions are not likely to keep pace with the financial requirements to bridge the yawning health gap, so eloquently described in The world health report. Under these circumstances we need to adopt cost-effective measures so that returns are maximized for every dollar spent by the World Health Organization. One way to do this might be to shift some programmes away from headquarters to places where their costs can be reduced and where their location may be more relevant to the subject of their intended research.

Another realistic way of meeting the health-for-all objectives would be for much greater attention to be given to determining where user charges can be applied and to what extent. The world health report has illustrated how a small amount like a dollar or less can sometimes help to save a life. What the report has not demonstrated is how some of these costs could be met by users themselves. In some cases the problem may not always be one of lack of funds but that of ignorance and non-availability of services. There is also a point related to the cost of producing drugs. There may be a strong case for the need to adopt more rational policies through a truly competitive system which can make drugs more affordable. Mr President, let us analyse all these issues further and look for realistic solutions.

I would like to take this opportunity to convey the Government of Pakistan's gratitude to Dr Hiroshi Nakajima, Director-General, for providing the leadership required for the improvement of global health. Yesterday, in the meeting of non-aligned countries, he also promised to transfer yearly 1% of the global budget from headquarters to various countries. I would like to acknowledge our gratitude for this very timely decision. I would also like to place on record our appreciation for the support and advice received from the Regional Director for the Eastern Mediterranean who has been actively cooperating with the health authorities in Pakistan. Finally, I would like to record our appreciation of the other multilateral and bilaterial agencies which have given valuable assistance for improvement of the health of the people of Pakistan.

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Merci au délégué du Pakistan. Je donne maintenant la parole au délégué du Lesotho et j'appelle le délégué de l'Algérie. Le délégué de l'Algérie prendra la parole au nom de l'Union du Maghreb 一 Jamahiriya arabe libyenne, Mauritanie, Maroc, Tunisie - et au nom de son propre pays. Les délégués de ces Etats Membres sont priés de se présenter à la tribune au moment de l'intervention.

Dr RADITAPOLE (Lesotho):

Mr President, honourable ministers, distinguished delegates, ladies and gentlemen, permit me to extend to the President, the Vice-Presidents and other officials of this Assembly my Government's, my delegation's and my own congratulations upon your deserved election to respective high offices of the Assembly. It is my delegation's sincere belief that with your able guidance and the expert steering of the Director-General and his team, the deliberations of the Forty-eighth World Health Assembly will be an unqualified success.

As one reads through the Director-General's review of The world health report, review of the Executive Board's report, as well as the proposed programme budget for 1996-1997，one cannot fail to be deeply moved by the enormity and ever-increasing demands made by Member States on the technical resources of WHO. These are the challenges to which the Organization has responded relentlessly not only for now but also for the foreseeable future.

The theme for this year is equity and solidarity in health - bridging the gaps. One cannot effectively address this issue without recognizing the factors which contributed to the socioeconomic crisis in which some of our countries find themselves. We talk of the 1980s as a lost decade for many developing countries, ten years of miserable economic performance and consequential erosion of welfare. In sub-Saharan Africa, for example, economic growth fell from an annual average of 6% between 1965 and 1980 to about 1% during the 1980s. Lesotho was no exception. Behind these grim statistics is hidden the extent and intensity of the vast human suffering. It was within this period that inequity in the distribution of income and resources became very severe. This resulted in a growing proportion of the population becoming vulnerable. This is a scenario that exists in my country, Lesotho, today. It is characterized by inequity in access to job opportunities, basic services including health, access to clean water and proper sanitation, and education. It is with this scenario in mind that the Government of Lesotho, pursuing prudent macroeconomic policies, sees an accelerated poverty alleviation initiative as a crucial imperative.

It is this socioeconomic crisis which necessitated the holding of the World Summit for Social Development, recently held in Copenhagen, and also the International Conference on Population and Development, held in Cairo last year. My Government remains fully committed to the decisions, recommendations and new direction coming out of both these conferences. Socioeconomic inequities, whether they exist within national boundaries, between States or regions, have an impact on the necessary equilibrium for stability. The crisis in which we find ourselves today is the cumulative result of inappropriate domestic policies exacerbated by hostile external environment. It took all of us to create this sad situation and therefore it needs the solidarity of all concerned parties to identify pragmatic, human-friendly and just development strategies to reverse the situation and give hope to millions of people who live with hopelessness. Such strategies should not be old wine in new bottles.

My Government's view on this matter is simple. We see partnership as representing a total sharing of power, resources and information in the context of solidarity based on shared values and goals. In order for this partnership to be sustained certain prerequisites are important. These include: a similar vision of the realities of our societies; a desire and means to share information; generalized solidarity based on mutual respect; and last but not least openness to the sharing of decisional powers and transparency of the decision-making process.

The Ministry of Health in Lesotho recently commemorated its hundredth anniversary. We have used the time to reflect, to analyse our health development strategies, to identify our failures and successes, and to chart the way forward as we plan for our health needs in the twenty-first century. In September of this year, a donors' conference on health and population is scheduled in Lesotho. This conference is a follow-up to the donors' conference for Lesotho which was held here in Geneva in January of this year. My Government's health sector plan for the period 1995-2000 will be tabled before our cooperating partners. This plan is not very ambitious. It is not expected to expand to any great extent the existing infrastructure, except as far as this is consistent with the government policy of equity and universal access to appropriate and quality health care.

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In conclusion, let me note that the increase in inequity and the poverty which stems from it is literally a matter of life and death. The poor in my country pay the price of social inequity with their health. We have within possible limits increased the national budgetary obligation to health care financing. However, additional resources are necessary to bridge the gaps. We count on WHO and our other cooperating partners and friends for this support. My Government will continue to restructure its economy with the belief that this effort will lead to increased economic capacity that will in turn enable adequate domestic support for delivery of social services.

On the global front, the world has seen too much suffering in the last 10 to 15 years. Our television screens and other media have been dominated by suffering of unimaginable proportions. This august body is not only obliged to say something on the social crisis, but has a moral and technical obligation to do something practical. Let us not stand by and allow this human catastrophe to accelerate. Let us not move into the twenty-first century with this scenario. The world has got sufficient resources and technical capacity to reduce this inequity. What we need is the will, determination and selflessness. Together we can bridge the gap.

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Le Dr CANDUCCI (Saint-Marin):

Monsieur le Président de séance, Mesdames et Messieurs, la délégation de la République de Saint-Marin souhaite tout d'abord féliciter le Président pour son élection à la tête de cette Quarante-Huitième Assemblée mondiale de la Santé.

Nous souhaitons également exprimer toutes nos félicitations au Directeur général pour son Rapport sur la santé dans le monde. A ce sujet, je voudrais dire que notre délégation partage entièrement les préoccupations qui y sont exprimées concernant les différences encore importantes qui existent au sein même de certains pays et entre les différents Etats Membres de l'Organisation sur le plan de la gestion sanitaire.

Les profonds changements politiques, socio-économiques et sanitaires qui se produisent actuellement dans le monde n'ont pas encore permis de surmonter les différences entre pays développés et pays en développement. La tragédie représentée par tant de conflits armés, qui continuent de surgir en divers endroits de la planète, constitue un obstacle et un frein à de nombreux programmes de développement. La pauvreté et l'endettement public croissants empêchent beaucoup de pays d'octroyer les ressources qui seraient nécessaires pour garantir un système sanitaire et social équitable. Lors du Sommet mondial de Copenhague, tous les gouvernements se sont engagés à mettre en oeuvre une solidarité concrète envers les pays en difficulté. L'initiative prise par quelques-uns d'annuler la dette d'un certain nombre de pays pauvres constitue un premier pas important en vue de dégager de nouvelles ressources en faveur des programmes de développement et non, comme par le passé, d'acquérir des armes nouvelles destinées à mener des guerres dévastatrices.

Notre délégation partage, par ailleurs, les préoccupations exprimées sur les taux encore trop élevés de mortalité infantile liés à des conditions de vie qui non seulement ne permettent pas de garantir la survie des nouveau-nés, mais n'autorisent même pas les interventions les plus indispensables des services de santé, face à la malnutrition et aux maladies infectieuses comme la tuberculose et le paludisme. Même si, dans son ensemble, la mortalité infantile a diminué en pourcentage au cours des dernières décennies, il est évident que les différences demeurent encore trop importantes entre pays riches et pays en développement. On peut souligner le même fait en ce qui concerne la protection de la santé des femmes et des personnes âgées qui sont souvent oubliées ou font l'objet de discrimination au niveau des programmes de santé, même dans les pays les plus développés.

L'augmentation inquiétante des maladies sexuellement transmissibles et du SIDA oblige les responsables de la santé de tous les pays à renforcer non seulement la recherche, mais plus particulièrement la prévention, en encourageant notamment la modification de certains modes de vie.

La République de Saint-Marin considère que dans la mesure où un gouvernement souhaite instaurer un programme de santé équitable de même qu'une véritable solidarité à l'égard de l'ensemble de ses ressortissants, il sera amené à examiner, dans le cadre de ses ressources économiques disponibles, le problème des priorités parmi lesquelles la santé de tous les citoyens doit occuper une place majeure. En réalité, le droit à la santé constitue désormais un principe fondamental des divers systèmes de santé nationaux. Par ailleurs, la protection de la santé est de plus en plus considérée comme un problème dont la responsabilité doit être assumée non seulement par l'individu, mais par l'ensemble de la collectivité. Il s'avère donc de plus en plus important de garantir à tous l'accès aux services de santé dans des conditions égales et conformément à des critères qualitatifs non discriminatoires. Dans une économie de marché, on ne peut oublier l'indispensable nécessité d'octroyer les ressources nécessaires à la santé.

En ce qui concerne la solidarité à l'égard des pays en développement, nous considérons qu'il est important de favoriser les programmes de coopération qui incluent des aides financières et technologiques, et plus particulièrement ceux qui encouragent et facilitent les projets d'engagement de personnel sanitaire et technique. La formation professionnelle des agents de santé ainsi que la présence dans les pays qui en ont un grand besoin d'un personnel de santé bien préparé sont des éléments qui doivent permettre de favoriser un renforcement des systèmes de santé dans les pays en développement et de réduire les disparités qui aujourd'hui encore s'avèrent excessives et inéquitables.

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Non à une simple forme d'assistance donc, mais oui à une véritable solidarité et à des orientations de recherche en vue de parvenir à l'équilibre indispensable entre la justice et l'efficacité à l'intérieur même des pays et, plus particulièrement encore, entre pays riches et pays pauvres.

L'OMS devra continuer à veiller, à promouvoir et à intervenir toujours plus pour sauvegarder les programmes adéquats de protection de la santé. L'Organisation devra en outre encourager ceux qui ont le plus de ressources à en octroyer une partie à ceux qui en sont le plus démunis, afin que l'objectif de la santé pour tous d'ici l'an 2000 ait quelque chance de se réaliser.

Mr SATA (Zambia):

Mr President, your excellencies, honourable delegates, ladies and gentlemen, I would like to congratulate our colleague, the President, who was elected to this august office. He well deserves his election. Whilst I am congratulating him, as a democrat I would like to express my disappointment and protest at the way he treated me at the time of opening this Assembly when I raised my hand on a point of order.

When we as an organization adopted the Alma-Ata Declaration and set for ourselves the goal of health for all by the year 2000 we were confident that our health problems had been clearly defined, their causes elucidated and strategies for their containment put in place. It was a time of justifiable euphoria. For once the assistance of the less fortunate looked possible. In that era of the cold war and of superpower rivalry, all of us seemed agreed and united on this one agenda item. At that time WHO was really in a position to assist link resources with identified priorities in countries and areas of most need. Today 15 years later, the euphoria of Alma-Ata has evaporated and has largely been replaced by a sense of helplessness and resignation to fate. As The world health report 1995 states, morbidity and mortality continue to rise. The health situation in most developing countries is getting worse. The traditional causes of ill-health and death are being compounded by newer epidemics like AIDS. With the end of the cold war, all the rich countries have become less caring and appear unconcerned with the plight of their fellow men, women and children. It is evident that in our present circumstances, those who have eyes do not see, those that have ears do not hear and those that can speak have become dumb. Zambia is very uncomfortable with this unfolding scenario. We note with extreme trepidation that WHO is slowly being marginalized and pushed away from being the centre of and playing the leading role in health matters worldwide. In such an environment WHO will experience greater difficulties in helping to link resources with identified priorities, especially in countries and areas most in need.

Cognizant of world opinion and dwindling resources in the face of mounting morbidity, mortality and new epidemics, we in Zambia decided to embark on radical health reforms whose vision is to provide cost-effective quality health care as close to the community as possible. The health reforms focus on quality, cost-effectiveness and families. To achieve this vision, we have restructured the administrative framework within which health services have to be produced. The districts, which in Zambia are the smallest government units that are closest to the community, have been designated as the focus of the production of health services. The role of the Ministry of Health headquarters and of the provincial or regional offices is to facilitate the districts to produce health.

Zambia sees great promise in these reforms. We continue to focus on our vision while striving to improve the health status of our people. Sometimes our preoccupation with individual disease-centred programmes is of tactical necessity and not a strategic policy shift. In this regard we can state that preventable communicable diseases are receiving due attention. Reductions in the incidence and prevalence of these diseases, though urgent and desirable, are not an end in themselves. If I may clarify this point, for us in Zambia a child who has been fully protected against immunizable disease but succumbs to malaria or to malnutrition or to cholera represents failure in the production of health services and dramatizes the urgent need to focus on the overall improvement of health status through comprehensive health packages.

May I take this opportunity to thank all our collaborating partners in our health reforms. Their generosity, flexibility and understanding have all individually and collectively advanced the cause of the health reforms. In WHO, we wish to specifically cite the role played by the WHO Representative in Zambia, and by WHO's programme on intensified cooperation with countries in greatest need. We wish we could say the same about WHO headquarters in general.

Zambia is sad and concerned at the new racial attitude and discrimination which the WHO leadership under the current Director-General has demonstrated. Africa has lost the slot which it occupied during the cold war. Africa today, whether it is in the United Nations proper or in WHO, is only recognized when it

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comes to the election of the Director-General. After the election has been secured it does not participate in decision-making but is used as a rubber stamp in all WHO deliberations. For example, the Director-General has a cabinet of ten, no African representation; he has 46 directors, one African is among the 46，but was not appointed by the current Director-General. WHO has 28 assistants to the 46 directors. Only two Africans are employed but not appointed by the current Director-General. Racialism is not only restricted to Africa but it has also extended to South-East Asia and the Caribbean. It is difficult to expect Africa to defend the Director-General on allegations of insulting the African race, because the Director-General has never bothered to submit to African Ministers the full text of his speech. We are the foot soldiers, but we are not being supported by our General in Geneva. If our General has no confidence in us, how does he expect us to deliver victories? Africans will in future use their votes more wisely than we did in 1988 and 1993.

WHO in The world health report 1995: bridging the gaps presented an analysis of the world health status with refreshing intellectual passion, unparalled in the recent past. The WHO we see worries us, as a Member State. Many Member States are not impressed with what they are calling an uninspired leadership in the Organization. A number of Member States have gone even further by cutting their contributions. We now want to ask: is WHO now in a position to link resources with identified priorities? Is WHO now part of the "bridge" or one of the "gaps" to be bridged? To answer these preliminary questions, one needs to first see how WHO is structured and staffed at its headquarters in Geneva. Of the 46 top posts including the Director-General at headquarters, 20 posts are from the European Region, but of these only one from Russia and one from Turkey; eight posts are from the Americas, but of these only two are from South America and nil from the Caribbean and Central America; 11 posts are from the Western Pacific, of these nine are shared by the rich nations of Japan, Australia and New Zealand; the remaining posts are occupied as follows: one by the African Region, two from Indonesia, two from Egypt, one from Tunisia, one from Kuwait and one from Sudan.

The point I am making is that, in WHO, the bias is globally against the areas and regions in greatest need. Not just Africa but all the countries with the most severe health problems are disadvantaged. The structure of WHO is further constrained by the racial and disparaging stance of its Director-General, from which the top WHO Secretariat staff has not distanced itself.

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Mr HASHIM (Bangladesh):

Mr President, Mr Director-General, excellencies, ladies and gentlemen, at the outset, I would like to join previous delegations in congratulating the President on his election as President of the Forty-eighth World Health Assembly. We are confident that under his able stewardship, the deliberations of this Assembly would be eminently fruitful. I would also like to convey through you the felicitations of the Bangladesh delegation to the other members of his bureau. We assure him of the fullest support of my delegation in the discharge of his duties.

As we gather here at the mid-point of the final decade of this century, it is appropriate that we reflect on how much we have matched our initiatives to our collective commitment, specially to the goal of health for all by the year 2000. In spite of the tremendous gains in human development in general and health-related technological advances in particular, the gap between the rich and the poor - between countries and between rich and poor segments within countries - has continued to grow wider. The promise of additional resources for social development, talked of with the end of the cold war, has largely not materialized. The resultant effect of the growing inequity is best reflected in the increasing difference in mortality rates. The health agenda today cannot be merely an exclusive medicare agenda. The efforts that go into the making of a policy response have a national dimension as well as an international dimension, the basic elements of which would require: ensuring access to primary health care for the poorest and the most vulnerable group of the population; institutionalizing safety-nets, medical and otherwise, to protect the poorest from risks which are beyond their control; and transforming rhetorics into concrete commitments in health care at leadership level, both political and social. There is, therefore, an urgent need to read health issues in the development context. In this whole paradigm, there are very clear requirements for country initiatives and also an open-ended WHO-driven global initiative.

As a densely populated developing country, Bangladesh addresses its health issues in conjunction with population planning. The policy is aimed at intensifying efforts for the dual objective of health for all by the year 2000 and a net reproductive rate of one by the 2005，the former goal being adopted over a decade ago. The principal strategies are: first, expansion of primary health care services including nutrition; second, maternal and child health based family planning; and third, improved cooperation between health and family planning workers. Indeed, successive health plans of the country have consistently emphasized primary health care. Increased allocation for the health and population sector, both in the development and revenue budget, reflects the priority of this policy.

We have made great progress as a result of the primary health care strategy in reducing the country's morbidity, mortality and fertility, even with our limited resources. The Expanded Programme on Immunization has been an area of significant forward movement, contributing to the speedy expansion of immunization coverage from 2% in 1984 to 69% ten years on. As part of the global initiative to eradicate poliomyelitis, Bangladesh recently launched a successful national immunization day to vaccinate all children under five years of age against poliomyelitis. The dramatic improvement in the use of oral rehydration therapy has also improved child survival significantly. Bangladesh has also focused on the community aspect of the health issue, the most significant of which is in rural water supply coverage.

Providing universal access to health services for every citizen, although formidable, has been the goal of every successive Government of Bangladesh since independence. We have adopted a strategy of improving

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the overall health status of the population and reducing fertility through a dovetailed development strategy that aims at improved nutrition, universal primary education, empowerment of women, promoting private enterprise, along with lower infant mortality targets and sustained priority programmes in the field of family planning. Nevertheless, considerable gaps between rural and urban populations and between the rich and the poor in terms of both health status and access to health services continue to exist in the country. Rapid urbanization and industrialization of the country has resulted in a large influx of rural population into the urban and suburban centres, and consequently overburdened the health facilities and public amenities. The urban environment and the quality of urban health services have both been seriously constrained. Besides, the problem of malnutrition is almost as acute among urban slum-dwellers as it is among the rural poor. As in most other developing countries, Bangladesh's goal of providing equitable services to all citizens, with its narrow resource-base, is a daunting task. The challenge is not only to provide services, but also to establish an effective and functional network of primary health care in a large part of the country. Special attention has to be given to the needs of countries in our situation to enable us to reach the threshold of performance in at least nation-wide primary health care.

The environmental dimension is another significant aspect in the scheme of health care. Bangladesh has a very large population within a small land area. We cannot afford environmental deterioration within the country or globally. We have taken measures to stem the problem of deforestation and to prevent the dumping of industrial waste. However, we have not been successful in preventing desertification of our valuable farmland. Providing adequate safe drinking-water during the dry season is increasingly becoming a matter of concern. This has adversely affected our ability to reduce some of the communicable diseases and is the cause of sporadic outbreaks of diarrhoea. Efforts at the regional as well as global levels would be required to tackle the lately recognized threats to the environment, more so in terms of visible North-South collaboration. In recent years, Bangladesh has experienced the resurgence of communicable diseases like malaria. In addition, there are the newer challenges such as AIDS. There has also been a rise in the incidence of cancer and cardiovascular diseases. We are actively pursuing the establishment of a national emergency preparedness and response centre to respond to the frequent natural disasters, disasters which seriously retard development gains in a natural disaster-prone country like Bangladesh.

In the 1990s, health problems in the world are as diversified as ever. In developed countries, health problems related to old age and degenerative diseases are increasingly gaining prominence, while in developing countries poverty-related and communicable diseases remain prevalent. Attempting to meet health needs of such a diverging nature, and simultaneously, is indeed a critical challenge for WHO. As we strive forward, realities keep us bound to our unfulfilled commitments of the present. The attention of the global community must now be focused on reducing inequities in health care. The vulnerability spectrum of people in the developing countries, specially the least developed ones, needs to be appropriately addressed in a renewed programme of action. The remaining five years of this century must witness an exemplary collaboration of national efforts, international support, rejuvenated research and development on communicable and infectious diseases, and participation of nongovernmental organizations, the private sector and transnational enterprises in the community aspects of public health.

There is a clear need for enhanced country allocations for developing countries, specially the least developed countries. WHO could also take on a new role as facilitator charged with the task of sensitizing donors about specific requirements of the least developed countries and encouraging enhancement of assistance in the field of health care.

Before concluding, we would like to express our appreciation of the very thorough and exhaustive report of the Director-General on the state of world health. His statement has been very illuminating, and the emphasis that he has laid on bridging the inequity in available medicare facilities and services is a recognition of the need to rededicate ourselves to renewed strategies for achieving health for all within a predictable timeframe.

It would be inappropriate if I were not to put on record our appreciation for the assistance and cooperation that Bangladesh has received from WHO. In this connection, we would like to recall that Bangladesh's entry into the United Nations system commenced soon after her emergence as an independent State with our membership of WHO. We are hopeful that the existing fruitful cooperation will continue for the attainment of our common goals.

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Je remercie le délégué du Bangladesh pour son intervention. Excellences, Mesdames et Messieurs les Ministres, honorables délégués, avant de lever la séance,

puisque nous sommes à la fin de la liste des orateurs de ce matin, je voudrais passer la parole au Directeur du Cabinet du Directeur général pour une brève communication.


Thank you Mr President. With your permission, I shall make two brief clarifying remarks. The first is for general information. A point of order is basically a request to the presiding officer to make use of a power inherent in his office or specifically given to him under the rules. Second, the Director-General is concerned and sympathetic with the remarks of the distinguished delegate of Zambia concerning geographical balance of WHO staff, and particularly at the higher grades and in Geneva, and he will speak on this matter under agenda item 29.1 in Committee B. Thank you, Mr President.


Je vous remercie, Monsieur le Directeur du Cabinet.

La séance est levée.


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EIGHTH PLENARY MEETING

Thursday, 4 May 1995, at 14:30


HUITIEME SEANCE PLENIERE

Jeudi 4 mai 1995，14h30


1. DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-FOURTH AND NINETY-FIFTH SESSIONS AND REVIEW OF THE WORLD HEALTH REPORT 1995 (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-QUATORZIEME ET QUATRE-VINGT-QUINZIEME SESSIONS ET EXAMEN DU RAPPORT SUR LA SANTE DANS LE MONDE, 1995 (suite)

The PRESIDENT:

The meeting is called to order. This afternoon we shall continue with the debate on items 9 and 10. The first two speakers on my list are the delegates of Brunei Darussalam and of Mozambique. I give the floor to the delegate of Brunei Darussalam.

Dr IBRAHIM (Brunei Darussalam):

Mr President, Mr Director-General, excellencies, distinguished delegates, ladies and gentlemen, Brunei Darussalam stands proud and honoured, with her Minister of Health, the Honorourable Dato Dr Haji Johar Noordin, having been elected to the high position of the Presidency of the Forty-eighth World Health Assembly. Clearly, it is a sign of personal recognition and a tribute to him as much as it is to our country and to our Western Pacific Region. On behalf of the delegation of Brunei Darussalam, I have the great honour and privilege to offer our congratulations and felicitations to you, Dato, on your election as President of this august Assembly. Our congratulations go also to the Vice-Presidents and the other officers for their election to these high offices of this Assembly. I am confident that with your extensive knowledge, wide experience and wisdom, and assisted by equally qualified and able Vice-Presidents, you and your team will guide the proceedings of this Forty-eighth World Health Assembly to fruitful completion. May I take this opportunity to thank the Director-General, Dr Hiroshi Nakajima, and members of the Executive Board for their untiring efforts of the past year for global health development, and congratulate them for presenting comprehensive and concise reports on the activities of the Organization. I would 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 and prompt assistance and support to us whenever required.

It is very timely that this year the central theme chosen for discussion at the plenary meeting is equity and solidarity in health - bridging the gaps. Despite remarkable improvements globally in health in the past decades such as improvement in life expectancy, reduction in child mortality, eradication of smallpox, and drastic reduction of vaccine-preventable diseases, enormous health problems still remain, particularly in the developing countries. Mortality rates in many developing countries remain unacceptably high, child mortality rates are about ten times higher and maternal mortality ratios are, on average, 30 times as high in the developing countries as those in the industrialized countries. Preventable deaths in children as a result of diarrhoeal and respiratory diseases are not appreciably reduced, and tuberculosis alone causes two million deaths annually in adults. The fundamental aim of health for all is to reduce inequalities and disparities in health both among countries and communities within them. Inequity exists in the provision of health care

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and distribution of health resources on political, ethnic, social, racial and economic grounds. Very often it is seen that those most in need get the least. Unless the widening gap between rich and poor, between one population group and another, between ages and between sexes is bridged, the WHO goal for health for all will remain a distant dream in many of the disadvantaged communities even in the twilight years of this century. Extreme poverty is recognized to be the world's biggest contributor to early death and the greatest cause of ill-health and suffering across the globe. Poverty goes hand-in-hand with illiteracy and ignorance, and together they lead communities to deprivation, disease and death. Social upheavals, strife, armed conflicts, economic turmoil and disasters - both natural and man-made - add to the burden of suffering and disease in the already impoverished societies. The gap between the rich and poor countries in terms of infant and child survival is one of the starkest examples of inequity. This disparity also exists between regions and population groups even in rich countries. In some of the least developed countries mortality among under-five children is about 200 per 1000 live births whereas in parts of the developed world the rate is only 6 per 1000 live births. Malnutrition contributes substantially to childhood diseases and deaths. A rapid shift towards urbanization has profound implications for the delivery of health services. Unplanned and chaotic growth of urban centres poses particular problems such as poor sanitation and housing, easy spread of infectious diseases and undesirable social upheavals, which often lead to breakdown of family units. Problems which appear to be local have international repercussions. These challenges need to be faced with common responses and collective action.

Brunei Darussalam is fortunate in that our country has attained most of the health-for-all goals set out by WHO. This is due to the peace and stability we enjoy in our region and, in our own case, to the dynamic and compassionate leadership of His Majesty the Sultan and the Yang Di-Pertuan of Negara Brunei Darussalam.

We firmly believe that the strategy of primary health care can provide greater equity in health to underprivileged and deprived communities. Economic policies conducive to sustained growth are among the most important measures the government can take to alleviate poverty and to improve the health of the population. At present in several countries public money is spent on health facilities of low cost-effectiveness, involving high-cost technology, whilst at the same time critical and highly cost-effective services such as essential clinical care of commonly prevailing health problems and preventive programmes of immunization and disease prevention remain underfunded. The poor lack access to basic health services and receive low-quality care. Government spending goes disproportionately to the affluent in the form of high-technology care in sophisticated tertiary care hospitals that only benefit few better-off urban groups. Policy-makers need to set priorities, taking into consideration the health needs of all sectors of the population and the available resources for equitable distribution. For several countries the economic burden of debt servicing is added to the already dismal financial situation due to their different priorities, both internal and external, which lead to more suffering for the disadvantaged.

Individual countries alone are not able to overcome problems of such magnitude. They have to forge solidarity within and between countries, foremost through the United Nations, its organizations and specialized agencies. WHO is, no doubt, best placed to provide the initiative and coordination for global health development.

It is our fervent hope that the international health community will remain committed to providing greater equity in health to all people of the world by adhering to the primary health care strategy. WHO has hitherto responded promptly to major health concerns of Member countries. Its next programme, spanning 1996 to 2001，focuses on lessening inequities in health, control of the rising costs of health care, eradication and elimination of selected infectious diseases, the fight against chronic diseases and promotion of healthy behaviour and healthy environment. This is indeed well-thought-out strategic planning, which we wholeheartedly support. I wish to make special mention of the initiative of the Western Pacific Region for "New horizons in health". This points to ways for collaborative health work for health promotion and protection in the countries, particularly the Island States in the Region.

In conclusion, once again, I wish to express our sincere appreciation and thanks to Dr Hiroshi Nakajima and Dr S.T. Han for their successful leadership and management of global and regional health affairs.

Le Dr ZILHAO (Mozambique):

Monsieur le Président, Monsieur le Directeur général, honorables délégués, Mesdames, Messieurs, au nom de la délégation de la République du Mozambique qui m'accompagne, j'ai le grand honneur' de m'associer aux orateurs qui m'ont précédé pour vous féliciter, Monsieur le Président, ainsi que les membres de votre bureau, d'avoir été élu pour conduire les travaux de la Quarante-Huitième Assemblée mondiale de

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la Santé. Je vous souhaite beaucoup de succès dans votre mission et j'espère que cette Assemblée nous permettra de discuter des problèmes qui préoccupent nos peuples et notre Organisation dans un climat de sérénité et de franchise.

Le Rapport sur la santé dans le monde, 1995, première publication préparée pour donner suite aux recommandations du Conseil exécutif, est bien présenté. Nous tenons à féliciter le Secrétariat pour ce document d'une importance notable. Le Rapport montre combien le monde est malade; il révèle que la plus grande source de souffrances dans le monde est la pauvreté extrême dans les pays en développement.

Cette Assemblée a lieu deux mois après le Sommet mondial de Copenhague pour le développement social, événement très important pour la vie de toute l'humanité car, pour la première fois, le monde entier s'est réuni au plus haut niveau pour se pencher, entre autres, sur les problèmes du développement, de la pauvreté, de la misère et de la faim, de la dette, de la dégradation de l'environnement et de l'instabilité politique 一 sans oublier les problèmes des réfugiés et des personnes déplacées - ， q u i menacent sérieusement la santé de l'homme et l'aspiration de l'être humain au développement. Le rôle de l'OMS dans le suivi du Sommet est indiscutable. C'est dans ce sens queje propose que nous fassions le point sur cette réunion afin que, à la lumière du Rapport sur la santé dans le monde qui vient d'être publié et du rapport du Directeur général sur l'activité de l'OMS en 1994，nous puissions conjuguer nos idées et nos efforts en vue d'une prise en compte prioritaire des problèmes de santé.

Avec la fin de la guerre en 1992, suivie de l'Accord général de paix, la paix au Mozambique est effective. Pour la première fois, des élections générales multipartites ont eu lieu en 1994 et un nouveau Gouvernement est au pouvoir depuis décembre 1994. La démocratie pluraliste est une réalité dans mon pays. La paix effective que le Mozambique connaît pour la première fois depuis 15 ans a commencé à créer un climat favorable au développement et au progrès sur le plan social.

Parmi les priorités que le Gouvernement a établies dans le cadre de la reconstruction nationale, je mentionnerai Г éradication de la pauvreté, l'amélioration de la qualité de la vie des populations les plus défavorisées, l'éducation, la santé, la justice sociale, la création de possibilités d'emploi en vue d'un vrai développement humain soutenu.

Dans le domaine de la santé en particulier, les objectifs majeurs pour l'année 1995 sont : l'extension de la couverture sanitaire au niveau périphérique, l'amélioration de la qualité des soins - qu'il s'agisse de la promotion de la santé, de la prévention, du traitement ou de la réadaptation - à tous les niveaux du système de santé, et le développement de la capacité gestionnaire du Ministère de la Santé à tous les niveaux en ce qui concerne la planification, l'exécution et l'évaluation des activités qui sont menées.

La situation de pauvreté et de sous-développement de mon pays se traduit par une réalité sociale marquée par des problèmes de santé et un profil épidémiologique caractérisé par des taux élevés de morbidité et de mortalité infantiles et maternelles, surtout dans les zones rurales et périurbaines où la couverture par les soins de santé et les conditions de vie sont précaires.

Les maladies transmissibles (notamment les maladies diarrhéiques, le paludisme, la rougeole) et la malnutrition sont encore les principales causes de morbidité et de mortalité au Mozambique. L'augmentation croissante de notre capacité diagnostique nous permet de mesurer l'ampleur de la pandémie d'infection à VIH/SIDA, qui prend des proportions géométriques semblables à celles qui sont observées dans les autres pays du monde. On estime que 400 000 adultes sont infectés par le VIH, dont 15 000 ont fait un SIDA. Les maladies sexuellement transmissibles sont un des principaux moyens de propagation du VIH. Nous sommes sûrs que la situation épidémiologique sera mieux étudiée après les années de guerre que nous avons connues.

Les accidents de la route, la violence et la sécheresse dans quelques zones du pays ont tendance à aggraver la situation sanitaire générale.

Malgré tout, nous sommes contents d'enregistrer des progrès dans les services. En 1994, nous avons fait le point de la situation et constaté que, par rapport à 1993, les consultations par habitant sont passées de 26 à 29 %. La couverture vaccinale par le DTC (troisième dose) est passée de 49 à 66 %，la couverture vaccinale pour la rougeole est passée de 60 à 66 % et le volume global des activités s'est accru de 9 %.

Entre-temps, le Mozambique a eu des problèmes d'approvisionnement en médicaments. Il faut souligner que 99 % des médicaments qui sont consommés dans le pays proviennent de dons. En 1994，la disponibilité pharmaceutique a été de US $0,97 par habitant contre US $1,23 en 1993.

Les efforts que nous menons en vue de la reconstruction nationale ne seraient pas possibles sans la contribution généreuse de la communauté internationale. Au nom de mon Gouvernement, je profite de l'occasion qui m'est offerte pour remercier tous ceux qui ont aidé au développement du système de santé national de mon pays pendant les années passées, et j'invite tous nos partenaires dans le secteur à continuer d'accorder leur soutien afin que le programme de reconstruction nationale défini par le nouveau Gouvernement soit viable. Investir dans le secteur de la santé, c'est aussi contribuer à une paix durable au Mozambique.

A48/VR/8 page 141

Dr SEIXAS (Brazil) {interpretation from the Portuguese)}

Mr President, Director-General, delegates, on behalf of the Brazilian delegation I congratulate you, Mr President, on your election; I am certain that under your guidance we will achieve the results we all yearn for in this forum. I take this opportunity to thank Dr Nakajima for the valuable work he has been undertaking, and I would also like to express my confidence and best wishes to the new Regional Director for the Americas, Dr George Alleyne.

The topic chosen for discussion at this Assembly leads me to share with this group of experienced professionals and citizens seriously committed to the idea of promoting equity and solidarity in health some thoughts presented recently by the Brazilian Minister of Health, Professor Adib Jatene.

The main idea involved in the promotion of equity and solidarity in health is reducing the contrary of equity which is not merely a fight against inequality but an attempt to eradicate unacceptable injustice still existing in most societies. We still observe that the privileges of some minorities are kept at an extremely high social cost which is detrimental to the interests of the majority. Certainly, this situation is not compatible with a minimum of solidarity in health. Solidarity should not be taken as poetic expression of an abstract and transient feeling, but as a basic and real support to promote happiness and pleasure: a lasting feeling to be shared with our fellow men; an attitude to be cherished and remembered by the future generations - solidarity in the sense that it fulfils a basic need of all human beings: perpetuity.

I would like to add a third element to this discussion on equity and solidarity. I refer to liberty, since it is one of the essential components of a trilogy that expresses the ideals of the most civilized humanism: liberty, equality and fraternity, which could be better translated, at present, as "liberty, equity and solidarity". The most cherished fruit of liberty is creativity, which is the capacity to procreate, to continue, to modify, to adapt, to expand, in such a sense that one of its main consequences is scientific and technological development. How are these scientific and technological advances incorporated into our history and how do they interfere with equity and solidarity among peoples and nations?

In the last decades the world has gone through enormous changes, and one of the characteristics of this process is that present societies are submitted to a scientific and technological development that has substantially increased the complexity of the issues related to the enormous technological advances, the exercise of medicine and the health care systems. In the 1950s, the available resources for diagnosis were very limited, which forced medical doctors continuously to improve their expertise in obtaining information from their patients. As a result, a strong relationship between the professional and the patient was established, based on a high level of responsibility and mutual respect. The continuous introduction of techniques and sophisticated equipment has caused a complete change in this scenario. Indeed, the period of advance started in the 1960s has been overwhelming, and has allowed us to become acquainted with the mechanism of diseases, physiopathologies of morbid phenomena and the verification of toxicity and bioavailability. These advances, however, have also resulted in the establishment of a powerful industry of equipment and medicines which acts aggressively in marketing. Medical doctors are being progressively transformed into employees with multiple jobs, since today the elements for diagnosis belong to public and private institutions. Huge investments made by hospitals throughout the world drive them into profit-seeking procedures based on cost/benefit considerations. These institutions also establish the number of laboratory examinations required to pay their debts. These aspects naturally affect the professional ethics itself; such a voracity in generating revenues explains why medical practice has become a mere business. Furthermore, the medical industry has its own research centres nowadays. Thus, the scientific knowledge which previously was the heritage of mankind is now the property of a few. The impact of this situation on the price of medicines is obvious, since these are set according to the interest of the companies and do not take into consideration the purchasing power of the population.

All these developments have also provoked substantial changes in the Brazilian epidemiology. The incidence of infectious/contagious diseases has decreased (smallpox and poliomyelitis have been extinguished, and measles is about to be eliminated). Diseases preventable by vaccination are being controlled, and antibiotics dominate the infectious illnesses. It is also important to note that all these diseases were short-lived but have progressively been replaced by chronic and degenerative diseases (cancer, heart diseases, diabetes, hypertension, among others), with long-lasting therapies. This phenomenon puts an extraordinary burden on the health systems of several countries.

What is the real percentage of the planet's population having access to health technological advances and able to afford the long-term and expensive treatment? Most of the world population does not have


A48/VR/7 page 142

effective access to the benefits of such advances. This reality should strengthen social awareness. The impact of this pattern of development has not affected the health sector alone. The social field as a whole has been hit by its influence. The process of urbanization has been drastically boosted, and the number of the socially excluded who have settled in the periphery of the large cities has significantly increased. The growing number of the elderly represents an additional burden, considering the scarce availability of jobs to the young who could support those who no longer work.

This situation is in itself a matter of concern, but it is particularly serious for developing countries. In these countries, the great range of highly efficient medicines cannot be afforded either by a large part of the population or by the governments, which ultimately are responsible for providing them for the poor. These facts and trends confirm the relevance of the topic proposed for debate at this Assembly.

The present relation between scientific and technological development and the prevailing economic and financial interests in society requires a new approach in order to reach a higher ethical standard. This strategy seems to be the only way to accomplish a model of development that integrates equity and solidarity with all aspects of health: physical, psychological, intellectual and social. We should aim at the promotion of a culture of values which adds to the concept of liberty an ethical component, encompassing individual and collective responsibilities.

Therefore, all WHO Member countries should seek proper instruments to create the political will to ensure that prices are compatible with the economic realities of most of the world's population. This is particularly true when the products are part of governmental programmes dedicated to assist the poor. I am referring to a political will that is shared by government, entrepreneurs, nongovernmental organizations and the community in general. In concrete terms, this political will might take the form of a fund to be created through the establishment of taxation on international financial operations. This proposal has been submitted to other forums, recently, and is under discussion in Brazil. By means of this fund the most urgent reforms needed in the systems of health assistance all over the world might become feasible, while the international community is engaged in finding mechanisms to mend the gap constituted by the current disparities in development and related inequalities.

This political will should not be interpreted as "the art of the possible", as defined by Bismarck, nor the "art of the impossible"，conceived by Bolivar, but the "art of making possible the necessary", in the words of the President of Brazil - Fernando Henrique Cardoso. With that in mind, values may prevail over interests. In short, we should put into practice the principle according to which the right to offer the best to a few will be legitimate only when the necessary for all is guaranteed.

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Dr SKRABALO (Croatia):

Mr President, Mr Director-General, excellencies, ladies and gentlemen, it is only the third time - after achieving independence and becoming a Member of the World Health Organization - that the delegation of my country takes part at the Health Assembly. However, even before that event, in the former, dissolved country, we were always the main factor in international health activities, and in particular in the collaboration with the World Health Organization.

H.E. Dr Andrija Hebrang, Minister of Health of the Republic of Croatia arrived yesterday in Geneva in order to participate directly in the work of the Forty-eighth World Health Assembly despite the heavy bombing of the Croatian capital Zagreb and its civilian facilities for two consecutive day. The very centre of Zagreb was hit by 22 projectiles plus their bombs, while in other Croatian towns like Dubrovnik, Karlovac, Sisak, Daruvar, Novska and Nova Gradska were inflicted human losses and serious material damages. These were deliberate, provocative and aggressive acts by the Serb extremists in Croatia's occupied territories. Yesterday, immediately after landing at Geneva airport, Minister Hebrang was acquainted with the Serbian terrorist attack which also hit the surgical theatre of the Central Children's Hospital in the very heart of Zagreb. That is the reason why he was obliged to leave Geneva immediately and is not able to be with us here today. According to the information received so far, the terrorist attacks on Zagreb during the last two days have so far caused the death of 6 persons, while 165 have been wounded. In the light of the above-mentioned barbaric attacks, I have the honour to deliver the speech on behalf of H.E. Dr Andrija Hebrang, Minister of Health of the Republic of Croatia.

Also, I would like you to remember that one of the founders of the World Health Organization, was our compatriot Croat, Professor Dr Andrija Stampar, who was the President of the First World Health Assembly in 1948. Already at that time Dr Stampar insisted on issues that also today come as leading ideas of The world health report 1995, namely "bridging the gaps". This can be achieved with equity and solidarity, a feature of the health system that is specially emphasized in this session. Since, as a new country coping with many difficulties, we have little capability to influence equity and solidarity on the international level, I shall discuss here how these principles are applied in our country - in the Republic of Croatia.

As you well know, Croatia is suffering from the results of Serbian aggression and still today approximately 17% of its territory is occupied. The consequences are catastrophic for the economic situation and therefore also for the health sector. The inflow of financial resources in the health sector has dropped to one-third of what it was in the year 1990, because 50% of our industry has been destroyed by Serbian attacks. During the past four years we have taken care of health needs of not only four and a half million citizens of the Republic of Croatia, but also of one and a half million refugees from Bosnia and Herzegovina as well as Croatian displaced persons. The aggressor has destroyed one-eighth of our hospitals and 20% of our primary health care facilities. In such a situation the basic question was how to ensure equitable access to the health system. The harsh economic crisis has particularly affected the population of our counties that are close to the front line. For these reasons, we have introduced a system in which counties that are in an economic sense better off contribute much more to the joint health care resources in order to provide funds for financing health care in counties where the economic capacities have been reduced as the result of war damage and devastation. We have decided to introduce such a system of financing health care not only to ensure equity and solidarity for the people of war-affected counties, but also for almost 400 000 refugees and displaced persons currently living in Croatia.

In accordance with our general economic policy to follow the principles and practice of developed industrial countries of Europe, we have introduced in our health system mechanisms and instruments of controlled, managed market forces, and we are now in the stage of careful privatization of primary health care services. In the reorganized system we are introducing elements of competitiveness. In this way, we, as a country in transition, fully accept and respect the need for economy in health, but it also has to be introduced in a controlled manner.

