Message from the Director-General Limits exist on what governments can finance and on their capacity to deliver services and to regulate the private sector. Hence the need for public policies that recog- nize these limits. Governments should retain responsibility for setting broad policy di- rections, for creating an appropriate regulatory environment, and for finance. At the same time they should seek both to diversify the sources of service provision and to select interventions that, for the resources each country chooses to commit, will provide the maximum gains in health levels and their most equitable distribution. At an interna tional level we need, collectively, to improve our capacity for humanitarian assistance and for responding to complex emergencies, when national health systems cannot cope Finally, there is a need to invest in expanding the knowledge base that made the 20th century revolution in health possible, and that will provide the tools for continued gains in the 21st century. Governments of high income countries and large, research-oriented phar maceutical companies now invest -and will continue to invest -massive resources in Much of this investment benefits all humanity, but at least two critical gaps re- main. One concerns research and development relevant to the infectious diseases that overwhelmingly afflict the poor. The other concerns the systematic generation of an information base that countries can use in shaping the future of their own health systems. A CORPORATE STRATEGY FOR WHO The challenges outlined above constitute an agenda for the world community as a whole governments and development agencies alike. Even as the lead agency in health, we have to recognize that the agenda is too broad for WHO alone. We therefore have to be realistic, and start to define how WHO can contribute most effectively to this agenda in coming years e intend that four interconnected strategic themes should guide the work of the whole Organization. The first two concern where we focus our efforts. The second two concern how we work. These are the themes that must guide our work we need to be more focused in outcomes; we need to be more effective in supporting health systems development re need to be more impact-oriented in our work with countries; we need to be more innovative in creating influential partnershi IMPROVING HEALTH OUTCOMES This theme runs through everything we do. Our first priority must be to reduce-then inate -the debilitating excess burden of disease among the poor. I am particularly concerned that we focus on health interventions that will help lead populations out of poverty. Let me highlight some key priorities as they are defined in the Proposed Budget 2000-2001 We are committed to reducing the burden of sickness and suffering resulting from com municable diseases. Roll Back Malaria is central to this approach. But we will also con tribute as effectively as possible to combating the global epidemics of HIVAIdS and tuberculosis, and to completing the eradication of poliomyelitis We need to step up our ability to deal with the rising toll of noncommunicable diseases pecial attention will be given to cancer and cardiovascular diseases. The Tobacco Free
Message from the Director-General xi Limits exist on what governments can finance and on their capacity to deliver services and to regulate the private sector. Hence the need for public policies that recognize these limits. Governments should retain responsibility for setting broad policy directions, for creating an appropriate regulatory environment, and for finance. At the same time they should seek both to diversify the sources of service provision and to select interventions that, for the resources each country chooses to commit, will provide the maximum gains in health levels and their most equitable distribution. At an international level we need, collectively, to improve our capacity for humanitarian assistance and for responding to complex emergencies, when national health systems cannot cope. • Finally, there is a need to invest in expanding the knowledge base that made the 20th century revolution in health possible, and that will provide the tools for continued gains in the 21st century. Governments of high income countries and large, research-oriented pharmaceutical companies now invest – and will continue to invest – massive resources in research and development oriented to the needs of the more affluent. Much of this investment benefits all humanity, but at least two critical gaps remain. One concerns research and development relevant to the infectious diseases that overwhelmingly afflict the poor. The other concerns the systematic generation of an information base that countries can use in shaping the future of their own health systems. A CORPORATE STRATEGY FOR WHO The challenges outlined above constitute an agenda for the world community as a whole: for governments and development agencies alike. Even as the lead agency in health, we have to recognize that the agenda is too broad for WHO alone. We therefore have to be realistic, and start to define how WHO can contribute most effectively to this agenda in coming years. We intend that four interconnected strategic themes should guide the work of the whole Organization. The first two concern where we focus our efforts. The second two concern how we work. These are the themes that must guide our work: • we need to be more focused in improving health outcomes; • we need to be more effective in supporting health systems development; • we need to be more impact-oriented in our work with countries; • we need to be more innovative in creating influential partnerships. IMPROVING HEALTH OUTCOMES This theme runs through everything we do. Our first priority must be to reduce – then eliminate – the debilitating excess burden of disease among the poor. I am particularly concerned that we focus on health interventions that will help lead populations out of poverty. Let me highlight some key priorities as they are defined in the Proposed Budget 2000-2001. • We are committed to reducing the burden of sickness and suffering resulting from communicable diseases. Roll Back Malaria is central to this approach. But we will also contribute as effectively as possible to combating the global epidemics of HIV/AIDS and tuberculosis, and to completing the eradication of poliomyelitis. • We need to step up our ability to deal with the rising toll of noncommunicable diseases. Special attention will be given to cancer and cardiovascular diseases. The Tobacco Free
