Regional Director’s address at the International Conference on the fifteenth anniversary of Turkmenistan’s National Health Programme

Speech by Ms Zsuzsanna Jakab, WHO Regional Director for Europe

20 July 2010

Ashgabat, Turkmenistan

Dear colleagues in public health, distinguished delegates, ladies and gentlemen,

It is an honour for me to be in Ashgabat at the opening of this Conference. I know that this is a remarkable event for Turkmenistan – a milestone – focusing attention on major health developments, taking stock of achievements and challenges, and fostering the country’s health agenda for the future.

This year the Conference celebrates the fifteenth anniversary of the National Health Programme of Turkmenistan. Over the last 15 years, the health landscape in your country, in central Asia and in the WHO European Region as a whole has dramatically changed.

Speaking of the Region, I would like to outline what I believe are our greatest public health opportunities and challenges, and focus your attention on some of them.

In the last decade, I think we have reached an exciting and challenging stage with the growing insight that efforts to improve public health require multisectoral approaches. This has opened new opportunities, but has also made our work more complex.
Our understanding of the importance of social health determinants has increased and the need to address them is rising on the development agenda, and the implementation of the Millennium Development Goals is urgent.
Rising rates of communicable diseases, particularly multidrug-resistant tuberculosis, HIV/AIDS and vaccine-preventable diseases, pose an ever-present threat. This highlights the need for every country to remain vigilant by strengthening surveillance and control systems.
Chronic diseases – heart disease, stroke, cancer, diabetes, mental illness and others – place a growing burden on development and absorb substantial amounts of health resources.
Health emergencies are now among the top concerns for public health decision-makers in every country in the Region. The International Health Regulations are an excellent tool that helps us to enhance health security and protect people from acute public health risks that have the potential to cross borders. We have seen them in action during the recent poliomyelitis (polio) outbreak in central Asia.

Let us look more broadly and closely at these challenges – they are shared by countries across the Region, including Turkmenistan, and will shape our future priorities.

Health determinants will receive a sharper focus in the WHO European Region. I was asked specifically by Member States to put more emphasis on these, and shortly after taking office, I set out to improve the way the WHO Regional Office for Europe works in this area. It makes sense to do so, as the deadline set for the Millennium Development Goals is getting closer. We want to put more emphasis on our strong programmes, such as those on HIV/AIDS, tuberculosis and multidrug-resistant tuberculosis, malaria, immunization, maternal and child health, Making Pregnancy Safer and improving gender equality.

We all know that tackling the social determinants of health is a must if we aim at reducing health inequities. The health divide in the European Region and the growing inequities in health both within and between countries in the Region, in conjunction with the changing demographic and social landscape in Europe, are of greatest concern. We have discrepancies between east and west, and discrepancies nearly everywhere between the rural poor, the urban poor and the residents of wealthy urban suburbs.

People in lower socioeconomic groups have at least twice the risk of serious illness and premature death as those in higher socioeconomic groups. When improvements do occur, the benefits are unevenly distributed, with those in higher socioeconomic groups often responding better to and benefiting more from health interventions.

Mortality in children under 5 years of age in the country with the highest rate is 40 times that in the country with the lowest rate. A child born in the Commonwealth of Independent States is three times as likely to die before the age of 5 as a child born in the European Union. The Millennium Development Goal for the under-5 mortality rate for Europe and central Asia is 15 deaths per 1000 live births by 2015. A lot of effort needs to be invested to reach this Goal.

Maternal mortality in central Asian countries remains at least double the Region’s average.

Countries in the eastern part of the WHO European Region have some of the world’s highest rates of multidrug-resistant tuberculosis (MDR-TB). These countries are also seeing an even more alarming trend: the emergence of extensively drug-resistant tuberculosis, or XDR-TB. This form is virtually impossible to treat, with mortality rates approaching 98%.

HIV/AIDS remains a major public health challenge for the whole of the Region. The latest data show the diversity of the HIV epidemics, and that prevention should be targeted in different ways across countries. Nonetheless, one challenge faced by all countries is that many of the people living with HIV are unaware that they are infected. Reducing the barriers to HIV testing and counselling is one of our key priorities. We hope that Turkmenistan will support us in this.