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We have introduced very strict control of financial transactions with a view to eliminating all unnecessary expenditure. Such reorganization is of course facing much opposition, but it is the only way to maintain equity in difficult economic times. With the reorganization of financial support to health we have managed to consolidate the financial management of our principal institutions responsible for health insurance. Important debts amounting to more than DM 350 million, which accumulated during the Communist period, have been settled, and in this way the regular supply of medicines and other materials has been consolidated. I would like to take this opportunity to state that we have always had very useful advice from staff of the WHO Regional Office for Europe, and on this occasion I should like to express our gratitude. Thanks to the introduction of successfully financial operations, we are planning for this year the first investments for development. We are proud of the fact that our health reorganization was accepted by the World Bank, which supported our next plans with a loan. Our cooperation with WHO has helped us in preparing that great project. Also, jointly with the Regional Office for Europe we are undertaking activities for the implementation of the Croatian Master Plan for Health. This plan includes, in addition to the rehabilitation of victims of war and the reconstruction of the health infrastructure destroyed in the war, the medium- and long-term plans for development of the Croatian health system. I would like to mention that we have been continuously receiving support from a large number of international organizations.

Thanks to the aforementioned changes in the organization of the health system in the Republic of Croatia, I am proud to inform you about a very special development in my country. In spite of difficult war conditions, economic crisis, destroyed hospitals and primary health care facilities, and a great number of refugees and displaced persons, the trends of our health care indicators provide for optimism. In the period of the reorganization of the health system, we are observing a decrease in infant mortality, which is now among the lowest in countries in transition and countries of central and eastern Europe. Maternal mortality has also decreased, life expectancy has increased and we are also pleasantly surprised with the age-adjusted death rates, as well as with specific mortality from the group of diseases that create most problems around the world, namely the cardiovascular diseases. During the same time, we need significant support to meet the expenditures for refugees and displaced people.

I would suggest that several conclusions could be drawn from our experiences. First of all, it is important to pay more attention to the development of health management in countries with limited financial resources. Efforts have to be concentrated on rationalization of limited financial resources, which include the introduction of competition, and careful privatization of primary health care services, introducing competition within the government-owned hospitals and strict control by the State of prices and the way funds are used.

The basic goal of the above-mentioned elements is to ensure that with available health institutions and their capacities it would be possible at the same time to maintain and apply the principles of equity and solidarity, while introducing controlled and managed market forces. We are sure that increased international collaboration and exchange of experiences about these principles, under the leadership and supervision of WHO, would pave the way for more just and efficient health systems in many countries.

With these conclusions we join all those who expect positive movements in the health status on global, regional and national levels, and with these wishes I would like to close this short address.

El Sr. MASSAD (Chile):

Señor Presidente: Muchas felicitaciones por su designación. Señor Director General, señores delega-dos, hace un año les contaba que el Estado chileno había intervenido con éxito en la salud de la población desde muy temprano en su historia. Les decía que esa intervención requería un nuevo impulso, para servir a los más necesitados, modificando radicalmente nuestras formas de gestión, nuestros mecanismos de asignación de recursos, además de impulsar cuantiosas inversiones, orientados por los principios de equidad, descentralización y participación. Hoy, un año después, vengo ante ustedes a informar con satisfacción de los avances logrados.

En primer lugar, después de varias décadas, hemos realizado un cambio importante en los programas básicos de salud, buscando responder al nuevo perfil demográfico, etáreo, cultural y epidemiológico de la población. Junto a los antiguos programas de salud del niño y del adulto, incorporamos separadamente el programa de la mujer, con una perspectiva integral de sus problemas que nos permite superar la restricción de considerarla sólo en cuestiones reproductivas; y el programa del adolescente, en el que se reconoce la complejidad y el impacto social de los problemas de salud emergentes de este grupo etáreo. Estamos enfrentando nuevas e interesantísimas cuestiones en campos que cobran gran importancia en la vida de los

A48/VR/7 page 146

chilenos. En segundo lugar, estamos involucrando activamente a los establecimientos asistenciales en la gestión de las tareas de salud pública. Para ello, celebramos lo que hemos llamado compromisos de gestión entre el Ministerio, los servicios de salud y los establecimientos asistenciales. Ello supone la definición compartida de objetivos de salud pública que deben ser cumplidos en un periodo determinado. Estos objetivos se refieren tanto a la obtención de resultados en los indicadores de salud de la población, como a la gestión operativa y financiera del servicio que los asume, correspondiendo al Gobierno aportar el financia-miento y la asesoría técnica necesarios. He querido referirme a estos compromisos porque, a través de ellos, es como hemos logrado algunos resultados que han sido calificados de espectaculares.

Por ejemplo, la campaña de prevención de enfermedades de común ocurrencia en el invierno se realizó durante 1994 precisamente a partir de la suscripción de compromisos de gestión entre el Ministerio y diversos servicios de salud. Ello nos permitió disminuir las muertes por neumonía de niños menores de cinco años en un 39% respecto de 1993. También logramos disminuir la letalidad de las infecciones meningocóci-cas desde un 10,6% en 1993 hasta un 8,2% en 1994，así como aumentar considerablemente las consultas médicas.

Un ámbito importantísimo en el que hemos desarrollado compromisos de gestión es el de las interven-ciones de alta complejidad. Este sector es precisamente uno de los más afectados por el deterioro financiero y tecnológico que sufrió el sistema público de salud en las décadas de los años 70 y 80. Dado que las enfermedades cardiovasculares constituyen la primera causa de muerte en el país, el esfuerzo principal estuvo centrado en la recuperación y desarrollo de la cardiocirugía. Durante la segunda mitad de 1994 logramos prácticamente duplicar las cardiocirugías, lo que no habría sido posible sin este programa de apoyo. Esperamos durante 1995 avanzar en la reducción de la brecha entre oferta y demanda en los servicios públicos para pacientes crónicos y cardiópatas congénitos. Asimismo, estamos concentrándonos en la resolución de los problemas neuroquirúrgicos, transplantes renales e intervenciones traumatológicas en patología crónica de caderas y columna vertebral, especialmente en los niños.

En tercer lugar, la prolijidad con que se han aplicado los programas de control del cólera y prevención del sarampión permitió que 1994 finalizara sin casos de cólera y sin casos de sarampión. Respecto de esta última enfermedad, nuestro país avanza en su erradicación definitiva: no se registran casos autóctonos desde 1993. Estamos desarrollando un censo serológico que nos permitirá establecer con precisión el momento en que corresponda impulsar una nueva vacunación contra el sarampión.

En los últimos diez años, la bacteria Haemophilus influenzae tipo В ha causado más infecciones graves y muertes en niños que los meningococos, en particular la meningitis. Tras dos años de estudios, dispone-mos de antecedentes suficientes para recomendar el uso de vacunas que comenzaremos a aplicar a partir de 1996 como parte de nuestro Programa Ampliado de Inmunizaciones. Por otra parte, estamos llevando a cabo una campaña de educación masiva a través de los medios de comunicación para prevenir la propagación del VIH/SIDA. El signo distintivo de esta campaña es que ha procurado respetar las distintas sensibilidades culturales y religiosas que coexisten en el interior de la sociedad chilena, presentando opciones de prevención que reconocen esta diversidad. La excelente respuesta que hemos tenido del público nos indica que estamos caminando en la dirección correcta.

Durante 1994 hemos iniciado la aplicación de nuevas formas de financiamiento de la atención primaria de salud, que permiten a la gente inscribirse en los consultorios y cambiarse si lo requieren, llevando consigo su financiamiento. Esto estimulará una mejoría de la atención a ese nivel. Al mismo tiempo, en más de la mitad de los consultorios del país se han logrado implementar mecanismos de atención que minimizan los tiempos de espera. En los hospitales se ha modificado también el sistema de financiamiento, y ha comenza-do a implementarse un sistema de pago según diagnóstico y tratamiento que estimula la mejor atención de los pacientes. Cincuenta hospitales implementarán este año mecanismos de participación comunitaria en su dirección, paso previo para avanzar en una mayor autonomía en la programación y en el uso de sus recursos. Los cargos directivos de los hospitales públicos se llenarán por estrictos concursos abiertos, garantizando así la calidad profesional y la igualdad de oportunidades.

La magnitud de los cambios que estamos intentando desarrollar en el sistema público de salud chileno nos ha enfrentado a conflictos de importancia con algunas de las principales organizaciones gremiales del sector. Ello ha ocupado nuestra atención de manera privilegiada, aunque sin descuidar las tareas permanen-tes, toda vez que la magnitud del esfuerzo realizado, así como la importancia de las definiciones estructura-les, exigen una gran legitimidad para proyectarlas y darles estabilidad en el tiempo. En ese sentido, este Ministerio no ha hecho más que insistir en la tesis fundante de los gobiernos democráticos en mi país: la necesidad de impulsar una gran concertación política y social por los cambios. Hoy vemos con optimismo cómo progresivamente los diversos actores se han ido plegando a esta fuerza de cambio que se presenta en

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la salud pública chilena. Confío en que ello nos permita aprovechar la gran oportunidad histórica que han abierto los gobiernos democráticos de Chile para avanzar en la dirección requerida.

Termino agradeciendo públicamente, en nombre del Gobierno del Presidente Eduardo Frei, la labor desarrollada por el Director General, Dr. Hiroshi Nakajima, especialmente por la dedicación que pone en el servicio a todos los habitantes de la tierra, y dando las gracias también a Sir George Alleyne, que ha asumido la dirección de la Organización Panamericana de la Salud. Muchas gracias, señor Presidente.

Mr FINETTE (Mauritius):

Mr President, Director-General, Regional Directors, honourable delegates, distinguished guests, ladies and gentlemen; first and foremost, on behalf of the delegation of the Republic of Mauritius, I would like to extend our heartiest congratulations to the President on his election as well as to the other members of the bureau and assure you of our full support. Your enlightened guidance will guarantee that our deliberations will be fully successful and produce fruitful results.

Our appreciation and gratitude go to Dr H. Nakajima, the Director-General, for his excellent account of the wide range of activities carried out by the Organization. I also wish to express our appreciation for all the endeavours in preparing the comprehensive report which is before us for our deliberation.

We are currently at a crucial stage in the history of mankind. As we stand on the threshold of the next millennium, the world is witnessing unprecedented turmoil in terms of loss of human lives and misery. Notwithstanding the immense knowledge available to mankind through technological advances such as robotic surgery, test-tube babies and genetic therapy and the ability to enhance health and human development, teeming millions are still craving for basic health care. Intercountry conflicts plaguing the African continent have led to the exodus of population in hundred thousands - mentally and physically shattered - to relatively safer areas, and there are insurmountable refugee problems. This should remind us of the challenges that still lie ahead and the need to strengthen our willingness to fight these problems and revive the hopes of the sick and deprived. Whenever man-made or natural calamities strike and bring about untold miseries, my Government has always remained sensitive to the plight of the needy. Following the severely condemned massacre of thousands of people in Rwanda, the displacement and exodus of large numbers of people to bordering countries and the passage of cyclones in our neighbouring country, Madagascar, spontaneous spurts of solidarity were seen to emerge from all the strata of our population in reaction to the emergency needs of those afflicted by these tragedies.

Within the framework of health-for-all policies, WHO is leading the world in providing technical support to Member States, coordinating international health activities and making intensive efforts to decrease the discrepancies in accessibility to health services. The endeavours of the Organization to provide leadership and to upgrade the standard of health care delivery in the world, including Mauritius, is very much appreciated. In the context of the present biennium, in technical cooperation programmes, together with health-for-all activities, priority has been given to the improvement of quality of health care, development of healthy lifestyles, support for health reform activities, development of human resources development for health and strengthening of the information system.

The standard of health of the Mauritian population has improved significantly over the last decades. This is clearly reflected in the substantial decrease in mortality and morbidity rates. The implementation of an efficient health care system over the years has indeed contributed towards this major achievement. Today, Mauritians are enjoying better health, higher quality of life and a longer life expectancy. The Government, through its primary health care delivery system, has been able to reach the masses successfully, as reflected in the immunization coverage and utilization of maternal and child health services. We in Mauritius firmly believe in the positive fall-out of a vigorous health promotion and protection programme. Our immunization programme covering six target diseases is an integral part of the basic district health package. Mauritius enjoys polio-free status, the last case of poliomyelitis dating back to 1967. Nevertheless this year World Health Day was observed to sustain the motivation for immunization in the spirit of global eradication of poliomyelitis.

Along with many other newly industrialized countries, Mauritius is in epidemiological transition. On the one hand we continue to record a decline in infectious diseases, on the other hand we are more than ever confronted by alarming rates for noncommunicable diseases such as diabetes, cardiovascular diseases and cancer. Contrary to communicable diseases, the diseases of affluence tend to be life-long, and the key to those problems lies as much with individuals as with the health service.

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The emergence of HIV and AIDS has baffled all of us with its tragic unknown proportions. The AIDS pandemic which is continuing its silent march is a serious threat to the hard work invested by many developing countries in achieving a substantial reduction in mortality. The disease can no longer be perceived as only a health problem, as it is a direct threat to the socioeconomic development of many countries and societies. In this connection, we highly commend the establishment of the joint and cosponsored United Nations programme on HIV/AIDS. The leadership role assigned to WHO is a challenge which will stay with us for decades. In my country the national AIDS control programme was initiated at a time when no case of AIDS was witnessed; we have had a relatively late introduction to the HIV/AIDS virus and we have so far succeeded in maintaining a low prevalence rate. However, we have to remain extremely vigilant given the high mobility of our citizens and the large inflow of tourists from countries of low prevalence.

Thanks to a fully comprehensive family planning programme on which my country embarked during the mid-1960s, and increasing vaccination coverage, Mauritius has undergone rapid demographic transition from high levels of fertility and mortality to a rapid decline in fertility, levelling off at around replacement level, along with a rapid decline in general fertility. Thus for the years to come our main concern will be the socioeconomic implications of an aging population.

Health care financing, the chosen theme for the technical discussions, could not be more appropriate. Against the background of escalating costs of health care services, coupled with the inability of governments to maintain growing budgetary allocations to the health sector, an assessment of health care financing mechanisms is imperative.

In this perspective my Government is at present in the midst of a complete analysis of all the fundamental issues besetting the health sector. With assistance from WHO and the World Bank, the Government has already embarked on a major review of the delivery of health services. An action plan is being formulated, and one of the major components is to work out the mechanism for health care financing. We are operating with a scenario of a public/private partnership in the delivery of health care. However, the Republic of Mauritius being a welfare state, health service in the public sector is provided free of charge. We are studying whether it is still financially possible also to provide tertiary "high-tech" care free of charge. As part and parcel of this national exercise a "burden-of-disease" study is currently in progress to analyse the cost-effectiveness of interventions against major diseases.

Conscious of the major financial and technical implications，we have obtained the support of WHO and the World Bank in this exercise. I wish on behalf of my Government to express our deep appreciation to the Director-General of WHO for the continuous support in the delicate task of proposing options for health care financing.

Finally, I wish to congratulate the Regional Director for Africa, Dr Ebrahim Malick Samba, on his election and assure him of our fullest support in his term of office.

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 WHO, which have worked alongside us in forging a stronger and healthy Mauritian nation.

Dr DROBYSHEVSKAYA (Belarus): Д-р ДРОБЫШЕВСКАЯ (Беларусь):

Уважаемый г-н Председатель, уважаемый г-н Генеральный директор, дамы и господа! Разрешите мне, г-н Председатель, от имени делегации Республики Беларусь поздравить

вас и моих коллег - ваших заместителей, с избранием на столь высокие посты и выразить уверенность, что международный авторитет, большой опыт и профессионализм позволят вам успешно руководить ходом настоящей сессии и решать сложные и важные проблемы здравоохранения. Я также хотела бы поблагодарить г-на Генерального директора и членов Секретариата за проделанную ими огромную работу со времени Сорок седьмой сессии Ассамблеи и великолепно подготовленный доклад о состоянии здравоохранения в мире. Прошел сравнительно небольшой период со времени возобновления работы Беларуси во Всемирной организации здравоохранения в качестве активного члена, и мы надеемся, что Республика сумела в определенной степени включиться в деятельность этой Организации по выполнению Восьмой общей программы работы и Программы ЕВРОЗДОРОВЬЯ для достижения поставленной цели здоровья для всех к 2000 г. Данная цель по сути является вневременной, и интенсивные усилия всех государств по обеспечению для населения своих стран возможно высокого уровня здоровья не должны ослабевать никогда. В то же время стратегия достижения

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здоровья для всех должна обновляться в соответствии с происходящими в мире изменениями, а планы действий отдельных стран - отражать новые возникающие требования. В этой связи мы высоко оцениваем усилия Всемирной организации здравоохранения по оказанию помощи странам в определении руководящих направлений работы, определении приоритетов, постановке реальных целей и задач в планировании, оценке и реализации политики в области здравоохранения. Основываясь на принципах, определенных ВОЗ, в 1994 г. Министерство здравоохранения Беларуси разработало Концепцию развития здравоохранения в Республике до 2000 г. Согласно данной Концепции, политика охраны здоровья будет, в частности, включать положения справедливости и равенства, обеспечения права людей на свободу выбора, доступа всего населения к медицинскому обслуживанию, обязательств людей по укреплению собственного здоровья. Концепция может служить основой для разработки национальной стратегии достижения здоровья для всех. Здоровье человека, как известно, является высшей социально-экономической ценностью любого общества, в то же время оно представляет собой зеркало социально-экономического благополучия этого общества. И здесь следует отметить, что, как и в большинстве новых независимых государств, система здравоохранения Республики Беларусь в настоящее время функционирует в чрезвычайно сложных условиях: глубокий экономический кризис, гиперинфляция, снижение доли национального дохода, направляемого на развитие отрасли, резкое ухудшение обеспечения медикаментами и медицинской техникой, их удорожание, ухудшение показателей состояния здоровья населения. В 1994 г. уровень смертности в Республике превысил показатели рождаемости. Данная ситуация усугубляется неподготовленностью органов здравоохранения к введению новых экономических отношений и решению концептуальных проблем здравоохранения. Особенно отрицательно сказывается на деятельности отрасли нестабильное и недостаточное финансирование, что привело к возникновению хронического дефицита медикаментов, оборудования, создало значительные трудности с оплатой питания больных, коммунальных услуг и других нужд лечебных учреждений государства. Понимая всю серьезность сложившегося положения, Минздрав проводит целенаправленную работу по адаптации отрасли к условиям суверенитета, перехода к рыночным отношениям. Продолжается создание правовой и нормативной базы здравоохранения, ведется поиск интенсивных и эффективных форм работы по приоритетным направлениям деятельности. По мере перехода к рыночным отношениям, система здравоохранения должна подвергнуться глубокому реформированию с созданием рынка медицинских услуг, многоканальным финансированием из государственных и негосударственных источников при защите прав наиболее социально незащищенных контингентов населения в рамках государственных программ. При реализации новых подходов возникает множество сложных проблем, поднимаются трудные вопросы. Одновременно возрастают требования к защите населения в сфере здравоохранения, особенно со стороны людей с хроническими заболеваниями, инвалидов и престарелых. Таким образом, органы, принимающие решения, касающиеся политики здравоохранения, стоят перед дилеммой между необходимостью радикальных изменений в системе и сознанием того, что резкая перестройка существующей системы может вызвать многочисленные трудности и нанести непоправимый вред уже функционирующим структурам. Поэтому предпринимаемые в этом направлении шаги должны осуществляться осторожно и постепенно, если мы хотим держать развитие ситуации под необходимым контролем. При этом темпы реформ также должны согласовываться с изменениями состояния экономики и социально-экономических отношений. На ситуацию здравоохранения в Республике продолжают оказывать негативное влияние и последствия катастрофы на Чернобыльской атомной электростанции, которые сегодня прямо или косвенно затрагивают практически всех жителей Беларуси. Действительность далеко не полностью соответствует ранее сделанным прогнозам наших и зарубежных ученых и специалистов. Об этом свидетельствует достоверно зарегистрированное ухудшение здоровья жителей Республики: растет заболеваемость анемией, туберкулезом, хронической патологией носоглотки, фиксируются изменения иммунной, эндокринной, нервной, кроветворной и других систем организма. Мы выражаем признательность Всемирной организации здравоохранения за ее участие в организации пилотных проектов Международной программы по медицинским последствиям Чернобыльской аварии (IPHECA). Вклад ВОЗ позволил нам поднять на определенную степень уровень исследований, отработать технологии обследования

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пострадавшего населения, ранней диагностики заболеваний, сбора, хранения и передачи данных о состоянии здоровья людей. Целесообразность и необходимость дальнейшей работы по программе (IPHECA) для полного выяснения медицинских аспектов последствий Чернобыльской катастрофы не вызывают сомнений. Эта работа будет иметь большое значение не только для пострадавших государств, но и для всего мирового сообщества. В этой связи мы выражаем надежду, что Всемирная организация здравоохранения сумеет найти возможности для продолжения исследований в рамках данной программы с целью выработки конкретных рекомендаций по минимизации воздействия радиационного эффекта на население. Наибольшую тревогу у нас продолжает вызывать состояние тиреоидной системы у детей. В настоящий момент зарегистрировано увеличение числа заболеваний раком щитовидной железы, что особенно характерно для местностей, расположенных наиболее близко к месту аварии. С 1986 г. в Беларуси прооперировано уже более 350 детей от 0 до 14 лет с раком щитовидной железы. Хотя увеличение числа заболеваний раком щитовидной железы пока еще не отнесено окончательно на счет Чернобыльской катастрофы и в зарубежных научных кругах до сих пор существует определенный скептицизм в отношении п р я м о й связи этого увеличения с радиацией, факт воздействия изотопов йода на жителей Беларуси заставляет нас рассматривать Чернобыль в качестве наиболее вероятной причины роста указанной патологии. В соответствии с этим, а также для объективной и беспристрастной оценки влияния последствий Чернобыльской аварии на рост патологии щитовидной железы Министерство здравоохранения Беларуси совместно с Европейским бюро Всемирной организации здравоохранения разработало и начало осуществлять Международный проект по щитовидной железе. Предполагается, что сотрудничающий центр ВОЗ по Международному проекту в г. Минске будет осуществлять свою деятельность в сети сотрудничающих центров Всемирной организации здравоохранения в Италии, Германии, Франции, Великобритании, Швейцарии и Японии. При этом Минский центр будет координировать все исследования по щитовидной железе и концентрировать результаты работ по данному проекту. Пользуясь случаем, я благодарю правительства Швейцарии и Люксембурга, которые внесли значительный вклад в обеспечение начала работ по данному проекту. Хотела бы надеяться, что правительства участвующих государств, а также других заинтересованных стран -членов Всемирной организации здравоохранения поддержат проект, в том числе и в финансовом плане. В заключение, от имени правительства Республики Беларусь, от имени Президента Республики Беларусь выражаю глубокую благодарность всем членам Всемирной организации здравоохранения, которые помогают нам решать проблемы Чернобыльской катастрофы.

Благодарю за внимание.

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-Huitième Assemblée mondiale de la Santé; je félicite aussi les Vice-Présidents de l'Assemblée et les Présidents des commissions qui ont l'honneur de vous aider dans l'accomplissement de votre mission. Je voudrais également adresser mes vifs remerciements au Directeur général, le Dr Hiroshi Nakajima, pour les succès incontestables dans sa mission d'amélioration de la santé des peuples du monde. Mes remerciements vont également aux Directeurs régionaux qui oeuvrent avec compétence à la réalisation de l'objectif de la santé pour tous.

Les progrès économiques ont apporté une vie plus saine à la population du monde. Cependant, en même temps, ces progrès ont induit de grands changements dans nos sociétés : l'industrialisation à outrance, l'urbanisation galopante, la détérioration de l'environnement favorisent la pauvreté de certains groupes de population et augmentent la marginalisation des groupes les plus vulnérables. L'allongement de l'espérance de vie, la réduction de la mortalité infantile, la baisse de la natalité entraînent le vieillissement de la population - ce qui engendre un nouveau besoin de services de santé - et un nouveau schéma pathologique causé par l'émergence de maladies chroniques et dégénératives qui s'imposent de plus en plus.

La vie moderne a parfois désintégré la structure familiale et accentué la marginalisation des groupes mères-enfants, ce qui compromet grandement leur développement individuel et social. Toutefois, même si la situation s'est améliorée sur le plan général, bien des injustices demeurent : dans certains pays, les plus

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pauvres, les nourrissons, les enfants et les femmes enceintes meurent à une fréquence vingt-cinq fois plus élevée que dans les pays les plus riches. La différence d'espérance de vie à la naissance peut atteindre trente ans. L'exode rural, motivé par la quête de meilleurs débouchés et d'un niveau de vie plus élevé, s'accompagne souvent d'un surpeuplement considérable qui génère de nouveaux bidonvilles. Or, cela aboutit inexorablement à de mauvaises conditions d'existence qui compromettent la vie, la santé et les valeurs sociales de milliards de personnes.

Face à cette injustice sociale qui s'accentue tous les jours, le développement humain va être menacé et le fossé qui se creuse entre les riches et les pauvres reflète le grand écart dans leurs revenus et la qualité de leur vie. Il faudra probablement remettre à plus tard la réalisation de l'objectif de la santé pour tous d'ici l'an 2000 qui donne le droit à toute personne humaine de s'épanouir pleinement et d'utiliser ses talents et son intelligence. Assurer un accès équitable aux services de santé fait partie de notre engagement. Notre mission de garantir aux pauvres et aux marginalisés cet accès équitable est une de nos premières préoccupations dans la stratégie du développement. Car la santé favorise l'atténuation de la pauvreté, la diminution du chômage et l'établissement de l'intégration sociale. La santé pour tous permettra donc de réduire l'écart entre le pauvre et le riche.

Nous devons bâtir par la même occasion une nouvelle solidarité humaine, solidarité née de notre souci commun de protéger, améliorer et enrichir la qualité de la vie; dans cette perspective, les interventions sanitaires ne se bornent pas à lutter contre la maladie, mais visent aussi à améliorer la qualité de la vie. C'est dans cet esprit que nous favorisons la collaboration menée dans le cadre de la politique de l'OMS; cette politique permet d'intensifier la coopération entre les pays et les peuples les plus démunis pour atteindre un état de complet bien-être physique, mental et social. Tous les habitants du monde doivent accéder, de cette manière, à un niveau de santé acceptable.

Bâtir la solidarité, c'est encore amener les hauts responsables politiques de tous les pays à se déterminer résolument en faveur de la santé en lui accordant la priorité nécessaire et en favorisant la réduction des inégalités en matière des soins de santé. La solidarité, c'est aussi encourager la coopération interrégionale, la collaboration entre les pays industrialisés et les pays en développement, sans oublier pour autant la participation de l'individu, de la famille et de la communauté, base active fondamentale de tout succès.

L'objectif de l'OMS, qui est d'amener tous les peuples du monde au niveau de santé le plus élevé possible, nous en sommes convaincus, reste inchangé. Ce concept d'accès à la santé pour tous par la stratégie des soins de santé primaires et au moyen des programmes destinés à éliminer des maladies reste l'un des éléments essentiels de la lutte contre la pauvreté, Г inéquité et l'injustice sociale.

Je félicite sincèrement le Directeur général, le Dr Hiroshi Nakajima, et les Directeurs régionaux pour les succès incontestables de l'OMS qui a obtenu, dans sa mission, une promotion importante de la santé. Je profite de cette occasion pour remercier le Dr S. T. Han qui a toujours été un collaborateur efficace et cette collaboration s'est toujours poursuivie.

L'Organisation a su reconnaître rapidement les occasions qui s'offrent pour les actions en faveur de la santé et les saisir à mesure qu'elles se présentent. Elle a su s'adapter aux changements mondiaux qui s'opèrent pour procéder à une réforme interne et structurelle; cela renforce et réoriente les services destinés à ceux pour qui les stratégies de santé pour tous sont un besoin et une volonté.

Il nous reste quelques années pour entrer au siècle nouveau. Nous devons améliorer notre méthode de travail afin d'atteindre l'objectif de la santé pour tous. Nous devons également renforcer la solidarité entre les peuples, garantir la notion d'équité pour que le mal du siècle qui finit soit banni au profit du rayonnement de la santé pour tous, au siècle prochain. Tout cela demande une grande force de cohésion dans un monde en mutation; le succès dépend d'une volonté commune et d'une détermination de tous et de notre Organisation à qui nous renouvelons toute notre confiance.

Mr SALA Vaimili II (Samoa):

Mr President, Mr Director-General, honourable ministers, distinguished guests, ladies and gentlemen, first of all I would like to congratulate you, Mr President, on your election to guide us through our deliberations during the Forty-eighth World Health Assembly. At this point I would like to bring greetings from our Head of State, Prime Minister and Government and the people of Western Samoa.

In the past decades WHO has striven to improve the quality of life of the people in the world. In doing so, many resources have been liberated to meet the challenge of health problems globally. It becomes more evident now that we have overcome many diseases but we are also facing many, many more as a result of environmental changes, lifestyle changes, and much more, the deadly disease of AIDS.

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My country, Western Samoa, has benefited a lot from the WHO programmes. This goes back four decades, when infectious diseases were the dreaded things in our everyday life. With the active participation of our country in WHO's Expanded Programme on Immunization, I am glad to say that some of the diseases, such as yaws, tuberculosis, leprosy, filariasis, poliomyelitis, whooping-cough, etc., have been completely eliminated in our country, and some others are almost under control at this stage. The life expectancy of our people which decades ago was between 43 and 45 years has improved greatly and it is now in the range of 63 and 65.

The vulnerability of the small island nations like Western Samoa to both climatic and also to environmental changes have influenced greatly our health programmes for improvement and also the sustainability of such health programmes in our country. Therefore we will depend very much on the helping hand of WHO. We would like to request, through this forum, your help, especially in the purchasing of our vaccines for immunization.

We give our full support for "Reproductive health: WHO's role in the global strategy". Reproductive health is an important part of general health. It has developmental and intergenerational components as well as improving the quality of life of individuals. Reproductive health should be introduced in countries and programmes as part of health, and should be made accessible within primary health care.

We have already heard several previous speakers mention the importance of equity and solidarity in health - bridging the gaps. But I wish to have your attention for a moment: we should appreciate that we are all living on this beautiful planet called the world. It is we who destroy it and create self-made diseases that kill so many innocent children of the world. I again pledge Samoa's commitment to equity and solidarity in health, and peace at all levels.

In conclusion, I would like to express our gratitude and sincere thanks to WHO, the Director-General, Dr Nakajima, and the Regional Director for the Western Pacific, Dr Han, for their continuous support to health programmes in Western Samoa.

Soifua\

Mr NGEDUP (Bhutan):

Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, may I begin by expressing the warmest felicitations of my delegation to you and the other members of the Bureau on your election to the high offices at this session of the Health Assembly. We are confident that under your able guidance the deliberations of this Assembly will be brought to a successful conclusion.

As the ingenuity and dynamism of human society propels mankind to the twenty-first century, we must still grapple with the most basic of all threats - the threat from diseases to survival. It is ironic that with every achievement in the field of medicine and associated sciences, the frailty of the human mind and body is only looming larger. New and alarming drug-resistant viruses and complex diseases appear to challenge the extent of our genius and material resources.

In a world that is fast shrinking under the compelling forces of globalization one is confronted with the sad realization that millions of people, young and old, in areas within and beyond national boundaries， will not see the dawning of a new century. Many of them will have succumbed to simple and preventable diseases, not because of old age or non-existence of medicines but because their social systems lacked the means to cope with their basic health needs and because they did not have the economic capacity to obtain them on their own.

My delegation would like to commend the Director-General and his team for The world health report 1995 which presents an analytical assessment of the current global health situation. While much has been achieved in pursuing the goal of health for all by the year 2000, the existing scenario in the developing countries calls for more concerted effort by the international community.

The central concerns calling for our collective attention at this session of the Assembly are equity and solidarity. Equitable access of all mankind to basic health needs is still a distant dream. Gross disparities exist in all forms. At one extreme there are the poor and the deprived who are exposed to all life-threatening diseases, while at the other extreme there are those among the affluent who enjoy the luxury of cosmetic procedures. In the ultimate analysis, it is true that poverty lies at the root of all ills. But I submit that in addition to the moral imperative there are other convincing reasons for the international community to assume a greater sense of shared responsibility to overcome, at the global level, the prevalence of the inequities.

It is heartening that our common concern for this vital social sector brings us together each year to share our experiences and to chart new courses for global initiatives. In this context, my delegation

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welcomed the convening of the United Nations Conference on Environment and Development in Rio de Janeiro, the International Conference on Population and Development in Cairo and the recently concluded World Summit for Social Development in Copenhagen. These have generated new insights into the functioning of and health hazards faced by the global society. Above all, these international gatherings have helped illuminate the fact that all aspects of human survival and growth are related and must be treated holistically. The need to adopt a multidisciplinary approach to the identification of social goals, the designing of strategies, the process of implementation, and impact assessment, has become ever more clear.

The coming together of all nations to address such vital concerns is a demonstration of the sense of solidarity that exists within the international community. Nevertheless, the scope for increasing cooperation at these levels remains large. There is, on the other hand, an equally great need for strengthening national policies and commitment. Often there are instances when a country's seriousness of political will and pronouncements is belied by its actual national expenditure profile. If we are to go beyond the rhetoric and accomplish the common aspirations stated at such gatherings, then the need for a higher level of solidarity and commitment is essential at community, national, and international levels.

Motivated by a strong sense of political will and supported by meaningful bilateral and multilateral cooperation, my country has taken major strides towards achieving the primary health care goals called for by the Alma-Ata Declaration of 1978. In the course of the last decade, Bhutan was able to bring down the infant mortality rate from 134 to 70 per 1000 live births and maternal mortality rate from 7.70 to 3.80 per 1000 live births; neonatal tetanus, iodine deficiency, vitamin A deficiency and leprosy have been either controlled or eliminated. No occurrence of poliomyelitis has been reported and 90% child immunization coverage is being maintained, and a decision has been taken to introduce hepatitis В vaccination. All health services including referral services abroad are provided free. Above all, decision-making power for basic health coverage lies in the hands of the communities themselves, with a strong element of community self-help and participation. Consequently, life expectancy has been raised from 46 to 66 years for our people. However, these successes have also resulted in an extremely high rate of population growth which we are addressing vigorously through public awareness campaigns, education, and intensification of family health services. These are evidence of equitable distribution of health care permitted by the meaningful support and solidarity of the international community.

WHO, since its inception, has played a pivotal role in providing guidance, support and coordination to improve the global health situation. It has accumulated and is still continuing to accumulate a wealth of information, expertise and technical capabilities to meet competently the ever-growing challenges that lie ahead of us. My delegation appreciates the far-sighted initiatives being taken by WHO to bring reforms within its system to meet new and emerging needs. Judicious use of the limited resources, with particular focus on the neediest, must be given special emphasis. Convinced of the continuing relevance of WHO, my delegation would call upon the international community to lend its fullest support to this noble Organization. We further take this opportunity to express our appreciation to Dr Nakajima, the Director-General, our Regional Director and all others in WHO for their valuable contributions in strengthening the health delivery system in my country.

As the year 2000 draws closer, every means must be employed to intensify our efforts to accomplish our cherished goal of health for all. However, care must be taken to ensure that in our enthusiasm to achieve that goal quantitative targets do not undermine genuine needs. In welcoming the initiatives taken by WHO to prepare strategies for the twenty-first century, we would like to urge that the questions of sustainability and qualitative improvement be given topmost priority.

Allow me, in conclusion, to wish all the distinguished delegates a fruitful Forty-eighth World Health Assembly. May our collective wisdom and efforts bring us a step closer to making our planet a healthier, happier and safer place.

M. SIDIBE (Mali) ：1

Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs les Ministres, honorables délégués, Mesdames et Messieurs, au nom du Mali, j'ai l'honneur de vous adresser, Monsieur le Président, mes vives félicitations pour votre élection à la présidence de la quarante-huitième session de l'Assemblée mondiale de la Santé. Je félicite également les Vice-Présidents et tous les membres du bureau qui ont

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.

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l'honneur de vous assister dans la conduite des travaux de cette session. Je tiens aussi à féliciter le Dr Nakajima et tout le Secrétariat qui peut être assuré de mon entier soutien en faveur de l'action de santé.

Monsieur le Président, la plupart des actions de santé que mon pays a menées dans le cadre des objectifs arrêtés pour 1994 ont subi les effets néfastes d'un contexte difficile, consécutif aux grandes crises économiques et sociales des années antérieures, auxquels s'est ajouté le changement de parité de notre monnaie, aggravant ainsi la pauvreté et rendant de plus en plus de Maliens vulnérables. Ainsi, malgré une augmentation significative de la part du budget de l'Etat affectée à la santé，qui, de 7,8 % en 1994 est passée à 8,1 % en 1995, beaucoup de nos compatriotes restent exclus du système de couverture sociale, les besoins en personnel socio-sanitaire restant insatisfaits et les infrastructures éloignées de la majorité de la population.

La réduction des fortes inégalités et le rétablissement de l'équité ont conduit à notre politique sectorielle de la santé qui vise à rendre les communautés responsables de leur développement sanitaire par une décentralisation qui donne aux collectivités la pleine jouissance de leur droit; par une approche fondée sur le potentiel humain qui garantit la prise en charge financière des réalisations librement acceptées sur la base d'un recouvrement des coûts et d'une solidarité nouvelle, prenant en compte les individus et les familles les plus démunis de la collectivité; et par la définition d'un "paquet minimum d'activités" compatibles avec l'état des priorités en matière de santé publique et avec les préoccupations fondamentales de la population. Aussi, cette dernière participe-t-elle effectivement à la définition de la nouvelle carte sanitaire et à l'installation de centres de santé communautaires en fonction de la carte sanitaire négociée. C'est dans un tel cadre que nous pensons pouvoir le mieux et le plus avantageusement contribuer à la santé dans le monde au sein de notre Organisation.

En effet, une récente évaluation a fait ressortir que, dans les aires géographiques disposant de centres de santé communautaires, la couverture sanitaire observée est très rapidement satisfaisante par rapport aux aires qui n'en disposent pas. Ainsi, en moins d'un an, dans les aires pourvues de centres de santé communautaires, la couverture par le BCG a pu atteindre plus de 90 % et la couverture par une troisième dose de vaccin antidiphtérique/antitétanique/anticoquelucheux/antipoliomyélitique 60 %, alors que les chiffres observés dans des aires voisines qui en sont dépourvues sont respectivement de 20 et 17 %. Par ailleurs, au niveau de ces structures, le coût moyen d'une ordonnance varie entre 500 et 800 francs CFA dans les centres de santé communautaires pouvant disposer de médicaments essentiels sous dénomination commune internationale (DCI), ce qui nous conforte dans notre choix délibéré en faveur de ces médicaments, le coût d'une ordonnance dans le système classique oscillant en moyenne entre 2500 et 4000 francs CFA.

Pour réduire convenablement tous les écarts, nous avons développé et mis en oeuvre une politique de solidarité qui vise à lutter contre les exclusions et les inégalités sociales, à prévenir et réparer les risques sociaux liés à la personne, et à promouvoir une politique en faveur des personnes âgées. Dans ce contexte, nous nous employons à développer des mécanismes sociaux aptes à soutenir les personnes âgées et les handicapés, et à assurer le financement. De même, les programmes en faveur des enfants sont développés et mis en oeuvre, conformément à nos objectifs intermédiaires portant sur le programme élargi de vaccination, la vaccination contre la rougeole, l'élimination du tétanos néonatal, la vulgarisation de la thérapie par réhydratation orale, la lutte contre les troubles dus à la carence en iode, l'élimination de l'avitaminose A et ses conséquences, l'éradication du ver de Guinée, l'encouragement de l'allaitement au sein exclusif pendant les quatre à six premiers mois. En outre, les programmes de santé publique en faveur des adultes notamment, nos programmes de lutte contre la lèpre, la tuberculose, le paludisme, la dracunculose, les maladies sexuellement transmissibles et le SIDA ont été réactualisés. Avec la conduite cette année, à partir du 15 mars, d'une enquête nationale sur la démographie et la santé, nous pensons pouvoir disposer des bases et indicateurs pertinents pour la surveillance des progrès en faveur de la santé pour tous d'ici l'an 2000.

Les questions importantes soulevées dans le Rapport du Directeur général ont retenu toute notre attention, d'autant qu'elles traitent des problèmes relatifs à la survie, au développement et à la protection de l'enfant, à la santé des personnes âgées et des couches défavorisées; plus particulièrement, nous souscrivons aux quatre grandes priorités que l'OMS envisage pour son action future. Ces priorités, si elles étaient assurées dans un cadre intersectoriel adéquat, nous permettraient de disposer des outils nécessaires à la mise en oeuvre de notre politique sectorielle à laquelle contribuent déjà les autres secteurs comme les finances, l'éducation de base, l'administration du territoire.

Le rôle joué par les partenaires au développement qui ont souscrit avec nous à cette politique et qui acceptent d'intégrer leurs interventions dans son cadre est à saluer ici. Avec leur appui, nous pensons bien pouvoir faire accéder tous les membres de notre communauté à des services de santé intégrés，continus et complets.

Notre Organisation, dont le rôle déterminant dans ce processus se passe de commentaires, devra particulièrement être plus présente à nos côtés pour le nécessaire renforcement des capacités gestionnaires nationales et l'organisation rationnelle de la lutte contre la maladie.

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Voilà, Monsieur le Président, quelques commentaires qu'il m'a paru nécessaire de faire au moment où nous discutons du point 10 de notre ordre du jour, commentaires dont la prise en considération nous aiderait à atténuer les inégalités et inéquités en matière de santé.

Dr MAKUMBI (Uganda):1

Mr President, honourable ministers, Mr Director-General, distinguished delegates, ladies and gentlemen, Uganda's delegation wishes, first of all, to congratulate you, Mr President, upon your election to the high office of President of the Forty-eighth World Health Assembly. We would also like to take this opportunity to extend the same felicitations to all the members of your office.

Some three years ago, a number of distinguished delegates were almost misunderstood when they strongly called for a review of the vision of WHO and urged the Director-General to redefine priorities and formulate appropriate strategies for improving the health status of the peoples of the world. Uganda's delegation is extremely glad to note that the above call was not in vain and wishes to thank most sincerely those distinguished delegates who boldly stood up for change in the Organization and the method of work of WHO. The courage and goodwill they displayed for the sake of humanity has begun to bear fruit.

For the first time in the history of WHO we are all now able to articulate confidently the need for the continued existence of the Organization. The world health report 1995 provides accountability for our collective efforts towards achieving better health for mankind, both globally and at national levels.

The emerging picture from The world health report shows that the burden of ill-health is vast across the age spectrum and that unacceptable inequities and huge gaps exist between the developed world and the least developed countries, most of which are found in the African Region. Diseases of backwardness dominate the picture in this Region and are holding up the socioeconomic development of the continent. For example 90% of malaria cases in the world are to be found in Africa, and - permit me to quote from document A48/3，paragraph 33 - "The estimated direct and indirect cost of malaria in Africa alone is expected to reach US$ 1.8 billion by 1995". In this respect malaria alone contributes very significantly to the abject poverty prevailing in Africa. Malaria, coupled with a multitude of other problems in the supply and accessibility of services points to a glaring fact - that WHO must evolve policies to direct investment in Africa and other least developed countries as a matter of priority; it is only then that the cycle of poverty, ignorance and disease will be significantly interrupted.

This investment in Africa must be done in partnership, because in most cases this group of countries has already risen to the challenge; all they need is critical support to exploit their varying potentials for the betterment of the quality of life among their populations and added prosperity in the developing world. In this regard Uganda's delegation wishes to appeal to members of this august Assembly to support the development of the Special Health Fund for Africa. This Fund was launched during the Fifty-second Ordinary Session of the OAU Council of Ministers in 1990. This Fund would go a long way towards complementing other sources of financing.

In the process of intensified partnership with Africa and other least developed countries, the first call ought to be for women and children, because these two categories are the key stakeholders in the hope and future of these countries. Efforts must also continue to stem the devastating effects of HIV/AIDS.

In bridging the gaps we should remember one old adage, "that the speed of a convoy is determined by the slowest boat". If we are to enter the twenty-first century in a better position, collectively as Members of WHO, the issue of the "slowest boat" has to be urgently addressed; and the report has clearly identified this boat.

Distinguished delegates, on the reports of the Executive Board, my country being a member of the Board can only reiterate that we stand for change and dynamic reforms to make WHO responsive and accountable to the peoples of the world. My delegation particularly endorses the resolution on intensified cooperation with countries in greatest need (document A48/2，paragraph 18).

