Opening address by the Regional Director

Regional Committee for Europe, Sixty-third session
Çeşme Izmir (Turquie), 16-19 septembre 2013

Mr President, your excellencies, ministers, delegates, partners, ladies and gentlemen,

It is with the greatest pleasure that I welcome you to the sixty-third session of the Regional Committee for Europe. It is a real honour and a privilege to be addressing you at a Regional Committee for the fourth time and I will present the major achievements and progress the last year has brought.

Before I continue, I would like to take a moment to thank each and every one of you. I am grateful for the spirit of cooperation in which we have worked together. There have been many changes for better health in our European Region in the last three years. It takes courage to change, and for that I applaud you.

In 2010, I proposed a five-year plan to improve health and to reduce inequalities in the European Region. Thanks to your support, the Regional Committee adopted it in 2010. We agreed to follow a roadmap with specific milestones, to enable the WHO Regional Office for Europe to respond to the changing environment and to further strengthen it as an evidence-based centre of health policy and public health excellence, which could better support the Region’s diverse Member States.

During the past three years, we have worked together to define our policy directions and to develop and agree on a number of important strategies and action plans. Most importantly, you, the Regional Committee, endorsed Health 2020 as a policy framework for health and well-being. This was very timely also due to WHO reforms. As I promised, now our focus is on implementation and action, as a joint undertaking with Member States and partners to make a difference in health.

Three years after you endorsed my proposed plan, I am honoured to report that work is either completed or very well advanced in all areas. Where it is not yet completed, it is because we are awaiting the final outcome of the reform process.

Today, I will particularly focus on selected priority areas, providing you an overview of impact and early results.

Health 2020 is a European regional initiative, yet it is also closely aligned with the continuing WHO reform, and it was needed in the light of the global and regional challenges we all need to address in an integrated way.

It shows how action on the whole spectrum of health determinants leads to wider benefits for society, including social, community and economic benefits.

To recall, Health 2020 has two strategic objectives and four priority areas, which structure my presentation.

Since Health 2020 was adopted in Malta, it has been an exciting year of progress and developments. We have directed our energy and corporate efforts towards making it a reality. This has been a systematic exercise focused on spreading awareness across the Region on various national and international platforms, and we have launched Health 2020 and its evidence-based studies at various high-profile events.

I am delighted that the two published documents are now available in all official languages to this Regional Committee. Further, we completed and expanded the core studies. I thank Professor Sir Michael Marmot, who so ably led the European review on the social determinants of health and health divide to its successful completion. We will launch the final report during this Regional Committee, and it will be the topic of discussion during the ministerial lunch today. We have also published a companion volume, on governance for health in the 21st century, a study led by Professor Ilona Kickbusch, which provides practical guidance and a wide range of participatory governance examples from across our Region and beyond. We plan to launch the joint WHO/Organisation for Economic Co-operation and Development (OECD) study on the economic case for public health action later in the year.

Already many countries across the Region have embarked on initiatives to develop national health policies in line with Health 2020. I am confident it will continue to be implemented according to your circumstances and needs, and will make a difference. We have supported you in adapting Health 2020 approaches, and I want to assure you that we will continue to give our fullest support in the future.

We are developing a package of tools and resources to assist Member States, as well as web-based information tools. It comprises nine interconnected components, which you will hear more about tomorrow.

We in the Regional Office applied the Health 2020 lens to all aspects of our work, integrating its strategic priorities in the operational planning process for 2014–2015. Meanwhile, we also strengthened our capacity to support the implementation of Health 2020, and I established the Division of Policy and Governance for Health and Well-being, which includes also the WHO European Office for Investment for Health and Development in Venice. Italy.

Given that so many factors affect health and that health affects so many areas of human life, progress can only come from whole-of-society and whole-of-government efforts. This is why everyone has a role to play in implementing Health 2020, from prime ministers to civil-society organizations and citizens. As indicated in the report on the social determinants of health, shortfalls in health result from society’s social, economic, environmental and cultural situation and require a life-course approach.

As for our work on the social determinants of health, I would like to acknowledge the excellent work carried out by our WHO European Office for Investment for Health and Development, and thank the Government of Italy for supporting it.

In 2012, you agreed on six overarching targets and asked us to develop a monitoring system for Health 2020.