There is one very important subject I would like to mention here: the WHO European Region is currently experiencing the first importation of wild poliovirus into the Region since it was certified as polio free in 2002. Since the spring, events have unfolded very rapidly.

Your neighbour – Tajikistan –reported a sharp increase of acute flaccid paralysis cases in early April of this year. Laboratory tests have confirmed the presence of wild poliovirus type 1 on 23 April. Genetic sequencing revealed that the poliovirus was most closely related to a virus from Uttar Pradesh, India.
WHO immediately offered its assistance to help Tajikistan and neighbouring countries in their response. We have deployed teams of experts on the ground to investigate the outbreak. Polio vaccines have been supplied, with the help of international partners, to all countries in need. WHO provides advice and assistance to governments in conducting national polio vaccination campaigns. So far, four rounds of national immunization campaigns using monovalent polio vaccine reached very high coverage in Tajikistan and similar national and subnational immunization campaigns have been conducted in neighbouring countries, including Turkmenistan.
Today, the risk of polio importation remains high and, and together with governments, we work hard to stop the transmission of the virus.

I want to stress that this outbreak has once more proved the importance of strong routine immunization and systematic surveillance. It has also proved the significance of timely and rigorous application of the International Health Regulations, which has allowed us to respond quickly and adequately to the risk of polio’s spreading.

Let me turn now to another aspect of health determinants, which have a broader meaning for us. We must also address the rise of chronic diseases. These diseases now impose the greatest share of the disease burden on all countries. Many chronic diseases require lifelong care, vastly increasing the burden on the health sector. These diseases also increase costs for families, health sectors and governments.

The health sector pays a very heavy price for chronic diseases. This observation is fully supported by the evidence. Cardiovascular diseases and cancer are the top killer diseases in the Region, causing more than half of all deaths. In Turkmenistan, a decade ago, cardiovascular diseases were the main group of causes of death, responsible for 63% of overall mortality. This trend continues.

The leading risk factors for chronic conditions are more or less the same for every part and country of Europe. Almost 60% of the disease burden in Europe is accounted for by seven leading risk factors, as measured by disability-adjusted life-years (DALYs): high blood pressure and tobacco, above 12%; alcohol, 10%; high blood cholesterol, up to 9%; overweight, 8%; low fruit and vegetable intake, over 4%; and physical inactivity, more than 3%. In Turkmenistan, the situation is similar. According to the latest reports, alcohol and tobacco use place the greatest burdens of disease on Turkmen men, and obesity and high blood pressure, on women.

But these problems are not insurmountable.

We in public health should be more committed to accelerating initiatives for safer pregnancy, integrated management of childhood illness and immunization. We should enhance our efforts to reach the target of universal access to HIV treatment, prevention and care. We should increase the momentum to eradicate malaria, and to control TB and MDR-TB. We have decided to build a special project on MDR-TB and we are now developing a regional action plan to combat MDR- and XDR-TB. Central Asian countries will have a central role to play in this project. We should scale up efforts to control tobacco, including full implementation of the Framework Convention on Tobacco Control. We should accelerate action to implement initiatives on the health of women and children, reproductive health, violence and injuries, and the growing burden that chronic diseases place on development.

At the WHO Regional Office for Europe, we would like to place more emphasis on prevention. It is crucial to seek greater efficiency by making preventive services as important as curative care, particularly in times of financial crisis.

The reason for promoting prevention is simple. It works. We have the evidence. For example, in the reduction of coronary heart disease mortality, the greatest benefits appear to have come from reductions in mean cholesterol concentrations, smoking prevalence and blood pressure levels. If major risk factors were eliminated, it is estimated that 80% of heart disease, stroke and type 2 diabetes, and 40% of cancer, could be avoided.

In many cases, prevention depends on decisions and actions in sectors beyond the direct control of health. It depends on tax and trade policies, government regulation of prices and packages, bans on advertising, bans on smoking in public places, etc. Such interventions require multisectoral approaches. Therefore we need to promote a real paradigm shift in the way we think about disease prevention, health promotion and intersectoral collaboration.