In conclusion, Mr President and distinguished delegates, The world health report 1995 and the reports of the Executive Board, provide us with a framework on which to identify priorities, build policies and enact strategic plans for reducing inequities and bridge the gaps, in a spirit of partnership and solidarity. My delegation joins the previous speakers in thanking the Director-General and his staff for the work well done. The constraint of incomplete data should be urgently addressed, especially among the least developed countries where most efforts are going to be targeted over the coming years.

r T h e t e x t tha t f o l l o w s w a s s u b m i t t e d b y the de lega t i on o f U g a n d a f o r i n c l u s i o n i n the v e r b a t i m reco rds i n accordance w i t h r e s o l u t i o n W H A 2 0 . 2 .

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2. ADDRESS BY DR HUMBERTO DE LA COLOMBIA ALLOCUTION DU DR HUMBERTO DE LA COLOMBIE

The PRESIDENT:

I would now like to suspend the meeting for a few minutes in order to welcome Dr Humberto de la Calle Lombana, Vice-President of the Republic of Colombia.


The PRESIDENT:

The meeting is called to order. My very pleasant duty, before we continue with the next item on our agenda is to welcome, on behalf

of the Health Assembly, Dr Humberto de la Calle Lombana, Vice-President of the Republic of Colombia, who is honouring us with his presence today. I now have the pleasure of inviting Dr Humberto de la Calle Lombana, to address the Assembly.

El Dr. de la CALLE LOMBANA (Colombia):

Señor Presidente, señor Director General, doctor Manuel Elkin Patarroyo, señoras y señores: A lo largo de mi vida he tenido en diversas ocasiones la responsabilidad de representar a mi país ante el concierto internacional. Tarea grata, pero al mismo tiempo difícil, en un mundo en que estereotipos y frases de cajón hacen carrera para definir una nacionalidad. Es poco lo que el mundo conoce de nosotros. Para la mayoría de ustedes, lo digo con tristeza, Colombia se asocia de inmediato con el narcotráfico. Pocos saben - o quieren saber - que allá, a miles de kilómetros de distancia de la serena Europa, en una esquina de América del Sur hay un país que lucha como pocos por ser cada día mejor. Contra los pronósticos de los escépticos, pese a la terquedad de los violentos y a la incomprensión de quienes nos miran desde la lejanía, tenemos una de las democracias más antiguas y estables del continente, una economía sólida que se abre al mundo y, lo más importante, un pueblo que encara el futuro con empeño y decisión.

Como resultado de nuestra convicción y de la responsabilidad que tenemos frente a la comunidad internacional, hemos enfrentado con todos los elementos a nuestro alcance la lucha contra el tráfico ilegal de drogas. En el combate de ese delito hemos entregado la vida de muchos de nuestros mejores hombres y a él hemos dedicado inmensos recursos de todo tipo. No existe en el planeta un ciudadano que rechace tanto el narcotráfico como un colombiano, precisamente porque sabe el daño que produce a las sociedades y porque ha vivido la violencia que genera. Pero no nos cansaremos de alzar nuestra voz para exigir el compromiso y la solidaridad de las naciones industrializadas en este campo. El narcotráfico es un delito internacional. Mientras no se combata el consumo y no se tomen medidas para evitar el tráfico de precurso-res clínicos provenientes de los países del primer mundo, estará lejano el día en que podamos ver un mundo sin drogas. En mi país mueren anualmente centenares de personas 一 entre ellas, policías, jueces y periodis-tas -por hacer frente a este delito. Se trata de colombianos honestos que no dudan en entregar su vida por defender los principios que guían la conducta de la inmensa mayoría de mis compatriotas.

Por eso hoy, ante este importante foro internacional, no puedo ocultar el orgullo que siento como colombiano al hacer entrega a la humanidad, a través de la Organización Mundial de la Salud, de la vacuna sintética contra la malaria. Y por supuesto, siento la enorme satisfacción de estar acompañado por su descubridor, un colombiano bueno y emprendedor, que sorteó todo tipo de dificultades y estrecheces para lograr este avance que hoy beneficia al mundo entero. Permítanme hacer una corta referencia al respecto. Manual Elkin Patarroyo es un hombre de la provincia colombiana. De su tierra natal de verano perpetuo un día partió hacia la fría Bogotá con la ilusión de adelantar estudios secundarios y luego hacerse médico, viaje que cada año emprenden miles de jóvenes colombianos y apenas unos pocos pueden culminar. Muy pronto el virus de la investigación científica se le metió en el organismo y, afortunadamente para todos, no hubo vacuna capaz de impedirlo. No fue, ciertamente, el camino más fácil. Patarroyo pudo escoger cualquier otra especialidad que le garantizara una existencia cómoda, sin grandes sobresaltos. Pero no. Terco, como dicen que son los científicos, persistió en esa vocación un tanto solitaria e incierta. Fue una decisión poco menos

CALLE LOMBANA, VICE-PRESIDENT OF

CALLE LOMBANA，VICE-PRESIDENT DE LA

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que osada cuando se tienen en cuenta la escasa tradición que teníamos en esa materia y la ausencia de recursos y apoyos para respaldarla.

La vacuna contra la malaria proviene de un país pobre y va dirigida, especialmente, a los pueblos más pobres de la tierra. Y ello nos alegra. Por un lado, porque queda demostrado, una vez más, que pese a la carencia de recursos económicos estamos haciendo un aporte significativo al bienestar de la humanidad. De otra parte, y esto es lo más importante, porque gracias al trabajo de un colombiano millones de personas de las naciones menos favorecidas podrán contar con una nueva esperanza de vida. Cada año la malaria cobra la vida de millones de personas del Tercer Mundo. En el mismo periodo, 300 millones de habitantes padecen la enfermedad, cifra similar a la población total de un país como los Estados Unidos de América. Es más, su impacto es tan desastroso para las regiones más pobres del mundo que en algunos países de Africa el 25% de los niños menores de cinco años fallecen por su culpa. No cabe duda de que la vacuna contra la malaria es un importante avance en el campo de la salud especialmente para las naciones del hemisferio Sur. Y también debemos resaltar que proviene de ese mismo Tercer Mundo, donde apenas se desarrolla el 3,2% de la investigación científica mundial. Pero su importancia rebasa el ámbito mismo de la lucha contra la malaria. Apunta a las más altas fronteras del conocimiento científico, pues remueve los principios que hacían que hasta ahora las vacunas fueran sólo biológicas. Patarroyo ha demostrado que a partir de la síntesis química de algunos péptidos que hacen parte del parásito mismo se puede generar una respuesta inmunológica efectiva contra la enfermedad.

Distinguido auditorio: La de hoy es una fecha de singular importancia en la historia colombiana. De igual forma, no dudo en afirmar que lo será para la comunidad científica internacional, en especial para la OMS, y para los millones de seres humanos que hoy están expuestos al contagio de la enfermedad. Sabemos que la magnitud de este descubrimiento científico será juzgada por la historia de la ciencia, que le otorgará el puesto que merece, lo mismo que el escrutinio riguroso y sereno de la comunidad científica internacional. Pero también estamos seguros de que su aplicación para beneficio de la humanidad no da espera como herramienta para el control y la prevención de la malaria. Queremos que esta vacuna esté al alcance de quienes pueden aplicarla, sin barreras económicas o políticas, en favor de la salud de los millones de vidas humanas que día a día están expuestas a este mal.

Deseo también resaltar el Informe sobre la salud en el mundo, 1995, publicado recientemente por la OMS. Tras un claro análisis, el documento señala que el principal factor de mortalidad y causa primera de enfermedad y sufrimiento en todo el globo es la pobreza extrema. Por lo tanto todos los esfuerzos deben estar encaminados a erradicar la pobreza de la faz de la tierra, con miras a encarar el siglo XXI sin las enormes desigualdades que hoy vivimos. En este aspecto las buenas intenciones no han podido plasmarse en acciones concretas. Por eso, no entendemos que apenas unos pocos países hayan cumplido con compro-misos adquiridos de tiempo atrás, como el de la inversión de por lo menos el 0,7% del PIB de los países industrializados en programas de cooperación con el Tercer Mundo. Es más, pese a tales compromisos, se está presentando una tendencia generalizada a reducir los montos totales de cooperación, tanto bilateral como multilateral, que vemos con suma preocupación.

No podemos permitir que las decisiones que benefician a los países más pobres se queden en el papel. De nada sirve que nos reunamos en foros tan importantes como la Cumbre Internacional sobre la Población y el Desarrollo de El Cairo, o la de Desarrollo Social de Copenhague, si de ellas apenas queda un catálogo de buenas intenciones. El mundo necesita hechos. De tal forma, los países en desarrollo pedimos que propuestas como la del 0,7%, la del 20/20 y las de redestinación de los recursos provenientes del desarme se pongan en marcha sin más dilación. Sólo así contaremos con acciones efectivas para combatir la pobreza.

La donación de la vacuna contra la malaria, más que un gesto de desprendimiento y humildad del Dr. Patarroyo, es un acto de solidaridad con la humanidad. Y este gesto simboliza el sentir del pueblo colombiano. Actos como éste deben llevarnos a pensar en la realidad que viven nuestros países, a modificar los parámetros con que nos miran y a analizar en contexto nuestra lucha por un futuro mejor. No puedo dejar de recordar las palabras de nuestro Premio Nobel de Literatura Gabriel García Márquez cuando, al referirse a la soledad de América Latina, dijo «La solidaridad con nuestros sueños no nos hará sentir menos solos, mientras no se concrete con actos de respaldo legítimo a los pueblos que asuman la ilusión de tener una vida más propia en el reparto mundial».

Señoras y señores: De manera respetuosa les solicito un aplauso para el Dr. Manuel Elkin Patarroyo. Muchas gracias.


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The PRESIDENT:

Thank you very much, Dr Humberto de la Calle Lombana, for your very illuminating and interesting statement.

I understand that an Agreement was signed this morning by Professor Patarroyo of the Republic of Colombia and the World Health Organization, which the Vice-President, Dr Humberto de la Calle Lombana, would now like to present to the Director-General.


The PRESIDENT:

I shall now give the floor to the Director-General.


Thank you, Mr President. Your excellencies, Vice-President Dr Humberto de la Calle Lombana of Colombia, Mr President of the Forty-eighth World Health Assembly, Dr Noordin, Professor Manuel Elkin Patarroyo, distinguished delegates, ladies and gentlemen, I am most grateful to you for your courtesy and generosity. It is an honour for all of us that the Republic of Colombia is represented at this Health Assembly by its Vice-President. It reflects the high level of commitment of your Government not only to health and social development, but also to international cooperation.

As I had occasion yesterday to mention to the Ministers of Health of the Non-Aligned Movement, the presidency of which will soon pass from Indonesia to Colombia, the malaria vaccine venture is an excellent example of what can be achieved for the world through technical cooperation between developing countries. It underscores the importance for developing countries of promoting education and health research as a basis for sustainable development; developing its own capabilities enables a country to focus on the scientific needs of its people.

Mr Vice-President, on behalf of the World Health Organization and the international community, may I ask you to convey our congratulations to Professor Manuel Elkin Patarroyo and our gratitude for his dedication to science and to the health of the people. Along the years the emergence of drug resistance and new virulent forms of malaria have faced us with increasing difficulties in carrying out our malaria control programmes. In the long run, sustainable control of malaria requires overall social and economic development including proper management and rehabilitation of the environment, but in the meantime we have to implement our global malaria control strategy with an integrated approach, which combines vector control activities, including the use of insecticide and impregnated bednets with social measures, drugs, and now a vaccine. Professor Patarroyo's vaccine opens new avenues to malaria control and brings hope and relief to millions of people in the world who are today at risk of death or disability because of malaria.

As you know, according to The world health report of this year, every year two million people die by malaria, of whom half a million are children, and this vaccine is particularly effective for children. I want to pay public tribute to Professor Patarroyo, to his generous gesture in surrendering any personal claim to commercial gain from this vaccine and to his desire to associate WHO in his endeavour to make this vaccine available to the greatest number of people possible and at a cost which is affordable to all. We are grateful to him and look forward to continuing this very important work with him and his colleagues in Colombia. Professor Manuel Elkin Patarroyo and his co-workers are showing the world that developing countries have a considerable store of creativity and scientific capability, and that inestimable benefits can be derived from this rich research potential if it is recognized and encouraged by national public policies and supported by the international community at large. Colombia must be congratulated for having provided its scientists with an environment conducible to research and development and on its generosity in sharing the fruits of its success with the rest of the world. This is a genuine sense of bridging the gap. Thank you very much.

The PRESIDENT:

I thank you, Dr Nakajima. I shall now suspend the meeting for a few minutes after which we shall consider item 13: Awards, and

its subitems. Please remain in your seats.

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3. AWARDS

DISTINCTIONS

The PRESIDENT:

The meeting is resumed.

Distinguished delegates, colleagues and friends, we are assembled here today for the presentations of the prizes awarded by the Léon Bernard Foundation, the Dr A.T. Shousha Foundation, the Jacques Parisot Foundation Fellowship, the Child Health Foundation Prize and Fellowship, the Sasakawa Health Prize, the Dr Comían A.A. Quenum Prize for Public Health in Africa and the United Arab Emirates Health Foundation 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 and Dr M. Hamdan, the distinguished delegate of the United Arab Emirates, representing the Founder of the United Arab Emirates Health Foundation.

Presentation of the Léon Bernard Foundation Prize Remise du Prix de la Fondation Léon Bernard

The PRESIDENT:

We shall start with subitem 13.1，Presentation of the Léon Bernard Foundation Prize. This prize is given to a person having accomplished outstanding service in the field of medicine. The Léon Bernard Foundation Prize for 1995 is awarded to Professor Manuel Elkin Patarroyo of Colombia.

Professor Patarroyo is the Founder and Director of the Institute of Immunology Hospital San Juan de Dios，National University of Colombia. He is also Professor at the School of Medicine at that University, and Expert Consultant and Adjunct Professor at the Rockefeller University.

Professor Patarroyo and his group in Bogotá, Colombia have developed the first safe and effective anti-malaria synthetic vaccine SpF66. The safety and efficacy of this vaccine have been tested in large-scale community controlled trials in Colombia, Ecuador, Venezuela and Tanzania. The vaccine is currently under trial in Gambia and on the border of Thailand and Myanmar.

This landmark in parasitological research is a major contribution to public health in developing countries.

It gives me great satisfaction, in the name of us all, to present Professor Manuel Elkin Patarroyo with the Léon Bernard Foundation Prize for 1995.

Amid applause, the President handed the Léon Bernard Foundation Prize to Professor Manuel Elkin Patarroyo. Le Président remet au Professeur Manuel Elkin Patarroyo le Prix de la Fondation Léon Bernard. (Applaudissements)

The PRESIDENT:

I invite Professor Patarroyo to address the Assembly.

El Profesor PATARROYO:

Señor Presidente, señoras y señores Ministros, distinguidos delegados, señoras y señores: El desarrollo de las poblaciones y las naciones se establece sobre las bases del respeto y la solidaridad. Sus leyes, normas y principios no son otra cosa que una toma de conciencia de estos valores. De igual manera, el crecimiento armónico de cualquier sociedad, unicelular o pluricelular, se fundamenta sobre la base de la generosidad y el altruismo.

Un organismo no puede crecer ni sostenerse cimentado exclusivamente en el egoísmo, sacrificando unidades o sociedades para permitir la supervivencia de unos pocos, los más fuertes, puesto que se sabe que, en la evolución, lo que hoy es fuerza, mañana tal vez sea debilidad. Y aun, como biólogo que soy, los

A48/VR/7 page 160

genes más egoístas conservan, si no a los individuos, sí los rasgos o la información genética de los menos favorecidos en ese instante. Por eso en nuestra ontogenia repetimos ineluctablemente los pasos de nuestra filogenia, y es esto lo que ha hecho posible nuestra supervivencia.

No podemos permitirnos entonces, señores, el lujo de ver desaparecer individuos, poblaciones, razas o especies bajo ninguna razón, ideología o bandera. La desaparición se justifica, tal vez, sólo si es produc-to de la única, lógica e ineluctable causa natural, que es el discurrir del tiempo.

Ha llegado el momento, damas y caballeros, de levantarnos para comenzar a estructurar un nuevo humanismo, lejos de los obsoletos partidismos sectarios que reflejaron su impotencia y fracaso, dejando tras de sí decenas, y diría que centenas de vidas humanas sacrificadas en su camino.

Es tiempo entonces, damas y caballeros, de que comencemos a preocuparnos más por el Ser Huma-no, sí, así con mayúsculas, que por fronteras, teorías, preeminencias, riquezas, poderes.

Debemos empezar a establecer juntos, y es esta Asamblea un excelente podio, una sociedad basada más sobre el respeto, la solidaridad y la generosidad, que sobre ideologías, razas o religiones. Porque como bellamente decía André Malraux «quien sólo respeta lo que cree, sólo se respeta a sí mismo, despreciando lo más importante y hermoso de la evolución, que es la diversidad creadora».

En mi país，Colombia, un país joven como todos los de América Latina, un puñado de jóvenes idealistas, quijotes, despistados o desorientados tal vez, que laboran en el Instituto de Inmunología de Bogotá, quisimos, sin la violencia de las armas ni la fuerza del poder, dedicar nuestras vidas en pos de unos sueños en los que imperaran el respeto a la vida, la solidaridad y la generosidad para con la humanidad.

Con esto en mente, quisimos luchar en la única forma y esfera que era asequible a nuestros ideales y capacidades: la ciencia, el conocimiento. Con ellos pretendimos resolver problemas universales para el bienestar del ser humano, y tener así una segunda oportunidad para que, de esta manera, la vida viva.

Dedicamos todos nuestros esfuerzos, desvelos y alegrías en pos de estos objetivos. Involucramos a nuestras familias, a nuestras amistades, a pueblos como el mío, Colombia, en la lucha por alcanzar estas metas. Convencimos a naciones amigas como Venezuela, Ecuador, Brasil, España，Suiza, Tanzania y Tailandia que, identificadas con los mismos sueños, metas, ideales y propósitos, querían luchar hombro a hombro en la solución de estos problemas y obtuvimos una respuesta que es la que hoy en día presentamos a ustedes: la vacuna de la malaria.

Imperfecta aún, ya que protege entre el 31 y el 60% de la población mayor de 1 año de edad, como les contaba a ustedes el señor Vicepresidente de Colombia, pero que, no obstante, si se mira bien dentro del contexto de la problemática, bien podríamos pedir prestada aquella frase «es un pequeño paso, pero un gran salto para la humanidad». En efecto, en el mundo, como lo decía el señor Director General, hay 300 millones de enfermos de malaria por año, 2 a 3 millones de vidas son cobradas anualmente, más de 100 países, los de ustedes, los nuestros, se encuentran afligidos por esta enfermedad, y más de 2500 millones de personas viven en estas áreas de riesgo.

Sí, es cierto, nos queda un largo trecho por recorrer, pero creo que ya hemos comenzado, y seguire-mos luchando por el ser humano, para que la vida viva.

El pueblo de Colombia, mi pueblo, mi Colombia tan criticada y tan satanizada en algunas oportuni-dades por el pecado de algunos pocos de sus hijos, como acontecería en cualquier nación, porque quien tenga las manos libres y limpias que tire la primera piedra, ha querido, porque le nace, porque es su esencia, porque es intrínseco en el pueblo de Colombia, solidarizarse con el resto de la humanidad en su sufrimiento y, generosamente, Colombia, mi pueblo, ha querido a través de esta benemérita institución que es la Organización Mundial de la Salud donar la patente que le da patria potestad, que le da derechos sobre su hija, que es la vacuna de la malaria.

Y también Colombia ha querido mostrarle al mundo que aun en las más difíciles de las circunstan-cias, siempre es el bien el que triunfa sobre el mal, la luz sobre la oscuridad, la solidaridad sobre la indiferencia y la generosidad sobre el egoísmo.

Hoy nos congregamos aquí, ciudadanos y naciones de todo el mundo, porque queremos decirles que nosotros, el pueblo de Colombia, luchamos para que un nuevo Humanismo, más humano, en donde reine el respeto, la solidaridad y la generosidad, los principios básicos sobre los cuales se establecen las socieda-des, se abra paso en el mundo, en una forma real y concreta. Porque, como dice nuestro Nobel Gabriel García Márquez, «luchamos para que todos los pueblos tengan una segunda oportunidad sobre la tierra», y que, por encima de todo, luchamos en el pueblo de Colombia para que la vida viva. Gracias.

The PRESIDENT:

Thank you, Professor Patarroyo. I would now like to suspend the meeting for a few minutes in order to allow Dr Humberto de la Calle

Lombana to take leave of us. I invite delegates to pay tribute to Dr Humberto de la Calle Lombana for the

A48/VR/7 page 161

support he has given this Assembly through his presence and his words to us today. I invite you to applaud him as he leaves.


Presentation of the United Arab Emirates Health Foundation Prize Remise du Prix de la Fondation des Emirats arabes unis pour la Santé

The PRESIDENT:

The meeting is resumed. One of the recipients of the United Arab Emirates Health Foundation Prize has requested that subitem 13.7, United Arab Emirates Health Foundation Prize, be taken earlier than planned as he has to leave Geneva. We shall therefore take up subitem 13.7 first, and then continue with the other subitems as they appear on the provisional agenda. It is our great pleasure, this year, to add a new prize for excellence to those already awarded by our Organization. This prize, established upon the initiative of, and with funds provided by, the Government of the United Arab Emirates, is awarded to a person or persons, institution or institutions, or a nongovernmental organization or organizations, having made an outstanding contribution to health development. The founder encourages nominations for the prize from all regions of WHO. The prize is awarded this year for the first time, jointly to the Child Survival Project of Egypt, and to Dr Abdul Rahman Abdul Aziz Al-Swailem of Saudi Arabia.

The Child Survival Project of Egypt is the materialization of efforts for child survival and safe motherhood in Egypt. The overall goal is to reduce mortality and morbidity in children under five years of age and in women of child-bearing age. It is supervised by the Ministry of Health.

The project has had a tremendous impact on the reduction of infant and child mortality through vaccination programmes against childhood communicable diseases and neonatal tetanus. It has improved the performance of primary health care systems in the areas of maternal and child health, immunization and the control of acute respiratory infections. The project has also developed a national system for the control of acute respiratory infections, introduced a national hepatitis В control and elimination programme, eliminated neonatal tetanus, and is approaching poliomyelitis eradication. It has developed a national neonatal care system and has promoted initiatives for safe motherhood and mortality reduction.

Dr Abdul Rahman Abdul Aziz Al-Swailem is currently Deputy Minister for Executive Affairs of the Ministry of Health of Saudi Arabia. Dr Al-Swailem has played a crucial role in the formulation and implementation of the national policy and strategy of health for all. As a result of the primary health care programme which he launched, the quality of health care has improved and there has been a notable reduction in maternal mortality. Under his responsibility, a vaccination programme has been successfully implemented, with a coverage of more than 90% of children under one year of age against all vaccine-preventable diseases.

Dr Al-Swailem's numerous achievements in the health field exceed national boundaries and benefit the whole region. Unfortunately, Dr Al-Swailem is not able to be present today to receive the award, and Dr Sami Al-Sughair, the distinguished delegate of Saudi Arabia will receive it on his behalf. It is clear that this first and well-deserved award augurs well for the future of the United Arab Emirates Foundation Prize, which I hereby present to the distinguished laureates.

Amid applause, the President handed the United Arab Emirates Health Foundation Prize to the Director of the Child Survival Project of Egypt, Dr Esmat Mansour, and to Dr Sami Al-Sughair on behalf of Dr Abdul Rahman Abdul Aziz Al-Swailem. Le Président remet le Prix de la Fondation des Emirats arabes unis pour la Santé au Dr Esmat Mansour, Directeur du projet égyptien de survie de l'enfant, et au Dr Sami Al-Sughair qui représente le Dr Abdul Rahman Abdul Aziz Al-Swailem. (Applaudissements)

The PRESIDENT:

I now invite Dr Esmat Mansour, Director of the Child Survival Project of Egypt to address the Assembly.

A48/VR/7 page 162

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Thank you, Dr Mansour. I now invite Dr Sami Al-Sughair to address the Assembly on behalf of Dr Abdul Rahman Al-Swailem.

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The PRESIDENT:

Thank you, Dr Sami Al-Sughair.

Presentation of the Dr A.T. Shousha Foundation Prize Remise du Prix de la Fondation Dr A.T. Shousha

The PRESIDENT:

We now continue with subitem 13.2，Presentation of the Dr A.T. Shousha Foundation Prize. The Shousha Medal and Prize is given to a person having made the most significant contribution to any health problem in the geographical area in which Dr A.T. Shousha served the World Health Organization. The Dr A.T. Shousha Foundation Prize for 1995 is awarded to Dr Ibrahim Mohammed Yacoub of Bahrain. Dr Yacoub is at present Assistant Under-Secretary and Acting Under-Secretary for Primary and Public Health at the Ministry of Health in Bahrain. Dr Yacoub has been assigned as Assistant to the Secretary-General of the Secretariat of Gulf States since its formation in 1976. During his career in government he has actively promoted primary health care policies in his country. He was instrumental in developing the College of Health Sciences (Nursing and Pharmaceuticals) and participated in the establishment of the Gulf Medical School in Bahrain. He is a well-known and respected personality in the Eastern Mediterranean Region.

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To reward such an outstanding contribution to health in the Eastern Mediterranean Region, I now have great pleasure in presenting Dr Ibrahim Mohammed Yacoub with the Dr A.T. Shousha Medal and Prize.

Amid applause, the President handed the Dr A.T. Shousha Foundation Prize to Dr Ibrahim Mohammed Yacoub. Le Président remet au Dr Ibrahim Mohammed Yacoub le Prix de la Fondation Dr A.T. Shousha. (Applaudissements)

The PRESIDENT:

I invite Dr Yacoub to address the Assembly.

Dr YACOUB:

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A48/VR/7 page 165

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The PRESIDENT:

Thank you, Dr Yacoub.

Presentation of the Jacques Parisot Foundation Medal Remise de la médaille de la Fondation Jacques Parisot

The PRESIDENT:

Ladies and gentlemen, I shall now proceed to subitem 13.3，Presentation of the Jacques Parisot Foundation Medal. This Foundation was established for the purpose of awarding every two years a fellowship for research in social medicine or public health. The Fellowship this year is awarded to Dr Alfred Ole Sulul of the United Republic of Tanzania. Since 1986, Dr Ole Sulul has been Director of Health Services in Arusha District in his country. Dr Ole Sulul's research proposal concerns the determination of financial management capability and willingness to pay for health services in urban and rural district communities in Tanzania.

Unfortunately Dr Ole Sulul is unable to be present to receive the award. Mr M.W. Mangachi, Chargé d'Affaires ad interim of the Permanent Mission of the United Republic of Tanzania at Geneva will receive the award on his behalf. It is with great pleasure that, on behalf of the Assembly, I invite Mr Mangachi to receive the Jacques Parisot Foundation Medal on behalf of Dr Ole Sulul.

Amid applause, the President handed the Jacques Parisot Foundation Medal to Mr Mangachi on behalf of Dr Alfred Ole Sulul. Le Président remet la médaille de la Fondation Jacques Parisot à M. Mangachi qui représente le Dr Alfred Ole Sulul. (Applaudissements)

The PRESIDENT:

I invite Mr Mangachi to address the Assembly on behalf of Dr Ole Sulul.

Mr MANGACHI:

Mr President, Director-General, honourable delegates, ladies and gentlemen, it is a unique honour for me to address you on this memorable day. I am greatly honoured to accept and receive this award on behalf of Dr Ole Sulul, who is a Medical Officer of Health of Arusha Municipal in Tanzania. This is an honour to me personally, and to all the people of Tanzania in general. Dr Sulul's winning research proposal was in the important and relevant area of determination of financial management capability and willingness to pay for health services in urban and rural district communities in Tanzania. You will, Mr President, agree with me that this is an important area，not only to Tanzania, but also to other developing countries. Tanzania pledges to share the results of this study with the rest of the world.

Once again, on behalf of the United Republic of Tanzania, I thank you for this unique honour.

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The PRESIDENT:

Thank you, Mr Mangachi.

Presentation of the Child Health Foundation Prize and Fellowship Remise du Prix et de la bourse de la Fondation pour la Santé de l'Enfant

The PRESIDENT:

We now go on subitem 13.4，Presentation of Child Health Foundation Prize. This prize is given every two years to a person having accomplished outstanding service in the field of child health. The prize for 1995 is awarded to Professor Deryaev Invar of Turkmenistan.

Since 1967 Professor Deryaev has been Head of the Child Diseases Department of Turkmen State Medical Institute. In this capacity he has trained a great many paediatricians. He was the first Doctor of Sciences and Professor of Paediatrics in Turkmenistan and was Head of the Turkmen Association of Paediatricians for many years.

Not only does Professor Deryaev provide advice to the health services of his country, he is personally much involved in promoting health education for the population.

Unfortunately Professor Deryaev was unable to be present at the ceremony and in the absence of a delegation from Turkmenistan, appropriate arrangements will be made to send the award to him.

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 subitem 13.5. This Prize is given to a person or persons, an institution or institutions, having accomplished outstanding innovative work in health development. The 1995 Prize is awarded jointly to Dr J. Torres Goitia Torres of Bolivia, and Professor Le Kinh Due of Vietnam.

Dr Torres Goitia Torres is a National Senator and is Chairman of the Senate Committee on Social Development. Since 1989 he has served as adviser on social policy to an organization representing 16 trade unions in the Andean area.

Dr Goitia has succeeded in making important changes in the health policies and delivery of health care in Bolivia. His realization of the importance of community participation and active promotion of this concept led to national mobilization for parasite control and mass vaccination campaigns resulting in the definitive disappearance of poliomyelitis, the temporary disappearance of measles and the reduction in the prevalence of goitre. He alerted the health authorities to the seriousness of Chagas disease, which resulted in the organization of the first campaigns to eliminate reduviid bugs. Dr Goitia established the National Medical Supplies Institute (INASME), which rationalized the use of drugs, reduced their price tenfold and expanded their distribution in rural areas. Professor Le Kinh Due holds the Chair of Dermatology at the Hanoi Medical College, and in addition holds the post of Director of the National Institute of Dermato-venereology of Viet Nam. He also serves as Director of the National Leprosy Control Programme. The World Health Organization honoured Professor Le's contribution to the leprosy control programme with the Health for All Medal in 1988. Professor Le has devoted nearly 40 years of his professional life to the campaign against leprosy in Viet Nam. His innovative programme has produced significant results.

Professor Le contributed greatly to the elaboration of multidrug therapy (MDT) programmes and their early application in Viet Nam. Owing to the sustained efforts and innovative strategies of Professor Le, Viet Nam has achieved the target of leprosy elimination in over half of the total population.

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:

Thank you, Mr President of the Forty-eighth World Health Assembly, distinguished winners of this year's Sasakawa Health Prize, Dr Torres Goitia Torres and Professor Le Kinh Due. First of all, let me

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extend my most sincere esteem and appreciation to all my colleagues who are making tireless efforts for the advancement of health and welfare for people on this earth. On behalf of the Sasakawa Foundation and the Sasakawa Memorial Health Foundation, I would like to express my heartfelt thanks to Dr Torres Goitia Torres of Bolivia and Professor Le Kinh Due of Viet Nam, the recipients of the Sasakawa Health Prize this year, whose leadership and dedication are the key to our well-being. Today being Mr Sasakawa's ninety-sixth birthday, he had hoped to attend this auspicious ceremony and to meet you and to speak to you in person, but his other engagements prohibit him to come to Geneva this year. So he has asked me, as Executive Managing Director of the Sasakawa Memorial Health Foundation, to deliver his message to you:

Mr President, Mr Director-General, distinguished delegates and friends, it is my firm belief that world peace could 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 instead we should organize our actions with the fundamental idea that the world is one family, all mankind are brothers and sisters, which as you may already be aware, is my life-long creed. I believe that my health also owes much to the efforts of a number of dedicated people worldwide so that I think I should not monopolize it myself 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 health which led to the adoption of the World Health Organization's idealistic call for health for all by the year 2000 and beyond. In 1984，by the strong recommendation of the then Director-General, Dr Halfdan Mahler, the WHO Sasakawa Health Prize was established with the aim of helping this health-for-all programme by adopting the primary health care approach and this year we welcome the eleventh year winners.

I am happy to recall that the past winners, including two doctors from the Republic of Colombia who developed the very innovative kangaroo mother method, which is now videotaped between the Committee A and Committee В rooms in this building. They have clearly demonstrated their dedication and leadership for better health for the world population. I am particularly pleased to note that every year an increasing number of governments and institutions are submitting their recommendations of candidates for this prize. As I learn of the activities of this year's winners I highly praise the dedication and commitment demonstrated by this year's winners in the difficult but rewarding task for promotion of primary health care in the community. I am particularly pleased to note that Dr Torres Goitia, on the basis of his various past activities for promotion of community-based health programmes plans to utilize the prize money to establish a special foundation to support the training of community leaders and to provide seed money for local integrated development in the municipalities.

I am also impressed by the lifelong dedication of Professor Le Kinh Due for leprosy control in Viet Nam, not only as a medical and public health specialist but as a poet by composing poems to educate and influence the general public for alleviation of stigma attached to leprosy. Through this dedication 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. Fifteen years ago people witnessed the historical declaration of the eradication of smallpox which was once regarded as impossible. It was a clear demonstration of an achievement by the worldwide coordinated efforts, not only of health professionals, but also of community resources. The Sasakawa Foundation was particularly glad that it could make its share of contribution to this historical human achievement. There are unfortunately a number of diseases which are still burdening the people in this world. Among them, leprosy has been one of the most dreaded as there are no other diseases that affect not only physical but mental and social well-being of the human being as much as leprosy. However, thanks to the never-tiring efforts of scientists and public health workers such as Professor Le Kinh Due and the advancement of various measures including multidrug therapy, the Health Assembly was able, in 1991，to declare that leprosy can be eliminated within this century if we all unite our efforts for the remaining years. I trust that most of you here in this hall are well aware that the Sasakawa Foundation, as well as my personal concern, is a commitment to the welfare of the leprosy sufferers in the world.

I believe the Sasakawa Memorial Health Foundation, which was established in 1974，on my seventy-fifth birthday, has been instrumental in a global upsurge of leprosy activities, most notably in the expansion of multidrug therapy now incorporated in the elimination of leprosy by the year 2000 campaign. I am happy indeed to learn of its better than expected success up to now and the very good prospects of achieving its goal, provided all concerned can unite their efforts. I am committed to the success of this global effort and as all of you are aware, at the leprosy conference held in Hanoi in 1994，the Sasakawa Foundation announced its commitment of US$ 50 million over five years to cover approximately one-third of the leprosy drug requirements estimated by the World Health Organization.

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I trust 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 this elimination programme also assures 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 the source of most universal human injustice which many leprosy sufferers have had to endure.

I would also like to emphasize that the global concerned effort is an urgent theme for the control of another very formidable task of fighting HIV/AIDS, which has a certain similarity with leprosy from the social justice and human rights viewpoint. On this auspicious occasion of the eleventh Sasakawa Health Prize awarding ceremony, in the hope of helping health-for-all activities, I would like to express my congratulations and appreciation again to the winners of the Sasakawa Health Prize, as well as to the governments for the tremendous work they have undertaken. I sincerely wish both of them success in the accomplishment of their future tasks. Lastly, I pray for good health, longevity and happiness to all of you in this Assembly and all the people on this earth. Thank you very much.

The PRESIDENT:

Thank you, Professor Kiikuni.

Amid applause, the President handed the Saskawa Health Prize to Dr J. Torres Goitia Torres and Professor Le Kinh Due. Le Président remet au Dr J. Torres Goitia Torres et au Professeur Le Kinh Due le Prix Sasakawa pour la Santé. (Applaudissements)

The PRESIDENT:

I now invite Dr Torres Goitia Torres to address the Assembly.

El Dr. TORRES GOITIA TORRES:

Señor Director General de la Organización Mundial de la Salud, Dr. Nakajima, señor Presidente de la Asamblea, señores Ministros, Embajadores, señoras y señores: Honrado, más allá de mis merecimientos personales, por tan importante distinción que me otorga la Organización Mundial de la Salud, no sé cómo expresar mi agradecimiento a la Fundación Sasakawa y a la propia Organización, que emplean el Premio para estimular las iniciativas innovadoras y respaldar la esperanza de los que, desde la defensa de la salud, buscamos un mundo de paz, de solidaridad y de progreso con justicia social para cimentar un verdadero Desarrollo Humano.

Vivimos tiempos de cambios que se aceleran en progresión geométrica. El progreso científico y tecnológico, con haber logrado formidables avances en los últimos años, no ha hecho otra cosa que impulsar un ritmo de crecimiento cuyos resultados todavía no podemos prever; los cinco años que nos restan para entrar en el nuevo milenio seguramente nos traerán sorpresas que no alcanzamos todavía a imaginar, como las generaciones pasadas no sospecharon siquiera la velocidad de las comunicaciones y los avances que han logrado la electrónica, y en general la ciencia y la técnica actuales.

Pero, al mismo tiempo, crece también el desafío que supone esforzarse por evitar que el poder y los recursos se concentren peligrosamente en pocas manos, mientras niveles de pobreza incompatibles con el progreso actual se extienden por un mundo incapaz de lograr un desarrollo equitativo. Un mundo que se hace cada vez más vulnerable a las presiones demográficas y sociales, y a los desequilibrios ambientales.

Debemos esforzarnos por humanizar el mundo actual y lograr que nuestras sociedades superen los conflictos, destierren las armas y desarrollen la solidaridad para robustecer la paz, la justicia y el bienestar. Si el desarrollo tiende a beneficiar al ser humano, podremos obrar en pro de la salud y la felicidad de nuestros pueblos, sin crisis ni conflictos intermitentes. La defensa de la salud puede contribuir mucho a tales objetivos si por salud se entiende la expresión integral de la calidad de vida y su defensa se identifica con la movilización social y no solamente con el trabajo burocrático restringido a un sector del Estado.

Nuestro modesto esfuerzo nació en un pequeño país, Bolivia, ubicado en el centro de Sudamérica, con no más de 7 millones de habitantes, que implantó profundos cambios e inició el desarrollo social con una reforma agraria y la introducción del voto universal en 1952. Este proceso, interrumpido en 1964 y sustituido en 1971 por un largo periodo de dictaduras militares, terminó solamente en 1982.

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Desde el Ministerio de Salud del primer gobierno democrático pusimos en práctica una política de salud participativa que cambió radicalmente los planes y programas elitistas, puramente asistenciaüstas, del pasado. Con las organizaciones populares de base que habían tenido un papel protagonista en la recupera-ción de la democracia, esta política se definía como La defensa de la salud, concebida como la lucha del pueblo unido contra el hambre, la miseria, la ignorancia y las injusticias sociales. Tal lucha no se puede organizar verticalmente desde el sillón de una autoridad, ni por obra de un milagroso paternalismo de los que pudieron lograr la formación de profesionales que la mayor parte de las veces eran así alejados del pueblo, en vez de unirse a él. La salud sólo puede darse como parte de las luchas de todos los desfavoreci-dos por mejorar las condiciones humanas de todos, solidariamente.

Se crearon los comités populares de salud, las unidades de rehidratación oral, las guarderías infanti-les populares y otros servicios con los cuales se impulsaron las movilizaciones populares de salud que surgieron para combatir las enfermedades inmunoprevenibles, las endemias locales como Chagas y paludismo, y para cumplir otras actividades inspiradas por el concepto de que la salud no se compra, ni se mendiga como un regalo, sino que se conquista con la movilización popular organizada. Este concepto sirvió para desarrollar la categoría de salud como derecho social y orientó una nueva forma colectiva de encarar la defensa de la salud que se mantiene en Bolivia y ha servido en lo concreto para bajar la mortalidad infantil de más de 180 por 1000 en 1980 a 75 por 1000 en 1990.

Actualmente, Bolivia está poniendo en práctica una Ley de participación popular. Esta ley, a cuyo estudio contribuimos con nuestra experiencia de los Comités Populares de Salud, es el gran recurso para otorgar poder político y medios económicos a toda la población del país, organizada en municipios democráticamente constituidos. Con arreglo a estas grandes transformaciones, que se dieron y se están dando en el país, uno de los más pobres del continente, pero también y por ello mismo uno de los más creativos, es como nos hemos propuesto avanzar en el progreso social y económico con una activa partici-pación popular. Pretendemos así que la solución a los graves problemas de atraso y subdesarrollo que debemos afrontar sea lograda con todos y sirva equitativamente para todos.

El honroso premio con el que nos distingue la OMS nos servirá para continuar más que nunca a fortalecer las energías que surgen de modo natural de las organizaciones populares y para contribuir con ellas a la búsqueda de soluciones democráticas que permitan mejorar la calidad de vida y la salud de nuestro pueblo y de los otros pueblos que deben enfrentar problemas parecidos. Muchas gracias.

The PRESIDENT:

Thank you, Dr Torres Goitia Torres.

I now invite Professor Le Kinh Due to address the Assembly.

Professor Le Kinh DUE:

Mr Director-General Dr Hiroshi Nakajima, Mr President of the Forty-eighth World Health Assembly, distinguished delegates and Members of the World Health Organization and nongovernmental organizations, ladies and gentlemen, it is a great honour for me to be selected as one of the two recipients of the prestigious Sasakawa Health Prize for 1995. This is at the same time an immense encouragement, not only for myself, but also for leprosy patients in Viet Nam and for all Vietnamese leprosy staff whose consistent efforts have contributed a great deal to this honour. On this occasion I would like to express my best thanks and to offer some intimate thoughts and impressions. For more than 30 years, I have been engaged in dermatology and the long hard campaign against leprosy has constituted my main preoccupation. I am very well aware of the responsibility to render some service to the sufferers, surely the most miserable among all miserable people. However, the biggest obstacle was the stigma that leprosy carries among lay people in Viet Nam. This can be illustrated by the Vietnamese saying "to run away like when you see a leper". Leprosy, tuberculosis, AIDS, cancer are the four incurable diseases, and leprosy was conceived as the most incurable of these. Although Dapsone has brought about some therapeutic effects the talk was only about stabilization of the disease and nobody at that period dared advocate the cure, still less the elimination or eradication of leprosy. Nevertheless, when you look at European countries, the remarkable phenomenon of the almost complete disappearance of leprosy without research or any control programme offers useful and meaningful evidence of the social character of leprosy, a disease that emerges, persists and disappears under certain social conditions. It was for this reason that Viet Nam, unlike some other countries, categorizes leprosy not in the communicable or infectious disease section, but as a social disease emphasizing its strong social aspect which consequently implies the need for social action, a multisectoral collaboration of all strata of society for its

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control and eradication. This innovative concept on the part of the Government is in fact a key factor of every achievement we have accomplished in leprosy control in Viet Nam, therefore the great honour I receive today at this solemn ceremony should be dedicated to our Ministry of Health. Viet Nam is economically a very poor country, heavily devastated by a long war of independence. Some people might be discouraged by the popular saying "poverty is a hindrance to wisdom". However, in analysing the true situation, we have benefited from some of the advantages our country enjoys: the cultural conditions of the Vietnamese population, the relatively high literacy rate, the widespread education and health systems covering all areas of the country, all of which create an efficient barrier to the spread of disease in general, and leprosy in particular, bearing in mind the picturesque proverb "Leprosy steps backwards in the presence of song". Against this background, coupled with certain characteristics objective to leprosy itself such as the low degree of contagion and its low spread which favours its control even in a poor country, our leprosy workers have every confidence in future success and have been encouraged to persevere in this work for decades using the primary health care approach. So if my humble achievements have merited an award my deep gratitude is due to those leprosy workers for their valuable contribution.

Lastly, on the occasion of this solemn award ceremony, allow me to express my warmest thanks to Dr Hiroshi Nakajima, the Director-General, and to the Executive Board of WHO, as well as to the Sasakawa Health Prize Committee for their kind support and appreciation. As a recipient of the prize I am happy to reconfirm here my willingness and determination to continue and to develop all possible innovative activities based on our primary health care system for the sake of leprosy and the leprosy elimination goal by the year 2000.