We have gone through an intensive consultative process. The full list of indicators will be presented to you tomorrow. Let me highlight that the Regional Office broke new ground by incorporating well-being in Health 2020. Now, to quantify a European target and relevant indicators on well-being, we started to develop a common concept and approach that would allow valid measurement and yield information useful in policy-making. All these are outlined in detail in The European health report 2012: charting the way to well-being, and I would like to thank Poland for hosting the launch of the report in March this year.

The Regional Office’s efforts include a life-course approach with a focus on disease prevention, health promotion and the quality of care.

Since 1990, the maternal mortality ratio in the WHO European Region has decreased by 54%, to the lowest level in the world. Nevertheless, the highest risk of death from causes related to pregnancy and childbirth in Europe is more than 40 times the lowest; the risk depends on where women live and receive health care.

We focused on improvements in access to quality primary health care for pregnant women, mothers and newborn babies. I would like to thank the Russian Federation for its support in reaching these objectives, particularly in countries in eastern Europe and central Asia. Supporting countries in decreasing this inequity is among our priorities and, with strong commitment from ministries, we have already started to observe improvements in the quality of maternal care based on lessons learnt.

Equal access to quality child and adolescent health services and care also remains a priority. We intensified our efforts to improve quality of hospital care, particularly in central Asia. Shorter hospital stays, reduced unjustified hospitalizations, significant reductions in unnecessary injections and savings in hospital costs are some of the early results.

Our latest report from the Health Behaviour in School-aged Children (HBSC) study on social determinants of health and well-being among young people, has won an award in the 2013 British Medical Association Medical Book Competition.

We would like to give you a progress report on child and adolescent health, and present our proposals for a renewed commitment aligned with Health 2020 at the next Regional Committee session.

We have stepped up our work through the Healthy Cities network to exchange good practices and to provide guidance on policies for age-friendly environments. Following the European Year for Active Ageing and Solidarity between Generations in 2012, this work is now supported by a major project of the European Commission, which is an important milestone for implementing our strategy and action plan for healthy ageing in Europe.

Health 2020 focuses on a set of integrated strategies and interventions to address major health challenges across the European Region from both noncommunicable and communicable diseases. Let me start with the noncommunicable diseases (NCDs).

The 2013 World Health Assembly delivered on the promises of the past two years: we have a new WHO Global NCD Action Plan. And the global monitoring framework, developed under Norway’s chairmanship last November, was unanimously endorsed. We can congratulate ourselves as a region on having played a leadership role in forging ahead with this global agenda.

We can also look forward with confidence. As you can see from this graph, in the last decade we have reversed the regional epidemic of circulatory diseases. They are now declining steadily in all parts of the Region, and we should be able to report a dramatic fall in both east and west by the target dates of 2020 in Europe and 2025 globally.

Nevertheless, at current rates, in 2025, a person of central or eastern Europe will still have six times the risk of dying from heart disease or stroke as a person in the west.

For this reason, we have to intensify our efforts and do better. For example, on World Health Day 2013 we reminded the Region of the dangers of high blood pressure. We mapped countries’ efforts to address hypertension and one of its root causes: salt intake. With the support of the Russian Federation, we have started a programme to strengthen action on NCDs in many countries, including supporting surveys and intersectoral policy development.

We developed a tool to assess barriers to and opportunities for NCD prevention and control in health systems and used it to make intensive assessments in Hungary, Kyrgyzstan, the Republic of Moldova, Turkey and Tajikistan. These experiences – as well as the implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases and the challenges Europe will face in the next decade – will be the main theme for the first European ministerial conference on NCDs. I would like to thank Turkmenistan for hosting the Conference in Ashgabat in December this year.

The European action plan to reduce the harmful use of alcohol provides the framework for effective policy actions. So far, 37 countries have national or subnational policies on alcohol and 10 more are developing them.

We surveyed alcohol consumption, harm and policy responses in all 53 Member States and published the Status report on alcohol and health in 35 European countries 2013. Adult per capita alcohol consumption has markedly decreased in the European Region as a whole over the past 20 years. In spite of the overall decline in consumption in western and central Europe, with the largest decline in southern Europe, the eastern part of the Region shows an upward trend.