The World Health Report 1999 Initiative is supporting and leading this approach. We will pay more attention to the delivery of high quality health care for children, ado- descents and women WHO is committed to making progress on the issues of population and reproductive health-with a special focus on maternal mortality and adolescent sexual and reproduc- tive health We will put the spotlight back on immunization as one of the most cost-effective health interventions We need to intensify our efforts to reduce the enormous burden of malnutrition, espe- cially in children. We will continue to support countries in their quest for access to affordable and high quality essential drugs We will work to see that mental health -and particularly the neglected scourge of depression-is given the attention it deserve We need to be better at responding to increasingly diverse kinds of emergencies and humanitarian crises We will develop our capacity within WHO-and in collaboration with others-to give advice on crucial health care financing issues. And we need to be able to deal more effectively with intersectoral issues- particularly the threats to health that result from environmental causes Let me focus on two of our key initiatives: Roll Back Malaria and the Tobacco Free Initia- tive. The world health report 1999 devotes a chapter to each of these Malaria and underdevelopment are closely intertwined. Over 40% of the worlds popu lation live where there is a risk of malaria. The disease causes widespread premature death and suffering, imposes financial hardship on poor households, and holds back economic rowth and improvements in living standards. Malaria flourishes in situations of social and environmental crisis, weak health systems and disadvantaged communities Its ability to develop resistance makes malaria a formidable adversary. Available and effective interventions -such as insecticide-treated bednets-fail to reach the people with the greatest burden of malaria. Capacity for malaria control is inadequate in endemic coun- tries, where health systems are often weak. Better implementation of current knowledge, and new products and technologies are all needed to break down the barrier to human progress which malaria poses. Overcoming these problems is a challenge for leadership, a challenge to be met by the Roll Back Malaria project Successful malaria control involves strengthening health systems. Weak health syste and uninvolved communities are part of the malaria problem. Because malaria is an acute condition with a rapid natural history, easy access to health care of good quality is vital in its management. Extemally driven initiatives, by-passing local and national health systems, are neither sustainable nor supportive of malaria control and health development. Many countries have begun the process of reforming their health system to improve perfo ance Malaria control, like the better management of all illnesses, needs to build on and support these changes Through strengthened health systems, total malaria deaths could halved-500 000 deaths could be averted annually -for about USl billion per ye additional spending a new willing to collaborate has been demonstrated. The Organization of African Unity, the World Bank and WHOs African Region have already planned a major African Initiative on Malaria which is expected to spearhead Roll Back Malaria in Africa. Roll Back
xii The World Health Report 1999 Initiative is supporting and leading this approach. • We will pay more attention to the delivery of high quality health care for children, adolescents and women. • WHO is committed to making progress on the issues of population and reproductive health – with a special focus on maternal mortality and adolescent sexual and reproductive health. • We will put the spotlight back on immunization as one of the most cost-effective health interventions. • We need to intensify our efforts to reduce the enormous burden of malnutrition, especially in children. • We will continue to support countries in their quest for access to affordable and high quality essential drugs. • We will work to see that mental health – and particularly the neglected scourge of depression – is given the attention it deserves. • We need to be better at responding to increasingly diverse kinds of emergencies and humanitarian crises. • We will develop our capacity within WHO – and in collaboration with others – to give advice on crucial health care financing issues. • And we need to be able to deal more effectively with intersectoral issues – particularly the threats to health that result from environmental causes. Let me focus on two of our key initiatives: Roll Back Malaria and the Tobacco Free Initiative. The world health report 1999 devotes a chapter to each of these. Malaria and underdevelopment are closely intertwined. Over 40% of the world’s population live where there is a risk of malaria. The disease causes widespread premature death and suffering, imposes financial hardship on poor households, and holds back economic growth and improvements in living standards. Malaria flourishes in situations of social and environmental crisis, weak health systems and disadvantaged communities. Its ability to develop resistance makes malaria a formidable adversary. Available and effective interventions – such as insecticide-treated bednets – fail to reach the people with the greatest burden of malaria. Capacity for malaria control is inadequate in endemic countries, where health systems are often weak. Better implementation of current knowledge, and new products and technologies are all needed to break down the barrier to human progress which malaria poses. Overcoming these problems is a challenge for leadership, a challenge to be met by the Roll Back Malaria project. Successful malaria control