I would also like to thank the President and all the delegates to the Forty-eighth World Health Assembly, the Regional Director of the Western Pacific, Dr S.T. Han, and the Director of the Action Programme for the Elimination of Leprosy, Dr Noordeen, who have encouraged me with their kind suggestions, the representatives of the International Federation of Anti-leprosy Associations and the International Leprosy Association (1LA)，and especially the Chairman of the ILA and Executive and Medical Director of the Sasakawa Memorial Health Foundation, who has supported me with his friendly advice.

I thank you all, ladies and gentlemen, and wish you all health and success.

The PRESIDENT:

Thank you, Professor Le.

Presentation of the Dr Comían A.A. Quenum Prize for Public Health in Africa Remise du Prix Dr Comían A.A. Quenum pour la Santé publique en Afrique

The PRESIDENT:

I shall now proceed with subitem 13.6, Presentation of the Dr Comían A.A. Quenum Prize for Public Health in Africa. The Comían A.A. Quenum Prize is awarded every two years for outstanding innovative work in health development and is given to a person or persons having accomplished notable advances in the health field particularly since the promotion of the strategy for achieving health for all by the year 2000. The Prize this year is awarded to Dr lone Bertocchi of the Catholic Mission Ngaoundaye, Central African Republic.

Dr Bertocchi has been working in community health in the Central African Republic for more than 15 years. As a result of her work, health delivery coverage has increased within 10 years to more than 84% in one district of the Republic. She has set up national primary health care programmes specifically aimed at the prevention or control of goitre, leprosy and onchocerciasis and has seen the successful introduction of a cost-recovery scheme in a health centre and its extension to many health posts.

I now have the pleasure in presenting the Prize to Dr lone Bertocchi.

Amid applause，the President handed the Dr Comían A.A. Quenum Prize for Public Health in Africa to Dr lone Bertocchi.

Le Président remet le Prix Dr Comían A.A. Quenum pour la Santé publique en Afrique au Dr lone Bertocchi. (Applaudissements)

A48/VR/7 page 171

The PRESIDENT:

I now invite Dr lone Bertocchi to address the Assembly.

Le Dr BERTOCCHI :

Monsieur le Président, Mesdames et Messieurs les Ministres de la Santé, distingués délégués, c'est un grand honneur pour moi de m'adresser à cette Assemblée, et de recevoir le Prix Dr Comían A. A. Quenum de Santé publique en Afrique. Ce Prix, créé à la mémoire de cet homme qui a consacré une grande partie de sa vie à asseoir un système efficace de santé en Afrique, m'encourage à faire davantage pour améliorer la qualité de la santé dans mon pays d'adoption, la République centrafricaine.

Ce Prix vient honorer les efforts conjugués de tous les acteurs de santé à Ngouandaye : médecins, personnel paramédical et membres des communautés villageoises qui ont contribué à la mise en oeuvre des soins de santé primaires dans notre district.

Je voudrais d'abord remercier la direction générale pour l'organisation de cette cérémonie au Siège, ce qui confère au Prix toute la solennité et l'importance que l'OMS accorde aux soins de santé primaires. Je voudrais aussi remercier le Comité régional de l'Afrique qui m'a sélectionné à sa quarante-quatrième session. Mes remerciements vont enfin à la mission catholique qui, par le passé, a soutenu financièrement mes activités et qui continue à le faire.

Je m'engage à utiliser les fonds de ce Prix pour aider à la construction de pharmacies villageoises de notre district à Ngouandaye.

Au-delà de ce discours officiel, permettez-moi, Monsieur le Président et distingués délégués, d'ajouter quelque chose, quelques paroles simples pour vous expliquer en quoi consiste mon travail qui a été récompensé par un Prix si important.

Laissez-moi vous raconter l'histoire de cet enfant que nous avons aidé à venir au monde il y a beaucoup d'années, dans une communauté de paysans. C'était un bébé pesant déjà moins de 2 kg et demi à la naissance, au début toujours malade : diarrhées, infections respiratoires, malnutrition; souvent, il a risqué de mourir. Bien sûr, je suis quand même médecin et j'ai pu le sauver. Ce bébé a grandi. Il est devenu une belle fille. Belle comme toutes les filles africaines quand elles sont en âge de se marier. J'ai vu la beauté de cette fille. J'ai pensé qu'elle pouvait aller se présenter à un concours de beauté; mais une fille de paysans, sans robe, sans chaussures, c'est rien, alors je suis devenue couturière. Je lui ai confectionné une robe de soirée. Je lui ai mis une couronne de diamants et des boucles d'oreilles. Je l'ai présentée au Ministre de la Santé. Il a dit : "ça va". Le Ministre l'a emmenée avec lui à Brazzaville pour participer à un concours de santé et de beauté. Bien sûr, nous avons gagné. Cette fille, je vous assure, elle est cent pour cent de pure race centrafricaine. Moi, je suis simplement couturière. Une bonne couturière. Permettez-moi, Monsieur le Président et distingués délégués, de tirer une conclusion. Partout en Afrique, il y a de belles filles comme ça.

Depuis quatre jours, j'assiste aux travaux de cette importante Assemblée. Quand on parle de l'Afrique, c'est toujours les sinistres, les désastres, les catastrophes. Il est vrai que c'est une période difficile pour l'Afrique. Le SIDA et la tuberculose galopent. Epidémies de choléra, guerres civiles, réfugiés, même génocides, sont ce qu'on écoute chaque jour à la radio. Moi, je ne suis pas un grand médecin, je ne suis pas un grand professeur comme ceux qui m'ont précédée tout à l'heure à cette tribune, je suis médecin de brousse. Un petit médecin de brousse qui vit loin de la ville, loin des grands bruits, mais j'ai le courage de vous dire qu'en Afrique, chaque jour, il y a des merveilles. En Afrique, chaque jour, il y a des petits miracles que personne ne voit, que personne n'écoute, parce qu'ils se passent en silence, sans bruit, et ces miracles sont les efforts énormes que de pauvres gens font chaque jour pour se sortir de la pauvreté, pour se prendre en charge, pour se libérer de la discrimination qui, encore aujourd'hui, existe en Afrique par rapport aux autres pays, car ces pauvres gens veulent construire un monde meilleur pour leurs enfants. Ce sont de petits miracles.

The PRESIDENT:

Thank you, Dr lone Bertocchi. We have now completed item 13. Before we adjourn, I would like to remind you that the inscription

to the speakers' list will be closed after this meeting. The meeting is adjourned.


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NINTH PLENARY MEETING

Friday, 5 May 1995，at 9:25

President: Dato Dr Haji Johar NOORDIN (Brunei Darussalam) later: Acting President: Dr J.R. de la FUENTE RAMÍREZ (Mexico)

NEUVIEME SEANCE PLENIERE

Vendredi 5 mai 1995，9h25

Président: Dato Dr Haji Johar NOORDIN (Brunéi Darussalam) puis Président par intérim: Dr J.R. de la FUENTE RAMÍREZ (Mexique)

DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-FOURTH AND NINETY-FIFTH SESSIONS AND REVIEW OF THE WORLD HEALTH REPORT 1995 (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-QUATORZIEME ET QUATRE-VINGT-QUINZIEME SESSIONS ET EXAMEN DU RAPPORT SUR LA SANTE DANS LE MONDE，1995 (suite)

The PRESIDENT:

Distinguished delegates, good morning. The ninth plenary meeting is now called to order. We will this morning continue with the debate on items 9 and 10，and 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.


The remaining speakers on the President's list are the Syrian Arab Republic, Fiji, Burundi, who has requested to make a brief statement additional to the statement made by the Central African Republic on behalf of the countries from central and west Africa, Solomon Islands, Barbados, Malaysia, Cyprus, Guinea-Bissau, Hungary, Albania, Cape Verde, Cambodia, Kiribati, Suriname, Iraq, Sao Tome and Principe, Ecuador, Malawi, Federated States of Micronesia, Saint Kitts and Nevis, Peru, Palau, The Former Yugoslav Republic of Macedonia and Angola.

The PRESIDENT:

Thank you, Dr Piel. Does the delegate of Malta wish to speak?

Dr VASSALLO (Malta):

Mr President, yesterday we requested to make an intervention in respect of item 10 on The world health report which was not available to us in time for when my Minister made his intervention. We wonder why we have not been put on the list of speakers. We are making this intervention on behalf of our country, Luxembourg and Iceland.

The PRESIDENT:

Thank you, Malta. With your agreement, we will give you a slot at the end of the day. I now call the first two speakers on my list, the delegates of the Syrian Arab Republic and of Fiji. I give the floor to the delegate of the Syrian Arab Republic, and call to the rostrum the delegate of Fiji.

A48/VR/10 page 173

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The PRESIDENT:

I thank the delegate of the Syrian Arab Republic. I give the floor to the delegate of Fiji, and call to the rostrum the delegate of Burundi, who has requested to make a brief statement, in addition to that made by the Central African Republic, on behalf of the countries of central and west Africa.

A48/VR/10 page 174

Mrs HONG-TIY (Fiji):

Mr President, honourable ministers, Director-General, distinguished delegates, ladies and gentlemen, as the Minister for Health for Fiji and leader of the delegation, I am honoured to have the opportunity to address this Forty-eighth World Health Assembly. On behalf of my delegation, I would like to offer you my sincere congratulations on your election to the high office of President, and we are confident that under your able leadership we will have a most successful Assembly. I would also like to express our immense pleasure at the admission of the Republic of Palau as a Member of the World Health Organization. We offer our heartiest congratulations to our sister island nation and we look forward to increased opportunities to work together as South Pacific island countries for the betterment of our people and indeed, for the WHO vision and our common goal of health for all.

This year's Assembly is focusing on the twin important themes of equity and solidarity; and I would like to comment on both from a South Pacific perspective and describe the present situation and our current and planned actions to improve matters. Firstly, Mr President, I would like to elaborate on equity in health care. This is a concept which is difficult to define to the satisfaction of all, although I am sure we all aspire to distribute our available resources fairly. One approach to reconsidering equity would be to analyse per capita health expenditure by region, race, gender, level of urbanization or any other factor which may be a basis for inequity. This is possible so long as expenditure is available for relevant health institutions or programmes and so long as there is information about the population being served, broken down according to the relevant criteria. This is problematical in Fiji and, I suspect, in many WHO Member countries.

Given the data difficulties when considering equity from the point of view of per capita expenditure, I would like to concentrate on two factors which I believe are particularly important for equity in health care for Fiji, namely physical access and insurance, and to share with you some of the ways in which we have sought to reduce inequities particularly between urban and rural dwellers. First I would like to touch on physical access. Fiji consists of around 300 islands of which about 100 are inhabited and much of the interior of the larger islands is rugged terrain in which travel is difficult. About half the population not only lives away from the cities and towns of Fiji, but also many of our rural dwellers live in relatively remote locations from which travel can be difficult and expensive. So access to health care by members of such communities is a key component of health equity in my country. We are conscious of the prime importance of genuine access by the whole population to both preventative and curative services because health services, no matter how good, are meaningless to those who cannot benefit from them. My Government has addressed this concern for equity through access by maintaining and developing our well-established network of primary health care facilities, more than 100 nursing stations and over 50 health centres for a population of around 780 000. These provide a solid base on which to maintain and develop genuinely accessible health services.

My Government continually seeks to strengthen access to this primary system by: ensuring that the remoter facilities are properly staffed and supplied (for example, our medium-term plan includes a wide-ranging upgrading of staff quarters so that we can more easily assign staff with families to all our facilities); developing a strategic and well-integrated health system across entire provinces; improving transport so that more of our health workers gain access to rural communities more often; and enhancing health education so that our people understand more about their own health and which services to access for what benefits (nongovernmental organizations can play an important supplementary role in this respect). By these concrete actions we are improving equity in the provision of primary health care across the whole of our scattered populace.

Allow me to elaborate on a number of areas where we are continually putting in a lot of effort. Fiji like many areas of the Pacific is experiencing a steady rise in noncommunicable diseases brought about by our changing lifestyles. With WHO cooperation, we are tackling these problems on many fronts. Infectious diseases also remain an important cause of morbidity and mortality, and an ongoing focus of WHO support. We are pleased to report that Fiji has achieved some notable successes. Leprosy, while still a problem in much of the Pacific, has now reached elimination targets. Our immunization coverage, which has been high for over a decade, is now over 90%. Cases of vaccine-preventable diseases are rare. We stand on the brink of certifying the eradication of poliomyelitis. Fiji is committed to the fight against AIDS and has taken important steps in this regard. The Fiji national programme against AIDS and sexually transmitted diseases has been successfully decentralized to facilitate a more community-oriented approach. Training courses to improve the clinical management of sexually transmitted diseases have been conducted for health workers at the primary care level throughout the country. In addition, a joint HIV/AIDS prevention project between the ministries of health and of education is developing curricula, producing educational materials and training primary- and secondary-school teachers on how to use these resources in their classroom settings. I also wish

A48/VR/10 page 175

to highlight the active involvement of the nongovernmental organizations in AIDS prevention and control. The Fiji Medical Association has started an HIV telephone hotline, and the AIDS Task Force of Fiji has opened a drop-in centre and provide health education with the help of peer volunteers. These are probably the first such services in the Pacific island countries.

With regard to our network of referral systems, patients needing access to secondary care at our subdivisional and divisional hospitals are referred to such hospitals by our primary care staff. Again through improvements to the ministry of transport, we are striving to ensure that all patients urgently needing such secondary care can be transferred to a subdivisional hospital quickly and in reasonable comfort and without incurring high costs. Access to tertiary care is clearly easier for people living near the major hospitals, but through the referral system, all those needing that level of care and treatment should obtain it. Also, since almost all health facilities have telecommunication links with headquarters, in extreme circumstances patients can be transferred quickly from any island or interior village by helicopter to a major hospital. Finally, there is the question of equal access to rehabilitative care. We are currently improving equity in this important area in partnership with a nongovernmental organization through the establishment of well-trained community rehabilitation assistants throughout the country. These staff support those with disabilities in their own communities and they are themselves drawn from those communities.

Turning briefly to the issue of insurance and equity, in Fiji we are currently identifying efficient, equitable, humane and sustainable arrangements for the financing of health care which make sense in our South Pacific context. Again I am sure many other countries are involved in a similar process. As we review patient charges and other means of recovering some or all of our costs of providing services, the question as to whether we are being fair to all our people in their widely varying economic circumstances is frequently asked. Some of our people live almost outside the cash economy, although I would not describe them as poor. As we overhaul our system of health care financing we need to enable people from these communities to protect themselves through suitable health insurance in the same way as any urban wage-earner. Awareness of the options and an understanding of the consequences of different choices is an important aspect of equity in this area. At present the health services in Fiji are largely free to rich and poor alike and we are determined to retain the equity inherent in the current system as we develop our financing requirements. To conclude on the problematical issue of equity, by concentrating on certain key factors, such as I have described, my Ministry is striving to identify and reduce any extreme inequities using currently available information.

Moving on to the question of solidarity, I would like to briefly describe some facets of regional solidarity on health issues in the Pacific. Such solidarity is perhaps particularly important to us Pacific islanders because of the relatively small size of our populations and our economies, the huge distances which separate us even within our own region, and the fact that many of us are in a similar state of transition as regards major health problems, with a decline in the traditional tropical diseases, but increases in noncommunicable diseases such as diabetes, heart problems and cancers. WHO has played a helpful role recently in reinforcing a sense of solidarity within our region by facilitating and funding regional conferences on key technical matters, such as health care financing, as well as wide-ranging ministerial-level discussions. Such forums strengthen our regional solidarity both through the exchange of useful technical information and also through the expression of our common aspiration to improve our health services.

In March this year my Government, in collaboration with the Regional Director for the Western Pacific, hosted a high-level conference for ministers of health of the Pacific islands and their permanent secretaries. The purpose of the conference was to give Pacific island health leaders the opportunity to discuss realistic and practical activities which would have a direct effect on improving the health of the countries in the region and, more important, offer a form of solidarity to our Pacific region. The result of this historic ministerial conference was the Yanuca Island Declaration on Health in the Pacific in the twenty-first century. The Yanuca Island Declaration is not just an abstract manifesto or declaration of principles. It is rather an expression of the commitment of the health leaders to specific concrete actions which will be reviewed in a follow-up meeting in two years' time. These actions include intensified cooperative efforts in relation to the development of the health workforce, in relation to the protection of the environment, and to the supply and management of pharmaceuticals, medical equipment and essential drugs in the Pacific. For example, in relation to the development of the health workforce, the Ministers agreed to intensify efforts to further strengthen collaborative relationships through networking and to involve all existing training institutions in the development of human resources for health. This is vital because small island countries do not have sufficient resources individually to establish all the training institutions they need in order to meet their health workforce needs.

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The unifying theme adopted in the Yanuca Island Declaration is the concept of "Healthy islands"，which we are very pleased to note that you alluded to in your address. This concept embodies a holistic view of health - a view which takes into account all aspects of a person's life and environment. It focuses on positive health - on health promotion and on health protection - and on how health can be sustained in the face of development. The concept implies the need for an integrated approach to health development and emphasizes the importance of further strengthening intersectoral collaboration as envisaged in primary health care. The basis for the "Healthy islands" concept can be found in the document entitled "New horizons in health". Last September, the Regional Director presented this document to the Regional Committee for the Western Pacific where it was warmly accepted. The Committee then urged the Regional Director to work with Member States on its implementation. I am pleased to say that the ministerial conference I initiated in Fiji has not only endorsed the "New horizons" approach but is also translating this concept into a practical and sustainable programme of action.

Environmental health is naturally a prime concern across the region and we have jointly accepted the "healthy islands" concept as the best approach to addressing underlying environmental issues common to Pacific islands. Health care financing is another general concern in our region and here also a feeling of solidarity fostered by conferences such as the one recently organized by WHO in our region puts us in a more informed position to tackle the politically contentious issues in this field. Finally, Mr President, solidarity in health promotion, which is a high priority in all ministries of health is being strengthened through a major project with a key regional health education component, and in future we see common approaches to legislation, such as tobacco control, as a productive area for cooperation resulting in mutual benefit.

I would like to close by expressing appreciation for the cooperation which Fiji has received from WHO through our close association with our South Pacific Representative based in Fiji and with the Regional Director, Dr Han, and his staff of the Regional Office for the Western Pacific. I would like to reaffirm my country's clear support, in turn, for WHO and its future work.

M. BATUNGWANAYO (Burundi):

Monsieur le Président, Monsieur le Directeur général, distingués délégués, Mesdames, Messieurs, nous avons l'insigne honneur de nous adresser, au nom de la République du Burundi, aux délégations du monde entier présentes à cette Quarante-Huitième Assemblée mondiale de la Santé à laquelle nous souhaitons pleine réussite. Qu'il nous soit permis de saluer et féliciter Dato Dr Haji Johar Noordin, Ministre de la Santé du Brunéi Darussalam, qui a été élu pour présider ces assises. Nos félicitations vont également au Dr Hiroshi Nakajima, Directeur général de l'OMS, pour les efforts qu'il n'a cessé de déployer afin de promouvoir le développement de la santé dans le monde entier. Des progrès ont certes été réalisés, mais les défis sont nombreux et des difficultés immenses persistent, surtout dans les pays en développement. Nous restons convaincus que ces obstacles sont surmontables moyennant un engagement franc et solidaire de la communauté internationale.

La présente session de l'Assemblée de la Santé se tient à une période riche en événements malheureux dans le monde. Le Burundi n'a pas été épargné : il vit en effet une crise socio-politique depuis 18 mois，crise consécutive à l'assassinat du président Ndadaye，le 21 octobre 1993. Les conséquences de cet assassinat ignoble ont été les massacres de populations innocentes, des assassinats politiques et ethniques, la destruction de certaines infrastructures, dont les centres de santé. Le système de santé a souffert en ce sens qu'il a subi beaucoup de dégâts; je peux citer notamment la mort d'un grand nombre de membres du personnel médical et paramédical, tandis que plusieurs centaines d'agents désertaient leur poste, la destruction des infrastructures sanitaires à des degrés divers, et le pillage des équipements techniques et non techniques et des médicaments, sans parler du charroi volé ou endommagé.

Les séquelles de ces actes de violence, de vandalisme et de pillage sont encore présentes aujourd'hui et sont la cause des dysfonctionnements de notre système de santé actuel. Je citerai quelques exemples pour illustrer mon propos. D'abord, pour diverses raisons, notamment des raisons de sécurité, le personnel de santé s'est concentré dans les villes, délaissant les unités périphériques qui constituent pourtant l'ossature même de notre système de santé qui repose sur les soins de santé primaires. A cela s'ajoute le fait qu'un nombre important de personnel étranger a quitté notre pays, créant un vide réel dans certaines unités de soins. Ensuite, la supervision des activités par les différents niveaux ainsi que l'approvisionnement en médicaments et autres matériels et produits médicaux renouvelables ont été jusqu'à aujourd'hui plus qu'irréguliers; cela est la conséquence de l'insécurité qui règne ici et là et de l'état défectueux du charroi ou tout simplement de l'absence de moyens de transport dans certains districts sanitaires. Il y a aussi le fait que les médicaments,

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qui étaient déjà en quantité insuffisante avant la crise, manquent cruellement puisque la demande est devenue plus forte étant donné qu'une population importante vit non seulement dans un traumatisme et un état d'anxiété permanents, mais aussi dans des logements de fortune très précaires. Ajoutons enfin que de son côté, la maladie fait plus de victimes parce que le système de santé est peu opérationnel. Les résultats du programme élargi de vaccination illustrent bien les lacunes du système depuis la crise. Un exemple : en 1992, la couverture vaccinale était de 90 % pour la tuberculose, 82 % pour la diphtérie, le tétanos et la coqueluche, 82 % pour la poliomyélite et 70 % pour la rougeole; en 1994，la couverture vaccinale n'a atteint que 48 % pour la tuberculose, 33 % pour la diphtérie, le tétanos et la coqueluche, 33 % pour la poliomyélite et 32 % pour la rougeole.

Nous tenons ici à rendre hommage à l'OMS, aux organisations internationales et non gouvernementales ainsi qu'aux pays amis, pour le soutien manifesté au Burundi dès le début de la crise. En effet, par leur truchement, bien des actions ont été menées notamment en matière de soins, d'approvisionnement en médicaments et autres produits médicaux renouvelables, de récupération nutritionnelle et de supervision des unités de soins. Cela a contribué à maintenir l'état sanitaire de la population à un niveau plus ou moins satisfaisant. Cependant, nous craignons principalement l'accroissement de l'incidence de l'infection à VIH au sein de la population en général et surtout dans les camps de personnes déplacées ou parmi la population dispersée sur les collines où elle vit dans des conditions fort déplorables dues notamment à la promiscuité.

Une autre inquiétude se rapporte à la santé de la famille qui se détériore, particulièrement celle de l'enfant et de la mère. La mortalité infantile et maternelle, déjà élevée, risque de s'accroître compte tenu des conditions de vie extrêmement difficiles. La femme, souvent surchargée par le travail ménager et agricole, épuisée par des grossesses rapprochées doit, dans la plupart des camps de réfugiés, jouer le rôle de chef de famille. En effet, le décès des hommes change la structure familiale et la distribution traditionnelle du travail, surchargeant davantage la femme.

Devant ce tableau pew reluisant que nous venons de brosser, d'aucuns pourraient céder au découragement. Or une lueur d'espoir se profile à Phorizon : en effet, la Présidence de la République, la Primature, le Gouvernement, l'Assemblée nationale et les partis politiques viennent de lancer une vaste campagne de sensibilisation dans tout le pays pour un retour rapide à la paix, à la sécurité et à la confiance mutuelle des composantes de la société burundaise. Nous osons espérer que cet engagement sera couronné de succès et que, dans un avenir proche, les Burundais reprendront le chemin de la raison pour reconstruire leur pays.

Nous avons l'intime conviction qu'une fois la paix revenue, nous aurons pour tâches principales la remise en état et la relance du système de santé national, ainsi que le développement des ressources humaines. Cette mission est capitale puisque nous devons à court terme rattraper au moins les résultats atteints avant la crise de 1993 et relancer plusieurs projets de grande importance mis en veilleuse. J'aimerais citer cinq exemples : tout d'abord, la poursuite de l'implantation des nouveaux hôpitaux et surtout des centres de santé pour améliorer l'accessibilité aux soins; je signalerais en passant qu'en 1993，80 % de la population rurale accédait à une unité de soins située à moins de 5 km. Vient ensuite la décentralisation des pouvoirs de gestion et de décision : neuf hôpitaux sur 35 étaient dotés d'une autonomie de gestion; cette politique se poursuivra jusqu'à rendre autonomes tous les hôpitaux et centres de santé puisque nous constatons que, dans les hôpitaux où elle a été appliquée, la qualité des services s'est améliorée sensiblement. L'amélioration de l'accessibilité financière des populations aux soins de santé est un autre projet qui repart. A ce propos, le Gouvernement burundais, avec l'appui de la Banque mondiale, a lancé un projet de création d'un système d'assurance-maladie pour le secteur non structuré qui représente 93 % de la population. Pour des raisons d'équité et de solidarité, cette assurance-maladie, contrairement au système en place actuellement, couvrira tous les volets de soins, y compris l'accès plus facile aux médicaments pour une population souvent démunie financièrement. Citons aussi la création d'une centrale d'achat de médicaments dont la mission est de mettre à la disposition de la population des médicaments essentiels à un prix abordable. Enfin, l'accessibilité à l'eau potable pour tous à moins de 500 m et au logement amélioré et décent pour tous d'ici l'an 2000 fait aussi partie du programme du Gouvernement qui est conscient que la plupart des maladies infectieuses et parasitaires sont des corollaires de l'hygiène précaire.

Outre ces innovations projetées ou en cours, le Ministère de la Santé publique poursuit et poursuivra ses orientations principales qui sont d'ailleurs soutenues par nos partenaires au développement, à savoir : poursuite de la lutte contre la maladie en général, lutte contre le SIDA et les maladies sexuellement transmissibles, poursuite des activités de planification familiale, relance du programme élargi de vaccination, intensification de la lutte contre les maladies diarrhéiques et les infections respiratoires aiguës, intensification de la lutte contre le paludisme dans les zones d'épidémie et d'endémie, et amélioration de la qualité des services et de la disponibilité du personnel soignant à tous les niveaux du système de santé.

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Etant donné la situation particulièrement difficile dans laquelle le Burundi se trouve actuellement, nous lançons un appel pressant aux pays amis, aux organisations internationales et aux organisations non gouvernementales pour qu'ils renforcent leur appui au système de santé national et leur assistance aux populations burundaises affectées par la crise.

Pour terminer, nous remercions vivement la coopération internationale, et particulièrement l'OMS, des actions salvatrices qu'elles ont menées depuis octobre 1993 et qu'elles continuent d'ailleurs à mener pour améliorer l'état de santé de notre population. Enfin, nous formons le voeu que l'Organisation mondiale de la Santé puisse, en cette fin de siècle, enregistrer des résultats significatifs dans l'éloignement du spectre de la maladie, de la faim et de la misère. Il faut absolument atteindre l'objectif de la santé pour tous, et tous pour la santé, d'ici l'an 2000，car ce sera là notre meilleur legs aux générations futures.

Mr MARA (Solomon Islands):

Mr President, your excellencies, Director-General and distinguished delegates, allow me to extend my delegation's congratulations to you, Mr President, and your Vice-Presidents, on your election to preside over this Assembly. I am sure, Mr President, that under your able leadership we will accomplish our agenda satisfactorily.

Concerning the subject we are supposed to focus our interventions upon in our debate here in plenary, equity and solidarity in health - bridging the gaps, we have been talking about equity and bridging the gaps, especially between the haves and the have-nots, for some time now and yet as the summary world health report reveals, there are indeed enormous gaps between the health status of countries, regions, groups of people, and so on. Clearly we have a long way to go, and yet the year 2000 is only a few years away. In the summary report it is stated that the world's biggest killer and the greatest cause of ill-health and suffering across the globe is listed almost at the end of the International Classification of Diseases with the code Z59.5 - that is "extreme poverty".

Whilst poverty may be the culprit，my view is that equally so, or even far more sinister, is another killer and cause of ill-health that I would call "extreme politics". We need to be aware of the facts that extreme politics could in a matter of seconds, hours or days undo the positive achievements in health that had taken years and years of hard work and efforts to produce. Indeed it is disheartening to note that where limited resources are available and the health needs are greatest very little resources are allocated for health whilst most resources are diverted elsewhere to issues that have adverse impacts on health, for example, for weapons of mass destruction; or for those who "have" to demand unnecessarily from the "have-nots" before assistance is given. I know that it is extremely difficult to solve these issues and perhaps this is not the mandate of WHO but I feel that globally WHO should strive at all times to work with relevant organizations and United Nations bodies and countries on these matters. However, let us look at our own Organization, WHO. Are we doing our best not to subject it to extreme politics? Are we deliberately not contributing to WHO for political reasons? We need to keep WHO free of extreme politics because it will not be healthy if it does become politicized. Our WHO needs solidarity for the sake of global health. The world is going through profound political, social, economic and health changes and our WHO is trying to adjust to these global changes. We, the Member States, should take this opportunity and institute positive changes in bridging the inequities and gaps.

As ministers of health, the custodians of health and welfare services in our own countries, are we doing enough to rally political support to ensure that health and welfare services are given the required resources and support? There are numerous examples in the world today of political commitments to health and welfare services that have resulted not only in better health status but also economic development. It is now up to us, the ministers of health, to lobby within our own countries for the destruction of weapons of mass destruction and warfare, including nuclear and chemical weapons. This world would be a safer and healthier world without them.

The Ad Hoc Committee on Orthopoxvirus Infections in September 1994 recommended that all stocks of variola virus should be destroyed, including all whitepox virus and other materials containing infectious variola virus in all WHO centres and other laboratories throughout the world. We have eradicated smallpox and wiped it from the face of the earth; the danger of a major laboratory accident and hence the appearance of the defeated enemy is real and we must avoid this mishap ever occurring. This should be done as soon as possible; we just cannot afford not to do so in view of emergencies and problems.

We should also bear in mind that whilst we strive to bridge the gap in health status there are other important issues, namely, the world's rapid population growth and environmental degradation, together with

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global warming. These issues are of importance in my view and hence WHO's involvement in the implementation of Agenda 21 and the programme of action of the International Conference on Population and Development is also important.

On 10 March 1995 the conference of ministers of health of the Pacific island countries adopted the "Yanuca Island Declaration on Health in the Pacific in the Twenty-first Century", as highlighted by my honourable colleague. This Declaration endorsed the concept of "healthy islands" as the unifying theme for health promotion and health protection in the island nations of the Pacific. The Declaration stated that healthy islands should be places where: children are nurtured in body and mind; environments invite learning and leisure; people work and age with dignity; and ecological balance is a source of pride. Above all, the Declaration recognizes that despite their diversity, the Pacific islands share many things in common and most importantly collaboration and sharing of resources is possible. Therefore I view this Declaration as a possible base for building solidarity and bridging the gaps in health in the Pacific island countries. WHO support in fulfilling the aspirations of the Yanuca Island Declaration is therefore crucial. In the Solomon Islands, a nationwide health services review will take place soon to identify any inequities and gaps in our health status and services. The results of the review will be the basis for the future strategy to bridge the gaps in the country.

Mrs THOMPSON (Barbados):

Mr President, Vice-Presidents, distinguished delegates, ladies and gentlemen, the Barbados delegation joins in congratulating you, Mr President, and your Vice-Presidents on your election, and wishes that, under your direction, this Forty-eighth Assembly will bear much fruit.

This year Member countries have been requested to focus on the topic of equity and solidarity in health - bridging the gaps. From a social and economic perspective, equity connotes equality and fairness. Just as solidarity connotes unity and oneness. Equity and solidarity are implicit in the WHO objective of health for all by the year 2000.

The Government of Barbados has long recognized the nexus between health and national development. We believe that good health is the inviolable right of our entire population of 250 000 people. To this end, since our independence in 1966，health care has been accessible to all our citizens. For，irrespective of colour, gender or socioeconomic background, health care is free of cost and is of high quality. We have a strong maternal and child health programme, an island-wide network of primary and geriatric health care facilities, a well-equipped tertiary care institution and a drug service which provides free pharmaceuticals to all persons under 16 and over 65 years, as well as to those suffering from chronic diseases. Barbados' economy, like that of many small island developing States, is dependent on tourism, which will not be sustainable if our environment is polluted and our sanitation poor. The existence of widespread disease among the world's people, including the prevalence of the epidemics of AIDS and violence, all militate against tourism and the maintenance of a high national health profile. A population that has a high morbidity level as a result of diabetes mellitus, cerebrovascular disease and other largely preventable diseases cannot form a strong and productive labour force. A person who is diseased cannot realize his full potential. The cost of caring for the sick and dying places severe strain on our limited resources. Put in this way, the correlation between good health and development becomes apparent.

There is also a relation between the fate of one country, developed or developing, and the rest of the world. Often the developed countries wish to remain in their own niches, contemptuous of the developing countries. Would it not be better however, to help set others on the road to development, so that your own country is not flooded with immigrants and refugees whose countries are underdeveloped and cannot therefore afford them access to even basic health care? Your nationals come to our shores. If our people are diseased then your citizens will return to you with diseases which they have caught from us. The diseases your citizens bring challenge our health systems and our resources. Witness how minor and common diseases of Europe decimated the Indians of the Caribbean and Latin America in the sixteenth century. It should be borne in mind that contagious and chronic diseases see no barriers. They are oblivious to gender, to socioeconomic background as well as to colour of skin. They affect us all.

One of the most tangible ways in which both developed and developing countries can show solidarity is in eliminating the inequalities which exist in the health care delivery system. This can be done through international cooperation and the sharing and pooling of resources. In some developed countries the level of wastage far exceeds the actual assets of some developing countries. Inequity exists because there is an unequal distribution of scarce resources. No sovereign nation wishes to be a beggar with cap in hand. As

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developing countries, we wish only to be helped towards self-sufficiency. Such help should take the form of the exchange of knowledge, information, technical expertise and skilled personnel.

People often do not appreciate the importance of good health until they become sick. It is imperative therefore that each individual takes responsibility for his own health by living healthy lifestyles with a good diet, adequate amounts of exercise and rest，and without substance abuse. Health promotion and education will go a long way towards encouraging our people to live healthy lifestyles. Equality and fairness in the delivery of health care will result from the empowerment of the individual and the community to take responsibility for themselves. It will result by providing all the peoples of the world access to prompt, efficient, relevant health care delivered by trained personnel.

The question for us all is how we can combine equality, fairness and solidarity to bridge the gaps that prevent our citizens from attaining good health, to bridge the gaps that prevent us from attaining national and international development. On his nomination as Director of РАНО, Sir George Alleyne said "I have for a long time been gripped by a vision of a world in which there is no 'otherness' in health. We may accept differences in physical characteristics but in a very real sense, in the case of health there should be no 'others' because we are indeed one, bound together by ties that go beyond our physiology". These remarks are most pertinent for, when we see each other as different, when we see two sets of people - ourselves and "others", then we allow our prejudices to keep us apart; then we fight against our own good health and development. Then there is no solidarity and the gaps become unbridgeable chasms. This is true of individuals, of institutions and of nations.

The world's people are its greatest resource. They are its wealth. Without good health, however, this resource becomes useless. The world is a village: we share the same ozone layer, the same waters, the same air. The world's citizens move from continent to continent with ease. Unless therefore with solidarity, with singleness of purpose，we ensure equitable distribution of the earth's resources and the protection of the earth's environment, then we are creating for ourselves a global inheritance of disease, disability, destruction and death. The Director of РАНО puts it in this way, "In this world that might be or will be, our citizens will truly see that health is for living and agitate that they might be allowed to live in the fullest sense of the word".

The people of the world dream the same dream whether they are in Japan, Geneva, Bridgetown (Barbados), Cook Islands, Cameroon, United States of America, United Kingdom, Belize or Brazil. It is a dream in which they are treated with respect and fairness; it is a dream in which they are healthy and lead productive and fulfilling lives. As health care policy-makers and providers, we can let this dream become a nightmare or we can help our people to fulfil it. I urge you to let us fulfil this dream by the year 2000.

Dato’ ISMAIL MANSOR (Malaysia):

Mr President, the Director-General of WHO, distinguished delegates, ladies and gentlemen, I extend warm greetings to you all from the Government and the people of Malaysia. May I congratulate you, Mr President, on your election to this prestigious post and may I also congratulate the Vice-Presidents and committee chairmen on their election to this august Assembly.

Malaysia has achieved significant progress since independence in 1957，and over the last decade has achieved strong economic growth. This has been achieved through having a stable government, political stability, racial harmony and religious tolerance in a multiracial, multi-religious and multicultural society. Our history of peace and harmony has contributed in no small measure to the impressive performance of the Malaysian economy, which has been associated with significant improvements in the health status of the people of Malaysia.

A key concern of Malaysia's national development effort since independence has been the emphasis on equity. The national development policy is based upon the principle of growth with equity. The development of our health services has given priority to equity considerations of access to these services in the two important dimensions of geographical access and, of increasing importance, cost access. With the rapid rate of infrastructure improvements throughout the country, 95% of the population in peninsular Malaysia have geographical access to some form of static health facility. Of greater concern today and for the future is the problem of cost access. We are in a transition, with changing patterns of diseases which will contribute towards rising health care costs, as these diseases need expensive institutional care focusing on high technology. At the same time, market forces have encouraged an unprecedented growth of a profit driven private health sector, which is mainly curative, and have contributed to the increasing costs of health care. To ensure equity through cost access, this issue of rising health care costs has to be addressed through

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acceptable cost containment measures. We have to ensure that there is effective allocation of our health resources, and that our interventions in creating health or in health care are appropriate and cost effective.

We are committed to the goal of health-for-all primary health care that encompasses the eight essential elements as enunciated in the Alma-Ata Declaration, namely, education concerning prevailing health problems and the methods of preventing and controlling them; promotion of food supply and proper nutrition; adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common diseases and injuries; and provision of essential drugs, as well as certain secondary and tertiary health care which should be made available, accessible and affordable to all, including the poor in the country, through various mechanisms of subsidy of the cost of health care by the Government. The types of secondary and tertiary health care that can be subsidized will depend on the ability of the country to pay. We believe that secondary and tertiary care for diseases and injuries should be subsidized by the Government, provided that such care will help to restore the persons concerned to good health and enable them to live an economically productive life.

We thank the Director-General for his report; it can be seen that much progress has been achieved in most nations in the implementation of strategies for health for all. However, at the same time, in many parts of the world, the provision of health care to the people is greatly hampered by war, and racial and religious conflicts, through the destruction of health facilities, interruption of community water supply, breakdown of environmental sanitation, mass exodus of people, and shortage of food and medical supplies. Therefore, peace is a very important prerequisite in any nation before we can talk about equity and solidarity in health in that nation. All health professionals and other health workers in all countries, should actively advocate the seeking and maintenance of peace among people of different ethnic groups in the respective countries. We should also abhor all forms of violence due to racism, religious intolerance and greed for power and wealth. The people of Malaysia sympathize particularly with the people of a number of countries around the world for their immense suffering due to war and ethnic persecution. Here, I wish to implore the health professionals and other health workers and health-related organizations in these countries to persuade their political leaders to end the meaningless wars as expeditiously as possible. The right to good health is an irrefutable right of every person in this world. We, as Members of WHO, in advocating health for all, should therefore exhibit our solidarity by helping Member States in practical ways to achieve equity in the distribution of health care resources and to reduce disparity in health status between population groups within and between nations. We have to lead the way to make people more healthy and to make this world a better place to live in.

I would like to reaffirm Malaysia's commitment to WHO and to ensuring that this Organization continues to serve the interests of the health of the people of the world in the decades to come. We appreciate the efforts of the Director-General and his staff in the important changes taking place in WHO. We are following closely the changes occurring in the Organization to meet the challenges facing us. We look forward to WHO maintaining its standards of excellence and towards strengthening its leadership role in looking after the health of the people of the world.

Mr CHRISTOFIDES (Cyprus):

Mr Chairman, on behalf of the Government and the people of the Republic of Cyprus, I would like to congratulate you for your election. I would also like to take this opportunity to acknowledge the hard work and dedication of the Director-General, Dr Nakajima, and once more reiterate our gratitude and appreciation to our Regional Director, Dr Gezairy, and the staff of the Regional Office for the Eastern Mediterranean for their support and all the ongoing collaborative activities in the field of health.

The historic resolution committing WHO and its Member States to the most daring and challenging goal of health for all by the year 2000 implied a massive undertaking on the part of Member States to bring about a health revolution. But today the critical issues involved in the global movement of health development must continue to be analysed, with special attention to equity and solidarity in health, between the developed and developing countries and within the countries, regions and communities, if we are to give to our people the quality of life which by all means is their fundamental right.

The health map of many countries and the health profile within countries still presents a dismal picture. There are still many major public health problems contributing to a high mortality and morbidity in some countries on the one hand, and other public health problems of the developed countries on the other hand, which are the result of growing industrialization and the emergence of major urban centres. The situation

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is complicated by the scarcity of human resources, the inadequacy of the health services and the deterioration of the demographic fabric. To add to this dismal picture, the global population expansion continues at the rapid pace of more than 100 million persons per year, despite the warning by several experts that limits to growth are imposed by finite resources of land, water and food. Until very recently, only a few have taken heed of these warnings.

It seems that humans show many signs of self-destructive madness. The environmental pollution, the depletion of the ozone layer and consequent increase in ultraviolet irradiation of the biosphere will make matters worse by disrupting the reproductive systems of delicate microorganisms and the immunological responses of larger species, including humans. If this scenario is even approximately accurate then strategic planning and awareness is more essential today than ever before. The health status of hundreds of millions of people in the world is still unacceptable. We have to ensure that our children's journey in life will be in a bright avenue passing through the golden gates of our love. Yet every day we witness on the small screen of television that millions of innocent children knock at the hideous gate of death after going through the ocean of our apathy, hypocrisy and cruelty. This picture is an indelible stigma and shame for all. More than half of the global population do not have the benefits of adequate health care. There is a wide gap between the developed and developing countries, in their levels of health and in their resource allocation. Moreover, within individual countries, whatever their level of development, similar gaps are also evident between different groups of population. Improvement in health has been equated with the provision of medical care dispensed by a growing number of specialists, using highly specialized medical technology for the benefit of the privileged few.

Admittedly, since the adoption of the Global Strategy for Health for All by the Year 2000 in 1981， health status - as measured by such indicators as life expectancy and infant mortality - has improved globally, once the opportunity for the availability of essential health care was given. However, the pace of improvement has been slower in the least developed countries and, as a result, inequity between the developing and least developed countries is greater than a decade earlier. Also, there is some evidence that disparities in health status have increased within countries between certain population groups. Millions of people are still without access to either all or some elements of primary health care.

Worldwide health systems development has increasingly reflected the concepts, approaches and philosophy of primary health care. However, the health systems have continued to give greater emphasis to specific diseases and conditions or to some elements of care and specific types of services, which sometimes does not facilitate meeting the overall health needs of people at different phases of their lives on a continuing basis. Therefore coverage by various elements of primary health care is unbalanced and distorted. There is also little evidence that international and bilateral funding agencies have significantly shifted their aid priorities towards the low income and least developed countries. In fact, although the resources available for health are limited, those that exist are seldom fully utilized and are often wasted or misused.

The process of dispersing the two categories of the health "haves" and the health "have-nots" must be accelerated through the development of cooperation on a worldwide basis amongst both developed and developing countries. Even the developed countries, despite their technological and economic strength, as previously mentioned, have too many chinks in their own armour. Mutual interdependence and cooperation among nations is therefore needed, which is in fact the principle of the United Nations. We are fully aware that some countries do not observe these; as a result, there is still the growing frustration that peace - which is the key to health and human development - is not maintained.

At the national level, health can flourish in a sociopolitical atmosphere which is conducive to progress. It is political will that will determine the pace of development. The endorsement of the four principal thrusts adopted by the ninety-fifth session of the Executive Board, with which we are in full agreement, is therefore imperative. But political will is not enough, as the management competence of the health sector will determine whether the full potential of the formidable political environment is translated into concrete action.

There should be a country-specific strategy based on the social, political, cultural and economic environment of the particular country, and it should be part of the social development system. The objectives should be defined in terms of broad national health development indicators. This will lay the foundation for the formulation of a detailed programme on the twin essentials of community participation and intersectoral collaboration.