We have seen tangible policy achievements in tobacco control. Tajikistan became a State Party to the WHO Framework Convention on Tobacco Control, which only three Member States in our region have yet to ratify. The Russian Federation adopted a strong tobacco-control law. Ukraine went smoke-free and banned tobacco advertising. Kazakhstan took leadership by adopting Europe’s strongest pictorial health warnings. And Ireland started introducing standard packaging for tobacco products.

Policy action brings tangible results. Turkey registered a 13% reduction in adult smoking prevalence between 2008 and 2012, a rate that bodes well for the Region’s achieving the global targets, if it is emulated in other countries.

The current discussions on the European Union (EU) Tobacco Products Directive have huge potential to strengthen European tobacco-control policies. WHO pledged technical and political support to the proposed Directive. But we must not rest on our achievements. The tobacco industry is escalating its actions and I urge all delegations here to stand strong against big tobacco.

We will discuss the implementation of the Framework Convention tomorrow, during the ministerial lunch, and I am pleased to welcome Dr Haik Nikogosian, Head of the Convention Secretariat.

We have made tremendous progress in nutrition and obesity in recent years.

You were very successful in establishing and scaling-up monitoring and surveillance systems critical to inform policies. Policy developments in countries were remarkable: 49 Member States developed or updated their national policies and several countries thoroughly evaluated them.

Nevertheless, the negative impact of unhealthy diets and physical inactivity, particularly childhood obesity, is high and still growing in countries in the European Region.

The WHO European Ministerial Conference on Nutrition and Noncommunicable Diseases in the Context of Health 2020, hosted by the Government of Austria, was an enormous success: 48 Member States attended and approved the Vienna Declaration, a milestone in public health in Europe. You have agreed to take coordinated action to effectively tackle unhealthy diets, obesity, malnutrition and physical inactivity.

This Regional Committee will discuss the Vienna Declaration and its proposed actions in detail.

And now let me focus on unfinished business in communicable diseases.

With commitment from you, we made good progress in implementing the European strategic action plan on antibiotic resistance. A harmonized and coordinated surveillance network is needed to provide Region-specific information. Working with partners, we supported the monitoring of antibiotic use in 17 Member States outside the EU; 12 are ready to publish their data for the first time. Through partnership with the National Institute for Public Health and the Environment (RIVM) in the Netherlands and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID), we established a new network for the surveillance of antimicrobial resistance (AMR) for all non-EU countries. These networks complement the excellent surveillance system for EU countries. We also supported countries in strengthening their intersectoral coordination and surveillance capacity.

Thanks to good collaboration with the European Centre for Disease Prevention and Control (ECDC), we helped expand European Antibiotic Awareness Day to non-EU countries in the Region. Here I would like to thank Her Royal Highness Crown Princess Mary of Denmark for her support.

Action to implement the Consolidated Action Plan to Prevent and Combat Multidrug- and Extensively Drug-Resistant Tuberculosis [M/XDR-TB] in the WHO European Region started to bear fruit; you will find details in the progress report.

This was possible onlz through substantial support to countries provided with partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the European Commission and ECDC. In total, WHO staff conducted 71 country visits during the past 2 years, supporting 23 Member States and organizing 9 in-depth programme reviews. I discussed with you and many heads of state the importance of a health-system approach to TB control.

Countries increased their capacity to detect MDR-TB, so that more than half of estimated cases are now detected in our Region. And treatment enrolment increased to 96% in 2012. Nevertheless, the treatment success rate varies widely, from 18% to 80%. We are working with Member States and the Global Fund to address remaining gaps.

I encourage you to visit the compendium of best practices in the exhibition area.

In response to the rising number of people living with HIV in the Region, we are implementing the European Action Plan for HIV/AIDS.

In 2011, the number of people on antiretroviral treatment in the European Region increased to 600 000, but treatment is not yet keeping pace with the approximately 1.5 million HIV infections.

Two key initiatives will help further implement our commitments. WHO’s new Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection offer a public health approach to scaling up treatment and containing transmission. We will organize a regional technical consultation in October; thanks to Turkey for hosting it.

We are also working towards elimination of both mother-to-child transmission of HIV and congenital syphilis in the Region, thanks to partnership with the Joint United Nations Programme on HIV/AIDS (UNAIDS), UNICEF and UNFPA.

