Professor Monnekosso
Regional Director
WHO (AFRO)
c/o WHO Assembly,
Geneva
May 1994
Your Excellency
Re: AFRO'S
TOWARDS HEALTH FOR ALL REPORT: A CONFIDENTIAL ASSESSMENT.
On behalf of the
Zambian delegation to the 47th World Health Assembly I wish to officially
acknowledge receipt of your report on your Office's work over the past ten
years presented to Afro Region delegates during a briefing session on 3rd of
May, 1994 at the Palais des Nations
Salle VII.
I wish first, to
express my delegation's appreciation of the verbal presentation in which you
personally highlighted, in impressive graphics, the tremendous amount of work
being undertaken by AFRO under your leadership. May I in the same breath
register, as I did verbally during my
intervention on your presentation, my
disappointment at the time allocated to a discussion by AFRO Ministers on this very important matter.
While conceding that Afro Health Ministers will hopefully be given ample time
to study this report during region-specific meetings, it is nonetheless disturbing, that an opportunity offered by
your office to Ministers during the World Health Assembly was scheduled in such
a way that ample time was only available to receive the presentation and not to
fully react to its substance there and then.
As you personally
acknowledged in response to my very brief remarks (constrained as I was by the time allocated), a decision to present
such an important document to AFRO Ministers who were delegates to the World Health
Assembly required that your office secured
adequate time during the session for sincere and informed discussion. Of
course, I am assuming that your primary intention of scheduling that session
was consistent with your current role as Regional Director and hence
your mandate to inform Regional delegates on your Office's activities! My fear
is that starved of time as the session was, we as Afro Ministers and delegates
were merely treated as recipients of a product we were not allowed to
critically and constructively engage you sir, in a healthy dialogue, on our
concerns regarding the key elements of your Office's activities.
I would be
insincere to your Excellency, if I did not state, on behalf of my Zambian
delegation as a whole, that the substance (saying nothing about the format) of
the presentation raised more questions than it answered. Even more confusing
for anyone who understood your presentation were your verbal responses to
questions posed by delegates during that session (which I had opportunity to
electronically record and attempt to appreciate after the session...a practice
I find better than writing notes). Specifically, I refer to your response to my
interventions. Please recall that in
unison with remarks by previous speakers from Swaziland and Kenya who expressed
concern on inter-agency collaboration on health programmes, particularly
contradictory instructions from AFRO on initiatives by other developmental
agencies, I wanted to know at least three things:
1. What has been
the specific role of AFRO in influencing the process of consensus-building in
the case of the UN-joint programme on AIDS? I elaborated by specifying Zambia's
role in this during the 11-14th March meeting of UN programme Directors in
Lusaka, and I expressed concern that AFRO's role could have been significantly
represented at such a meeting given the priority nature of the problem of AIDS
in Africa and the potential impact the Joint program may have on existing
programmes in the region.
YOUR SUBSTANTIVE
RESPONSE
As I said there is
a problem in joint programmes. Each one wants to protect his territory, this or
that mandate. I agree there is more to be done on this...you and me can discuss
this in detail sometime...
MY FOLLOW-UP
REMARKS
It is precisely
because of the knowledge that there are problems in inter-agency collaboration that more proactive leadership
is necessary...leadership who will help build consensus where none exists.
Leaders who will act beyond agency turf-politics and provide a vision of the
common purpose. That is why the Lusaka meeting was called. It was an
opportunity to reconcile differences. Inter-agency networks which act beyond
the unproductive restrictions of their
'mandates' are needed in an African regional health strategy. They will
not emerge by accident, they must be deliberately constructed. That requires a
shift in leadership styles among those whose responsibility it is to act in the
service of health development in the region. It is the only way partnership for
health in Afro can be enhanced.
2. The Dakar
Declaration by African Heads of State represented in my judgement, one of the
most significant events on the AIDS calendar in Africa. For once, Heads of
State were unanimous on an Agenda for Action on AIDS. As a person who ( with the
OAU, ADB and GPA) has had to work on
that agenda following the declaration , to give it more concrete operational
meaning, I wanted to know why AFRO has not taken further initiatives to
actualise the implementation of that Declaration. I cited the Government of
Tunisia which, with the direct support of GPA (Geneva) has gone further in
elaborating on specific issues such as AIDS and the African Child which I had
the opportunity to contribute to among other fellow Ministers?
YOUR RESPONSE
On the Dakar Declaration,
this is why I say that some Declarations are not worth the attention of African
Heads of State. Often, there are products of people outside the health field,
like Foreign Ministers...leaving out those in charge of the health
field...Heads of State are dragged into making declarations on this and
that.... This is one issue delegates may wish to discuss in detail sometime as
we have run short of time....