Health systems should be developed to provide a maximum of quality care at a minimum cost, and steps should be taken to minimize the decisions which may result in wastage. Policy-makers and health service funders must take care to avoid inadequate recurrent cost funding, including foreign exchange, avoid duplication of programmes, and give emphasis to rural services versus urban, basic services versus tertiary, and avoid the unnecessary purchase of high-cost drugs and technology. Health service managers should

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develop mechanisms to avoid inappropriate allocation and misuse of staff, inappropriate allocation of transport and inadequate maintenance of stocks. Health care workers must ensure an appropriate diagnosis and treatment, and avoid overutilization or underutilization of services.

Economic and educational policies should be developed in parallel and synergy to health policies, and plans should be made with vision and creativity. Our targets should include, amongst others: transfer of resources from the developed countries to the less developed countries; great efforts, to be made by policy-makers to include the health sector in their economic strategies and policies; the development of new partnerships and new health alliances, with mechanisms for networking and use of modern technology for better communication; the establishment of mechanisms for strengthening the cooperation between the public and private sectors, and the expansion of collaboration with other agencies and nongovernmental organizations; the shifting of emphasis on to individual and community responsibility, ethical values and respect for human life; and the reassessment of activities in the field of management, research, health promotion, health education, human resource development and the collection/dissemination of information with careful monitoring.

The rapid political, economic and social changes of recent years have affected more or less all national health services, which have to function with the criteria of cost containment and careful strategic and detailed planning. While the necessity for long-term planning and benefits cannot be denied, it is also true that health improvements in the short term can be built into long-term planning. However, such improvements require a conscious effort to achieve a measurable impact on health. This，in fact, is one of the few criteria for success.

In conclusion, I would like to emphasize: the need for all development to support the drive for equity in health; the need to emphasize the moral value in human terms of all actions towards health development; and the need to widen national and international partnerships in health development. A Greek philosopher 2500 years ago declared himself to be a world citizen. The ancient Greeks worshipped health and equity, and built temples for these goddesses. All nations regard health as a carrier of gladness and happiness. If we listen carefully to all these voices and messages from the past and adopt them as a way of life and guideline for policy-making, accepting that health in every corner of the world is everybody's business and concern, we would then bridge the gaps and achieve equity and solidarity in health.

Dr ARAUJO (Guinea-Bissau) {interpretation from the Portuguese)}

Mr President, ministers, distinguished guests, ladies and gentlemen, on behalf of the Government of the Republic of Guinea-Bissau and my delegation, may I first of all congratulate the President, Vice-Presidents and other officers on their elections. I should also like to congratulate the Director-General and members of the Executive Board on the excellent reports they have submitted. May I take this opportunity to thank the Director-General and the Regional Director for Africa for their unflagging efforts in favour of health for all in particular in terms of my country, Guinea-Bissau. I should also like to congratulate the new Directors, Dr Ebrahim Malick Samba and Dr George Alleyne on their election as Regional Directors of the African and American Regions. May I wish them every success in the implementation of the difficult but noble tasks which have been entrusted to them with a view to the health of our continents. Your excellencies, ladies and gentlemen, the Forty-eighth World Assembly is taking place at a very special time for my country, Guinea-Bissau. After a process which lasted several years, leading us to a democratic multiparty regime and which was completed last year with the first multiparty elections and the creation of a new executive body, the Government's programme that has just been approved by parliament gives priority to social sectors. Our Government intends to step up efforts, so health action is more effective in matching the aspirations of the population and eliciting their participation and involvement. However, despite all these efforts and the support we have received from the international community, the needs of our populations are still far from having been met. The work of WHO and other partners in development is therefore of paramount importance to avoid bottlenecks and pave the way for harmonious development of the health system in accordance with the plans. We are therefore extremely pleased to see in the Director-General's report issues which are of great importance and most topical, and which are part and parcel of the major challenge, health for all, which was launched for our governments. Guinea-Bissau is one of the poorest countries in the world, and the health status is conditioned by the economic and financial crisis, in particular measures provided for in the structural adjustment plan which is currently being implemented. Thanks to WHO support and support of all other


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peoples involved, and despite an unfavourable economic context, we have registered some progress, such as decentralization, and an improvement in the management of our services and health programmes in the various regions of the country.

Within the framework of our policy, we emphasize the coordinated integrated implementation of certain priority components in primary health care, at all levels of the system. The aim is to foster a broader community participation. All these activities make up the strategic goals for health development in the medium term: development and upgrading of human resources; improvement of equipment and infrastructure; supply and management of essential drugs; development of health information systems; maternal and child health; improvement of the water supply system and environmental health and sanitation; reinforcement of our national ability to combat disease, in particular malaria and AIDS, and strengthen our ability to cope with emergency situations.

To attain these goals, Guinea-Bissau attaches great importance to coordinating external assistance with a view to a more rational use of resources. To this end，we currently have a WHO technical cooperation programme. This enables us to strengthen certain priority programmes, and to develop new programmes. We wish here very sincerely, to thank WHO and other organizations present here for all these initiatives which afford concrete support for Guinea-Bissau.

HIV and AIDS are a source of major concern in Guinea-Bissau. At the beginning of the epidemic, the predominant virus was HIV 2，but more recently，HIV 1 has also appeared. This creates serious problems of morbidity and mortality, and will do so in the next few years. The resurgence of certain infectious and endemic diseases, like tuberculosis, represents a threat for our future, given a very fragile health system. In October 1994，we were surprised by a cholera epidemic which caused many victims and shifted a large amount of resources from other programmes which needed such funds. From this rostrum I should like publicly to thank WHO and all the countries which provided technical and financial aid to our country with a view to containing this epidemic. As in terms of the major and endemic diseases, we welcome the successful results of onchocerciasis control, particularly in terms of reduction in prevalence, thanks to the use of Ivermectin. We hope that the results obtained will further be consolidated with the support of our partners in WHO. Our Government also attaches great importance to maternal and child health, and family planning. We note with pleasure that several elements in this major programme are part of the agenda of this Assembly. This will enable us to reinforce our activities with a view to reducing the still too high rates in our country. All these points which we shall be discussing in the course of our work, fully reflect the strategy in our region. Within the framework of maternal and child health, we should like to underscore the importance of the International Conference on Nutrition, and we are in the process of implementing its resolutions. We are preparing the national food and nutrition programme in close collaboration with WHO and FAO. We are also in the process of conducting a study on the addition of iodine to salt, with the support of WHO. Thanks to these organizations' support, our country will soon be in a position to promote and adopt an intersectoral approach in the field of nutrition, and food safety and security. This will make it possible to raise awareness and involve various sectors of our society in terms of the importance of nutritional disorders responsible for various public health problems, with an impact on morbidity and mortality in the most vulnerable groups of our population.

At the beginning of this year, in conjunction with WHO and UNICEF, we launched a vaccination campaign to eradicate poliomyelitis by the year 2000, eliminate neonatal tetanus and reduce morbidity and mortality from measles. His Excellency, the President of the Republic chaired the official ceremony to launch this campaign. Very recently, our Prime Minister, accompanied by WHO and UNICEF representatives, headed an important governmental delegation which visited all regions of the country in order to present and explain the goals of this campaign.

Mental well-being is an important indicator of a healthy lifestyle and a high standard of living. We should like here to draw your attention to mental health problems which are on the increase in our country due to a growing prevalence in risk factors rooted in the serious economic problems affecting us. We thank WHO for the support given to our country in order to organize a few months ago an interregional seminar on mental health for Portuguese-speaking countries in Africa. We will need resources to prepare a national plan with a view to sorting out preventive action, and action to treat psychological and mental health disorders.

WHO is the privileged partner of governments in the efforts they make to bring about health for all. We should like here to make special reference to intensified cooperation with WHO. Our country has benefited from considerable international aid per capita. We note, however, that this aid only had a very limited impact on the standard of living of our population, in particular in the field of health. Owing to the absence of appropriate mechanisms for management and coordination at a central level, this aid remains very

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fragmentary. Mindful of these problems, and of the need to bring about deep-seated reforms in the health sector, our Government is in the process of implementing a decentralization policy for the regional and local levels. WHO has been supporting this process through the intensified cooperation department for many years now. The programme to reinforce health management has already made it possible to train a large number of workers and improve their performance. Results are very encouraging and we wish to thank WHO for the support already given to Guinea-Bissau. We hope this support will continue, particularly in terms of strengthening, planning and management, and improving the coordination of external assistance.

As of 1945，Member States of the United Nations have had to deal with the problem of poverty. Of course we would like to eradicate it. We think that the problem of poverty and misery facing many countries of the world must indeed be tackled. Of course, this was discussed in Cairo and Copenhagen, and no doubt it will be discussed at length in Beijing. We place great hopes in all these global efforts to improve the human condition, and tackle the most serious social problems, in particular, poverty, unemployment, and social exclusion. Through this direct approach, we hope we will be able to meet the fundamental needs of our populations. We are quite convinced that democracy, transparency and responsibility or accountability in management and the administration of public affairs are the indispensable foundations which will enable us to achieve social development with man as a focal point of reference.

To wind up my statement, I should like once again to stress the importance which our country and Government attach to technical cooperation within the framework of regional integration and within the context of our geographical and linguistic context. Strengthening cooperation between developing countries and developed countries will no doubt make it possible more effectively and efficiently to implement health programmes and to make more judicious use of limited resources which are available to improve the health and well-being of our populations. Mr President, distinguished guests, ladies and gentlemen, on behalf of my Government and my delegation, I should like to thank you for your attention and I hope that at the end of our work we will approve recommendations and conclusions which will enable us better to respond to the legitimate aspirations of our peoples, that is, access to better health.

The PRESIDENT:

Distinguished delegates, as I am obliged to leave the meeting for a few hours, I would now like to request the fourth Vice-President, Dr de la Fuente Ramírez of Mexico to take over the presidency this morning. In the afternoon, at 14:30, the fifth Vice-President, Mr Than Nyunt of Myanmar will preside at the beginning of the plenary.

Dr J.R. de la Fuente Ramírez (Mexico), Vice-President, took the presidential chair. Le Dr J.R. de la Fuente Ramírez (Mexique), Vice-Président, assume la présidence.

El PRESIDENTE INTERINO:

Es para mi un placer y un honor presidir esta Asamblea. Reanudaremos ahora el debate sobre los puntos 9 y 10. Cedo la palabra al delegado de Hungría e invito a venir a la tribuna al delegado de Albania.

Dr KÔKÉNY (Hungary):

Mr President, Mr Director-General, distinguished delegates, ladies and gentlemen, it is a privilege for me to have the opportunity to address the plenary session of the Forty-eighth World Health Assembly. First and foremost let me congratulate the President and Vice-Presidents for being elected.

I definitely share the views and endorse the proposed priority areas described in The world health report 1995. I fully agree with the opinion that the globalization and growth of poverty, together with its influence on the global health status of the population, and the widening gaps between and within continents and countries, are the basic problems we have to deal with. Global organizations like WHO have a leadership role in facing these challenges. This is the message - and not something else - which should be made public from this highest level of the international health community.

I come from a country, Hungary, situated in central Europe, which is paying painful social and health costs for economic transition. Government measures to stabilize the economy and improve the balance of the central budget inevitably include cuts in social expenditure and restrictions on health expenditure, in a

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period of growing poverty and needs. In our opinion, in the present situation, the only possibility for health policies is to try to find an escape route forward by speeding up reform processes. We are aware of the fact, by now, that reform cannot be realized without hurting various interests. But, at the same time, we still would like to go on with the health-for-all policy, preserving equity and accessibility as much as possible, elaborating regional health policies within the country, focusing on health promotion and primary disease prevention, and developing primary health care and home care in parallel with the reduction in the number of hospital beds.

When overall reforms have to be implemented under circumstances of scarce resources, shortcomings in planning and decision-making processes at all levels can result in placing unbearable extra burdens on society and the economy. And this is the point where WHO can play an essential role in supporting national governments by providing expertise, by promoting and enabling the exchange of experience and best practice among countries. We have to stress here that the Regional Office for Europe recognized this urgent need in the countries of central and eastern Europe, and acted accordingly, which we very highly appreciate.

We accept and appreciate the leading role of WHO, not only in promoting and supporting the formation of national health policies, but in coordinating international aid and assistance activities in the health field. We share the views of representatives of WHO that countries which are in need of international aid and assistance should, first and foremost, elaborate their own health policies and strategies, and that aid programmes should be targeted at supporting first their elaboration and then their realization. The rapprochement initiative, promoting better cooperation among international organizations active in the health field, could essentially contribute to a more coordinated and efficient use of resources, both intellectual and financial.

From among the number of ongoing activities at the European level, may I refer to the wide-ranging and outstanding actions and developments in environmental and health issues. The Second European Conference on Environment and Health held in Helsinki in June 1994，the establishment of the European Environment and Health Committee, the pilot project promoting and supporting the elaboration of multisectoral national environmental health action plans, and other developments well demonstrate the importance attached to these issues. We do hope that through these activities we can find ways for uniting all national and international agents in decreasing environmental health hazards, in contributing both to preserving the environment and, through it, to promoting better health. We are proud of the fact that Hungary joined these activities from the very beginning, which is the sign of our commitment to environmental health issues.

Besides global and European-level cooperation, we attach great importance to closer cooperation with surrounding countries at subregional level. That is why, this February, the Minister of Welfare of the Republic of Hungary invited health ministers from neighbouring countries to discuss questions of future cooperation. We do hope that this fruitful meeting will serve as a starting point in a long-term working relationship in the field of epidemiology, environmental health and the prevention of drug abuse.

Honourable colleagues, allow me to direct your attention to a question that has already been raised several times during World Health Assemblies of recent years. This issue is the regional allocation of budgets. We do think that the present allocation does not reflect the changed situation in many countries in Europe, taking into consideration the gaps among the different parts of the continent. Growing poverty, bad health status of the population, poor epidemiological situation due to noncommunicable diseases and inequities in basic health services are phenomena present in our continent as well, though traditionally it is a major donor region of WHO. We are aware of the financial difficulties faced by this Organization but still we think that, through restricting global management costs, the budget of the European Region could be increased without touching upon the budget of other regions also facing very deep problems. Global solidarity is a key issue. Global problems can only be solved by global cooperation. The more we understand each other's problems, the better we can unite our forces in trying to solve them. WHO always was and hopefully will remain a key agent in these efforts.

Le Professeur CIKULI (Albanie):

Monsieur le Président, Monsieur le Directeur général, Excellences, Mesdames et Messieurs, permettez-moi de vous donner quelques précisions concernant la manière dont l'équité est présente dans la formulation actuelle des documents albanais de politique de santé, quels sont les mécanismes que nous avons déjà mis en oeuvre et ceux qui le seront dans un proche avenir.

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Actuellement, le Ministère albanais de la Santé développe une nouvelle politique qui rassemble des documents de politique spécifique pour chaque secteur de la santé. L'élaboration de ces documents de politique de santé se fait au sein du Ministère par différents groupes de travail qui collaborent étroitement avec la Faculté de médecine, l'Institut de santé publique et quelques experts étrangers. Un processus de gestion participative a été adopté pour la rédaction des différents documents. Les principaux éléments qui concernent l'équité dans ces documents sont examinés ci-dessous.

Le Gouvernement albanais assume la responsabilité de la santé de toute la population albanaise, et il est convaincu que le développement de la santé de la population est un investissement important pour le développement socio-économique global de l'Albanie. Cette politique nouvelle est guidée par l'expérience des autres pays et certains concepts, comme la politique de la santé pour tous. La protection de la santé de la population, la promotion de modes de vie sains et la prévention des maladies sont les principes les plus importants de cette politique.

Le Gouvernement et le Ministère de la Santé se sont engagés pour considérer que les soins de santé primaires sont la composante la plus importante du système national des soins de santé. Le système de santé albanais sera fondé sur des principes tels que la décentralisation des processus de décision, la solidarité entre les différents groupes de population à travers un système d'assurance-maladie, la justice sociale par l'amélioration de l'équité et des soins de santé pour ceux qui en ont le plus besoin. La vision globale du Ministère de la Santé concernant les soins de santé consiste à rendre les services de santé accessibles à tous les Albanais à un coût raisonnable.

L'équité d'accès aux services de santé sera améliorée au moyen de la remise en état des infrastructures et des équipements des centres de santé. Cette remise en état suivra des normes nationales : au premier niveau de référence, travailleront des médecins de famille, assistés par des infirmières de famille et des sages-femmes. Le second niveau de soins de santé est représenté par la direction de santé publique de district qui regroupe les secteurs hospitaliers et les soins de santé primaires; chaque district possède au moins un hôpital de district. Le district est donc l'unité opérationnelle qui a reçu une autonomie décentralisée de décision, de fonction, d'allocation de ressources et de responsabilité pour l'approvisionnement et la supervision du premier niveau de soins. Les patients n'auront accès au second niveau de soins qu'à travers un système d'orientation-recours initié par les médecins de famille. Le second niveau s'occupera également d'activités dans les domaines de la promotion et de la prévention de la santé, de la recherche opérationnelle en santé publique et de la formation du premier niveau.

Quelques-uns de nos objectifs à long terme sont en relation directe avec l'équité : il s'agit d'abord de contribuer à la réduction des maladies et invalidités au sein de la population, plus particulièrement chez les nourrissons, les enfants, les femmes et les personnes âgées; nous chercherons ensuite à améliorer la gestion des services de santé afin d'augmenter leur efficacité et leur qualité de soins, de réallouer et de redistribuer équitablement les ressources matérielles, financières et en personnel.

Un des mécanismes que nous avons mis en oeuvre pour améliorer l'accessibilité aux soins de santé est le développement et l'adoption de normes pour les soins de santé. L'Albanie est un pays très montagneux : environ 35 % de la population vit dans des régions souvent très retirées; l'accessibilité géographique est de ce fait parfois réduite. Même si les transports se sont fortement développés depuis 1990，la vitesse moyenne d'un véhicule dans les régions reculées ne dépasse pas 20 km/h. La couverture sanitaire offerte dans le passé par les services de santé albanais ayant été relativement bonne, nous avons décidé de garder une sage-femme dans chacun des 2880 villages du pays, bien que les infrastructures de santé ne soient en état que dans 28 % d'entre eux. Des critères ont maintenant été mis en place pour améliorer l'accessibilité aux centres de santé et pour les remettre en état ou les reconstruire. Chaque commune possède au moins un centre de santé qui est accessible en moyenne en moins de 2 heures à pied. Parmi les membres des autorités locales, un membre a pour responsabilité d'assurer la couverture sanitaire selon des critères d'équité. Ce membre peut se référer directement au Ministère de la Santé ou au préfet.

L'accessibilité financière aux soins de santé primaires, secondaires ou tertiaires est garantie pour toute la population car les services médicaux sont gratuits. L'accessibilité financière est un peu moins forte pour les soins dentaires et les médicaments, car ces deux services ont été récemment privatisés. Cependant, les prix des médicaments - en particulier ceux des médicaments essentiels - sont contrôlés par les services publics et seront remboursés à travers un nouveau système d'assurance-maladie. L'assurance santé couvre également le coût des médicaments nécessaires pour le traitement des enfants de moins d'un an, des invalides，des étudiants, des chômeurs, des retraités et des personnes qui reçoivent une aide économique. De plus, certains patients atteints d'une maladie chronique bénéficient d'un traitement gratuit. Suite à une récente décision du Conseil des Ministres, le traitement de quelques maladies infectieuses sera également gratuit dans un proche avenir; cela contribuera à améliorer l'utilisation des services de santé selon les besoins. Il n'y a actuellement

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pas de barrières entre les différents groupes sociaux ou minorités concernant l'accès aux services publics de santé.

Quels sont les mécanismes permettant d'améliorer la distribution équitable des équipements médicaux et du personnel de santé ？ Des critères ont été mis au point et sont pour le moment fondés sur des données relatives à la population et aux ressources existant dans les différents districts; il est certainement nécessaire de compléter ces critères pour assurer une distribution plus objective et réaliste des ressources. Le problème de la redistribution des médecins généralistes n'est pas aisé, car il y a actuellement une forte propension de leur part à vouloir travailler en milieu urbain.

Voyons maintenant les mécanismes visant à garantir une qualité égale des services. Ici les différents partenaires jouent un rôle important. Tout d'abord, l'Institut d'assurance-maladie a différents moyens pour évaluer la qualité des prescriptions médicales et l'exécution de celles-ci dans les officines pharmaceutiques; les ordonnances non conformes ne sont pas remboursées. Des évaluations mensuelles des prescriptions seront réalisées par l'Institut et donneront des indications importantes concernant la pratique des médecins et la qualité de leurs prescriptions; ces évaluations permettront également d'obtenir des renseignements sur la situation épidémiologique prévalant dans le pays. Au niveau périphérique, une unité de district de l'Institut d'assurance-maladie a le droit et l'obligation de contrôler les prescriptions des médecins et leur exécution par les pharmacies.

Pour conclure, Monsieur le Président, je dirais que, d'une manière générale, le Ministère de la Santé s'est engagé à respecter la Déclaration d'Alma-Ata qui précise que les inégalités sont inacceptables à l'intérieur d'un même pays et à s'efforcer d'atteindre le premier objectif fixé par le Bureau régional de l'Europe, à savoir "Arriver à une meilleure santé". Le Ministère de la Santé élabore actuellement une nouvelle politique nationale de santé qui contiendra des objectifs d'équité, en particulier en faveur des femmes, des personnes âgées, des chômeurs, des invalides et des autres groupes désavantagés; cela impliquera un haut degré d'engagement d'équité sociale. Nous sommes convaincus qu'il sera difficile d'atteindre tous ces objectifs et que tendre vers l'égalité pour tous est peut-être un rêve; mais nous concentrerons tous nos efforts pour réduire le plus possible, et le plus vite possible, l'inégalité dans les soins de santé.

Le Dr MEDINA (Cap-Vert) {interprétation du portugais) ：1

Monsieur le Président de séance, Monsieur le Directeur général, Mesdames et Messieurs les Ministres, Mesdames, Messieurs, permettez-moi, en premier lieu, au nom de la République du Cap-Vert et en mon nom personnel, d'adresser mes vives félicitations au Président pour son élection à la tête de la quarante-huitième session de l'Assemblée mondiale de la Santé.

Le Cap-Vert, malgré son manque de ressources naturelles et des cycles de sécheresse récurrents qui se prolongent depuis plus de vingt ans et qui se sont aggravés au cours des années, a accompli de grands progrès dans le domaine de la santé grâce non seulement à l'engagement de tout son peuple dans le processus de développement et aux transferts effectués par les émigrés en faveur de leur famille, mais aussi à la gestion sérieuse des appuis internationaux des pays amis.

Le chemin parcouru depuis l'indépendance du pays, en 1975，sous l'élan de la communauté internationale et de l'OMS ne fut pas facile. Le tissu socio-économique cap-verdien, structurellement fragile du fait de la rareté des ressources naturelles, rend mon pays vulnérable au chômage, à la pauvreté, à l'émigration et aux maladies. Le manque de pluies a donné naissance à une nature insalubre et hostile malgré tous nos efforts pour lutter contre la désertification.

Le climat de paix et de tranquillité socio-économique dans lequel nous vivons, où l'exercice de la démocratie est devenu une certitude, a permis la création d'un espace pour une bonne gestion et une rentabilisation des ressources que l'aide internationale met à notre disposition. Grâce à cela, ce petit pays de la côte occidentale de notre continent a pu atteindre des buts satisfaisants dans son programme de soins de santé primaires.

Nous avons toujours été animés par la pertinence de l'OMS, par la Déclaration d'Alma-Ata et par l'objectif de la santé pour tous d'ici l'an 2000. Les niveaux que nous avons atteints ne pourront être maintenus ou améliorés que si l'on renforce le partenariat.

Le rythme des changements, des conflits et des bouleversements qui affectent la planète, un peu partout, rend n'importe quelle prévision et/ou planification aléatoire. Compte tenu des signaux que nous avons pu remarquer, nous craignons d'être pénalisés par le ralentissement de l'aide internationale. Si ceci arrive,

1 Conformément à l'article 89 du Règlement intérieur.

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ironiquement, ce sera à cause de notre bonne gestion des ressources mises à notre disposition et du climat de paix qui règne dans le pays. Toutefois, nous ne croyons pas que ceci puisse se produire.

Au niveau des soins de santé primaires, notre situation, en comparaison avec le continent, est confortable, mais il nous reste encore beaucoup à faire pour atteindre les objectifs recommandés par l'OMS. Notre tâche, en ce qui concerne la politique de santé, est devenue plus complexe en raison de notre situation de transition épidémiologique. Nous avons des conditions de milieu et des conditions humaines liées au sous-développement, alors même qu'augmentent les pathologies et les causes de mort caractéristiques des pays développés.

L'insularité rend, elle aussi, plus difficile la gestion des cadres. Il nous faut investir dans la formation car la moitié de nos médecins sont des coopérants. La formation, notamment la formation différenciée, est un défi que nous devons relever, surtout si l'on tient compte des centaines d'évacuations que nous faisons chaque année vers le Portugal et qui représentent une charge de plus en plus difficile à supporter.

Comme si toutes ces difficultés ne suffisaient pas, et qui résultent de notre insertion géostratégique dans le continent, nous continuons à lutter contre une épidémie de choléra qui s'est installée dans notre région et qui nous a frappés en novembre 1994. Le manque d'eau et le niveau de pauvreté d'une partie de notre population ont créé de grandes difficultés pour combattre cette épidémie; en ce moment, nous craignons qu'elle devienne endémique, comme c'est le cas dans quelques pays voisins.

En cette année 1995，des difficultés supplémentaires nous attendaient. Le 2 avril, le volcan de la quatrième île, qui est la plus peuplée, après quarante-quatre ans d'inactivité, est entré en éruption, obligeant à évacuer 5000 habitants des quatre villages les plus menacés par les laves qui ont atteint une hauteur supérieure à 2000 mètres. Les personnes ont été rassemblées dans des campements, et il faudra les réinstaller dans d'autres régions car ces villages sont devenus inhabitables. Les effets négatifs sur la santé de la population de cette île sont faciles à évaluer.

Nous mettons l'Assemblée de la Santé au courant des difficultés que nous traversons, car nous sommes sûrs que les progrès réalisés jusqu'ici n'auraient pas été possibles sans la solidarité internationale.

Le Cap-Vert et son peuple savent être reconnaissants et solidaires. Nous nous trouvons partout dans le monde à vendre notre force de travail car la nature ne nous a pas gâtés. De toute façon, cela nous satisfait car nous savons que nous avons ainsi contribué à la construction d'autres endroits sur cette planète.

Sans santé, il n'y a pas de développement. Sans développement social, il n'y aura pas de paix. Nous voulons défendre la santé de nos populations pour que nous puissions contribuer à la paix dans le monde, comme nous l'avons fait jusqu'à présent.

Le Dr DY (Cambodge):

Monsieur le Président de séance, Monsieur le Directeur général, honorables délégués, Mesdames, Messieurs, c'est pour moi un privilège de participer à la Quarante-Huitième Assemblée mondiale de la Santé. Au nom du Gouvernement royal du Cambodge, je voudrais féliciter sincèrement le Président, les Vice-Présidents et les autres membres du bureau à l'occasion de leur élection. Je tiens également à exprimer au Directeur général, M. le Dr Hiroshi Nakajima, et au Directeur régional pour le Pacifique occidental, M. le Dr S. T. Han, mes plus vives félicitations pour le travail accompli au cours de l'année écoulée.

Les recommandations du Président d'accorder une attention particulière au thème "Equité, solidarité, santé - réduire les écarts" sont tout à fait appropriées à la situation mondiale actuelle. En effet, que voyons-nous ici et là dans le monde ？ Encore des guerres, encore des décès, encore la pauvreté. Des décès : chaque année, douze millions d'enfants meurent avant l'âge de cinq ans, quatorze millions de personnes meurent de maladies infectieuses et parasitaires, car la moitié de la population mondiale n'a pas couramment accès au traitement des maladies les plus communes, ni aux médicaments les plus essentiels. La pauvreté : plus d'un milliard de personnes, c'est-à-dire plus du cinquième de la population mondiale, vit dans une pauvreté extrême. Outre la pauvreté absolue, la pauvreté relative de ces personnes restreint sérieusement leur accès à la santé.

En tant que représentant d'un pays appartenant au groupe des pays les moins avancés, où le budget annuel pour la santé est inférieur à 2 dollars par habitant, je me sens bien placé pour parler des défis que ces pays ont à relever pour offrir des soins permettant de satisfaire les besoins de santé élémentaires.

Sortant d'une longue période de guerre et d'isolement, un pays comme le Cambodge est confronté à des besoins particuliers, mais il dispose également de possibilités spécifiques. Or un nombre croissant de pays appartient à cette catégorie caractérisée par l'entrée dans une période de reconstruction après un conflit. Pour retenir un aspect positif de cette situation, on peut souligner qu'elle donne la possibilité de rebâtir un système

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de santé qui répond aux nouveaux besoins et aux nouveaux défis, un système délivré des dogmes hérités du passé et des intérêts corporatistes. La période de reconstruction offre une occasion unique pour élaborer un cadre et une politique sanitaires sur lesquels on pourra construire à mesure que le développement économique prendra corps. Cependant, un pays passe rapidement d'une telle période à la phase de développement qui est commune à beaucoup de pays en développement et qui s'étend sur un plus long terme.

Par ailleurs, en cette période de difficultés économiques, la capacité des donateurs à soutenir l'effort de reconstruction d'un système de santé est plus limitée qu'elle ne l'a jamais été dans l'histoire récente. La réalité actuelle d'un pays moins avancé est de trouver les 12 dollars par habitant et par an pour couvrir les besoins de santé de base tels qu'ils sont définis dans le Rapport sur le développement dans le monde 1993. Où trouverons-nous ces ressources ？ Pour les pays les moins avancés, ce déficit financier est le défi de la prochaine décennie. Il est clair que les ministères de la santé ne pourront combler ce déficit en matière d'offre de soins essentiels qu'en définissant le nouveau rôle qu'ils devront tenir au XXIe siècle. Pour les pays moins avancés comme pour les autres, cela signifie que la définition d'un système de santé et du cadre dans lequel il est appelé à fonctionner doit suivre une approche aussi pluraliste que possible. Le rôle d'un ministère de la santé devra, de plus en plus, être orienté vers un rôle d'organe qui définit la politique sanitaire, qui fixe et garantit des normes et dirige les ressources vers les priorités essentielles en matière de santé. Un tel système de santé doit promouvoir des formes novatrices de partenariat entre le gouvernement, les donateurs, les organisations non gouvernementales, le secteur privé et, plus important encore, avec la communauté elle-même. Ce partenariat doit garantir l'accès des plus démunis aux services de santé, tout en assurant que les différentes composantes d'un "paquet minimum de services essentiels" soient disponibles, abordables et offrent un bon rapport coût/efficacité. La responsabilité à l'égard de la communauté, de même que son implication directe (en tant que consommatrice de soins) devraient occuper une position centrale en matière d'amélioration de la qualité des services de santé.

Nous ne devrions pas sous-estimer ce défi : il exigera en effet que le rôle de nos ressources humaines, qui sont notre capital le plus important, soit entièrement reconsidéré. Beaucoup ne se sentiront que peu concernés par un tel changement. Les intérêts dans lesquels les groupes professionnels se reconnaissent ne devraient pas être, eux non plus, sous-estimés. Cependant, si nous ne relevons pas ce défi, il est à craindre que les systèmes de santé s'effondreront, et que nous aurons à déplorer d'être les témoins du développement d'activités incontrôlées et inadéquates, en particulier dans les segments les plus défavorisés des zones urbaines. Le fossé entre le riche et le pauvre se creusera. Paradoxalement, les possibilités de changement peuvent être plus importantes dans les pays traversant une telle période de reconstruction. Mesdames et Messieurs, nous qui en avons la responsabilité, nous devons saisir cette occasion, car elle n'est que passagère.

Mr TEKEE (Kiribati):

Mr President, Mr Director-General, your excellencies, distinguished ladies and gentlemen, as it is my first time to take the floor, allow me to join other speakers in congratulating the President and Vice-Presidents of this Forty-eighth World Health Assembly on their election to their prestigious offices. I know that through the President's wise counsel and capable leadership this august Assembly will be able to achieve its set objectives.

Allow me also to congratulate the Director-General and the Chairman of the Executive Board on the excellent presentation and comprehensive introduction of the very important reports, The world health report, incorporating the Director-General's report on the work of WHO, and the Executive Board reports on its ninety-fourth and ninety-fifth sessions, which has set the scene for fruitful dialogue and debate, and should also lay the foundations for further appropriate action in all Member countries.

Equity in health care and health service provision has become an important objective of health programmes and interventions, especially now when health resources are still inadequate to allow full implementation of essential health programmes such as immunization, maternal and child health including family planning, nutrition and communicable disease control, to name a few. Strategies aimed at achieving equity in health will also enable movement towards a fairer distribution of these scarce resources and a narrowing of the health gap between the haves and the have-nots so that health as a fundamental human right and as a social goal becomes more realistic and attainable. Economic equity is probably a subject not worth considering at present as its attainment is very difficult, if not almost impossible, and at the same time it is not fundamental to the achievement of the health-for-all goal.

Achievement of equity in terms of accessibility, quality and utilization of health services will be realizable with the involvement of the people in the planning and implementation of all health promotion and

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disease prevention activities and interventions. This is because it is the people themselves who will be ultimately responsible for their own health, while government and international agencies and organizations such as WHO play an enabling role only. Without the full commitment and involvement of the community, no health activities will be sustainable and consequently long-term health benefits will also not be possible. In actual fact, without community involvement and with a lack of respect of cultural norms and values, disillusionment may result and well-intended health programmes may become counter-productive in the end.

The underlying principles of solidarity also imply the involvement of people in all planning and decision-making exercises to ensure long-term viability and sustainability of health care programmes. This is because, when people are part of the decision-making process, long-term commitment and willingness to share and use whatever resources are available in the community will be assured.

In Kiribati, the Government, in collaboration with nongovernmental organizations and other bilateral and multilateral agencies, has been striving to achieve equity in its health programmes through the use of primary heath care. It recognized the fact that the principles of primary health care are still essential to the achievement of both equity and solidarity, and therefore these same principles that were first resolved during the Alma-Ata Conference and later at Riga are being reaffirmed with some modifications to suit existing local situations and conditions. It is also realized that, in order to achieve equity, political will and commitment to the principles of primary health care are necessary, together with health staff commitment and community participation. The politicians, the health workers and the community are the main driving forces in the move towards equitable health care services, with other forces such as finance and economics providing the necessary support towards the final achievement of the health-for-all goal.

Financing of health care services to ensure equity is a very difficult but very important matter to address, as it is both a political and also a community issue. It requires a strong and stable government to get people to contribute towards the cost of health care services, especially when previously the government has traditionally been the one doing it. An affordable, acceptable and appropriate scheme for health care financing that ensures equitable health care services is an important element of primary health care but has not been an easy one to implement. In cases where people have to share the cost of health services, the policy should include consideration of the case of the poor and the vulnerable, and should exempt them from the full burden of payment. Financing schemes such as government subsidies or health insurance schemes, if appropriately implemented, should ensure equity. It is also essential to encourage the promotion of community norms and values that contribute to equitable health services, especially in these times when there is a rapid move away from the subsistence economy to a more cash dependent economy that brings with it higher demands and aspirations of the people，which may be beyond the means of governments to satisfy.

There have been some lessons learned already through the use of the primary health care approach in Kiribati which have been considered to be important in the sustainability and achievement of its health and social goals. Whereas it has been customary for primary health care to operate in an integrated and horizontal fashion, with emphasis on "bottom-up" planning in comparison with the former vertical programme approach and "top-down" planning, it has now been the experience in Kiribati that a mixed approach is probably the way to move towards equity in health and also in the achievement of the health-for-all goal. This approach has been adopted also as a means to strengthen and to improve programme implementation and output through stressing accountability and responsibility, which seemed to have been diluted in the integrated horizontal programme approach. Signs of success of this new approach have been seen already; however, more time is required to finally assess its outcome in terms of health outputs and indicators. The above approach, however, cannot be successful without the usual management support coupled with staff commitment and technical competence. This is a responsibility that has been taken up by the Government with the assistance of WHO and other organizations such as UNDP, UNFPA, UNICEF and the European Union, and also through bilateral assistance, mostly from Australia, New Zealand, China, Japan, the United Kingdom, Israel, Germany and the Republic of Korea, for training in other areas as well. I would like to take this opportunity, on behalf of the Government and people of Kiribati, to thank them for all their assistance and support, and hope that this continues to grow in the future.

Because of the Government's belief in the strengthening of management and technical support as a means of providing appropriate and cost-effective services, a lot of resources are being invested in this area. I would also like to mention here the part that has been played by WHO in supporting the Kiribati School of Nursing and also the Medical Assistance School, as well as postgraduate medical training which has strengthened overall health care and health services provision in my country. Along the same line, Kiribati would also like to commend the work of other countries within the Western Pacific Region that have been working very hard to strengthen this vital area of health manpower training from which Kiribati has benefited.

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I would like, therefore, to urge WHO and other donors to continue to provide support and assistance to these counties.

In order to keep pace with the rapidly changing world, it is also very important that cooperation and collaboration take place not only at the community and national levels but also at the international level, so that global equity and social justice, through the spirit of harmony and solidarity, will finally lead us to our goal of health for all by the year 2000 and beyond.

Finally, I must thank WHO, the Director-General and all his staff, and especially our Regional Director Dr S.T. Han and his staff from the Western Pacific Region, for the assistance and strong support that they have provided to Kiribati over the years, both financially and technically, which has made a great impact in the level of health now enjoyed by my people. It is true that there is still a long way to go yet, in order to reach the level of indicators now enjoyed in developed countries; but peace, happiness and contentment are part of the mental and social well-being that has been promoted by WHO, which I think is easier to attain in my country than the improvement in disease indicators. However, I know that with strong political will and community resolve, and with the continued support of WHO we will sooner or later achieve equity in health and the health-for-all goal, based on the principles of primary health care.

Dr KHUDABUX (Suriname):

Mr President, distinguished delegates, Dr Nakajima, ladies and gentlemen, it is indeed a pleasure to participate once again in the discussions of this august Assembly, in a common effort to improve human health. The world health situation demands that we continue to collectively map out strategies and actions necessary for the sustainable promotion and protection of individual and collective health status.

It is more than 15 years ago that the Alma-Ata Declaration was adopted and The world health report 1995 summary indicates a number of achievements, but also areas where development is yet to be attained. We thank the Director-General and the Executive Board for their highly informative reports that are tentatively showing a way ahead. The task remains ambitious and immense, if we really want to succeed in achieving the goals which we set ourselves so optimistically.

In my country, Suriname, severe problems in socioeconomic development remain. There is a continuing structural deterioration in service delivery, due to shortages of human and financial resources. Despite the continuing economic stagnation, we should like to report that the health status in selected areas has been maintained. The expanded programme on immunization and the control of diarrhoeal diseases continue successfully. The last confirmed poliomyelitis case was reported in 1982. Diphtheria and pertussis have not been seen in a very long time, and leprosy is nearly under control. Tuberculosis had, to all practical purposes, been eradicated but a few cases have recently come to light, although no clear relationship with AIDS could be established.

Recent attention on malaria control has focused on the introduction of the new vaccine developed by Professor M.E. Patarroyo and discussions regarding assistance from Colombia, where this vaccine has been developed, are being pursued with great interest. Breast-feeding has been actively promoted and become almost universal, ironically supported by the inability to import infant formula.

I now turn to growing social problems of unemployment and poverty in the world, that have a serious negative impact on health, as mentioned in The world health report 1995. The approaches recently propagated by international institutions, especially those dealing with financing aspects, fail to provide lasting solutions and, indeed, contribute to growing inequity and greater disparities, amongst others, in health. In our view, economic growth at all costs cannot alone solve the problem of inadequate human development. Without doubt, there is a need for a multifactorial approach. I humbly submit that a single focus on economic development, neglecting behavioural and societal factors, would be inadequate for the purpose of protecting and improving health status. In this Organization, we have accepted that health is rooted in social development. However, the recent direction for action has been mainly dictating market and privatization approaches, and equity in health seems to have fallen by the wayside.

Even if total national wealth were to be equitably distributed, it is doubtful whether our health care systems and services would be in a position to overcome the threat to health status caused by environmental and behavioural factors. Therefore, greater emphasis should be placed on approaches that would assist countries to increase health awareness in people, to stimulate their responsibility for self-reliance concerning social and technological developments, and the provision of preventive and curative care of acceptable quality.

Furthermore, trade and political relationships between the industrialized countries and the developing world are a major determinant for the present inequity between nations. The sense of responsibility and

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solidarity that we share here cannot materialize in a climate where the exports of developing countries are valued so little. The Declaration of Alma-Ata on primary health care gave us hope that one day it would be possible to achieve at least equity in health some day. How are we to proceed from here with the health-for-all movement? The world health report 1995 is very brief on the way ahead in indicating how to bridge the gaps. In paraphrasing the previous Director of the Pan American Sanitary Bureau, Dr Carlyle Guerra de Macedo, I should like to stress: the need for development and growth based on specific and effective decisions; that democracy must promote a way of life in which entire populations participate in decision-making which affects their daily life; believing that no country has the political and economic power to pursue development on its own, no country can act in isolation, but regional and global integration must be actively pursued in a spirit of equity and sharing; present short-term achievements should not prejudice the pursuit of medium-term development and stability, and the respective responsibilities of local, national and international actors in the pursuit of health for all should be clarified and supported.

Despite the foregoing, we should not forget the legions of dedicated health workers who toil under adverse conditions to provide the best health care they can. I submit that we owe them a debt of gratitude. For without them the target of health for all would remain illusive.

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Le Dr MARQUES DE LIMA (Sao Tomé-et-Principe):

Monsieur le Président, Madame et Messieurs les Vice-Présidents, Monsieur le Directeur général, Messieurs les directeurs régionaux, honorables délégués, tout d'abord, je voudrais au nom de la délégation de Sao Tomé-et-Principe, féliciter le Président pour sa brillante élection à la tête de cette auguste Assemblée, ainsi que les autres membres du bureau. Je suis convaincu que, sous sa sage direction, nos travaux aboutiront au succès que nous tous attendons en faveur de la santé des populations de nos pays. Je félicite aussi le Directeur général du rapport succinct qu'il nous a présenté, plein d'idées et de préoccupations sur la santé dans le monde, et qui sera source de réflexions profondes de la part aussi bien des participants ici présents

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à la Quarante-Huitième Assemblée mondiale de la Santé, que des gouvernements de tous les Etats Membres, désireux qu'ils sont tous d'amener nos peuples au plus haut niveau de santé, malgré les contraintes bien mises en évidence dans le rapport. Mes félicitations vont aussi au Dr Ebrahim Malick Samba, Directeur régional de l'OMS pour l'Afrique, à qui je souhaite vivement les plus grands succès dans sa noble lutte pour la santé dans notre Région, confiant dans ses capacités déjà démontrées de "leadership" et dans ses compétences techniques et gestionnaires.

Bien que les pays en développement aient enregistré des progrès en ce qui concerne l'état de santé de leur population, en termes aussi bien de mortalité que de qualité de vie, la disparité entre pays développés et pays pauvres est énorme. Le Rapport sur la santé dans le monde met en évidence l'absence d'équité dans ce qui se réfère à l'accès aux soins de santé. Les populations des pays en développement font face à une situation sociale et économique déplorable, chaque jour plus pauvres et plus malades, arrivant souvent à des situations d'extrême misère qui choquent la conscience et qui portent atteinte à la dignité humaine. A ces populations sont niés les soins essentiels qui leur permettraient de vivre une vie meilleure et plus saine. Si des facteurs tels que la croissance démographique et la mauvaise gestion des ressources peuvent être à l'origine du chaos économique et social dans lequel ces populations vivent, nous ne pouvons pas ne pas mettre ici l'accent sur le rôle de ce qui est déjà si fréquemment invoqué : l'injuste relation des échanges commerciaux auxquels nos pays sont soumis. C'est cette injuste relation des échanges commerciaux qui ne motive ni la production, ni la productivité, qui fait croître et éterniser la dette, qui perpétue la dépendance, engendre la pauvreté, empêche le développement économique et nie aux populations l'accès à la santé et à une meilleure qualité de vie.