Outbreaks of measles and rubella continued in 2012 and 2013 in various countries, and imperil the Region’s goal of eliminating measles and rubella by 2015. This is the main reason for presenting you with a package of accelerated action and a call for stronger commitment to eliminating these diseases. I look forward to the discussion on this agenda item on Wednesday.

Now let me give you an update on sustaining the European Region’s polio-free status, as called for by the Regional Committee in 2010. At its annual meeting in May, the European Regional Certification Commission identified the countries at risk for transmission following poliovirus importation and stressed the need for vigilance. The Commission had good reason. A large outbreak in 2010 threatened the Region’s polio-free status, and the recent importation of wild poliovirus into the Region reminds us of the need to keep up our guard.

Israel has conducted systematic environmental surveillance over the past 25 years, and detected type 1 wild poliovirus earlier this year, closely related to the viruses isolated in Egypt and Pakistan. This indicates virus circulation in the environment in Israel. I want to underline that there have been no cases of paralytic poliomyelitis, thanks to the very high immunization coverage in Israel.

Indeed, gold-standard surveillance and reporting have enabled Israel to respond effectively by conducting supplementary immunization activities to interrupt transmission and prevent exportation and possible cases. We have worked with the national authorities since May this year to support their investigation and response. Introducing bivalent oral polio vaccine (OPV) and reaching close to 800 000 children since mid-August are tremendous achievements. I thank the Minister of Health, the Director-General for Health and the Prime Minister for taking action and personally engaging in the campaign.

The Certification Commission will meet next month to review the outcomes of Israel’s action to interrupt transmission, and the risk to the Region’s polio-free status.

High national and subnational immunization coverage, hand in hand with strong surveillance, is key to achieving disease-control targets. Political commitment is an absolute necessity, no longer an option. We at WHO fully intend to do our part. We will consult you, during the matters-arising session on Thursday, on the formulation of a European regional vaccine action plan harmonized with the Global Vaccine Action Plan and aligned with Health 2020.

Let me briefly mention that European Immunization Week was again a success, with all 53 Member States participating.

Progress towards malaria elimination is good, with only 253 cases in 2012. The European Region could be the first WHO region to complete the elimination process.

Nevertheless, re-emerging vector-borne diseases, especially dengue and chikungunya fever, are of increasing concern in the Region. Mosquito vector activity is a growing problem, driven mostly by the globalization of travel and trade, urbanization and climate change. As requested by the 2012 Regional Committee, we developed a regional framework for action, in cooperation with you, ECDC and the European Mosquito Control Association (EMCA), to be discussed on Tuesday.

Improving public health and ensuring people-centred health systems – including human resources for health, health financing and enhanced governance – are all key focus areas of Health 2020. On health research, let me thank the European Advisory Committee on Health Research (EACHR) and Professor Tomris Turmen, its Chair, who is represented here by the Vice-Chair, Dr Laura Rosen, and the outgoing Chair, Professor Martin McKee, for supporting and coordinating research in international health.

Universal health coverage means that all people have access to the high-quality health services they need (including prevention, promotion, treatment and rehabilitation), while protecting them and their families from financial hardship. And it is relevant for the whole Region: countries affected by the economic crisis need to safeguard access to needed services. Political commitment to move towards universal health coverage is growing in countries in the eastern part of the Region.

Universal health coverage is among my priorities and I am committed to intensifying our support for achieving and sustaining it in the coming years.

Two important events related to strengthening health systems are coming up later this year.

Five years after its adoption, we will discuss the implementation of the Tallinn Charter at a high-level meeting in October; thanks to Estonia for hosting it. We will exchange inspiring examples of health-system strengthening and agree on future directions to fulfil our commitments in the context of Health 2020.

In addition, the thirty-fifth anniversary of the Declaration of Alma-Ata on Primary Health Care will be celebrated in November. We are working closely with Kazakhstan to prepare for a meeting at which we will describe the status of primary health care in the Region and the way forward to integrate the essential public health operations into it.

There is compelling evidence for going upstream and integrating disease prevention, health promotion and other essential public health functions, along with work on social determinants, into health systems, as requested by the 2012 Regional Committee.