involves strengthening health systems. Weak health systems and uninvolved communities are part of the malaria problem. Because malaria is an acute condition with a rapid natural history, easy access to health care of good quality is vital in its management. Externally driven initiatives, by-passing local and national health systems, are neither sustainable nor supportive of malaria control and health development. Many countries have begun the process of reforming their health system to improve performance. Malaria control, like the better management of all illnesses, needs to build on and support these changes. Through strengthened health systems, total malaria deaths could be halved – 500 000 deaths could be averted annually – for about U$1 billion per year of additional spending. A new willingness to collaborate has been demonstrated. The Organization of African Unity, the World Bank and WHO’s African Region have already planned a major African Initiative on Malaria which is expected to spearhead Roll Back Malaria in Africa. Roll Back
Message from the Director-General Malaria differs from previous efforts to fight malaria. It will work to create new tools for controlling malaria, and by strengthening health systems for sustainable health improve ment Roll Back Malaria will also act as a pathfinder, helping to set the direction and strat egy for more integrated action in other priority areas, such as tuberculosis control and safe motherhood. Greater reliance on partnerships in fighting malaria will inform WHOs ap proach to other major health challenges and to the development of effective coordinated multipartner action lomentum for action against malaria has been increasing fast. Strong political support has come from the Organization of African Unity and the G8 group of the most industrial- ized countries. Four international agencies with major concerns about malaria and its e fects on health and the economy -UNICEF, the United Nations Development Programme, he World Bank and the World Health Organization-agreed, at a meeting of agency heads in October 1998, jointly to support Roll Back Malaria with WHO leadership Let me now turn to the Tobacco Free Initiative. The tobacco epidemic claims a large and rapidly growing number of premature deaths every year. Our estimates suggest that in 1998 the world suffered about 4 million tobacco-related deaths; to put this slightly differ- ently, about one in twelve adult deaths in 1990 resulted from tobacco use and, by 2020 tobacco will cause as many as one in seven. Perhaps 70% of these will be in the developing world. Millions more suffer from disabling lung or heart disease, impotence or impaired This tobacco toll is now growing most rapidly in developing countries. Can the momen tum of the epidemic be slowed? Have government policies been able to counter the mar- keting strength of the industry and the addictive powers of nicotine? The record here is clear: effective control strategies exist and governments that have adopted them have suc- ceeded in reducing tobacco use. The challenge is to transform ongoing successes into far more comprehensive global efforts At the same time that it is saving lives, tobacco control will also save money. Resources committed to tobacco production will be freed, but as this is at best a gradual process todays producers will suffer few transition costs. Consumer"benefits"from tobacco use accrue substantially to addiction- addiction acquired for most smokers while they were children or young teenagers. A recent and comprehensive World Bank review concludes unequivocally that tobacco control results in net economic as well as health benefits What lessons have we learned concerning the design of effective anti-tobacco strate gies? This report concludes that effective action rests on four principles of control oviding public health information through media and schools, and banning tobacco ing and promotion; using taxes and regulations to reduce consumption encouraging cessation of tobacco use in part by encouraging less harmful and less ex- pensive ways of delivering controlled and diminishing quantities of nicotine building anti-tobacco coalitions and defusing opposition to control measures e These measures cost relatively little and, through tobacco taxes, can more than finance hemselves. Each contributes to the control agenda, and typically each would be included in national control strategies Yet how best to design the implementation of these measures in a national or local ntext is still a puzzle; how to counter the opposition of the multinational tobacco indus- try remains a constant challenge; and how to tap the global moral, intellectual and political commitment to tobacco control for advancing a national agenda is often an unanswered
Message from the Director-General xiii Malaria differs from previous efforts to fight malaria. It will work to create new tools for controlling malaria, and by strengthening health systems for sustainable health improvement. Roll Back Malaria will also act as a pathfinder, helping to set the direction and strategy for more integrated action in other priority areas, such as tuberculosis control and safe motherhood. Greater reliance on partnerships in fighting malaria will inform WHO’s approach to other major health challenges and to the development of effective coordinated multipartner action. Momentum for action against malaria has been increasing fast. Strong political support has come from the Organization of African Unity and the G8 group of the most industrialized countries. Four international agencies with major concerns about malaria and its effects on health and the economy – UNICEF, the United Nations Development Programme, the World Bank and the World Health Organization – agreed, at a meeting of agency heads in October 1998, jointly to support Roll Back Malaria with WHO leadership. Let me now turn to the Tobacco Free Initiative. The tobacco epidemic claims a large and rapidly growing number of premature deaths every year. Our estimates suggest that in 1998 the world suffered about 4 million tobacco-related deaths; to put this slightly differently, about one in twelve adult deaths in 1990 