Il est urgent et nécessaire que l'on inverse cet état de choses. Cela implique que les pays développés aient la volonté politique de conduire à des changements et à la perception du fait que la pauvreté des quatre cinquièmes de la population mondiale est un élément déstabilisateur pour la paix et la sécurité que nous désirons ardemment et que nous voulons préserver. L'équité à l'intérieur des pays suppose de donner la priorité à la canalisation des ressources humaines, financières et matérielles en faveur des soins de santé primaires au niveau des districts dans les zones rurales et dans les quartiers surpeuplés des zones urbaines où les populations vivent dans des conditions inacceptables, qu'il s'agisse d'assainissement, d'approvisionnement en eau ou de logement. Cela suppose aussi que les districts de santé aient des techniciens formés à la gestion des services de santé au niveau des districts, qu'ils aient la capacité de "leadership" et qu'ils soient motivés pour travailler dans des conditions mauvaises et assez difficiles.

Monsieur le Président, dans la mesure où, du fait de ces conditions, il est nié aux quatre cinquièmes de la population mondiale l'accès à la santé, où un cinquième de la population mondiale vit aujourd'hui dans une extrême pauvreté, où, pour des raisons économiques, les budgets de la santé sont réduits de façon drastique et où l'on entrevoit la tendance des donateurs à financer chaque jour un peu moins le développement des pays du Sud, nous ne pouvons pas parler de solidarité. La solidarité signifie d'abord que la santé est un droit qui aide tous les peuples du monde, ensuite qu'il faut agir pour que ce même droit soit garanti de façon générale et universelle à tous les citoyens.

Nous croyons que les ressources disponibles sur notre planète sont suffisantes si elles sont utilisées de façon rationnelle, intelligente et humaine, pour que chacun de nous puisse mener une vie productive et être en meilleure santé. Il appartient à chaque individu, à la famille, à la société, aux gouvernements, aux organismes internationaux de contribuer à donner à l'homme davantage de vie et de dignité, quel que soit l'endroit où il se trouve.

Nous exhortons l'OMS à veiller à ce que la mise en oeuvre du neuvième programme général de travail soit plus pragmatique et, dans la mesure du possible, moins bureaucratique afin de mieux appuyer les Etats Membres dans leur recherche de réponses aux exigences sanitaires de cette fin de siècle.

El Dr. ESPINOZA (Ecuador):

Señores miembros de la Mesa de la Asamblea: Quiero empezar felicitando a los señores Presidente y Vicepresidentes de la 48a Asamblea Mundial de la Salud por la acertada elección de que han sido objeto. Igualmente al señor Director General por la organización de esta importante reunión. A pesar de los grandes esfuerzos realizados por los países en vías de desarrollo, la dura realidad de los indicadores de salud, la opinión de los pacientes y usuarios de los servicios de salud obligan a revisar las actuales estrategias y prácticas para la ejecución de los distintos programas. Tales indicadores pueden resumirse en el estanca-miento de las coberturas de algunos programas preventivos, el recrudecimiento de enfermedades infecciosas tales como la malaria, el dengue, el cólera, la tuberculosis, y sobre todo las deficientes condiciones de atención en unidades ambulatorias y hospitalarias.

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La atención de salud en el Ecuador sufre en la actualidad una profunda crisis de financiamiento, que ha conducido a una importante limitación en el acceso, cobertura y en la calidad de la atención que se ofrece, en especial a los sectores más empobrecidos de la población. Como un primer indicador que resume la situación descrita, diversos estudios estiman que al menos el 30% de los habitantes del país no está cubierto por servicios institucionales de salud. De este porcentaje, la gran mayoría corresponde a la población indígena, que aún pertenece a sectores rurales dispersos, y a los habitantes de los sectores urbanos margina-les. Con esta ocasión permítanme revisar algunos aspectos más importantes en el análisis del contexto de la meta de la salud para todos.

Uno de los problemas que se evidencian son los antagonismos conceptuales que se mantienen en algunas instancias, como es la separación entre prevención y reparación, sin tomar en cuenta el concepto integral de la salud. Esta dicotomía ha causado en algunos casos decisiones políticas tales como el asignar preferencialmente recursos a determinados programas y desatender a otros. La atención primaria, en su expresión más general, se da en todos los niveles del sistema; no se trata de antagonizar entre atención primaria, secundaria y terciara; todo lo contrario, hay que integrarlas. La salud es una sola, y su progreso depende del desarrollo armónico de todas sus partes, desde lo sanitario hasta lo hospitalario.

Todavía se mantiene una estratificación y un paralelismo entre los sistemas de servicios que prestan las diferentes instituciones del sector, evidenciándose la existencia de un sistema de servicios descoordinado, sectorizado e ineficiente para responder a los principales problemas de salud. Esta estratificación produce diferentes grados de calidad en la atención, dispersa los escasos recursos presupuestarios en acciones fragmentadas y paralelas. Así también, se puede evidenciar una descoordinación entre las instituciones formadoras de recursos humanos, de investigación científica y tecnológica y de las instituciones encargadas de dar atención de salud. No existen estrategias definidas que orienten la formación de los recursos humanos en relación con las necesidades y el mercado laboral, así como sobre las prioridades de investigación para la solución de los importantes problemas de salud de la población.

Otra característica es la insuficiente asignación presupuestaria. La necesidad de atender múltiples problemas sociales en los países en desarrollo se traduce en la escasez del presupuesto destinado al sector salud. Esto explica la deficiencia en la infraestructura de las unidades operativas, la falta de equipamiento, insumos y medicamentos que permitan una adecuada atención. Si bien la cobertura de los servicios de salud se ha incrementado en el Ecuador, no es menos cierto que su calidad sea la más adecuada.

Se evidencia también falta de apoyo político. Es prioritario reconocer la importancia que tiene el sector salud para el desarrollo de la sociedad y su relación con los sectores productivos para elevar el nivel de vida de la población. La falta de apoyo político al sector salud puede conducir a un debilitamiento del sector y a que su presencia en los niveles de decisión política no tenga un rol protagónico.

El análisis anterior nos conduce a manifestar que, pese a los grandes esfuerzos realizados y los logros obtenidos, la baja calidad y la insuficiente cobertura de los servicios de salud marcan la característica del sector a fines del siglo XX y comienzos del XXI.

Con estos referentes, en el Ministerio de Salud Pública del Ecuador nos hemos propuesto un proceso de reforma del sector fundamentado en los principios de equidad, solidaridad y excelencia y dentro de un proceso autosostenible. El principio de equidad deberá cubrir todas las dimensiones geográficas, políticas, técnicas y operativas, pero fundamentalmente deberá garantizar salud y bienestar social a toda persona, independientemente de su condición social, económica, étnica, de edad y de sexo. El principio de solidaridad deberá expresarse como la ayuda y cooperación que rebase las fronteras políticas, geográficas, sociales e individuales y, fundamentalmente, entendiéndose que la solidaridad es un principio para la supervivencia en mejores condiciones de vida, salud y paz. El principio de excelencia debe asegurar el que todos los usuarios accedan a servicios con dignidad, oportunidad y calidad. La excelencia del sistema dependerá ante todo de la integración del sistema de salud en el desarrollo científico y tecnológico, así como en un adecuado modelo de gestión que asegure la participación conjunta de los gobiernos locales y de la comunidad.

Estos principios deben estar orientados por tres grandes categorías, como son: la atención integral, la investigación y la adecuada formación de recursos humanos. La atención integral deberá articular la atención primaria, secundaria y terciaria y coordinar las acciones de prevención, fomento, curación y rehabilitación. La investigación científica deberá asegurar la utilización de conocimientos a fin de descifrar, adoptar e innovar tecnologías aplicadas al campo de la salud, así como la creación de nuevos conocimientos para resolver los problemas fundamentales de la salud. La formación y capacitación de recursos humanos ha de garantizar el funcionamiento del sistema acorde con las necesidades reales y propias.

Este proceso de reforma del sector salud deberá orientarse en el marco de la universalidad y humanis-mo, tendente a beneficiar prioritariamente a los grupos de población más vulnerables y depauperados. En

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este contexto, el proceso de reforma del sector salud deberá además tener los siguientes atributos: ser democrático, participativo, transparente, dinámico, flexible, integrado y progresivo.

Finalmente, señor Presidente, quiero destacar la muestra de solidaridad humana de nuestra hermana República de Colombia, cristalizada en la entrega a la Organización Mundial de la Salud de la patente de la vacuna antimalárica desarrollada por un científico latinoamericano, el Dr. Patarroyo, cuyo ejemplo, acorde con la sensibilidad del pueblo ecuatoriano, deberá servir de ejemplo a la comunidad internacional. Muchas gracias.

Dr MTAFU (Malawi):

Mr President, Director-General, Dr Nakajima, your excellencies, distinguished delegates, ladies and gentlemen, please allow me to congratulate the President and Vice-Presidents on being elected to their high offices. I would also like to congratulate the Director-General for his sobering report on the world's health status. It was clear from his address that major health problems still face most of the developing world. Most of our resources are spent on preventable diseases. The average cost for prevention or even treatment of most of these diseases is but a fraction of the average monthly consumption of bottled water in most of the developed countries. Tap-water from most of these countries is quite safe and palatable!

We cannot address the problems of equity and solidarity in health when poverty is so rampant. In my country, Malawi, 60% of our people live below the poverty line. The Government has therefore targeted future development to the alleviation of poverty. The health sector has been given priority, as has primary education. Women take the brunt of the effects of poverty. Our development programmes are deliberately skewed towards addressing "gender issues". In this vein, prominence has been given to family issues, safe motherhood initiatives and the girl child programmes.

Equity in health in Malawi is plagued by fluctuation of currencies which often implies diminished health resources in real terms. Therefore, although the budget allocation for health is 17% in Malawi, this may not amount to much in real terms. However, major changes have taken place in addressing equity in health. Resources allocated to tertiary services, which are mostly located in urban centres, have decreased from 40% to 25%. Our efforts are now directed at providing adequate health facilities close to the people, in the form of community participation, erection of health centres, and equipping of district hospitals which function as referral centres for the district.

Our next challenges in providing equity in health are, first, the provision of adequate communication in terms of transport and radio or telephone between the communities, health centres and the district or tertiary centres; this will therefore entail ready access to the tertiary centres for our rural population who may need referral. Secondly, cost-sharing should be introduced so that fees collected from those able to pay can be ploughed back into improving and strengthening the health services for the wider population. Thirdly, our rural communities must have access to well-qualified health cadres, and in this regard the Government is not only increasing the numbers of health trainees, but also the quality of our trainees.

In addressing the problems of equity and solidarity at global level, we have to be blunt and say that more needs to be done by those with the means, in partnership with those with the least means. Malawi has shown quite clearly that primary health care - public health - can work and this is true of most other developing countries. The incidence of cholera and diarrhoeal diseases has dropped dramatically, despite adverse climatic conditions, namely those of drought year after year. This is quite remarkable, because illiteracy in Malawi is still high, above 60%, hence the introduction of free primary education by the present democratically elected Government. Immunization against most of the preventable diseases covers more than 98% of the vulnerable population and recent reports of schistosomiasis also show that the incidence has gone down, and this can only be due to health education and provision of simple curative services. Yet Malawi spends less than US$ 12 per capita on health.

The point I am trying to make is simply that global partnership between the developed world and the developing world can reduce the wide gap between us. Most donors are now concerned with health sector reform. This is not a new phenomenon in Africa, as most governments have been reforming for quite a long period. While we in the developing world accept the need for relevant and appropriate reforms, there is a need to support the ongoing programmes against mostly preventable diseases like malaria, diarrhoeal diseases, acute respiratory infection and now again tuberculosis, which greatly reduce the economic output of those individuals affected by these diseases.

My appeal to those endowed with financial resources is simply to listen to our pleas, because the evidence of success with the limited resources that most of us have is there for all to see. The way to

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bridging the gap in equity and solidarity between the different countries is by serious dialogue and the willingness to help each other. Obviously this will require that the recipient has a transparent and accountable system. I am in no doubt that most of the debilitating diseases of this century can be diseases of yesterday, just like smallpox, which will soon be joined by poliomyelitis.

El PRESIDENTE INTERINO:

Doy las gracias al delegado de Malawi. Antes de levantar la sesión quiero recordarles que la reunión de la Comisión В tendrá lugar hoy, a las 14.30，en la sala XVII; que la reunión de la Comisión de Creden-ciales tendrá lugar a la misma hora en la sala VII y que la sesión plenaria se reanudará aquí, también a las 14.30. Muchas gracias a todos los delegados, se levanta la sesión hasta esta tarde.


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TENTH PLENARY MEETING

Friday, 5 May 1995，at 14:30

Acting President: Mr THAN NYUNT (Myanmar)

DIXIEME SEANCE PLENIERE

Vendredi 5 mai 1995，14h30

Président par intérim: M. THAN NYUNT (Myanmar)

DEBATE ON THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-FOURTH AND NINETY-FIFTH SESSIONS AND REVIEW OF THE WORLD HEALTH REPORT, 1995 (continued) DEBAT SUR LES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-QUATORZIEME ET QUATRE-VINGT-QUINZIEME SESSIONS ET EXAMEN DU RAPPORT SUR LA SANTE DANS LE MONDE, 1995 (suite)


The Assembly is called to order. It is a pleasure and an honour for me to preside over this Assembly, and we shall now continue with our debate on agenda items 9 and 10 while Committee В resumes its meeting. I still have seven speakers on my list, and I now call to the rostrum the delegates of the Federated States of Micronesia and of Saint Kitts and Nevis.

I give the floor to the delegate of the Federated States of Micronesia.

Dr PRETRICK (Federated States of Micronesia):

Mr President, Vice-Presidents, Director-General, your excellencies, honourable health ministers, honourable delegates, I am honoured to deliver this address to the Forty-eighth World Health Assembly on behalf of my Government.

The Federated States of Micronesia are privileged to take part in the discussion and formulation of a global policy for world health and to have the opportunity to express its views to this august body. Let me at the outset extend my sincere congratulations to the President of this Health Assembly on his election and to the Vice-Presidents.

On behalf of my Government I also wish to congratulate the new Member State, Palau. I would like to thank the Director-General and the Executive Board for their guidance and direction

in helping Member States to focus on relevant issues which we must consider at this Assembly. We have been asked to focus our remarks on global policy issues and to give special attention to equity and solidarity in health - bridging the gaps.

In 1979 WHO established the goal of health for all by the year 2000. While we have made great strides towards achieving greater coverage, utilization and quality of care, inequities remain in the distribution of health benefits. These inequities persist between the developed and the developing world, between localities, and between groups in society. In many cases these disparities have been increasing. We face great challenges to equity in health care. A disproportionate share of health resources go to the well-to-do. This trend may be accelerated by efforts to privatize health care. Although privatization may produce certain cost efficiencies, it also risks dividing the recipients of health care into the privileged and the second-class citizens. Of course, it is an illusion to think that the world can be walled off into different health sectors according to socioeconomic status. The reappearance in the developed world of communicable diseases like tuberculosis and the emergence of pandemics like AIDS continually remind us that health problems know no boundaries. To meet these challenges, we need to look to ways to expand our sense of solidarity - to build bridges, not walls.

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We must also continue to recognize that health and nutrition are inevitably connected with problems of population, poverty, education, and the environment. Addressing all these concerns makes demands upon limited resources. Effective solutions require long-range vision and multidisciplinary approaches.

How can we maintain a sense of solidarity amidst this struggle over limited resources? Solidarity calls for a sense of responsibility for those whose lives touch our own in some way. This sentiment is most strongly tested in dealing with the most vulnerable in our midst. Solidarity tests our commitments and draws upon our willingness and capacity to make sacrifices. But in asking for these sacrifices we must keep in mind that everyone will benefit if we can achieve health for all. Health is a basic prerequisite to achieving one's goals in life. Equity in health means that all people have a fair opportunity to realize their full health potential. Inequity in health care is the result of poverty and isolation, but it is not only that; it is the result also of failures of vision and the misuse of resources. In a world of scarce resources we must learn at times to make difficult decisions between providing basic care to all and providing expensive, high-technology procedures for the few. We must do this while not reducing health care to the lowest common denominator.

At the international level, solidarity means that aid agencies must learn to coordinate their efforts and adjust their agendas to the needs of developing countries. We can help people help themselves by building on their own experience and knowledge. At the local level, communities must be increasingly involved in health care. All sectors of society should be involved to meet health goals in an equitable manner. People will use their local health facility when they know it can provide them with reliable care. Solidarity at the local level should be the focus of the decentralization of health care.

These concerns about equity and solidarity are hotly debated in the realm of health care finance. Although we must be conscious of escalating health care costs, cost containment cannot be the sole determinant of health care financing. Mere cost-containment can mean the reduction in services for those groups that need them most. One of the objectives behind compulsory health insurance is the promotion of social solidarity. Yet in the more developed countries compulsory health insurance has been fiercely attacked. These attacks call into question our capacity for solidarity and our commitment to equity. Furthermore, although we should seek equitable health coverage, we should maintain creative research and experimentation in health financing schemes.

The Federated States of Micronesia, a Pacific island State that is poised between the developing and the developed worlds, has managed some notable triumphs in health care delivery. In the last few years, we have improved the delivery of primary care by returning to the older dispensary system which serves local populations more effectively than the more costly central hospitals. We have trained people from the communities to work in the dispensaries as part of an overall effort to decentralize health care and make its delivery more equitable. In so doing, we have made notable progress in preventive medicine and achieved major cost-savings. These achievements have been built upon a recognition of the value of solidarity and the natural ties of community.

The training of Micronesian physicians by the Pacific Basin Medical Officer Training Programme School has created a core of personnel with a high degree of training who retain a strong commitment to their communities. We believe that the Federated States of Micronesia has set a high standard for the delivery of primary care, an example from which other countries could benefit.

While many of our people in the Federated States of Micronesia are poor by standards of developing nations, we have a substantial middle class. Thus, our citizens suffer both from diseases like tuberculosis and leprosy and from "lifestyle" diseases associated with development, including obesity, diabetes and high blood pressure. Those with some wealth and access to power may benefit from the referral system, whereby certain individuals have their cases referred for treatment off-island at tertiary care facilities. At times this system has been abused, and the well-to-do have received expensive care for questionable conditions. Such resources could have provided substantial basic services for the less fortunate. We need to be prepared to make tough decisions to preserve equity in the system.

At the regional level, the Federated States of Micronesia participated in the charter meeting of the Pacific Basin Medical Association (PBMA) in early April. The PBMA is a professional association to represent the interests of physicians and patients in the Pacific region. Its goals include the development of continuing medical education and professional standards. We believe that the PBMA will build regional solidarity to improve health services. Finally, at the PBMA meetings we shared a vision of a satellite network linking Pacific countries to provide equal access to medical information throughout the region and the world. Maybe the bridges of the future will be built electronically.

We hope that these experiences may be helpful to you, and we look forward to learning from your experiences.

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Mr AMORY (Saint Kitts and Nevis):

Mr President, Mr Director-General, distinguished delegates, I am honoured to have the opportunity to address this Assembly on this very important issue of health equity and solidarity - bridging the gaps. The Federation of Saint Kitts and Nevis has considered several strategy issues that we believe can bridge the gaps in equity and solidarity in health at the global level. We must state, however, that we do not intend to explore these issues in any great detail, but rather to raise concerns to initiate discussion. We aim to create that dissatisfaction that will eventually lead to progress. We must also state that our position is underpinned by the philosophy that the peace of the world depends on the health of the world.

The first issue we wish to raise is that of commitment; the commitment that goes beyond the rhetoric of political will. We refer to commitment that facilitates the development and enactment of the necessary administrative and legislative structures to allow efficient functioning of the health sector and the necessary financing to allow for effective implementation of programmes.

In Saint Kitts and Nevis, our commitment to providing equity and good quality health care to its population of 43 000 is high. We commit 15% of expenditure to health, i.e., approximately US$ 250 per capita, 44% of this total going toward health investment. There is one health care worker for every 75 persons, one hospital bed per 200 persons and there are health centres within easy access. Immunization of children against major communicable killer diseases is mandatory. Even with this commitment, developing countries like ours cannot be satisfied with their accomplishments but must continue to experiment with strategies and guard against destructive debilitating diseases like HIV/AIDS, cancer and diabetes.

We note the progress made towards the attainment of health for all by the year 2000 as stated in The world health report, 1995 of the Director-General, WHO. We are heartened by the growing international support for health, but lament the fact that the commitment of 0.7% of GDP towards development assistance has not been realized. It is our view that much more may have been achieved if the world's leading nations were more committed towards bridging the gap for equity. We call on the World Health Organization to use its influence to ensure that these promises are met.

Given too, that nongovernmental organizations have access to significantly more funding than WHO and other United Nations organizations, it may be advisable for national governments to forge partnerships with nongovernmental organizations to use them as the implementing arm for some aspects of the health delivery service.

Enough cannot be said about the elimination of high-risk behaviour in the promotion of healthy life-styles. We may say also that the health of the nation depends on the health of its people, and in this regard we would certainly rank very highly the need for good nutrition and recreation among the strategies for the promotion of equity in health. We also wish to direct the attention of this Assembly to three life-threatening behaviours. One relates to the fear of the use of experimental drugs in developing countries; the other refers to the threat to our fragile environments posed by the transportation of toxic and nuclear wastes through our waters; and the third to the dangers posed by additives and pesticide residues in food and in use for agricultural development. These are real concerns as they expose our populations to hazards which we are incompetent to deal with effectively. In all this there is a role for WHO that must be debated and enunciated in unambiguous terms, and we call on this Assembly to begin this debate.

Paragraph 270 of document A48/4 refers to an oversupply of doctors in some countries, but stops short of noting the disparity in health services between nations. Yet we know that there are nations within the same geographical zone (e.g., the Americas) where basic health care is not readily available and others where health care is very highly developed. We know, too, that through the information highway there can be a sharing of resources through "distance diagnosis", imaging, etc. Indeed, telemedicine must be studied by WHO as one mechanism for bridging the gaps and for achieving solidarity and equity.

There is also a second aspect to this divide. It is that which separates Western medical practices and Eastern practices. We read constantly of the healing/therapeutic capacities of acupuncture, vitamin therapy, polarity, etc., as alternate forms of health treatment. In our view it is incumbent upon WHO to review these forms of medicine, and act as a "clearing" house to guide Third World nations as we come into contact with these practices.

The third aspect of the divide exists at the grass-roots level where each society has developed its own forms of healing. This is commonly referred to as herbal medicine. The delegation of Saint Kitts and Nevis recommends that this form of health care be researched and documented and used as a foundation on which to build appropriate health care systems which could be more cost effective and more accessible and acceptable to more people.

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We cannot divorce the goal of sustainable development from the goal of health for all by the year 2000. The two are interdependent, and we can state that economic and social development would be less achievable if there continued to exist gaps in equity and solidarity in health among nations. Hence we applaud the efforts of national governments, international donors and international institutions to provide basic amenities such as potable water, food, clothes, shelter and jobs to all of humanity. After all, as noted in the report, if adverse socioeconomic and political constraints are not ameliorated, health damaging lifestyles can become aggravated, and increased violence, mental and behaviourial disorders could result, thereby widening the gaps between those who are well-off and those who are not. Within this amelioration, particular attention must be paid to the management of reproductive health, aimed towards the reduction of family size. This can become one of the most critical factors in the reduction of poverty and the provision of good health for more of the world's population. We must also look to greater investment in health facilities, in health education so that our people can become more focused on their responsibility to provide a better quality of life for themselves and their nations.

Finally，Saint Kitts and Nevis would like to congratulate the President and all other members of the head table on their election to office. We also acknowledge the tremendous achievements of all nations present and that of WHO and wish continued success to all. Thank you, Mr President, and may God give us strength in our human endeavour.

El Dr. SANTA MARIA (Perú):

Señor Presidente, señor Director General, señoras y señores: En nombre del Gobierno del Perú y en el mío propio queremos expresarle, señor Presidente, nuestras felicitaciones por su elección y desearle el mayor de los éxitos en la conducción de esta 48a Asamblea Mundial de la Salud，para lo cual le ofrecemos todo el apoyo de nuestra delegación. Asimismo, queremos felicitar al señor Director General, Dr. Nakajima, por su gestión frente a la OMS y por haber puesto en marcha el proceso de reformas que consideramos nos ayudará a todos a superar con eficiencia los problemas sanitarios que afectan al nivel de calidad de vida y de salud de nuestra población.

Señor Presidente: En el Perú se han dado significativos avances, traducidos en una serie de reformas estructurales y económicas, con lo que se está logrando que el país sea competitivo en el contexto internacio-nal. Hemos comenzado a solucionar nuestros problemas manifestados en una profunda crisis económica y en el lamentable deterioro social. La población peruana es de aproximadamente 23,5 millones de habitantes, concentrándose casi el 30% en la capital del país. La información estadística disponible muestra importantes cambios en la composición, estructura y distribución espacial de la población, destacándose dos modelos de desarrollo demográfico: el urbano y el rural, con características clinicoepidemiológicas y socioeconómicas muy particulares.

La mortalidad infantil ha experimentado un descenso importante en el país en la última década, llegando en la actualidad a 58 por 1000 nacidos vivos, gracias al incremento significativo de la cobertura de inmunizaciones en los menores de un año, el uso de sales de rehidratación oral para el manejo de las diarreas y el cólera, las campañas de prevención y tratamiento de las infecciones respiratorias agudas y la neumonía, la disminución de la tasa de analfabetismo en las mujeres de edad fértil, y la mayor participación en la salud por parte de las organizaciones comunales.

Otro aspecto importante de salud en el país es la salud materna y la desnutrición infantil. Un gran porcentaje de la población que ingresa a la edad escolar tiene algún grado de desnutrición crónica; el Ministerio de Salud viene desarrollando acciones cuya finalidad es disminuir su prevalencia, las mismas que están circunscritas al desarrollo de un Programa de Alimentación Complementaria orientado a atender a las madres, mujeres gestantes y niños menores de un año como grupos prioritarios.

También la tuberculosis obligó al Ministerio de Salud del Perú a desplegar esfuerzos orientados a desarrollar una mayor capacidad de diagnóstico y tratamiento en los últimos años. Estamos en condiciones de afirmar que antes de ingresar en el siglo XXI la magnitud del problema de la tuberculosis se habrá reducido en un 40%，hecho que para el país tendrá un enorme impacto en las perspectivas del desarrollo sustentable en el terreno social y económico; de ahí que el reto en el próximo quinquenio será sostener la lucha antituberculosa, que hoy constituye orgullo de la salud pública en el país y modelo para las Américas.

Se han registrado más casos de malaria en áreas de alto riesgo, debido en parte al notable incremento del cultivo de arroz en esas zonas. Ante tal situación, el Ministerio de Salud, en coordinación con el Ministerio de Agricultura, ha dispuesto durante 1994 la distribución de más de 250 000 tratamientos antimaláricos.

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Otro problema que queremos destacar es el avance del SIDA. Resulta de fundamental importancia que tanto los países en desarrollo como los desarrollados concentren sus esfuerzos para combatir a este flagelo y a sus consecuencias. En el Perú, desde que se notificó el primer caso de SIDA en 1980，se han registrado menos de 10 000 casos. Sabemos que puede existir un subregistro, pero aun así es una cifra baja, por esto nuestro principal objetivo es la educación y prevenir la transmisión del VIH y así reducir el impacto del SIDA en individuos y en la sociedad.

Los presupuestos asignados al Ministerio de Salud en lo que a inversiones se refiere presentan en estos últimos años una tendencia creciente. El Gobierno peruano ha suscrito con el Banco Interamericano de Desarrollo, así como con el Banco Mundial, préstamos orientados a ejecutar proyectos que conlleven al reforzamiento y mejoramiento de la infraestructura y gestión de los servicios de salud; recursos externos que sumados a los del Tesoro Público permiten ejecutar estos y otros proyectos en el marco de la Política Nacional de Salud.

Paralelamente, el Gobierno viene ejecutando el Programa de Salud Básica para Todos como prioridad gubernamental y orientado a financiar el desarrollo de un conjunto de intervenciones básicas capaces de producir una mejora sustancial en el nivel de salud de la población. Este conjunto de intervenciones básicas tiene tres grandes protagonistas que comparten responsabilidades para su ejecución y éxito: los servicios básicos de salud, las organizaciones comunitarias y los ciudadanos en general. El Programa de Salud Básica para Todos es, por su conceptxialización, el eje central del accionar del Ministerio de Salud, por ello lejos de ser un programa de corto plazo, se proyecta más allá del año 2000，hasta consolidar la reforma sectorial asegurando el acceso de la mayoría de la población al paquete básico de salud.

Señoras y señores: Deseo terminar con una breve reflexión. Este siglo será conocido por los muchos avances técnicos que se han producido y han ayudado al desarrollo de nuestras naciones. Además, probable-mente, en estos últimos años - antes de iniciar el siglo XXI 一 veremos algunas cosas increíbles. Pero también es cierto que el siglo XX puede ser considerado una época de ataques masivos contra la vida, una serie interminable de guerras y una destrucción permanente de vidas humanas inocentes. Llama la atención que estos atropellos se produzcan en nuestra sociedad, donde tanto se ha hablado de derechos humanos. Hace un año, en este mismo lugar los representantes de casi 200 naciones y un grupo numeroso de represen-tantes de organizaciones no gubernamentales nos dimos cita para confirmar nuestro compromiso con el mundo entero, un compromiso que nos lleva a promover la justicia，la libertad y por supuesto la salud. A lo largo de este año nos hemos preguntado muchas veces: ¿se está haciendo lo realmente necesario por los marginados, los rechazados, los eliminados, o simplemente se repiten los objetivos y métodos planteados por otros, sin pensar si es lo realmente conveniente para las naciones? Nos hemos preguntado cuál es la verdadera diferencia entre los gravísimos males de las guerras pasadas y las actuales, con la moderna tendencia del culto a la violencia en todos sus niveles, como lo es la eliminación de los hijos no deseados por medio del aborto, la drogadicción, fruto del narcotráfico, el hedonismo, etc. Todos los gobiernos e instituciones han manifestado su rechazo de estas acciones que a veces quieren justificarse o minimizarse con razones seudocientíficas.

Señoras y señores: Mi país ha vivido muchos años de violencia y pobreza, por la presencia del terrorismo criminal y la inflación. Gracias a Dios, actualmente estos dos males terribles están prácticamente eliminados. Nos enfrentamos al fin del siglo con optimismo. Es nuestro objetivo primordial el constituir un estado sólido y eficiente, que concentre sus esfuerzos en la ética, la moral, en promover educación y salud, las infraestructuras básicas, la justicia y la seguridad.

Señor Presidente, excelentísimos señores: Reiteramos el compromiso ante la honorable 48a Asamblea Mundial de la Salud de seguir luchando por mejorar los niveles de salud en la América Andina. Muchas gracias.

Mr UEDA (Palau):

Mr President, Director-General, honourable delegates, representatives, ladies and gentlemen: at the outset, I congratulate the President for his deserving election to chair the Forty-eighth World Health Assembly. I would like also to congratulate all the Vice-Presidents on their election and Dr Nakajima for his tireless efforts in working for the greater benefits of the health of the people of the world.

I also wish to congratulate Dr Han, Regional Director for the Western Pacific, on his excellent work in assisting the Republic of Palau and the Pacific regions.

My remarks today are not so much on equity and solidarity in health but a statement as the newest Member of WHO. We shall join in activities and aspirations in partnership with other nations to improve the quality of life for peoples of the world.

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It is a great honour and privilege for me to stand here today representing my country before this distinguished World Health Assembly and to witness the honour vested in the people of the Republic of Palau as the newest Member. I bring to you personal greetings from His Excellency, the President of the Republic of Palau, Mr Kuniwo Nakamura, and good wishes from the people of Palau.

As you may all know, the Republic of Palau has been a recipient of WHO benefits in the past under the umbrella of the United States of America in its trust territory status. On 1 October 1994 this Republic became an independent nation, and immediately sought membership of the United Nations and was granted full membership status on 15 December 1994，when it became the 185th Member. In March 1995 the President of the Republic submitted the formal instrument to the Secretary-General of the United Nations in accordance with Article 79 of the WHO Constitution seeking membership of WHO.

I state these events and dates so that you will see the enthusiasm that Palau has had in seeking membership to these distinguished organizations and association of nations to signify its great interest in the pursuit of equity and solidarity in health - bridging the gaps; demonstrating that no matter how small the Republic of Palau is, we seek to join in fellowship with other nations in cooperation and interest of achieving the requirements of basic health needs of the people around the world. The WHO goal of health for all is reflected in the Constitution of the Republic of Palau in which, to quote, "free or subsidized medical care" will be provided to the people so that no one is denied care, regardless of whether or not a person has money or health insurance to cover the cost. In spite of the fact that more than 11% of the national budget is allocated to health care, we are often forced to seek other sources of funds to supplement the costs of running the programmes; as tertiary care uses up a good amount of our budget through referral of patients abroad for medical care and treatment not available on the Island. This is due to a lack of highly sophisticated medical equipment and trained personnel.

As a newly independent nation, the Republic of Palau is now at the juncture of the development of the overall master plan for the country, and moving forward to building a stronger economy. But we must first develop specific and clear policies and regulations for using our resources wisely. Our national goal of strengthening the economy is the central focus of our attention, at the same time improving the health status of our people on a long-term sustainable basis through improvement of preventive and primary health care. In all these activities, health and education have been set as the top priorities of the national Government of Palau, where we plan to educate our people to manage effectively the economy, including the health care system of the country.

Although the Republic of Palau will benefit more than it can give or share with the rest of the world, we, as a nation, give our full commitment to uphold and support the principles of the WHO Constitution. We further give our full cooperation to work with the Member nations, associated organizations, both governmental and nongovernmental organizations, and to promote and protect the health of all people. In our past association with WHO through the United States of America, we have witnessed and experienced the excellent work of WHO through the Regional Office for the Western Pacific under the directorship of Dr Han. We have benefitted from the available services and programmes, and have witnessed the spirit of goodwill and brotherhood, including the care and cooperation that has significantly assisted our people in developing and improving their knowledge, skills, and sense of responsibilities for the pursuit of good health, as demonstrated elsewhere throughout the entire Western Pacific Region.

As an independent nation and a Member of this Organization now, the Republic of Palau is confident in pledging its full allegiance to WHO to join in the activities to achieve all the set objectives, goals and aspirations in partnership with the rest of the Member nations and to improve the quality of life not only of the people of Palau but of the rest of the world.

With these short remarks, I thank you and wish you all a good and productive Health Assembly.

Le Professeur FILIPCHE (Ex-République yougoslave de Macédoine):

Monsieur le Président de séance, Monsieur le Directeur général, Mesdames et Messieurs, chers confrères, l'évolution et la réforme de la médecine entraînent des conséquences extrêmement importantes tant sur le plan humain que sur le plan social. C'est d'abord la disparition de la conception artisanale de la recherche et des soins médicaux. La médecine moderne ne peut envisager un acte aussi simple que jadis; elle réclame aujourd'hui de nombreux examens complémentaires fort divers. Dans bien des cas, la nécessité d'une observation attentive et des recherches compliquées en laboratoire exigent de plus en plus un séjour dans une clinique ou un hôpital. Il en va de même pour nombre de traitements qui ne peuvent être envisagés à domicile. On a donc assisté, ces dernières années, à une évolution communautaire de la médecine qui accompagne cette évolution sur le plan social.

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Diagnostiquer et guérir devient de plus en plus onéreux alors que l'individu perd chaque jour son indépendance et sa liberté; ne pouvant supporter seul les frais que sa santé nécessite, il demande à la collectivité, c'est-à-dire à l'Etat, de le prendre en charge. Devant une telle évolution des dépenses de santé, ne sera-t-on pas, à l'avenir, obligé de faire de plus en plus un choix dans les malades susceptibles de bénéficier des meilleurs progrès de la science médicale ？ Mais alors, sur quels critères pourrons-nous nous appuyer pour accepter ou refuser un traitement ？

Si la maladie n'est plus une catastrophe physiologique grâce au progrès médical, elle est par contre devenue, en raison des dépenses qu'elle entraîne, une réelle catastrophe financière. Et cela justifie l'intervention de la collectivité : en effet, grâce à elle, le malade et sa famille peuvent subsister malgré l'arrêt de travail, mais le médecin a aussi la possibilité de recourir à des moyens diagnostiques et thérapeutiques qui seraient, pour beaucoup, trop onéreux.

Un autre élément qui est particulièrement important pour la vie économique d'une nation est l'allongement de la vie dû aux progrès prodigieux de la médecine moderne. Alors que dans certains pays encore ravagés par la famine et la mortalité infantile la moyenne de vie ne dépasse pas 20 ans, elle a considérablement évolué dans les pays occidentaux. En République de Macédoine, par exemple, elle était de 28 ans en 1900，de 58 ans pour les hommes et de 61 pour les femmes en 1960，et de 72 pour les hommes et 73 pour les femmes en 1993. On meurt moins jeune, certes, mais est-il exact de dire que l'on vit plus vieux ？ C'est là l'immense problème de la prolongation de la jeunesse et de la prolongation de la vie qui, de tout temps, a tourmenté les hommes.

C'est aussi le problème de la solidité du corps humain, que l'on compare à tort à une machine extraordinaire puisqu'il résiste à tous les climats - des pôles aux tropiques 一，à toutes les nourritures, au travail excessif, à la fatigue et aux soucis. Les trente mille milliards de cellules environ qui constituent notre organisme sont autant d'usines microscopiques travaillant jour et nuit et sans repos pour assurer cet équilibre qui est notre santé. Or la vie moderne qui est anti-hygiénique au maximum s'oppose à la vie normale de nos cellules et favorise notre vieillissement. Aussi, cet adage médical reste toujours vrai : "Prolonger la vie, c'est apprendre à ne pas la raccourcir."

C'est ainsi qu'intervient dans la vie de l'individu un environnement chaque jour plus nocif et plus destructif; le progrès n'est qu'une gigantesque et diabolique entreprise de destruction de la nature et forcément de l'homme lui-même. Qu'il s'agisse du déboisement, de la pollution de l'eau, de celle de l'air que nous respirons，de l'emploi d'engrais chimiques, tout concourt à blesser la nature; l'homme moderne prépare donc pour lui-même un avenir catastrophique. On peut dire qu'il devient de plus en plus un organisme malade, agressé continuellement et en cela il nous intéresse tout particulièrement.

Dans cette situation, la médecine change de caractère, elle devient une médecine d'analyse de plus en plus distincte de la médecine de synthèse. La médecine d'analyse se transforme en une médecine de laboratoire : le malade s'adresse en effet à des laboratoires comme à des personnes normales; la personnalité physique des médecins qui travaillent dans les laboratoires prend une importance secondaire. On demande à ces médecins des compétences exigées d'un ingénieur ou d'un bon technicien. Ces médecins remettent des comptes rendus d'expériences relatives aux seules parties du corps qu'ils auront été chargés d'explorer.

Toutefois cette situation devrait grandir le rôle du médecin. L'objet de la médecine n'est pas de soigner un nez, une langue, un foie, un rein ou une prostate, non, il est de soigner un homme, il est de considérer l'ensemble du corps de cet homme, sa physiologie et son âme. Nous ne devons jamais oublier que l'homme est à la fois un être physique et un être malade. C'est cet ensemble indissociable qui constitue notre personnalité : la maladie, comme la santé, est propre à chacun de nous. Et cela est d'autant plus vrai pour notre spécialité qu'elle a profité plus que toute autre des extraordinaires progrès de la science. Cependant, l'importance de ces progrès, Mesdames et Messieurs, ne doit pas faire perdre le sens de l'humain et le respect que nous devons à la personnalité de nos malades.

Nous considérons cette conception comme faisant partie de la réforme des systèmes de la santé en République de Macédoine. Dans nos efforts, nous bénéficions de l'appui de l'Organisation mondiale de la Santé et nous espérons que, dans un avenir très proche, nous aurons en République de Macédoine un bureau représentant l'Organisation.

Le Dr EPALANGA (Angola):

Monsieur le Président, Monsieur le Directeur général, Mesdames et Messieurs les délégués, Mesdames et Messieurs, j'aimerais commencer mon intervention en félicitant le Président et les autres membres du bureau pour leur élection et les assurer du soutien total de la délégation angolaise. Permettez-moi également de saluer M. le Directeur général et de vous souhaiter à tous plein succès dans vos travaux.

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Nous rendons hommage à M. le Professeur Monekosso qui, tout au long de sa mission à la tête du Bureau régional de l'OMS, a mené à bien, avec détermination et ardeur, les initiatives tendant à assurer le bien-être et le développement des pays africains.

C'est un privilège et un plaisir de pouvoir nous pencher, au cours de cette Quarante-Huitième Assemblée mondiale de la Santé, sur les problèmes de santé du monde en général et des pays en développement en particulier. Nous saisissons cette occasion pour adresser à M. le Dr Ebrahim M. Samba nos chaleureuses félicitations pour sa nomination au poste de Directeur régional, et nous lui souhaitons un grand succès dans l'exercice de ses nouvelles fonctions, tout en l'assurant de la coopération pleine et permanente de l'Angola dans sa mission, ardue mais honorable.

Nous sommes très fiers d'avoir le privilège et l'occasion de nous pencher tous ensemble au cours de cette Assemblée sur les questions de l'équité et de la solidarité en matière de santé, à un moment où le monde entier cherche des solutions aux problèmes politiques, sociaux et économiques, entre autres, qui se posent un peu partout sur la planète; grâce à l'action des Nations Unies, la solution de ces principes est chaque fois plus proche.

Nous reconnaissons les efforts déployés par l'OMS qui soutient les bureaux régionaux dans leur action en faveur de la santé pour tous les pays du monde et, en particulier, sur notre continent. Toutefois, il reste encore d'innombrables problèmes et le continent africain est celui qui en présente le plus en matière de santé. En ce qui concerne l'Angola, l'impact de la guerre sur la population est étendu et profond, atteignant de façon particulièrement dramatique les enfants, les femmes et les personnes âgées. Les taux élevés de mortalité infantile et maternelle reflètent la dimension de ce problème, pour lequel le grand nombre d'orphelins, d'enfants, de personnes âgées, abandonnées et handicapées, ne représente que la partie visible de l'iceberg. La situation d'instabilité vécue au cours des dernières années, ainsi que la crise économique, ont eu des conséquences non seulement sur le repli du réseau sanitaire national et des programmes de santé en cours, notamment ceux qui concernent les enfants, les femmes et les problèmes de santé publique prioritaires, mais aussi sur l'accès à l'eau potable et la disponibilité alimentaire, composantes parmi d'autres de la santé.

La conjonction de ces contraintes, ajoutée à la situation du système de santé que nous venons de décrire, s'est traduite par l'aggravation des indicateurs sanitaires nationaux. Malgré les limitations du système de surveillance épidémiologique national, une importance particulière doit être attachée à la sous-alimentation grave, aux explosions épidémiques par transmission hydrique (choléra, hépatite, dysenterie bacillaire), aux niveaux élevés de maladies diarrhéiques, d'infections respiratoires aiguës et de rougeole, sans oublier la recrudescence du paludisme, de la tuberculose, du SIDA et de la trypanosomiase humaine.

Face à ce tableau préoccupant, le Gouvernement angolais s'est fixé les priorités d'action suivantes : relevé de la situation économique dans tout le pays, remise en état des infrastructures, redistribution des ressources humaines en faveur des unités de santé rurales et périurbaines, formation de cadres et de personnel technique et administratif, approvisionnement technique et matériel, régulier et continu, lutte contre les grandes endémies, y compris contre l'infection à VIH/SIDA, surveillance épidémiologique, participation communautaire et recouvrement des coûts de gestion de la santé.

C'est avec plaisir que j'annonce à ce forum que la situation politique et militaire en Angola a évolué positivement, avec la perspective d'une paix durable pour le peuple angolais, grâce à la signature, le 20 novembre dernier, du Protocole de Lusaka. Ceci permettra de résoudre progressivement les graves problèmes posés par la reconstruction du pays ainsi que d'autres problèmes auxquels nous sommes confrontés en ce moment.

Maintenant que la guerre est finie, le Gouvernement doit relever d'innombrables défis dans le domaine social et humanitaire; la réintégration sociale des effectifs excédentaires à démobiliser, le soutien diversifié aux millions de personnes déplacées et aux réfugiés qui retournent dans leur région d'origine, la reconstruction des infrastructures de base, le déminage, sont quelques-unes des tâches que nous devons réaliser.