I have heard about the importance of prevention during my visits to and meetings with Member States, including Turkmenistan. Many countries are seeking WHO’s support in this area. Many want to make prevention a cornerstone of their public health systems, and we will help them, while at the same time continuing to strengthen health systems.
Some of the issues I have mentioned are reflected in the health landscape in your country. I am sure that this distinguished audience is very familiar with these challenges and opportunities at the national level. And I sincerely hope that you will address them while shaping the country’s future health agenda.

Speaking about the future, we are already assisting our Turkmen colleagues with the development of the country’s new national health strategy – a road-map, a strategic plan that will help to develop specific, ambitious, yet achievable and country-specific health targets.

One of the goals of my visit to Ashgabat is to assure the Government of WHO’s support in developing this critical tool. The political will of the Turkmen Government to develop the health strategy is very encouraging. We are glad that the Turkmen health authorities have already mapped out the road towards developing this document. We anticipate that, in this process, we will need to consult much more closely and involve the best expertise we have.

Developing a striving yet feasible national health strategy is an ambitious task. And one must have solid evidence to make sure the objectives set for this work can be reached. It is critical to get the evidence right. We need evidence to support countries as they establish their own priorities and select the best strategies for reaching them. We and our partners in Turkmenistan will focus more of our attention on this. A set of WHO tools can help in this task, and we can put them all at your disposal, first and foremost to get a good baseline analysis. The practice is that, in the process of development of national health strategies, under the leadership of the government, a multipartner mechanism is often established in order to allow all stakeholders to systematically and regularly provide input into all phases of the strategic plan development. Usually, stakeholders include the state planning organization, the ministry of finance, but also players outside the government, representatives of civil society and international partner organizations. We hope that this practice can be applied in Turkmenistan as well.

Since Turkmenistan joined WHO in 1992, WHO has worked in close collaboration with the Turkmen Government to establish and implement a wide array of collaborative programmes, including those for disease prevention, control and eradication; healthy environments and lifestyles; and family health.

We are very pleased with some successes: Turkmenistan is on its way to being certified as a malaria-free country. The latest reports show good coverage with the DOTS strategy for TB, and Turkmenistan has reported very high immunization coverage and responded to the threat of polio importation from neighbouring Tajikistan. Advertising of alcoholic beverages and tobacco products in the media has been banned and healthy living has been made a compulsory subject at school.

At the same time, we know where the immediate challenges lie and where more needs to be done. WHO and the Turkmen Government have signed a bilateral agreement, outlining the following top-priority areas for our cooperation in 2010–2011.

We agreed to work together on finding the best ways to strengthen the Turkmen health system. More work needs to be done in aligning this system to the requirements of the International Health Regulations on national surveillance and response.

We are also looking at mobilizing efforts for effective implementation of interventions for maternal, newborn and child health.
Further, we will look into strengthening the surveillance and control of major communicable diseases, including HIV/AIDS, TB and MDR-TB, malaria and vaccine-preventable diseases. The work to strengthen the national HIV surveillance system and health information systems to provide adequate response to HIV/AIDS is very important.
Greater emphasis will be given to preventing and reducing disease, disability and premature death from chronic and lifestyle-related illnesses such as cancer, heart diseases and stroke, along with more effort for tobacco control, and violence and injury prevention.
Together we will explore ways of mobilizing investments to upgrade infrastructure and equipment, to ensure an adequate supply of medicines and other supplies, and to ensure the correct skill mix in the health workforce.
The fact that the Government has placed democratization and the rule of law very high on its agenda is prompting us to stress the need to develop and enhance accountability mechanisms at all levels in public health, with participation of all interested stakeholders, including patients, people living with HIV/AIDS and/or TB, and others. We also would like to help the Turkmen Government strengthen national public health monitoring system with proper, technically sound, gender-sensitive and human-rights-based indicators.

Here I wish to stress the importance of efficient partnerships. To do what we have planned to do together, we will need to bring in more international support in terms of resources. WHO is happy to be able to assist in engaging with international health partners to bring in programme funding.

Finally, as we look to the work we have to do together in the future, I want to assure you that WHO stands ready. Let’s focus on what really matters: synergy, action and results. We know what to do. And we know that we need to do it together, as this is the best way to strengthen public health and reach our common goal of better health for our populations.

Thank you very much for your attention.