We engaged intensively with Member States to support effective policy decisions that reduce the adverse effects of the economic crisis on health outcomes and equity. The WHO Barcelona Office for Health Systems Strengthening carries forward this work, and I thank them and I thank Spain for supporting it.

Four years after the first meeting on the topic, our work in this area culminated in the Oslo conference on health systems and the economic crisis in April, generously hosted by Norway. It brought together both the health and finance sectors, reaching agreement on an outcome document about which you will hear more on Tuesday. Let me underline that the participants emphasized that, even with restricted budgets, governments and health ministries have choices, and can focus on areas and services that encourage economic growth and reinforce equity.

In addition to our work to build evidence, we aim to strengthen policy-makers’ capacities. All feedback from the participants shows that our annual Barcelona Course on Health Financing is excellent, and I encourage you to send representatives to attend it.

Further, we are receiving an increasing number of requests from Member States for support to comprehensive reforms. For example, the Greek Government is committed to pursuing health-system reform. As requested by the Government and the EU Task Force for Greece, WHO recently agreed to play an expanded normative and technical role in developing health-systems policy in Greece, with Greece.

I would also like to commend Cyprus, Ireland and Portugal for similar fruitful collaboration on health-system reforms, aiming to safeguard access to quality services and universal health coverage.

As the lead agency of the health cluster in humanitarian emergencies, we help countries prepare for and cope with emergencies and health crises.

We revised our emergency procedures, upgraded the emergency operations centre at our new premises in the new UN City, in line with the new global WHO Emergency Response Framework, and tested it in several simulations.

We are also supporting countries such as Azerbaijan, the Russian Federation and Slovenia in preparing for mass gatherings.

Another important area of health security is building core capacities to implement the International Health Regulations (IHR) through expert training and table-top exercises. In February 2013, in collaboration with the European Commission and with support from Germany and the United Kingdom, we held a meeting in Luxembourg, taking stock of the implementation process five years after IHR’s entry into force. The progress report gives details and on Thursday we will seek your guidance on the criteria for extensions beyond the 2014 deadline for core capacities.

With the crisis in the Syrian Arab Republic triggering large-scale population displacement and a growing number of refugees in neighbouring countries, we coordinated a United Nations interagency health-needs-assessment mission in December 2012 to refugee camps in southern Turkey. It concluded that high-quality health services are provided to refugees in Turkey.

In close consultation with the Turkish authorities, we are scaling up our response capacity by establishing a WHO field presence in southern Turkey.

A systematic assessment of the health effects of a rapidly changing environment is essential and must be followed by action to ensure benefits to health.

Tomorrow you will hear a report on the work of the European Environment and Health Ministerial Board and Task Force.

Pioneering the health-in-all-policies approach, we are working through the European environment and health process with Member States and key partners, to provide evidence and support countries in implementing intersectoral approaches.

We scaled up technical support to countries to achieve their commitments under the Parma Declaration on Environment and Health, producing a number of new assessments and tools, and establishing new networks on chemical safety and economics. We are grateful to all the Member States and partners that generously support our work on environment and health, particularly to Germany for its continued support of the WHO European Centre for Environment and Health, in Bonn, and a project that advanced several countries’ preparedness and capacities to address the health challenges posed by climate change.

Now, let me give you an overview of major developments in the Regional Office and WHO globally, focusing on the managerial and governance aspects of our work. We continued to improve our efficiency, seek sustainable funding, deepen and extend our partnerships, and strengthen communications.

In April 2013, we moved our head office in Copenhagen to the new UN City, along with all the United Nations agencies in Denmark. We are deeply grateful to the Danish Government for its generosity in providing excellent premises. We were honoured to have Her Majesty Queen Margrethe of Denmark and United Nations Secretary-General Ban Ki-moon inaugurate UN City.

WHO is reforming to be better equipped to address increasingly complex health challenges in the 21st century. Significant progress has been made in moving forward the reform agenda since I reported to you last year, mostly owing to the unprecedented engagement and active involvement of Member States. I am immensely grateful to you for contributing in so many different ways.

Let me take this opportunity to thank all staff in the Region for their contribution to the process and adapting to the changes required by reform. There has been thorough collaboration at all levels of WHO, with full leadership of the Director-General and engagement of all the regional directors in the Global Policy Group. I very much appreciated the opportunity to co-chair, with Dr Asamoa-Baah, the WHO task force on resource mobilization and management and take an active role in the financing dialogue.