resulted from tobacco use and, by 2020, tobacco will cause as many as one in seven. Perhaps 70% of these will be in the developing world. Millions more suffer from disabling lung or heart disease, impotence or impaired pregnancies. This tobacco toll is now growing most rapidly in developing countries. Can the momentum of the epidemic be slowed? Have government policies been able to counter the marketing strength of the industry and the addictive powers of nicotine? The record here is clear: effective control strategies exist and governments that have adopted them have succeeded in reducing tobacco use. The challenge is to transform ongoing successes into far more comprehensive global efforts. At the same time that it is saving lives, tobacco control will also save money. Resources committed to tobacco production will be freed, but as this is at best a gradual process today’s producers will suffer few transition costs. Consumer “benefits” from tobacco use accrue substantially to addiction – addiction acquired for most smokers while they were children or young teenagers. A recent and comprehensive World Bank review concludes unequivocally that tobacco control results in net economic as well as health benefits. What lessons have we learned concerning the design of effective anti-tobacco strategies? This report concludes that effective action rests on four principles of control: • providing public health information through media and schools, and banning tobacco advertising and promotion; • using taxes and regulations to reduce consumption; • encouraging cessation of tobacco use in part by encouraging less harmful and less expensive ways of delivering controlled and diminishing quantities of nicotine; • building anti-tobacco coalitions and defusing opposition to control measures. These measures cost relatively little and, through tobacco taxes, can more than finance themselves. Each contributes to the control agenda, and typically each would be included in national control strategies. Yet how best to design the implementation of these measures in a national or local context is still a puzzle; how to counter the opposition of the multinational tobacco industry remains a constant challenge; and how to tap the global moral, intellectual and political commitment to tobacco control for advancing a national agenda is often an unanswered
The World Health Report 1999 question No central point has existed for accumulating the experience of what does and does not work - or for mobilizing political, legal and financial resources to assist govern ments or elements of civil society that are committed to tobacco control. It was to fill these gaps-to provide the requisite leadership-that we launched the global Tobacco Free Initia tive on 21 July 1998. A major milestone for the initiative will be the adoption of a"Frame work Convention on Tobacco Control "by 2003, and initial efforts towards this are well under way. SUPPORTING HEALTH SECTOR DEVELOPMENT WHO has always been strong at responding to specific requests. The Organization is good at fielding highly qualified technical experts. But often individual experts tend to see the world through their own expert lenses. WHO has, however, been less good at helping senior decision-makers deal with the big picture We know that senior policy-makers in ministries of health do not have the luxury of focusing on single issues. Health is one of the most politically and institutionally difficult sectors in any country. If WHO is to earn a leadership role in health, we cannot deny the responsibility of helping our colleagues to deal with complexity. In many countries, national governments have tended to look to other agencies fo advice on issues that affect the sector as a whole. who has to be a more reliable and effective supporter of countries as they reform and restructure their health sectors. We also have to be clear that reform is not an end in itself. It is a way of making sure that people particularly poor people- get a better deal from their health system Many determinants of better health lie outside the health system altogether: they lie in better education(and in ensuring that girls have the same educational opportunities boys). They lie in cleaner environments, and in sustained reductions in poverty. We must understand these linkages. One path to better health for all is for those of us within the health sector to serve as active and informed advocates of health-friendly policies outside the sector The second path is through reform of health systems themselves. Reform today, in much of the world, will take place in a context of increased reliance on the market forces which have increased productivity in many sectors of the world economy. But markets have failed to achieve similar success in health services or health insurance. At the same time, many of the new products critical to improving health originate in the private sector. Active govern ment involvement in providing universal health care has contributed to the great gains of recent years-but many governments have overextended themselves. Efforts to provide all services to all people have led to arbitrary rationing, inequities, nonresponsiveness and inadequate finance for essential services. Where, then, do the values of who lead when combined with the available evidence finance everything for everybody. This"classical "universalism, although seldom advanced extreme form, shaped the formation of many well-established health systems. It achieved aportant successes. But the old universalism fails to recognize both resource limits and the limits of government Our values cannot support market-oriented approaches that ration health services to those with the ability to pay. Not only do market-oriented approaches lead to intolerable inequity with respect to a fundamental human right, but growing bodies of theory and evidence indicate markets in health to be inefficient as well. market mechanisms have enormous utility in many sectors and have underpinned rapid economic growth for over a century in