La mobilisation de l'aide financière et humanitaire constitue la condition sine qua non pour que nous puissions relever les défis qui se posent à nous dans les circonstances actuelles. Le Gouvernement n'est pas en mesure d'assumer seul cette responsabilité. Dans ce contexte, nous invitons la communauté internationale, notamment la communauté africaine, à nous apporter sa contribution. Nous en appelons par conséquent à cette Assemblée, à la communauté internationale et à toutes les organisations gouvernementales et non gouvernementales, pour qu'elles soutiennent par tous les moyens possibles le gouvernement africain.

Nous nous félicitons de l'initiative des Nations Unies qui ont mené ces derniers temps une action intensive en vue de mobiliser des ressources supplémentaires en faveur de l'Angola; l'appel lancé à la communauté internationale à Genève en janvier 1995 et les efforts déployés par l'OMS et l'UNICEF pour dynamiser les soutiens au secteur de la santé en sont des exemples.

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Nous félicitons M. le Directeur général pour les efforts qu'il a déployés en détachant des membres de son équipe dans le cadre de l'aide humanitaire à l'Angola.

En ce qui concerne l'intensification de la coopération avec les pays et les peuples les plus démunis et l'aide humanitaire d'urgence à l'Angola, nous tenons à remercier les divisions des opérations de secours d'urgence et de l'action humanitaire, et de la coopération intensifiée avec les pays pour leur travail conjoint et les efforts faits pour coordonner l'aide arrivant en Angola. De même, nous félicitons l'OMS pour la tenue au Caire, en 1994，de la Conférence internationale sur la population et le développement, et pour le Sommet mondial pour le développement social. A nos yeux, il y a un rapport étroit entre ces deux événements, puisque nous considérons que la politique de santé fait partie intégrante de la politique sociale et économique d'un pays, dont l'objectif final est le développement humain.

Pour conclure, Monsieur le Président, j'aimerais exprimer une fois encore notre reconnaissance pour le soutien que nous avons reçu du Directeur général, du Directeur régional, de l'Union européenne et de la Banque mondiale. Cette reconnaissance s'adresse également à des pays comme la Suède, la France, l'Italie, l'Espagne, le Portugal et l'Angleterre, qui financent en Angola des activités liées à la santé. Nous ne voulons pas non plus manquer de faire part de notre reconnaissance à des pays qui, comme le Brésil ou Cuba, font à l'Angola une place dans des activités de formation technique et professionnelle. Enfin, et ce ne sont pas les moins importants, nous remercions pour leur immense soutien les Etats-Unis d'Amérique, la Russie et les organisations non gouvernementales internationales, Médecins sans Frontières, Save the Children Fund, Caritas Internationalis (liste non limitative du grand nombre d'organismes qui aident notre pays).

Monsieur le Président, je viens de mentionner quelques exemples vivants de la solidarité dont l'Angola a été l'objet de la part de la communauté internationale. Ce n'est qu'ainsi que nous serons capables de mener des politiques sociales justes, qui permettront non seulement que les services de santé soient accessibles à tous, mais aussi que l'aide soit fournie à ceux qui en ont réellement besoin.

A tous ceux qui contribuent directement ou indirectement à l'amélioration de la santé en Afrique et dans le monde, un grand merci.

Dr FEKADU (Eritrea):1

Mr President, Mr Director-General, excellencies, honourable delegates, ladies and gentlemen, on behalf of the State of Eritrea, I would like to extend my congratulations to the President and to the other officers of the Assembly and wish you every success in your task and effort.

Eritrea, the newest nation in Africa has emerged from 30 years of dark period in its history. A country that 40 years ago had one of the most developed economies in black Africa is now lagging behind most countries in the continent. Its economic and social infrastructure has been devastated by the war. Its people who were dynamic and creative have been reduced to dependence on food handouts.

The Eritrean Government is striving to reverse this situation. The Ministry of Health, like all other governmental bodies in the country, inherited a devastated health infrastructure and inadequate manpower. What is more, the coverage of the health services was limited to selected areas only and the great majority of the country was without the basic health services.

Presently, however, many parts of the country that were denied the benefit of basic health services, have access to some sort of health facility. Many nationwide health programmes have been initiated and are being implemented at the grass-root level throughout the country. All this is being done in spite of the financial and manpower constraints that the country is suffering from.

Eritreans, like many people in the developing world, suffer from common communicable diseases. Children die or are disabled by diarrhoea, malaria, respiratory infections, malnutrition and vaccine-preventable diseases. To mention a few cardinal health parameters, infant and child mortality rates are estimated to be over 135 and 200 deaths per 1000 live births, respectively, and maternal mortality, estimated to be over 700 per 100 000 live births, is one of the highest in the world, yet basic obstetric care is lacking in many parts of our country.

The national health policy is based on the concept and principles of primary health care. In adopting this policy, the Government of Eritrea endeavours to make basic health services available to the majority of the Eritrean population. The current priorities include the functional restoration of health facilities which have been damaged by war or which are in a state of decay because of inadequate maintenance, and the

1 The text that follows was submitted by the delegation of Eritrea for inclusion in the verbatim records in accordance

with resolution WHA20.2.

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expansion of available health services to populations which currently lack health care through the construction of new facilities.

At the time of liberation in 1991, there existed only seven hospitals, four health centres and 71 health stations in the country. By the end of 1994，in addition to qualitative changes, the facilities were increased to 18 hospitals, 36 health centres and 122 health stations. Many of these health facilities still require improvements in the physical context or additional equipment and supplies. Notwithstanding current needs to improve the infrastructure, these achievements were only possible because of contributions from the active participation of local communities as well as generous support from interested partners and the donor community.

The provision of adequate supply of essential drugs to all levels of the health services; construction of local drug production facilities and distribution warehouses; as well as the formulation of associated policies for the safe and effective use of pharmaceuticals by health practitioners: great progress has been achieved in these areas. Policies and regulatory legislation for the pharmacy sector have been formulated, plans for the relocation of the former Eritrean Liberation Front production facility have been finalized, and inventory and distribution systems expanded.

To improve the efficiency of health services provision as well as to ensure career opportunities, job satisfaction and competence of our health personnel, the Ministry has adopted a policy to train, streamline and standardize existing categories of health workers. By the end of 1994, nearly a thousand of various categories of middle-level health professionals had been trained and upgraded.

Repatriation and reintegration of nearly half a million Eritrean refugees from the Sudan and elsewhere have posed more pressure on the health task and responsibility of the Government. The Ministry is actively participating in the repatriation programme, and provides health screening and services in reception centres and at settlement sites.

The control of communicable diseases, in particular malaria, which is the most prevalent disease in our country is found distributed over 75% of the country's land surface affecting about 67% of the population. In order to tackle this problem, the Ministry of Health integrated malaria control at each level of health services and this is being implemented in line with the global malaria control strategy. Although malaria continues to pose serious health problems, we believe this approach will be effective to prevent deaths and reduce the incidence of severe malaria.

Although an expanded programme on immunization was launched in a few urban centres earlier, nationwide expansion was only possible after liberation in 1991. Despite efforts to establish health facilities, a cold chain and surveillance systems, coverage still remains very low. However, a national review of the expanded programme on immunization is in process and an accelerated programme for universal child immunization is expected to be launched by the end of the year.

Diarrhoeal diseases and respiratory infections are the main causes of illness and death among children. Support for controlling these diseases has been given by bilateral and multilateral donors. National programmes for the control of diarrhoeal diseases and acute respiratory infections will begin in the near future and will be an integral part of our primary health care programmes.

War and successive droughts, a high prevalence of infectious diseases, low household food security and poor nutritional habits have all contributed to poor nutritional status. In addition to protein-energy malnutrition, deficiencies of micronutrients such as iodine, vitamin A and iron are widespread. In order to improve household food security, an intersectoral task force on household food security and nutrition has been established.

Although HIV/AIDS has not yet presented problems on a serious scale, steps are being taken to contain it and if possible to further reduce the current level of incidence. An AIDS prevention and control programme which was established in 1992 is now being strengthened with the support and collaboration of WHO.

Tuberculosis control activities have been carried out over a period of many years, but irregularly. Consequently, the coverage with BCG vaccination is only 16% and hence the risk of infection is known to be high. Similar to other disease control efforts, the control of tuberculosis has been integrated with other health services at all levels of the health system.

In conclusion, Mr President, it is my view that in such a short lapse of time considerable progress has been made in the rehabilitation and construction of new health facilities that allowed for an improved health service delivery because of the inherited principles of self reliance, strong commitment of the Government, active participation of the people and support and collaboration of interested partners and the donor community.

A48/VR/10 page 209

Yet, there remains much to be done to respond to the basic health needs of the Eritrean people. On behalf of my Government and the Eritrean people, I would like to extend my appreciation to those who have supported our efforts to date and, on the basis of the principles of international solidarity and equity on health, appeal for their continued collaboration and extended participation in the years to come.

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Mr PILGRIM (Trinidad and Tobago):1

Mr President, the delegation of the Republic of Trinidad and Tobago wishes to join in congratulating you, the Vice-Presidents and other officers on your election to office at this Forty-eighth World Health Assembly. We would also like to extend congratulations to the Director-General and his staff as well as the Executive Board for their work and excellent reports since the last Assembly. The delegation has noted The world health report 1995: bridging the gaps which describes, among other things, the state of world health, where health gains have been made in some areas - for example infant mortality and overall life expectancy. Sadly, there has been deterioration in certain other health areas, especially in the least developed countries, in addition to disturbing patterns of increasing incidence of cholera, tuberculosis, AIDS, and the reappearance of the dreaded plague. It can be said that the present world health picture is one of mixed images.

Trinidad and Tobago is a developing country in transition, with planned projections for economic restructuring and diversification of its economy. Public sector reform and new opportunities for the private sector are important elements in this new thrust. This is solidly intertwined with progressive social policies to ensure equity and sustainable development for its citizens. It is within this context that our health sector is being reformed, to provide a more efficient and responsive health care system while ensuring that the present philosophy of equity and access to health care for all citizens is maintained and enhanced. The

1 The text that follows was submitted by the delegation of Trinidad and Tobago for inclusion in the verbatim records

in accordance with resolution WHA20.2.

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structure of the public health system in Trinidad and Tobago has historically followed a very centralized model. As part of the wider approach to reform of the public sector, the Government of the Republic of Trinidad and Tobago has embarked on an initiative to improve the health care system by decentralizing the delivery of heath care services. For this purpose the country has been divided into five administrative regions, termed "regional health authorities", each of which is managed as an operationally autonomous entity by a board of directors with responsibility for the provision of comprehensive health care within a defined geographical area. The Ministry of Health is now responsible for the determination of health policy, establishment of standards, and the monitoring of services delivered by the regional health authorities. The guiding principles which inform the health care system are based on: greater efficiency in health care delivery; improved accessibility; improved quality of care; and equity, affordability and sustainability of care. The reforms not only deal with new administrative structures but also with the establishment of a partnership and empowerment of the national community in health matters. The new mission statement describes the work of a ministry of health: "in the business of promoting wellness and ensuring the availability of quality health care to the people of Trinidad and Tobago in an affordable, sustainable and equitable manner". The main strategy for achieving the mission is through primary health care. It is envisaged that improvements in the primary care system will redound to the benefit of the overall health care system by effectively addressing a number of diseases at the preventive stage, in addition to reducing demands on secondary and tertiary facilities. The Government will seek to ensure that the most vulnerable groups in the population will be targeted for the appropriate health care services and support in an effort to close gaps between socioeconomic groups.

Funding for many of the health sector reform studies has been obtained from the Inter-American Development Bank in the form of nonrefundable technical assistance, and for this the Government of Trinidad and Tobago is indeed very grateful. Much progress has been made by the country in improving its health status as reflected in The world health report 1995, where it is listed as one of the Member States of WHO that has achieved all three health-for-all targets. Diseases preventable through immunization are rare; there have been no cases of poliomyelitis since 1972, and like the rest of the English-speaking Caribbean countries, Trinidad and Tobago is well on the way to eradicating measles. A national measles immunization campaign undertaken in 1991 achieved a 95% coverage in the under-15-year-old population. Trinidad and Tobago has so far successfully warded off the cholera epidemic which has affected several countries in the Region of the Americas, and surveillance of diarrhoeal diseases has been intensified. However chronic noncommunicable diseases are problems which continue to wreak havoc with the nation's health. Cardiovascular diseases, cancer, diabetes mellitus and cerebrovascular diseases are the leading causes of morbidity and mortality. Violence, accidents and injury are also cause for concern, as they are the most common causes of death in young males and an important contributor to disability and years of potential life lost. It is because most of these diseases are lifestyle-related, and therefore preventable, that the emphasis in health reform has been placed on health promotion. Trinidad and Tobago hosted the first regional health promotion conference in 1993 from which a Caribbean Charter on Health Promotion was developed. The Charter and its implementation strategies have the full endorsement of the Government; this is evidenced by the fact that Trinidad and Tobago was quick to convene its national health promotion conference in June 1994 in order to sensitize as wide a cross-section as possible of the national community about the beneficial effects of health promotion, and to elicit their support.

Another facet of the health sector reform is the need to find new ways of financing the sector. Studies have been commissioned to facilitate the introduction of a national health insurance system. It is envisaged that such a system will provide supplemental funding to the sector, thereby ensuring the sustainability of the health services and offering in return a more equitable distribution and an improved quality of care.

The changes that are under way are ambitious and revolutionary, certainly for the Caribbean Region, but the Government is convinced that they are necessary if the health services are to be delivered more efficiently and if there is to be improved equity, access and quality of care.

The health sector reform programme is compatible with the strategic orientation and programme priorities of PAHO/WHO. We have been extremely fortunate to have had the benefit of the guidance and support of the Pan American Health Organization in our reform efforts. We have also worked closely with РАНО in furthering cooperation in health among the region's governments through the Caribbean Cooperation in Health Initiative.

Mr President, the Government of the Republic of Trinidad and Tobago stands ready to work with other governments and with WHO in the implementation of global strategies for the development of health for our populations.

A48/VR/10 page 211

Ms SPENCER (New Zealand):1

Mr President and Mr Director-General, New Zealand congratulates WHO on the release of the first world health report. This initiative, bringing together as it does a wide range of comparative statistics on health, paints a stark picture of the distance there is to travel to the goal of health for all by the year 2000. The report also offers grounds for hope, recording the progress that has been made, for example, on the development of immunization, the reduction of diarrhoeal diseases in children, the reduction of endemic diseases like leprosy and dracunculiasis，action against the spread of HIV/AIDS and the improvement of nutrition.

New Zealand would like to offer some observations on the first priority identified in the report - to ensure value for money by using the available resources as efficiently as possible and redirecting them to those who need them most. As a developed country we have good health status and a well developed health infrastructure, unlike some of the poorest countries in the world. We are nevertheless operating in an environment where the resources which can be devoted to health services are finite, and we are aware that with the aging of the population the need to better direct expenditure on health will become even more pressing. We are taking a particular, targeted approach to improving equity within an environment of funding constraint, and believe it may be of interest to other Member countries.

The legislation which underpins the New Zealand health system identifies the interaction between quality and resource constraint. It defines the Government's objective as the desire to secure for the people of New Zealand the best health, the best care or support for those in need of services and the greatest independence for people with disabilities that is reasonably achievable within the amount of funding provided. New Zealand health services are substantially publicly funded, with four regional health authorities charged with the purchase of health and disability support services for the people in their regions. The Government, through the issuing of annual policy guidelines to the regional health authorities, defines the principles which are to underline the purchase of health services and the health gain areas which are to be given priority. The principles identified are equity, effectiveness, efficiency, safety, acceptability and risk management. Equity is defined in two ways: improving equality of access according to the ability to benefit from services and decreasing disparities in health status within and between population groups.

Improving equality of access focuses on setting national minimum standards for purchasers for waiting times for health services; geographical access (both in terms of time required to reach a service and distance from the location of health service facilities) and affordability (while user part charges have been imposed for some publicly funded services, an overall limit has been identified, and charges are abated, or higher subsidies are paid for people on low incomes, children, and people with chronic illness who are high health service users).

Work is also going on to examine the circumstances under which people can best benefit from particular health services. The National Advisory Committee on Core Health and Disability Services has moved from attempting to establish a list of publicly funded services to address the issue of the best use of publicly funded resources, both from the perspective of overall effectiveness, and from the benefit to be gained by the individual. The potential for better matching health services to the multiple needs of some individuals is also assisted by the integration of the purchase of all services, from public health to primary and secondary care and disability support services under one purchaser. The distribution of public funding to regional health authorities for personal health services is based on a funding formula which has as its objective to assist in achieving equality of access to core personal health services, according to need. While its basis is on population distribution between regions, it includes adjustments for special needs factors, such as a health and equity score, the unmet needs of the Maori and a premium where purchasers face higher costs of service provision because of the geographic distribution of their population. A similar formula for disability support services funding is to be implemented from 1 July 1995. This system combines national minimum service standards, guidance to purchasers on purchasing principles and central funding, with the flexibility for regional health authorities to purchase services which most effectively and efficiently meet the needs of their local populations.

The second facet of equity relates to decreasing disparities in health status. This recognizes that in all population groups there are some individuals who will require additional support and effort by health service providers to ensure that their needs for health and disability support services are met. It also recognizes that

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.

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there are population groups whose health status falls well below that of comparable groups. This applies particularly to the Maori, the indigenous people of New Zealand, who fare worse than other population groups on a range of health status measures, including infant mortality and life expectancy. Along with these principles sit health gain priority areas. These have been identified as areas in which the Government expects purchasers to give particular emphasis to improving health status and promoting independence. They are currently Maori health, child health, mental health and physical environmental health. In these areas, purchasers are expected to identify issues of regional and local importance; identify cost-effective responses and prioritize services and shift resources to higher priorities. Mental health services have been identified as a health gain priority area because in New Zealand, as elsewhere in the world, as The world health report indicates, mental health has been a comparatively poorly resourced service. A national mental health strategy has been developed which identifies five key strategic directions: implementing community-based and comprehensive mental health services; encouraging Maori involvement in planning, developing and delivering mental health services; improving the quality of care; balancing personal rights with the protection of the public and developing a national alcohol and drugs policy. For Maori health, the focus is on building on a three-year strategy to improve Maori health by making service delivery and decision-making systems responsive to Maori needs, improving the responsiveness of mainstream services to the needs of Maori and encouraging the development of Maori service providers and focusing on illness especially prevalent among Maori and the health of the when (family) particularly children, young people and women.

New Zealand believes that continuing to focus on the goal of improving the health of those who need it most, while facing up to the inevitable reprioritization that is needed to finance this approach within an environment of constrained resources, is the way of the future. We fully support the recent initiative of reprioritization requested by the Executive Board. New Zealand believes that in the future budget increases for WHO should be linked to high priority activities, and should not be considered until the alternative of diverting funds from lower priority activities has been explored.

Le Dr MBUMB MUSSONG (Zaïre) ：1

Monsieur le Président de séance, Excellences Mesdames et Messieurs les Ministres, Monsieur le Directeur général de l'OMS, honorables délégués, Mesdames et Messieurs, c'est un honneur et un privilège pour moi de m'adresser du haut de cette tribune de l'Assemblée mondiale de la Santé à la communauté internationale représentée par des délégations de haut niveau de vos pays respectifs.

Avant toute chose, je voudrais saisir l'opportunité qui m'est offerte pour adresser au Président, au nom de ma délégation et en mon nom personnel, mes vives félicitations pour sa brillante élection à la présidence de la Quarante-Huitième Assemblée mondiale de la Santé. Tout naturellement, j'associe à ces félicitations les Vice-Présidents et tous les autres membres du bureau, qui ont l'honneur de le seconder dans 1 ' accomplissement de cette importante et délicate mission.

J'aimerais également féliciter le Directeur général et le Conseil exécutif pour les rapports présentés à cette Assemblée et pour le choix judicieux des programmes qui y sont exposés et qui feront l'objet de résolutions pertinentes. La mise en oeuvre de ces résolutions permettra, j'en suis persuadé, de faire un grand pas vers l'instauration de la santé pour tous.

Je voudrais aussi saisir cette occasion pour regretter et déplorer la situation qui sévit actuellement dans des pays membres de la Communauté des Grands Lacs, à savoir au Rwanda et au Burundi. La République du Zaïre, qui fait également partie de cette Communauté, a des frontières communes avec ces pays et partage les retombées de cette situation, notamment le poids de près de deux millions de réfugiés. La communauté internationale est interpellée pour faire cesser les massacres qui déciment ces peuples et pour apporter toute l'aide nécessaire à l'amélioration de la situation sociale et sanitaire des populations en déplacement forcé et de celles qui les accueillent.

L'Afrique subsaharienne en général et la République du Zaïre en particulier sont confrontées aujourd'hui à une crise de la santé d'une ampleur sans précédent, consécutive elle-même à une crise socio-économique, engendrée par une crise politique due à une longue et pénible transition qui est loin d'être à son terme, et par un embargo des coopérations bilatérales et des principaux bailleurs des fonds qui fait payer un lourd tribut à des populations innocentes.

Cette crise de la santé est caractérisée, premièrement, par la résurgence de maladies comme le paludisme, la trypanosomiase, l'onchocercose et la tuberculose, jadis jugulées, deuxièmement, par la

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.

A48/VR/10 page 213

détérioration croissante des infrastructures sanitaires, la dégradation des soins due à la baisse du budget de la santé et à la sévère pénurie des médicaments, ne permettant plus de prendre correctement en charge les patients, ni d'assurer efficacement la couverture vaccinale aux enfants de 0 à 5 ans, ni de mettre en oeuvre le développement des systèmes de santé susceptibles de garantir l'amélioration durable de l'état de santé de nos populations, troisièmement, par l'apparition et l'augmentation des cas de SIDA, dont les conséquences sociosanitaires et socio-économiques sont particulièrement graves dans un pays aussi fragilisé.

Cette crise de la santé se trouve aggravée notamment par la récession économique, qui d'avance inhibe tous les efforts à entreprendre pour transformer radicalement la situation sanitaire dans le pays. Des efforts importants ont cependant été déployés dans le pays pour renforcer les soins de santé primaires, grâce à la mise en oeuvre de stratégies fondées principalement sur la décentralisation et sur la participation communautaire à tout le processus gestionnaire, au financement des services de santé et à l'accessibilité géographique et financière aux médicaments.

C'est dans ce cadre, marqué par la volonté d'améliorer la situation sanitaire de la communauté nationale，que le pays, déjà confronté à d'énormes difficultés internes, a dû consentir des sacrifices largement au-dessus de ses capacités d'intervention.

Le droit à la santé et l'objectif égaiitaire de la santé pour tous, conforme au devoir d'équité, nous imposent, en dépit de l'adversité, d'intensifier les efforts pour consolider nos programmes opérationnels en faveur des groupes vulnérables que sont les enfants, les adolescents, les femmes (en particulier, les femmes enceintes et allaitantes) et les personnes âgées, ainsi que les populations exposées à des risques épidémiologiques spécifiques, sans perdre de vue la nécessité de faire face aux situations urgentes devenues très fréquentes.

Il me plaît de saluer du haut de cette tribune l'action des organisations non gouvernementales qui se sont investies à nos côtés dans les efforts pour l'amélioration de la santé de la population, surtout face aux situations urgentes. Cette aide d'urgence, bien que très appréciée, devrait être complétée par des actions dans le sens du développement sanitaire durable, qui seul pourra permettre à terme d'assurer une couverture sanitaire acceptable.

Ce développement sanitaire, à envisager dans un monde en perpétuelle mutation, repose sur les concepts qui privilégieront des approches faisant appel au rôle croissant que devraient jouer l'individu, la famille et les communautés de base dans le domaine de la santé et de l'environnement, à l'intégration d'autres disciplines et d'autres secteurs pour l'amélioration de la santé, de manière à mieux prendre en compte tous les facteurs déterminants de la bonne santé, à la promotion des mesures aidant les individus à agir eux-mêmes, en collaboration avec les familles, les communautés et les services, pour prendre en main et améliorer leur santé, enfin, à la prise en compte de la fragilité de la vie humaine et de la nécessité de protéger cette vie par tous les moyens qu'offrent la science et les progrès de la technologie.

C'est dire qu'en plus des infrastructures sanitaires de base qu'il faut renforcer ou réhabiliter, équiper et doter d'un personnel qualifié en nombre suffisant, le développement des systèmes de santé devra parallèlement faire appel aux disciplines et secteurs liés à la santé et accroître les forces intrinsèques des individus, des familles et des communautés par une éducation et une motivation appropriées, dans des conditions d'existence et de travail propices, en vue de relever d'ici l'an 2000 les défis prioritaires.

Dans le cadre du Sommet mondial pour les enfants, les actions à entreprendre visent à permettre au Zaïre d'atteindre les objectifs suivants : réduire d'un tiers les taux de mortalité infantile et juvéno-infantile, respectivement de 137 % et 213 %，à 89 % et 142 %; augmenter la couverture vaccinale des enfants de moins d'un an de 23 % à 80 %; diminuer le taux de mortalité maternelle de 800 à 400 pour 100 000 naissances vivantes; réduire la malnutrition chez les enfants de moins de cinq ans de 25 % à 13 %; augmenter l'accès à l'eau potable de 22,8 % (39 % en milieu urbain, 17 % en milieu rural) à 100 % et à des moyens d'évacuation des excreta et d'assainissement de 10 % (20 % en milieu urbain, 4 % en milieu rural) à 100 %; augmenter le taux net d'inscription dans l'enseignement primaire de 60 % à 80 % des enfants scolarisables; mettre en application les principes de la Convention relative aux droits de l'enfant qui impliquent également la protection des enfants en situation particulièrement difficile.

Sur la base des objectifs du Sommet mondial, la Conférence organisée par Г OUA en décembre 1992 à Dakar a défini des objectifs intermédiaires que devaient atteindre les pays africains, d'ici fin 1995, par des plans d'action nationaux.

Il s'agit d'augmenter de 75 % à 80 % le taux moyen de protection vaccinale contre la diphtérie, le tétanos, la coqueluche et la tuberculose (celui du Zaïre est de 19 %), et de garantir un taux de vaccination de 90 % contre la rougeole pour l'enfant et contre le tétanos en ce qui concerne les femmes en âge de procréer.

A48/VR/10 page 214

Pour une telle entreprise, dans laquelle mon pays est résolument engagé, le concours de la communauté internationale est incontournable. Aussi, je saisis cette occasion pour demander à la communauté internationale de reprendre et d'intensifier ses efforts de coopération avec mon pays confronté à de nombreux défis pour l'aider à les surmonter et à assurer le bien-être de nos populations. A cet effet, mon pays a adressé au Directeur général une requête résumant les besoins prioritaires du Zaïre, pour lequel il sollicite l'appui des pays, des organisations de coopération, des bailleurs de fonds et des organisations non gouvernementales qui participent à cette Assemblée.

Je terminerai mon message en réitérant la gratitude de mon pays à la communauté internationale pour ses efforts soutenus en vue de la normalisation de la situation au Zaïre et en exprimant le souhait que les travaux de la Quarante-Huitième Assemblée mondiale de la Santé contribueront de façon déterminante à la sensibilisation des populations, des gouvernements, des organisations non gouvernementales et des institutions internationales, pour que la santé occupe la place qui lui revient dans les efforts pour le développement humain et dans le processus de développement socio-économique.


As agreed earlier, the delegate of Malta will be allowed to speak from his seat; I therefore give the floor to the delegate of Malta.

Dr VASSALLO (Malta):

Mr President, the delegation of Malta is making the following statement on behalf of itself and the delegations of Iceland and Luxembourg. The statement concerns item 10 of the agenda, and specifically The world health report 1995, which was circulated to us earlier this week.

Our three delegations, while thanking you, Mr President, for this opportunity, would like to express our serious concern at what is stated in Annex 3 of The world health report which, in respect of our countries, is not factual and could cause serious embarrassment to our Governments. In Annex 3，Tables Al , A2 and A3, our countries are not shown in the category of countries meeting all three health-for-all targets, that is, life expectancy at birth above 60，infant mortality rate below 50，and under-five mortality rate below 70. In the footnote in respect of these three targets, it is stated that estimates of the under-five mortality rate for less populous countries have been excluded. We find this puzzling, given the fact that our country's statistics were regularly supplied to WHO and these show that our three countries have more than met these three targets. Moreover, under-five mortality data which has been left out in our respect, could easily have been derived from the data we have supplied. We have made representations to the appropriate division of the Secretariat which has informed us that values for the three health-for-all health status targets were derived from estimates of UNDP based on their 1992 revision of World Population Reports. However, on page 99， paragraph 2.4 of the report, the source is shown as UNICEF. The Secretariat has proposed to issue an addendum after the estimates for less populous countries are prepared by UNDP. My delegation has since been informed that data have been found in a UNICEF document. We find the course of action of simply issuing an addendum unsatisfactory and therefore unacceptable. In the light of the statement we have just made, our delegations respectively request that the Secretariat issue, in addition to the addendum, a statement before the end of this Assembly to the effect that our countries have met all three health-for-all targets, namely those for life expectancy, infant mortality and under-five mortality, and further that this statement be included in the records of this Assembly.


I thank the delegate of Malta. We have now completed the list of speakers. The debate on items 9 and 10 is now concluded. The Chairman of the Executive Board is unable to be with us to comment on the debate which we have just concluded, as he is participating in the discussions on global change in Committee B. He has asked me to inform you that your views on the report of the Executive Board will be conveyed to the Board at its forthcoming session. I now have much pleasure in giving the floor to the Director-General，who wishes to say a few words.

A48/VR/10 page 215


Thank you, Mr President, your excellencies, ladies and gentlemen. First of all I wish to thank you all for the words of praise and appreciation you have had for the first issue of our World health report 1995. We have taken due note of the request from some countries that we should help them to publicize more detailed or corrected and comprehensive data on the health status of their population, as, for example, the delegate of Malta stated on behalf also of Luxembourg and Iceland. Let me reassure you all that this is but the first issue of The world health report; there will be many others. The presentation will be improved and the data regularly revised. We are being greatly encouraged by the interest the Assembly has shown in the report as an innovative means of information on world health in WHO's programme of technical cooperation with countries and in the prioritization exercise which we have been carrying out within the proposed programme budget 1996-1997. During this very rich debate, delegations focused on offering concrete and useful proposals for future action to bridge the gap in health development and fight poverty and the world's deadliest diseases. The proposals have included guidance on priorities and resource allocation, health interventions and collaboration mechanisms. All delegations have expressed their concern that immunization activities should be continued, expanded and strengthened and, more particularly, that every effort should be made to ensure the global eradication of poliomyelitis. The priorities you have identified include the promotion of maternal and child health and women's health, the control of HIV/AIDS, the development and accessibility of essential drugs and vaccines and the control of major parasitic diseases such as malaria. You have also expressed general concern for the control of environmental health hazards, cancer, cardiovascular diseases and programmes related to aging, mental health and substance abuse. Beyond identifying priorities and major directions for action you have highlighted ways and means to enable and sustain health development at all levels. You have stressed the strategic importance of making primary health care services available to all people in their local communities. You have advocated establishment of new health alliances across all sectors of government and society at local，national and international levels. You have underscored the crucial need for political commitment - higher levels of political commitment - particularly to ensure integrated health policies and sustainable funding. You have also advocated enhanced coordination between all local, national and international health partners. In other words you have stressed the need individually and collectively to achieve a fair balance between rights and responsibilities, between self-help and cooperation, between self-reliance and solidarity. Achieving this we will ensure that we can sustain development and bridge the health gaps which all of you stress as a global priority.

Finally, you have reaffirmed WHO's unique role within the United Nations system to protect and promote the health of all through advocacy and technical cooperation. You have acknowledged WHO's resolve and efforts within its reform process to improve and continuously update its response to evolving health challenges. "Bridging the gaps" is a subtitle of The world health report, and was the central theme of your general debate in the Assembly this year. It expresses our determination turned into action to achieve equity in access to and utilization of health care for all.

Mr President, your excellencies, ladies and gentlemen, once again I thank you for your continuous support to the World Health Organization.


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 world health report incorporating the Director-General's report on the work of the Organization. I take it that the Assembly wishes to commend the Director-General for the new approach to reporting on the world health situation and to express its satisfaction with the manner in which the programme of the Organization is being implemented? After noting specific comments on the part of some of the delegations on the data contained in The world health report, I am sure that the Director-General will make every effort to further improve the reporting in the future. This he has confirmed just now. In the absence of any objection, this will be duly recorded in the records of the Assembly.

The meeting is adjourned.

The meeting rose at 16:00. La séance est levée à 16 heures.

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ELEVENTH PLENARY MEETING

Monday, 8 May 1995, at 17:40


ONZIEME SEANCE PLENIERE

Lundi 8 mai 1995，17h40


1. SECOND REPORT OF THE COMMITTEE ON CREDENTIALS1

DEUXIEME RAPPORT DE LA COMMISSION DE VERIFICATION DES POUVOIRS1

The PRESIDENT:

The meeting is called to order. The second report of the Committee on Credentials, is contained in document A48/51, which has been

distributed to delegates. 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.

2. ADOPTION OF THE AGENDA ADOPTION DE L'ORDRE DU JOUR

The PRESIDENT:

I would like to report to you the decision of the General Committee, which met on Friday 5 May, with regard to the title of item 31 of the agenda. The General Committee came to an agreement that the title of this item should read as follows: "Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine". I understand that the Assembly is in agreement with the General Committee's proposed title for item 31. The revised agenda which will be distributed to you later will take this into consideration.

3. PROGRAMME OF WORK PROGRAMME DE TRAVAIL

The PRESIDENT:

With regard to the programme of work of the Assembly, the General Committee decided that tomorrow, Tuesday, 9 May, there will be no plenary. However, both committees A and В will continue with their deliberations in the morning and in the afternoon. At 17:40 the General Committee will meet.

As announced in the Journal of Saturday, 6 May, on Wednesday, 10 May, there will be neither plenary nor meetings of the committees of the Assembly.

I recognize the delegate of Hungary, on a point of order.

1 See reports of committees in document WHА48/1995/REC/3. 1 Voir les rapports des commissions dans le document WHА48/1995/REC/3.

A48/VR/12 page 217

Dr SZATMÁRI (Hungary):

I wish to make a point of order in this matter. It has never before been the practice in WHO to honour any of the national or religious holidays. As this practice was changed for the first time this year as a result of the decision of the General Committee, we would like to express our concern in this respect. We are anxious that the Health Assembly will not be able to finish its work and there will be no quorum to vote on the appropriation resolution for the programme budget for 1996-1997，which would mean that a new Health Assembly would have to be convened. We would therefore ask the Director-General to put this matter on the agenda of the Executive Board at its ninety-sixth session, and come forward with a suggestion for future years. Thank you.

The PRESIDENT:

The remarks of the delegate of Hungary are noted and will be recorded in the proceedings of this Health Assembly.

The General Committee decided on the following tentative timetable for Thursday, 11 May and for Friday, 12 May, on the understanding that this will be further reviewed at its meeting tomorrow (announcements in this connection will be made in the main committees): on Thursday, 11 May, both Committees A and В will meet in the morning and in the afternoon. At 17:40 there will be a plenary meeting. On Friday, 12 May at 9:00，Committees A and В will meet as necessary, and will finalize draft resolutions and reports. The plenary will meet to review the reports of the main committees, followed by item 15, Closure of the Forty-eighth World Health Assembly. The exact timing of the plenary will depend on the progress of work of the committees.

I wish to remind you that the appropriation resolution may be taken up in the committees either late on Thursday or early on Friday morning, and that it is essential to have a quorum for this resolution.

4. FIRST REPORT OF COMMITTEE A1

PREMIER RAPPORT DE LA COMMISSION A1

The PRESIDENT:

We shall now consider the first report of Committee A, as contained in document A48/50; 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: "Emergency and humanitarian action"? In the absence of any objections, the resolution is adopted.

The second resolution is entitled "Intensified cooperation with countries in greatest need". 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.

5. FIRST REPORT OF COMMITTEE B1

PREMIER RAPPORT DE LA COMMISSION B1

The PRESIDENT:

We shall now consider the first report of Committee disregard the word "Draft" as this report was adopted by the contains three resolutions which I shall invite the Assembly

B, as contained in document A48/48; please Committee without amendments. This report to adopt one after the other.


A48/VR/10 page 218

Is the Assembly willing to adopt the first resolution entitled "Interim financial report on the accounts of WHO for 1994 and comments thereon of the Administration, Budget and Finance Committee"? In the absence of any objections, the resolution is adopted.

The second resolution is entitled: "Status of collection of assessed contributions and status of advances to the Working Capital Fund". Is the Assembly willing to adopt this resolution? In the absence of any objections, the resolution is adopted.

The third resolution is entitled: "Members in arrears in the payment of their contributions to an extent which would justify invoking Article 7 of the Constitution". 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 B.

6. E L E C T I O N O F M E M B E R S E N T I T L E D T O D E S I G N A T E A P E R S O N T O E X E C U T I V E B O A R D E L E C T I O N D E M E M B R E S H A B I L I T E S A D E S I G N E R U N E P E R S O N N E P A R T I E D U C O N S E I L E X E C U T I F

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 (document A48/52).

I draw your attention to the list of 12 Members drawn up by the General Committee in accordance with Rule 102 of the Rules of Procedure. In the General Committee's opinion these 12 Members would provide, if elected, a balanced distribution of the Board as a whole. These Members are, in the English alphabetical order: Algeria, Argentina, Australia, Bahrain, Barbados, Bhutan, Brazil, Croatia, Egypt, Ireland, Republic of Korea, Zimbabwe. Are there any comments or any objections concerning the list of 12 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 12 Members as proposed by the General Committee? I see no objection. I therefore declare the 12 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.

Before adjourning, I should like to remind you that, as announced in the Journal on Saturday, there will be no official meetings of the Assembly on Wednesday. The next plenary meeting will be held on Thursday at 17:40. The meeting is adjourned.

S E R V E O N T H E

D E V A N T F A I R E

The meeting rose at 18:00. La séance est levée à 18 heures.

A48/VR/12 page 219

TWELFTH PLENARY MEETING

Friday, 12 May 1995，at 11:30


DOUZIEME SEANCE PLENIERE

Vendredi 12 mai 1995，llh30


1. THIRD REPORT OF THE COMMITTEE ON CREDENTIALS1

TROISIEME RAPPORT DE LA COMMISSION DE VERIFICATION DES POUVOIRS1

The PRESIDENT:

The Assembly is called to order. Belatedly may I wish the distinguished Muslim delegates a fruitful and spiritually rewarding Eid Al-Adha.

Our first item of business is to consider the third report of the Committee on Credentials. A meeting of the Bureau of the Committee was held, in accordance with Rule 23 of the Rules of Procedure, but there has been insufficient time to allow for the translation and printing of the report. I shall therefore present the report on behalf of the Bureau. The Bureau examined the formal credentials of the delegation of Equatorial Guinea which had been seated provisionally in the Health Assembly pending the arrival of its formal credentials. These credentials were found to be in conformity with the Rules of Procedure, and the Bureau of the Committee therefore recommends that the Assembly recognize their validity. Does the Assembly accept this report of the Committee on Credentials? I see no objection, the report is therefore adopted.

2. SECOND REPORT OF COMMITTEE A1

DEUXIEME RAPPORT DE LA COMMISSION A1

The PRESIDENT:

I would like to report to you that when the General Committee met for the last time on Tuesday, 9 May, it gave me the authority to schedule our programme of work according to the progress in the two main committees in such a way that the Assembly adjourns no later than this afternoon. It also 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. Before we proceed therefore, we shall hear from the two main committees which met the whole of yesterday and this morning.

We shall start with the second report of Committee A, contained in document A48/55. Please disregard the word "Draft" as the report was adopted by the Committee without amendment. This report contains seven resolutions which I shall invite the Assembly to adopt one after the other.

Is the Assembly willing to adopt the first resolution entitled: "Revision and updating of the International Health Regulations"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the second resolution entitled: "Reorientating medical education and medical practice for health for all"? In the absence of any objections the resolution is adopted.


A48/VR/12 page 220

Is the Assembly willing to adopt the third resolution entitled: "Prevention of hearing impairment"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the fourth resolution entitled: "Reproductive health: WHO's role in the global strategy"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the fifth resolution entitled: "An international strategy for tobacco control"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the sixth resolution entitled: "Control of diarrhoeal diseases and acute respiratory infections: integrated management of the sick child"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the seventh resolution entitled: "Communicable diseases prevention and control: new, emerging and re-emerging infectious diseases"? In the absence of any objections the resolution is adopted and the Assembly has therefore approved the second report of Committee A.

3. SECOND REPORT OF COMMITTEE B1

DEUXIEME RAPPORT DE LA COMMISSION B1

The PRESIDENT:

We shall now consider the second report of Committee В contained in document A48/53. Please disregard the word "Draft" as the report was adopted by the Committee without amendment. This report contains eleven resolutions and two decisions 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: review of the Constitution of the World Health Organization"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the second resolution entitled: "WHO response to global change"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the third resolution entitled: "WHO response to global change: renewing the health-for-all strategy"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the fourth resolution entitled: "WHO response to global change: Technical Discussions"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the fifth resolution entitled: "Appointment of External Auditor"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the sixth resolution entitled: "Assessment of new Members and Associate Members: assessment of Palau"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the seventh resolution entitled: "Scale of assessments for the financial period 1996-1997"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the eighth 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 ninth resolution entitled: "Real Estate Fund"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the tenth resolution entitled: "Salaries for ungraded posts and the Director-General"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the eleventh resolution entitled: "International decade of the world's indigenous people"? In the absence of any objections the resolution is adopted.

I now invite the Assembly to adopt the decisions, one after the other. Is the Assembly willing to adopt the first decision entitled: "Annual report of the United Nations Joint

Staff Pension Board for 1994"? In the absence of any objections the decision is adopted. Is the Assembly willing to adopt the second decision entitled: "Appointment of representatives of the

WHO Staff Pension Committee"? In the absence of any objections the decision is adopted and the Assembly has therefore approved the second report of Committee B.


A48/VR/12 page 221

4. THIRD REPORT OF COMMITTEE В1

TROISIEME RAPPORT DE LA COMMISSION B1

The PRESIDENT:

We shall now consider the third report of Committee В contained in document A48/54. Please disregard the word "Draft" as this report was adopted by the Committee without amendment. This report contains seven resolutions which I shall invite the Assembly to adopt one after the other.

Is the Assembly willing to adopt the first resolution entitled: "Consolidating budgetary reform"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the second resolution entitled: "Reorientation of allocations"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the third resolution entitled: "Paris AIDS Summit"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the fourth resolution entitled: "Recruitment of international staff in WHO: geographical representation"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the fifth resolution entitled: "Health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine"? In the absence of any objections the resolution is adopted.

I now call upon the delegate of Israel.

Dr LAMDAN (Israel):

Thank you, Mr President. At the beginning of this Assembly it rapidly became clear that there were two ways to go on the agenda item before us: the way of contention or the way of consensus. Contention,, stirred up in part by certain countries in the Middle East not fully reconciled to the peace process, would have taken us back to the bad old days, when this forum was highly politicized and used as an arena to make diplomatic warfare against Israel. Happily, good sense won out and it was agreed that this item should be dealt with on the basis of consensus between those parties directly concerned, as in fact was the practice last year. And indeed consensus has again been achieved, reflecting the ongoing peace process and the changes on the ground including the fact that since 1 December 1994 responsibility for health services has been transferred to the Palestinian Authority, not only in Gaza and Jericho, but in wider areas still administered by Israel.

Consensus of course means compromise, and compromise frequently means giving way on points which are not entirely to one's satisfaction. This is the case in this consensus resolution. I will not go into a； detailed analysis of the text but I do wish, Mr President, to take this opportunity of putting on record the fact that Israel is still not happy about the title of the item which continues to contain elements which are both contentious and obsolete. As Dr Fathi Arafat indicated last year, a new title should be found which would focus essentially on health assistance for the Palestinians so that all our children can live in friendship and peace. In practice the title should accurately reflect and track the language of the resolution. This has been, and remains, our position.