WHO reform is clearly having an impact. The work of the Regional Committee and Standing Committee of the Regional Committee (SCRC) demonstrates that WHO is an organization of Member States that exercises its important functions primarily through Member States. With guidance from the Regional Committee and SCRC, we ensured greater coherence and better governance in the European Region. The SCRC working group on governance addressed issues such as governing-body memberships, timely proposal of amendments to proposed resolutions and screening of credentials, which will be further discussed on Wednesday.

The World Health Assembly gave WHO a clear direction for the programmatic component of reform by approving the Twelfth General Programme of Work and the Programme Budget for 2014–2015. These give us a vision and a plan of action.

The Programme Budget has several new characteristics: a more realistic assessment of income and expenditure, a robust results chain and a clear description of the contribution of each level of WHO to the work. The concepts behind and lessons learnt from the European Region’s 2012–2013 “contract”, which I presented two years ago as “the strategic tool for accountability”, were a major contribution to the global process.

During this Regional Committee session, I will present the implementation of the Programme Budget for 2014–2015 in the European Region, which is well advanced. Health 2020 guides the transformation of the Assembly-approved Programme Budget into European operational planning. We had a ten-day Office-wide retreat to ensure coherence, particularly in implementing Health 2020, and we consulted Member States to define the priorities of the biennial collaborative agreements. According to our business model, staff based at the head office will continue to provide technical support to our Member States.

But the Programme Budget still needs to be financed. Our first financing dialogue took place in June, a successful meeting with full support of Member States and partners. I look forward to working with you towards the second meeting in November. I have great hope that this innovative mechanism will ensure a fully funded programme budget, and end the financial uncertainty in delivering our workplans.

To ensure sustainability at the Regional Office, we took measures that would not affect the delivery of our commitments to Member States, including lowering staff costs (by reducing recruitment while preserving technical capacity and excellence), and reducing travel costs and spending on consultant services.

I promised the 2010 Regional Committee we would develop a partnership strategy for the European Region. While awaiting decisions on collaboration with non-state actors to deliver on this commitment, I am happy to report that we continue to work with a broad range of partners, engaging actively and deepening our collaboration more and more every year.

In the Regional Office, we strengthened collaboration with the EU and its institutions. Let me present a few highlights. We continued to work with and support the health priorities of countries holding the EU Presidency: Cyprus, Ireland and Lithuania. We welcomed a delegation from the EU Committee of the Regions to the Regional Office. We had a large number of important events and worked with the European Parliament. We discussed our joint roadmaps with the European Commission during the very successful meeting of senior officials held at WHO headquarters in June. These roadmaps have deepened our collaboration significantly.

We have increased the range and depth of work with partners such as United Nations agencies, the World Bank, OECD, global health partnerships (particularly the Global Fund and GAVI Alliance), subregional networks and civil-society organizations.

I am honoured to welcome regional directors of UNICEF and UNFPA. We three will sign a joint framework for action during the partnership session on Wednesday. It aims to support you in achieving the health-related Millennium Development Goals (MDGs) and address new challenges in the context of Health 2020 policies.

Apart from various regional events and conferences, there were many occasions during the year for bilateral discussions with Member States. I visited 18 countries and had the opportunity to meet with you and your presidents and prime ministers, promoting intersectoral approaches and ensuring that health is placed high on the governments’ agendas.

It was an honour to welcome 13 health ministers and delegations to the Regional Office during the year. I value these visits, as they are very useful in guiding our work and choosing areas for future collaboration.

In addition we started developing country cooperation strategies (CCSs), signing the first CCS in the Region with Switzerland in May, along with the Director-General. We have started developing CCSs with Belgium, Cyprus, Greece, the Russian Federation and Turkey.

Subregional mechanisms remain an increasingly effective way to work with Member States. We are implementing activities with the South-east Europe Health Network (SEEHN) and subregional projects with countries in the Commonwealth of Independent States.

Ours is a complex and beautiful region, home to 900 million of the world’s people and approximately 86 languages. Its diversity gives us a unique opportunity to draw on an incredibly wide range of expertise and experience.

We are at the forefront of progress in so many areas of public health. I am sure that, together with you, we can make it.

Thank you for your attention.