MY FOLLOW-UP
QUESTION
If this is the
official status on the Dakar Declaration on the Agenda for Action on AIDS in
Africa my questions now are: (a) how come during its discussion in May 1992 in
Geneva by African Health Ministers, you personally talked about your
involvement in that initiative? (b) Why does it appear in your report presented
to Afro delegates to the 47th World Health Assembly briefing as part of your
Office's contributions in 1992 to 'Shaping African Health Policies'? (c) Is it accurate that health experts or
sectors were not involved when the initiative was lively debated in Geneva in
May 1992, and further, the then Health Minister of Nigeria Professor
Ransome-Kuti and a select number of Health Ministers were in fact the political
engineers of the initiative?
(c) Specifically,
what makes that Declaration and follow-up operational strategies not worth the
attention of either African Heads of State or your Office for follow-up? If future declarations won't suffer the same
fate, this is an important question.
3. The Third point
I raised is the question of resources. The world is facing dwindling resources.
The 'Health Package' concept that appears in your District strategy, and as you
stated in your earlier remarks, is derived from the World Bank Initiative, is
not a cheap one. I must state that I have also contributed conceptually through
my reform work in Zambia and critically in my participation on the
Bank-sponsored Expert panel on Better Health Reforms for Africa. For those of
us who are working with this concept on the ground will admit that it calls for
considerable resource mobilization for capacity-building and package
implementation at the District level. What substantive initiatives or rather
what capacity exists at AFRO for aiding member countries in resource
mobilisation in support of this initiative?
NO DIRECT RESPONSE
MY OUTSTANDING
CONCERN
1.
As the package
concept is central to the Regional Director's current strategy as discussed
recently in Yaounde by various country representatives of AFRO and WRs in the
AFRO region (a meeting I had some opportunity to witness); and noting your
earlier remark to a similar concern on 'Better Health package' as a World Bank
Initiative to which you have rendered conceptual clarity, I have the following
remarks on the compatibility problem in the AFRO strategies. First, I wish to
remind your Excellency that during the Paris meeting of the Bank-sponsored
panel, your representative Dr. Elias Lambo ( who came as an observer),
expressed and I shared in his concern during the debate, that the Bank concept
of 'package' was designed in some substantive respects using the device of
“cost-effective catchment population”, to reduce the number of layers or levels of health
interventions. This would in turn, eliminate certain interventions at the community or health
centre level. This measure, when applied to maternal issues, could prove
retrogressive as referrals from health centres to the District hospitals let
alone from the community to the health centre in the region are real
constraints. The point is, what degree of flexibility exists in such packaging
technology ? What is the cost assessment of packages? How can packaging reflect not only the cost
factors but the epidemiological peculiarities of each country, regions within
countries or indeed special vulnerable populations within each region of a
country? In other words , what is the Regional Strategy for Better Health in
Afro?
2.
Your Excellency ,
I have many more questions specific to your report but I would be unfair to register them publicly if I have
not given you prior opportunity to reflect on them as I did in the case of the
above. I wish to remind you of my
closing remarks during my intervention that my questions or comments were
directed at three main issues pertinent to the work of Afro: What leadership
must be provided at this level as we enter the threshold of the twenty-first
century bearing in mind Africa's poor
prognosis on major health and economic indicators ? What systems of
accountability must be institutionalised at AFRO to afford confidence building
among member countries and other interested partners in initiatives taken by
AFRO such as the Africa Health Fund which you and me had opportunity to briefly
discuss in Yaounde? And lastly, what capacity exists at AFRO region Office now
to construct sustainable partnership for 'Better Health' in the Region today?
My sincere hope, your Excellency, is that you will
afford member countries more opportunity
to provide you with feedback on your efforts in less contested times and
circumstances than you afforded us during the session in question. I am ready
and able to engage you in a systematic dialogue on Health Strategy based both
on the conceptual and practical experiences of a member country such as Zambia
where we are seriously reconstructing our health field in the interest of our
future generations. I wish to state on behalf of my delegation, that our
interests is to see greater capacity at Afro that will bring out the best out
of a cadre of staff that Africa can boast about. My belief in the potential that exists at
Afro is derived from a comparative assessment of similar resources in other
regions of WHO that I have opportunity to interact with. They is no doubt in my
mind that our experts at Afro and within member countries across various health
sector disciplines, can excel and compete in their quality of products with any
other from the rest of the world if a will exists to bring this potential out
by those in positions such as you hold.
Your Excellency, I wish once more, to thank you
sincerely for the time you took to brief us and hope that my delegation's
reactions are consistent with the intentions that underpinned your presentation
to delegates on the performance of AFRO.
Yours sincerely
Dr Katele Kalumba, MP
Zambian Delegation to the 47th World Health Assembly
Deputy Minister of
Health,
Government of the Republic of Zambia.
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