As to the substance of the matter the resolution does, in fact, relate to the technical assistance and health programmes which this Organization can provide for the Palestinians, and to the aid that can be given to the Palestinian Authority to enable it to run and develop its own health system. For my part, I should like to conclude by reiterating the call made by my Minister in the general debate to all countries that can assist the Palestinian Authority to help it establish a sustainable medical care system - for the sake both of the Palestinians and of peace itself.

Thank you, Mr President.

The PRESIDENT:

I thank the delegate of Israel. Your comments will be fully recorded in the verbatim record. I now recognize Palestine.

1 See reports of committees in document WHA48/1995/REC/3. 1 Voir les rapports des commissions dans le document WHA48/1995/REC/3.

A48/VR/12 page 222

Mr KHOURI (Palestine):

OjjjJi o J—» с Jji jj-b-cJi Ji j dJL^J ^P ^ Pl Ol 二 jl — — ^ J l J l û у я - j l r�JLb c^x： JUIPI c JJl jl DJ Ь-LJjI ¿^ ^J US" a^JuJl j ^ J l 4-Jl p ûî — ^ ^ I S .^-JLpL^j j^kÛ l^-i Lh ib^Jl a^yJl ÎjSil

j/^ OÍ j Jlp ioUtjl jUL 二j*^ LaJl 广UJl (J U* L- jAJ» Loi；

ií I Я^д^З丨�Jjb ^ ^ j j j¿jx； ^ JUib ÛâJ ^ Цл-¿‘广）^ CU -toL- îi Jjjji

The PRESIDENT:

I thank Palestine; your comments will be noted in full in the verbatim records. Is the Assembly willing to adopt the sixth resolution entitled: "Establishment of the joint and

cosponsored United Nations programme on HIV/AIDS (UNAIDS)"? In the absence of any objections the resolution is adopted.

Is the Assembly willing to adopt the seventh 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 and the Assembly has therefore approved the third report of Committee B.

5. THIRD REPORT OF COMMITTEE A1

TROISIEME RAPPORT DE LA COMMISSION A1

The PRESIDENT:

We shall now consider the third report of Committee A, as contained in document A48/56; please disregard the word "Draft" as this report was adopted by the Committee without amendment. This report contains the resolution entitled "Proposed appropriation resolution for the financial period 1996-1997". As the Committee adopted the resolution, we can delete the word "proposed", and the resolution should now read: "Appropriation resolution for the financial period 1996-1997". 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 third report of Committee A.

6. REVIEW AND APPROVAL OF THE REPORTS OF THE EXECUTIVE BOARD ON ITS NINETY-FOURTH AND NINETY-FIFTH SESSIONS EXAMEN ET APPROBATION DES RAPPORTS DU CONSEIL EXECUTIF SUR SES QUATRE-VINGT-QUATORZIEME ET QUATRE-VINGT-QUINZIEME SESSIONS

The PRESIDENT:

We now come to the conclusion of item 9，Review and approval of the reports of the Executive Board on its ninety-fourth and ninety-fifth sessions.

Now that the main committees have finished their consideration of the Executive Board's reports, we are in a position to formally take note of these reports. From the comments which have been made, I take it that the Assembly wishes to commend the Board on the work performed and express its appreciation of the dedication with which the Board has carried out the tasks entrusted to it.


A48/VR/10 page 223

7. SELECTION OF THE COUNTRY IN WHICH THE FORTY-NINTH WORLD HEALTH ASSEMBLY WILL BE HELD CHOIX DU PAYS OU SE TIENDRA LA QUARANTE-NEUVIEME 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 interests 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-ninth World Health Assembly will be held in Switzerland. In the absence of any objections, it is therefore so decided.

8. STATEMENT BY THE DIRECTOR-GENERAL DECLARATION DU DIRECTEUR GENERAL

The PRESIDENT:

I would now like to invite Dr Nakajima, Director-General, who has asked for the floor, to say a few words. Dr Nakajima, you have the floor.


Mr President, excellencies, honourable delegates, ladies and gentlemen, two years ago, I committed WHO to a far-reaching process of reform which, from the start, has been designed and carried out in close consultation with the governing bodies and Member States of the Organization. In the past few days, reviewing the progress made so far, the Assembly approved the concrete changes which we have introduced in our structures, procedures and methods of work. I wish to thank you all for your support and to assure you that we will continue implementing the reform process along the lines which you have endorsed within this Assembly and on the Executive Board's recommendations.

The first issue of The world health report，prepared at your request, has been particularly well received. It has been hailed as a valuable update on the world's health, helping countries and agencies to assess priority needs and focus on "bridging the gaps" in terms of health for all individuals and communities, in all countries and continents. The special event on health planned for 1998 to prepare for health beyond the year 2000 should be an historic opportunity to renew our commitment to health for all at the highest political level.

The Assembly has just approved the programme budget for 1996-1997 by consensus, including revised criteria for prioritization and shifts in allocation of resources in favour of countries. The difficult economic situation experienced by practically all countries is reflected in the decisions you have made and the constraints these imply for WHO's future action in support of health development.

The Secretariat will do its best to absorb cost increases as instructed by the Assembly. Our first concern will be to safeguard the priority areas which have been identified, and especially the programmes and cooperation activities directed to countries in greatest need and population groups that are most vulnerable. With the support and efforts of all, we hope that the implementation of our cooperation programmes at country level will not be adversely affected by the financial constraints imposed on the Organization.

I would like to thank all Member States for their understanding and cooperation, particularly on some of the difficult issues we have had to deal with, including budgetary matters.

Mr President, I wish to thank you personally for the excellent manner in which you have conducted this Forty-eighth World Health Assembly. You have greatly facilitated the work of the Assembly and helped the spirit of consensus to prevail as it should in the best interests of the Organization as a whole. I would like to extend my thanks and congratulations to the Vice-Presidents of the Assembly, the Chairmen, Vice-Chairmen and Rapporteurs of all the committees, and all the members of the General Committee, and express gratitude also for the advice which will help us in further strengthening WHO's global leadership on public health issues and international health cooperation.

A48/VR/10 page 224

Mr President, excellencies, ladies and gentlemen, I shall conclude by expressing my overriding concern that we should all rise to the challenge of bridging the gaps in health status and development for all the peoples of the world, and especially the poorest and most vulnerable. To achieve this and effectively promote the future of international health cooperation we must stand united. Together we must uphold the excellence and integrity of our Organization. I have been elected to the post of Director-General to serve the whole membership of the Organization. I believe in the World Health Organization, its mission and community of purpose. I shall continue to discharge the responsibility that has been entrusted to me, with the support and participation of all Member States and regions. I appeal to all of you to share this heavy burden of responsibility with me, in a spirit of friendship, solidarity, and mutual support between nations.

The PRESIDENT:

Thank you, Dr Nakajima. I shall now adjourn the meeting.

The meeting was adjourned at 12:10. La séance est levée à 12hl0.

A48/VR/10 page 225

THIRTEENTH PLENARY MEETING

Friday, 12 May 1995，at 12:15


TREIZIEME SEANCE PLENIERE

Vendredi 12 mai 1995，12hl5


CLOSURE OF THE SESSION CLOTURE DE LA SESSION

The PRESIDENT:

The meeting is called to order. I now have much pleasure in inviting Dr Fatma Mrisho, Chairperson of Committee A, to come to the rostrum and to address the Assembly and speak on behalf of the members of Committee A.

Dr MRISHO (United Republic of Tanzania) (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，I have pleasure in sharing with you my impressions of the discussions in Committee A. Many important issues were addressed. Time does not permit me to communicate detailed discussions, and I will therefore touch upon only the major issues. However, that does not imply that those omitted are any less important.

The first item was the third report on the monitoring of progress in implementation of strategies for health for all by the year 2000. While expressing appreciation for the report, including the proposed plan of action, a number of suggestions were made to limit and simplify the number of indicators. These proposals would be considered in the revision of the framework by the Executive Board.

The Committee then proceeded to review the programme budget for the financial period 1996-1997， including budgetary reform, and the distribution of allocation of financial resources across the Organization and among the various programmes, as proposed in the programme budget for 1996-1997. Audiovisual presentations were extremely helpful to better understand the new format and the strategic approach utilized in this, the first budget in the Organization's Ninth General Programme of Work, A number of suggestions to further improve the budget format were made; however, there was general consensus in recognizing the more user-friendly format.

It was in the fourth meeting of Committee A, Mr President, that we continued consideration of Agenda item 18.2, "General review", which was taken in conjunction with Agenda item 19，"Implementation of resolutions". Under the subsection on Emergency and humanitarian action there was general consensus that WHO had a limited, but clearly defined, area of competence, namely, that of coordinating health and health-related measures and provision of relief and rehabilitation in emergencies. Delegations emphasized the partnership approach which concerned governments, bilateral donor agencies, other agencies of the United Nations system and nongovernmental organizations to ensure complementarity of action.

The resolution on emergency and humanitarian action, EB95.R17, was adopted, with amendments, by consensus. Discussion then moved to the subsection on intensified cooperation with countries in greatest need. Delegations expressed their agreement with the approach to place major emphasis on strengthening the capacity and performance of the health sector in the poorest countries in a manner specific to the needs of the country. Resolution EB95.R8，"Intensified cooperation with countries in greatest need"，to further pursue and strengthen this programme was adopted, with some amendments, by consensus.

A48/VR/10 page 226

Mr President, I am sure that all the honourable delegates will agree with me that biomedical and health information and trends are an extremely important component of national health infrastructures. In order to orient health services to priority needs, country health information systems are vital. We need to further efforts to strengthen national capability in this field so that countries could better monitor and evaluate their own health policies and their progress towards health for all. In the discussion on the subsection dealing with organization and management of health systems based on primary health care, Committee A reaffirmed primary health care as the pillar for health system development and the need to improve the organization and management of health systems to support primary health care.

The subsection on human resources for health generated considerable interest, since health care providers are at the core of all health care systems. The Committee considered resolution EB95.R6， "Changing medical education and medical practice for health for all". The numerous amendments were indicative of the importance given by Member States to this subject. While there was great divergence of opinion, in view of the large number of amendments it was decided to call a drafting group and the resolution was later adopted by consensus.

The discussions of the Committee proceeded to section 4.1 of the programme budget, "Family/community health and population issues", under which was taken the extremely important topic of maternal and child health and family planning. Delegates reaffirmed that reproductive health is an integral part of health in the context of primary health care and family health. While emphasizing the importance of the Organization's continued technical and scientific leadership in this priority area, the Committee underlined the need for close collaboration with other relevant agencies of the United Nations system. The draft resolution contained in document A48/10, "Maternal and child health and family planning: quality of care" generated intense discussion and numerous amendments, after which it was adopted by consensus.

Next, Mr President, the Committee considered the Director-General's report on tobacco or health, together with resolution EB95.R9, "An international strategy for tobacco control". This item was seen as a major global health problem, and WHO's activities in the struggle to prevent tobacco-related diseases, while taking into account the concerns of developing countries that might be dependent on tobacco production, were commended. A series of amendments in order to strengthen the resolution were made, and it was adopted, as amended, by consensus. The Committee stressed the need for WHO to work in close collaboration with the United Nations focal point on tobacco control, situated in the United Nations Conference on Trade and Development (UNCTAD).

Under the subsection on nutrition, food security and safety, the Committee reviewed progress, including relevant action taken by WHO on the World Declaration and Plan of Action on Nutrition. The importance of normative activities, including the development of guidelines, scientific criteria and methodologies, as well as their widespread dissemination, was recognized.

With regard to the subsection on environmental health, the Committee endorsed the strategy and programmes for the promotion of environmental health, and of chemical safety, which emphasized integrated approaches dealing with health and environment problems and underscored the importance of supporting national, sustainable development.

In moving to the final section of the proposed programme budget considered by Committee A, namely section 5 on the integrated control of disease - in view of our heavy workload, Committee В was kind enough to take from us section 6 - we found ourselves somewhat pressed for time, nevertheless the discussions were full and interesting. The programmes for the control of diarrhoeal diseases and acute respiratory infections are essential to achieve goal 3 of the WHO's Ninth General Programme of Work, 1996-2001，"to ensure survival and healthy development of children", and the corresponding targets of reduction of infant mortality and mortality under five years of age. Despite progress in these control programmes, and particularly diarrhoea, these diseases remain the largest contributors to childhood mortality, followed by malaria, measles and malnutrition. There was consensus in the Committee that the goal and targets of child survival would be achieved more rapidly, and at lower cost, if all major causes of childhood illness and death are approached in an integrated way. Delegates welcomed and commended this initiative but noted that care should be taken when implementing the new approach not to disrupt progress already being made in addressing specific childhood diseases. In view of the extensive debate, there were numerous amendments to resolution EB95.R11, "Control of diarrhoeal diseases and acute respiratory infections: integrated management of the sick child", after which it was adopted by consensus.

Committee A drew attention to the importance of controlling tuberculosis, a major killer of adults in both industrialized and developing countries, and recognized the highly cost-effective control strategy which WHO has developed. The efforts of the tuberculosis programme to strengthen its collaboration with donor

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agencies, such as the World Bank, to mobilize much larger resources for global tuberculosis control efforts were endorsed.

In its discussion on tropical diseases, Committee A stressed the burden of sickness attributable to tropical diseases, mainly in the least developed countries. The control of and research and training in tropical diseases were seen as priorities, and delegates recognized the considerable progress in the prevention and control of a large number of tropical diseases.

Mr President, the Committee noted that new, emerging and re-emerging infectious diseases are an increasing threat to global public health and it was emphasized that active surveillance was needed at country level to be able to identify and suggest control measures for these diseases before they reach epidemic potential. Resolution EB95.R12, "Communicable diseases prevention and control: new, emerging and re-emerging infectious diseases", which focuses further attention and action on this important matter was widely debated and, with amendments, adopted by consensus.

Finally, in the subsection on the prevention of hearing impairment, the Committee noted with concern the growing problem of largely preventable hearing impairments in the world, presently estimated at 120 million people with hearing disability. It was recognized that hearing impairment in children is of particular importance in view of the developmental and educational implications. Furthermore, hearing difficulties in the elderly are a major cause of communication problems. Given the significant public health aspects of avoiding hearing loss, the Committee adopted resolution EB95.R7, "Prevention of hearing impairment". Under proposed programme budget subsection 5.3 on the control of noncommunicable diseases, the Committee noted with concern the increasing problem of noncommunicable diseases, both in developing as well as in industrialized countries. The need for more emphasis on affordable prevention at all stages and for the better integration of preventive and curative services was highlighted. Emphasis was given to the need to move away from a fragmented, disease-oriented approach, noting that for noncommunicable diseases, we need to advocate greater integration between programmes.

The eleventh session addressed agenda item 18.3, financial review of the programme budget. Mr Aitken, Assistant Director-General, provided delegates with an overview of the different levels of inflation and exchange rates for the dollar and how they affect the Organization's budget in each of the six WHO regions, as well as headquarters.

At this point, Mr President, members of Committee В joined us for what was, perhaps, the most important session - to debate the appropriation resolution for the financial period 1996-1997，since, with no approved funds, all our work in Committee A would come to nothing. The Committee was presented with two draft resolutions, the first with combined amendments proposed in conference papers 5 and 8 and the second, proposed by the Director-General, containing amendments proposed in conference paper 5. Discussions were vigorous; however, no agreement could be reached and a working group was convened to try and achieve a consensus. I am extremely pleased to be able to inform you, Mr President, distinguished delegates and colleagues, that we adopted by consensus the amended appropriation resolution earlier this morning - a word of sincere appreciation to all the distinguished delegates.

To conclude, Mr President, we had a heavy agenda which was made somewhat lighter because of the transfer of the item on AIDS and two resolutions to Committee B. However, more important to the efficiency and efficacy of Committee A's work was the spirit of cooperation and consensus which ensured that a number of extremely complex and difficult issues were dealt with in a manner that they deserved, that is, with a focus on technical aspects and contents.

In closing, Mr President, I wish to express my sincere appreciation to my distinguished colleagues in Committee A for their invaluable contributions and making it possible to successfully conclude our task. I wish you, Mr President, and all the distinguished delegates a safe trip home. On behalf of my country, I thank you all.

The PRESIDENT:

Thank you, Dr Mrisho. I should like to congratulate you very warmly for your excellent presentation and also for the outstanding way in which you have presided over the Committee. The next speaker will be the Chairman of Committee B，Professor Wojtczak, and I have much pleasure in inviting him to come to the rostrum and to take the floor and speak on behalf of all the members of Committee B.

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Professor WOJTCZAK (Poland) (Chairman, Committee В):

Mr President, Director-General, distinguished delegates, ladies and gentlemen, dear friends, it is a great pleasure for me to present to you an overview of the work of Committee В during this year's World Health Assembly. I shall concentrate my remarks only on the highlights of the Committee's work as the full details can be found in the report and in the resolutions.

Committee В discussed WHO's response to global change at length. The process, which began in previous years, has now picked up speed and has proved to be dynamic and inspiring. Delegates indicated their appreciation of the reported progress in the implementation of the recommendations. Also, some impatient voices were raised asking for even faster momentum. Many aspects of global change were discussed, but the one which provoked a lengthy debate was renewing the health-for-all strategy. All those who participated in the discussion felt strongly that it was important to ensure that WHO obtain high visibility and that all sectors should be involved, especially the social sector and the environment. In order to attract the attention health deserves, it should be placed high on the political agenda. The debate was very lively, especially concerning the proposed event to be used to obtain a high-level political endorsement of a health charter based on the new global health policy. A consensus was reached to arrange such a high-level multisectoral special event connected with the World Health Assembly in 1998 and in conjunction with the fiftieth anniversary of WHO.

Another highlight of the work of Committee В was the appointment of the External Auditor. The Committee considered the very professional candidatures submitted and, after discussion, came to its decision by secret ballot. The holder of the office of the Auditor-General of the Republic of South Africa was appointed External Auditor of the accounts of WHO for the financial periods 1996-1997 and 1998-1999, and I should like to extend my congratulations to him. The Committee also warmly thanked the Comptroller and Auditor-General of the United Kingdom of Great Britain and Northern Ireland for the very valuable work he has done for the Organization.

The longest debate in Committee В was on the subject of the joint and cosponsored United Nations programme on HIV/AIDS. The keen interest in this item was indicated by the fact that over 50 delegations took the floor. The resolution adopted was the product of consensus and was cosponsored by over 70 delegations.

Mr President，consensus has been the key word of our Committee. How better can this be illustrated than by the resolution on the health conditions of, and assistance to, the Arab population in the occupied Arab territories, including Palestine? For the second year in a row, exemplary mutual understanding and conciliation were displayed not only in agreeing to a title satisfactory to all, but also in adopting the substance of the resolution by consensus, with over 40 sponsors.

One of the resolutions presented to Committee В for consideration was entitled "Recruitment of international staff in WHO: Global leadership". After a politically sensitive discussion, which was most important for the future of the Organization and which attracted a lot of attention from inside and from outside the Committee and also from the media, the distinguished delegates of the two Member States who had proposed and sponsored the resolution withdrew it in the spirit of conciliation and consensus.

Financial matters are a major component of the work of Committee B, namely, the review of the financial position of the Organization, external audit matters, scale of assessments, review of the Working Capital Fund and the Real Estate Fund. Two resolutions related to the budget were approved by the Committee: one on consolidating budgetary reform, the other on reorientation of allocations. The annual report of the United Nations Joint Staff Pension Board was noted; and Dr Larivière from Canada was appointed as a member of the WHO Staff Pension Committee and Dr Tangcharoensathien of Thailand as alternate member. Collaboration within the United Nations system and with other intergovernmental organizations encompasses a number of matters of global concern, such as the International Conference on Population and Development, the World Summit for Social Development, and the Fourth World Conference on Women. In this context a resolution on the International Decade of the World's Indigenous People was adopted. The Committee also adopted a resolution on health assistance to specific countries. In conclusion, Committee В had nine meetings during which we dealt also with several topics transferred by the General Committee from Committee A.

Mr President, distinguished delegates, Director-General and staff of WHO, it has been an honour and a privilege for me to serve as the Chairman of Committee В and also it has been a very exciting venture. We were able to deliberate in a spirit of conciliation and mutual understanding subjects typical for the World Health Assembly, and many vitally important matters were settled in this way, paving the road forward for

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this Organization to continue its work in strength and unity. All the resolutions considered by the Committee were adopted by consensus. Not a single vote was held. I should like to thank all those who were involved in the process, thanks to whom these difficult questions were resolved. I would like to give special thanks to the secretariat of Committee В for their support and cooperation and to underline their devotion and efficiency which enabled the Committee to complete its agenda in good time. Finally, I would like to extend my thanks to you, Mr President, to the Vice-Presidents, and to Dr Nakajima and his staff for their cooperation and support during the work of the Committee. As I said at the end of our work in Committee B，we are soon leaving for home and therefore I would like to wish you, Sir, Dr Nakajima and his staff and all delegates, friends and their families a very good journey and good health in the coming year. Bon voyage.

The PRESIDENT:

Thank you, Professor Wojtczak. Please accept my congratulations on your comprehensive report and on conducting the work of Committee В so well.

Your excellencies, honourable ministers, ambassadors, distinguished delegates, Director-General, colleagues and friends, all of us by now must have taken a good dose of words, therefore I promise to be brief with my closing remarks.

Distinguished delegates, ladies and gentlemen, I have listened to your deliberations during the past two weeks and have noted with great attention and care the declarations made, the concerns that were expressed, the hopes and aspirations that were renewed and reiterated, and the messages that were conveyed. In brief, a diagnosis at this regularly yearly check-up of our Organization's status of health has been undertaken once more. The theme adopted for this Forty-eighth World Health Assembly was bridging the gaps. We have addressed these gaps. The gaps were identified, the gaps were defined, the gaps were examined. Do these gaps constitute a labyrinth for which we might need an Ariane to give us the thread so that we might find the paths or rather the trails to the bridges? I do not think so, because you have expressed your own concerns and manifested your own commitments and support to WHO's mission. In doing so, each one of us brought the pillars for these bridges. It gives me great pleasure to note that the most recent pillar, Palau, an island country in the Pacific, comes from the Western Pacific Region. The world health report 1995, which has just been published by WHO, identifies and describes the gaps and suggests certain ways of bridging them. The strategies for health for all, which we updated during the Forty-eighth World Health Assembly, will reinforce the structure of our bridges.

I believe the time has now come to build the bridges. We can construct these bridges if we have the tools and the equipment. We also have the appropriate resources. Let us ensure that the budget we have adopted by consensus at this Assembly for the financial period 1996-1997 will sustain us in achieving our targets during this period, particularly in fulfilling our commitment to alleviate the health conditions of the vulnerable and the marginalized. The budgetary reforms will reflect the concerns you expressed at the Assembly so that transparency and accountability are ensured. This process must be monitored and evaluated. It must be part of the total reform process being undertaken by our esteemed Organization. In this regard, we must commend our Director-General and his staff for the substantial progress made so far, and for introducing and cultivating reform as part of WHO management culture.

How then, should WHO construct these bridges? The Ninth General Programme of Work of WHO has prescribed a number of ways of doing this, and the The world health report advocates a number of activities required to build the bridges. The report, inter alia, calls for: reform of health services worldwide in order to meet the challenges forced on countries by dramatic political, economic and social changes; alleviation of poverty and social integration; and equity, solidarity and social justice in health. To this, I must add the need to build productive alliances with civil society. For the essence of WHO's mission is in allowing its constituents the possibility of shaping the framework in which their targets and their rights, responsibilities and obligations are defined in a health agenda. That mission of our Organization remains basically as valid today as it was almost fifty years ago. What needs to be emphasized is WHO's role in technical cooperation as a complement sine qua non to its normative role as the directing and coordinating authority on international health work. The health agenda must be based on equity, solidarity and social justice, and render the pursuit of our highest aspirations.

Let us make use of the many windows of opportunity which have been opened for WHO to carry out its mission. Let us not depart from this mission. Let us pursue our health agenda. We must draw a map of WHO's road towards the superhighway of integrated development, the rainbow of health for all. Henceforth, let us together compose our health agenda based on our collective commitment and solidarity in

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order to ensure, not only for our children but also for our children's children, a healthy life that is free, responsible and productive.

Whilst we are meeting here, we note with great concern that one of our Member States is going through the tragic experience of an outbreak of the Ebola virus, for which WHO has already sent a team of experts to investigate and provide technical advice to the Government. It is hoped that the rapid and effective steps will bring this outbreak to an end as soon as feasible.

Before closing, I wish first to thank the official of the Government of Switzerland and the Canton of Geneva who came to address the opening ceremony, and the representative of the Secretary-General of the United Nations and Director-General of the United Nations at Geneva for his very constructive remarks. Secondly, I wish to thank the Director-General, Dr Hiroshi Nakajima, for your leadership and guidance, and I assure you of my full personal support and cooperation in discharge of your onerous duties. Through you, I wish to thank all members of the Secretariat, especially those behind the scenes, for their assistance. They may be behind the scenes, but without their work the smooth running of this meeting would not have been possible. Last, but not least, I wish to thank all of you distinguished delegates and friends, for your constructive contributions, collaboration and tolerance, which have facilitated my task in bringing our work to a fruitful conclusion. I wish you all bon voyage and a safe journey home. God willing, some of us will see each other again next year, if not sooner.

With mixed emotions I formally declare the Forty-eighth World Health Assembly closed.

The session closed at 12:50. La session est close à 12h50.

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 WHA48/1995/REC/l.

INDEX DES NOMS DES ORATEURS

Cet index contient les noms des orateurs dont les interventions figurent dans le présent volume. On trouvera dans le document

WHA48/1995/REC/l la liste complète des délégués et autres participants à la Quarante-Huitième Assemblée mondiale de la Santé.

ABDEL FATTAH, A. (Egypt/Egypte), 122 ABDULLAH, A. (Maldives), 77 ADAMS, A. I. (Australia/Australie), 73 AMADOR, M. A. (Spain/Espagne), 68 AMORY, V. (Saint Kitts and Nevis/Saint-Kitts-

et-Nevis), 201 ANTELO PÉREZ, J. (Cuba), 35 ARAFAT, F. (Palestine), 142 ARAUJO, E. S. (Guinea-Bissau/Guinée-Bissau),

183 ARAYED, J. S. AL- (Bahrain/Bahrein), 133

В ARAN, D. (Turkey/Turquie), 94 BATAYNEH, A. AL- (Jordan/Jordanie), 79 BATUNGWANAYO, C. (Burundi), 176 BERTHELOT, Y. (representative of the

Director-General of the United Nations Office at Geneva/représentant du Directeur général de l'Office des Nations Unies à Genève), 2

BERTOCCI, I. (Dr Comían A. A. Quenum Prize for Public Health in Africa/Prix Dr Comían A. A. Quenum pour la Santé publique en Afrique), 171

BOTTOMLEY, V. (United Kingdom of Great Britain and Northern Ireland/Royaume-Uni de Grande-Bretagne et d'Irlande du Nord), 57

BUTALE, C. J. (Botswana), 86

CALLE LOMBANA, H. de la (Colombia/ Colombie), 156

CANDUCCI, S. (San Marino/Saint-Marin), 129 CESSA Y-MARENAH, C. (Gambia/Gambie), 53 CHATTY, M. E. (Syrian Arab Republic/

République arabe syrienne), 173 CHEN Minzhang (China/Chine), 36 CHRISTIE, W. (Norway/Norvège), 78 CHRISTOPHIDES, M. (Cyprus/Chypre), 181 CIKULI, M. (Albania/Albanie), 186 COSTER, С. DE (Belgium/Belgique), 119

DEGUARA, L. (Malta/Malte), 71 DENG, G. (Sudan/Soudan), 132 DIRECTOR-GENERAL/DIRECTEUR

GENERAL, 18，158，215，223 DOUSIKEEV, A. (Kazakhstan), 51 DROBYSHEVSKAYA, I. (Belarus/Bélarus), 148 DUE, Le Kinh (Sasakawa Health Prize/

Prix Sasakawa pour la Santé), 169 DY, N. R. (Cambodia/Cambodge), 189

EPALANGA, M. S. (Angola), 205 ESPINOZA, P. (Ecuador/Equateur), 195

FATIMIE, S. (Afghanistan), 111 FEKADU, T. (Eritrea/Erythrée), 207 FILIPCHE, I. (The Former Yugoslav Republic

of Macedonia/Ex-République yougoslave de Macédoine), 204

FINETTE, J. R. (Mauritius/Maurice), 147 FIO-NGAINDIRO, G. (Central African

Republic/République centrafricaine), 48

page 232

FOWZIE, A. H. M. (Sri Lanka), 92 FUENTE RAMÍREZ, J. R. de la (Mexico/

Mexique), 83

GOITIA TORRES, T. (Sasakawa Health Prize/ Prix Sasakawa pour la Santé), 168

GUIDOUM, Y. (Algeria/Algérie), 128 GUZZANTI, P. (Italy/Italie), 46

HAMADE, M. (Lebanon/Liban), 131 HASHIM, M. A. (Bangladesh), 135 HONG TIY, S. (Fiji/Fidji), 174 HUTTU, T. (Finland/Finlande), 89

IBRAHIM, Hajr Abdul Latif bin Haji (Brunei Darussalam/Brunéi Darussalam), 138

IDE, S. (Japan/Japon), 31 ISMAIL MANSOR, Dato' (Malaysia/Malaisie),

180

JAVORSKY, t . (Slovakia/Slovaquie), 118 JOO, Kyung Shik (Republic of Korea/

République de Corée), 44

KHOURI, R. (Palestine), 222 KHUDABUX, R. M. (Suriname), 192 KIIKUNI, К. (Sasakawa Health Foundation/

Fondation Sasakawa pour la Santé), 166 KIM Su Hak (Democratic People's Republic of

Korea/République populaire démocratique de Corée), 109

KÔKÉNY, M. (Hungary/Hongrie), 185 KRAMMER, C. (Austria/Autriche), 62 KUMATE, J. (representative of the Executive

Board/représentant du Conseil exécutif), 16

LAHURE, J. (Luxembourg), 42 LAMDAN, Y. (Israël/Israël), 221 LE VAN TRUYEN (Viet Nam), 97 LEE, P. R. (United States of America/Etats-Unis

d'Amérique), 30 LJUBIC, B. (Bosnia and Herzegovina/Bosnie-

Herzégovine), 99

MADUBUIKE, I. (Nigeria/Nigéria), 55 MAKUMBI, J. G. S. (Uganda/Ouganda), 155 MANGACHI, M. W. (Jacques Parisot

Foundation Fellowship/Bourse de la Fondation Jacques Parisot), 165

MANSOUR, E. (United Arab Emirates Health Foundation Prize/Prix de la Fondation des Emirats arabes unis pour la Santé), 162

MARA, G. (Solomon Islands/lies Salomon), 178 MARANDI, A. (Islamic Republic of Iran/

République islamique d'Iran), 70 MARLEAU, D. (Canada), 33 MARQUES DE LIMA, A. S. (Sao Tome and

Principe/Sao Tomé-et-Principe), 194 MASSAD, C. (Chile/Chili), 145 MAZZA, A. (Argentina/Argentine), 65 MBUMB MUSSONG, C. R. (Zaire/Zaïre), 212 MEDINA, J. (Cape Verde/Cap-Vert), 188 MEGHJI, Z. H. (United Republic of Tanzania/

République-Unie de Tanzanie), 80 MENDO, P. (Portugal), 74 MINCU, I. (Romania/Roumanie), 101 MOLIERE, J. (Haiti/Haïti), 102 MRISHO, F. H. (United Republic of Tanzania/

République-Unie de Tanzanie), Chairman of Committee A/Président de la Commission A, 225

MTAFU, N. G. A. (Malawi), 197 MUBARAK, О. M. (Iraq)，193 MUHAILIN, A.-R. S. AL- (Kuwait/Koweït), 59 MUTISO, G. M. (Kenya), 98

NAKAJIMA, H., see/voir DIRECTOR-GENERAL/DIRECTEUR GENERAL

NECAEV, E. A. (Russian Fédération/Fédération de Russie), 84

NGEDUP, S. (Bhutan/Bhoutan), 152 NOONAN, M. (IrelandArlande), 63 NOORDIN, Dato Dr Haji Johar (Brunei

Darussalam/Brunéi Darussalam), President of the Forty-eighth World Health Assembly/Président de la Quarante-Huitième Assemblée mondiale de la Santé, 11, 229

OURAIRAT, A. (Thailand/Thai'lande), 41

РАК Chang Rim (Democratic People's Republic of Korea/Républ ique populaire démocratique de Corée), 107

PALACIO, M. (Nicaragua), 104 PATARROYO, M. E. (Léon Bernard Foundation

Prize/Prix de la Fondation Léon Bernard), 159

PHILIPPS, P. (Jamaica/Jamaïque), Chairman of the Committee on Nominations/ Président de la Commission des Désignations, 8，9, 123

page 233

PIEL, A. L. (Cabinet o f the Director-General/ Cabinet du Directeur général), 7，137, 172

PILGRIM, E. (Trinidad and Tobago/Trinité-et-Tobago), 209

POLITOPOULOS, C. (Greece/Grèce), 115 PRETRICK, E. K. (Federated States o f

Micronesia/Etats fédérés de Micronésie), 199

RABBANI , R. I. (Pakistan), 125 RADITAPOLE, К . D. (Lesotho), 127 RAJPHO, V. (Lao People's Democratic

Republic/République démocratique populaire lao), Acting President of the Forty-seventh World Health Assembly/ Président par intérim de la Quarante-Septième Assemblée mondiale de la Santé), 1’ 5’ 150

ROXAS, M. G. (Philippines), 116

SALA Vaimi l i I I (Samoa), 151 SANTA M A R Í A , С. (Peru/Pérou), 202 SATA, M. С. (Zambia/Zambie), 130 SEGOND, G.-O. (representative o f the Conseil

d'Etat o f the Republic and Canton of Geneva/représentant du Conseil d'Etat de la République et Canton de Genève), 4

SEIXAS, J. C. (Brazil/Brésil), 141 SIDEBE, M. (Mali), 153 SIL VERA, С. (India/Inde)，25 SKRABALO, Z. (Croatia/Croatie), 144 SNEH, E. (Israël/Israël), 39 SOGAIR, S. M. AL - (Saudi Arabia/Arabie

Saoudite), 75 SOLARI, A. (Uruguay), 113 SPENCER, K. (New Zealand/Nouvelle-Zélande),

211 STAMPS, T. J. (Zimbabwe), 7，90 SUGHAIR, S. A L - (United Arab Emirates

Health Foundation Prize/Prix de la Fondation des Emirats arabes unis pour la Santé), 162

SUJUDI (Indonesia/Indonésie), 61 SZATMÁRI , M. (Hungary/Hongrie), 217

TEKEE, K. (Kiribati), 190 TERPSTRA, E. G. (Netherlands/Pays-Bas), 45 THALÉN, I. (Sweden/Suède), 29 T H A N N Y U N T (Myanmar), 56 THANI , H. Bin Suhaim A L - (Qatar), 209 THOMPSON, H. E. (Barbados/Barbade), 179 T U L A D H A R , P. R. (Népal/Népal), 95 TYPOLT, O. (Czech Republic/République

tchèque), 50

UEDA, M. M. (Palau/Palaos), 203

VASSALLO, A. (Malta/Malte), 172’ 214 VEIL, S. (France), 27 V I T K O V A , M. (Bulgaria/Bulgarie), 87 VOIGTLÀNDER, H. (Germany/Allemagne), 82 VOLJC, B. (Slovenia/Slovénie), 110

WOJTCZAK, A. (Poland/Pologne), Chairman of Committee B/Président de la Commission B, 228

YACOUB, I. M . (Dr A. T. Shousha Foundation Prize/Prix de la Fondation Dr A . T. Shousha), 164

Y U M J A V , S. (Mongolia/Mongolie), 108

Z ILHAO, A. A. (Mozambique), 139 ZOCHOWSKI, R. J. (Poland/Pologne), 65 Z U M A , N. D. (South Africa/Afrique du Sud), 24

page 235

INDEX OF COUNTRIES AND ORGANIZATIONS

This index lists the countries, organizations and bodies represented by the speakers whose names appear in the index

on the preceding pages.

AFGHANISTAN, 111 A L B A N I A , 186 ALGERIA, 128 A N G O L A , 205 ARGENTINA, 65 A U S T R A L I A , 73 AUSTRIA, 62

ECUADOR, 195 EGYPT, 122 ERITREA, 207

FIJI, 174 F I N L A N D , 89 FRANCE, 27

B A H R A I N , 133 BANGLADESH, 135 BARBADOS, 179 BELARUS, 148 BELGIUM, 119 B H U T A N , 152 BOSNIA A N D HERZEGOVINA, 99 BOTSWANA, 86 BRAZIL , 141 BRUNEI D A R U S S A L A M , 11，138，229 B U L G A R I A , 87 BURUNDI , 176

C A M B O D I A , 189 C A N A D A , 33 CAPE VERDE, 188 CENTRAL A F R I C A N REPUBLIC, 48 CHILE, 145 CHINA, 36 COLOMBIA , 156 CONSEIL D ' E T A T OF THE REPUBLIC A N D

C A N T O N OF GENEVA, 4 CROATIA, 144 CUBA, 35 CYPRUS, 181 CZECH REPUBLIC, 50

DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, 107，109

G A M B I A , 53 G E R M A N Y , 82 GREECE, 115 GUINEA-BISSAU, 183

HA IT I , 102 H U N G A R Y , 185, 217

I N D I A , 25 INDONESIA, 61 I R A N ( ISLAMIC REPUBLIC OF), 70 IRAQ, 193 IRELAND, 63 ISRAEL, 39’ 221 I T A L Y , 46

J A M A I C A , 8，9，123 JAPAN, 31 JORDAN, 79

K A Z A K H S T A N , 51 K E N Y A , 98 K I R I B A T I , 190 K U W A I T , 59

L A O PEOPLE'S DEMOCRATIC REPUBLIC, 1’ 5，150

L E B A N O N , 131

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LESOTHO, 127 L U X E M B O U R G , 42

M A L A W I , 197 M A L A Y S I A , 180 M A L D I V E S , 77 M A L I , 153 M A L T A , 71’ 172，214 M A U R I T I U S , 147 M E X I C O , 83 M I C R O N E S I A (FEDERATED STATES OF),

199 M O N G O L I A , 108 M O Z A M B I Q U E , 139 M Y A N M A R , 56

N E P A L , 95 N E T H E R L A N D S , 45 N E W Z E A L A N D , 211 N I C A R A G U A , 104 N I G E R I A , 55 N O R W A Y , 78

P A K I S T A N , 125 P A L A U , 203 PALESTINE, 142, 222 PERU, 202 PHILIPPINES, 116 P O L A N D , 65’ 228 P O R T U G A L , 74

Q A T A R , 209

SAINT KITTS A N D NEVIS, 201 S A M O A , 151 S A N M A R I N O , 129 SAO T O M E A N D PRINCIPE, 194 S A U D I A R A B I A , 75 S L O V A K I A , 118 SLOVENIA , 110 S O L O M O N ISLANDS, 178 SOUTH AFRICA, 24 SPAIN, 68 SRI L A N K A , 92 SUDAN, 132 SURINAME, 192 SWEDEN, 29 S Y R I A N A R A B REPUBLIC, 173

T H A I L A N D , 41 T H E FORMER Y U G O S L A V REPUBLIC OF

M A C E D O N I A , 204 T R I N I D A D A N D TOBAGO, 209 T U R K E Y , 94

U G A N D A , 155 UNITED K I N G D O M OF GREAT B R I T A I N

A N D N O R T H E R N I R E L A N D , 57 U N I T E D N A T I O N S OFFICE A T G E N E V A , 2 U N I T E D REPUBLIC OF T A N Z A N I A , 80, 225 U N I T E D STATES OF A M E R I C A , 30 U R U G U A Y , 113

V I E T N A M , 97

REPUBL IC OF K O R E A , 44 R O M A N I A , 101 R U S S I A N F E D E R A T I O N , 84

ZAIRE, 212 Z A M B I A , 130 Z I M B A B W E , 7, 90

page 237

INDEX DES PAYS ET ORGANISATIONS

Cet index contient les noms des pays, organisations et organismes divers représentés par les orateurs dont les noms

figurent dans l ' index précédent.

A F G H A N I S T A N , 111 AFRIQUE D U SUD, 24 A L B A N I E , 186 ALGERIE, 126 A L L E M A G N E , 82 A N G O L A , 205 A R A B I E SAOUDITE, 75 ARGENTINE, 65 AUSTRALIE , 73 AUTRICHE, 62

BAHREIN, 133 BANGLADESH, 135 BARBADE, 179 BELARUS, 148 BELGIQUE, 119 BHOUTAN, 152 BOSNIE-HERZEGOVINE, 99 BOTSWANA, 86 BRESIL, 141 BRUNEI D A R U S S A L A M , 11，138’ 229 BULGARIE, 87 BURUNDI , 176

CAMBODGE, 189 C A N A D A , 33 CAP-VERT, 188 CHILI , 145 CHINE, 36 CHYPRE, 181 COLOMBIE, 156 CONSEIL D ' E T A T DE L A REPUBLIQUE ET

C A N T O N D E GENEVE, 4 CROATIE, 144 CUBA, 35

EGYPTE, 122 EQUATEUR, 195 ERYTHREE, 207

ESPAGNE, 68 ETATS-UNIS D ' A M E R I Q U E , 30 EX-REPUBLIQUE Y O U G O S L A V E DE

M A C E D O I N E , 204

FEDERAT ION DE RUSSIE, 84 FIDJI, 174 F I N L A N D E , 89 FRANCE, 27

G A M B I E , 53 GRECE, 115 GUINEE-BISSAU, 183

H A I T I , 102 HONGRIE, 185, 217

ILES S A L O M O N , 178 INDE, 25 INDONESIE, 61 IRAQ, 193 I R A N (REPUBLIQUE I S L A M I Q U E D ’ ) ’ 70 I R L A N D E , 63 ISRAEL, 39, 221 ITAL IE , 46

J A M A Ï Q U E , 8’ 9’ 123 JAPON, 31 JORDANIE, 79

K A Z A K H S T A N , 51 K E N Y A , 98 K I R I B A T I , 190 KOWEIT , 59

page 238

L E S O T H O , 127 L I B A N , 130 L U X E M B O U R G , 42

M A L A I S I E , 180 M A L A W I , 197 M A L D I V E S , 77 M A L I , 153 M A L T E , 71’ 172，214 M A U R I C E , 147 M E X I Q U E , 83 M I C R O N E S I E (ETATS FEDERES DE), 199 M O N G O L I E , 108 M O Z A M B I Q U E , 139 M Y A N M A R , 56

N E P A L , 95 N I C A R A G U A , 104 N I G E R I A , 55 N O R V E G E , 78 N O U V E L L E - Z E L A N D E , 211

OFF ICE DES N A T I O N S UNIES A GENEVE, 2 O U G A N D A , 155

P A K I S T A N , 125 P A L A O S , 203 P A L E S T I N E , 142，222 P A Y S - B A S , 45 PEROU, 202 PHIL IPPINES, 116 P O L O G N E , 65，228 P O R T U G A L , 74

Q A T A R , 209

REPUBLIQUE A R A B E SYRIENNE, 173 REPUBLIQUE CENTRAFRICAINE, 48 REPUBLIQUE DE COREE, 44 REPUBLIQUE D E M O C R A T I Q U E

POPULAIRE L A O , 1’ 5’ 150 REPUBLIQUE POPULAIRE

D E M O C R A T I Q U E D E COREE, 107，109 REPUBLIQUE TCHEQUE, 50 REPUBLIQUE-UNIE DE T A N Z A N I E , 80’ 225 R O U M A N I E , 101 R O Y A U M E - U N I D E GRANDE-BRETAGNE

ET D ' I R L A N D E D U NORD, 57

SAINT-KITTS-ET-NEVIS, 201 SA INT-MARIN , 129 S A M O A , 151 SAO TOME-ET-PRINCIPE, 194 SLOVAQUIE, 118 SLOVENIE, 110 SOUDAN, 132 SRI L A N K A , 92 SUEDE, 29 SURINAME, 192

T H A Ï L A N D E , 41 TRINITE-ET-TOBAGO, 209 TURQUIE, 94

U R U G U A Y , 113

V I E T N A M , 97

ZAIRE, 212 Z A M B I E , 130 Z I M B A B W E , 7，90

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