xiv The World Health Report 1999 question. No central point has existed for accumulating the experience of what does and does not work – or for mobilizing political, legal and financial resources to assist governments or elements of civil society that are committed to tobacco control. It was to fill these gaps – to provide the requisite leadership – that we launched the global Tobacco Free Initiative on 21 July 1998. A major milestone for the initiative will be the adoption of a “Framework Convention on Tobacco Control” by 2003, and initial efforts towards this are well under way. SUPPORTING HEALTH SECTOR DEVELOPMENT WHO has always been strong at responding to specific requests. The Organization is good at fielding highly qualified technical experts. But often individual experts tend to see the world through their own expert lenses. WHO has, however, been less good at helping senior decision-makers deal with the big picture. We know that senior policy-makers in ministries of health do not have the luxury of focusing on single issues. Health is one of the most politically and institutionally difficult sectors in any country. If WHO is to earn a leadership role in health, we cannot deny the responsibility of helping our colleagues to deal with complexity. In many countries, national governments have tended to look to other agencies for advice on issues that affect the sector as a whole. WHO has to be a more reliable and effective supporter of countries as they reform and restructure their health sectors. We also have to be clear that reform is not an end in itself. It is a way of making sure that people – particularly poor people – get a better deal from their health system. Many determinants of better health lie outside the health system altogether: they lie in better education (and in ensuring that girls have the same educational opportunities as boys). They lie in cleaner environments, and in sustained reductions in poverty. We must understand these linkages. One path to better health for all is for those of us within the health sector to serve as active and informed advocates of health-friendly policies outside the sector. The second path is through reform of health systems themselves. Reform today, in much of the world, will take place in a context of increased reliance on the market forces which have increased productivity in many sectors of the world economy. But markets have failed to achieve similar success in health services or health insurance. At the same time, many of the new products critical to improving health originate in the private sector. Active government involvement in providing universal health care has contributed to the great gains of recent years – but many governments have overextended themselves. Efforts to provide all services to all people have led to arbitrary rationing, inequities, nonresponsiveness and inadequate finance for essential services. Where, then, do the values of WHO lead when combined with the available evidence? They cannot lead to a form of public intervention that has governments attempting to provide and finance everything for everybody. This “classical” universalism, although seldom advanced in extreme form, shaped the formation of many well-established health systems. It achieved important successes. But the old universalism fails to recognize both resource limits and the limits of government. Our values cannot support market-oriented approaches that ration health services to those with the ability to pay. Not only do market-oriented approaches lead to intolerable inequity with respect to a fundamental human right, but growing bodies of theory and evidence indicate markets in health to be inefficient as well. Market mechanisms have enormous utility in many sectors and have underpinned rapid economic growth for over a century in
Message from the Director-General Europe and elsewhere. But the very countries that have relied heavily on market mecha nisms to achieve the high incomes they enjoy today are the same countries that rely most heavily on governments to finance health services. With the exception of only the United States, the high income market-oriented de- mocracies mandate universal coverage. Their health outcomes are very high. They have contained expenditures to a much smaller fraction of GDP than has the USA (7-10% versus 14%) In the one country where it was studied- Canada-introduction of National Health Insurance resulted in increased wages, reduced unemployment and improved health outcomes Therein lies a lesson This report advocates a"new universalism"that recognizes governments'limits but re- tains government responsibility for leadership, regulation and finance of health systems The new universalism welcomes diversity and, subject to appropriate guidelines, compe- tition in the provision of services. At the same time it recognizes that if services are to be provided for all then not all services can be provided. The most cost-effective services should be provided first. The new universalism welcomes private sector involvement in supplying service providers with drugs and equipment, and encourages increased public and private investment in generating the new drugs, equipment and vaccines that will underpin long-term improvements in health. But it entrusts the public sector with the fundamental responsibility of ensuring solidarity in financing health care for all. It further alls for a strategic reorientation of ministries of health towards stewardship of the entire ystem through participatory, fair and efficient regulation. Countries approach WHO with concems about health finance broadly defined, more than on any other question Our thinking in this area generally reflects this new universalism We are rapidly building internal capacity to learn about health finance and to respond more effectively to questions concerning it Regaining our place at the centre of the health sector development agenda is a chal- lenge for the whole of WHO; it is one reason why I have launched a project under the title of Partnerships for Health Sector Development. The project will be working to advance our strategic agenda on several fronts. It will work throughout the Organization to estab lish a health sector development perspective in all aspects of our work. It will also be concerned to help to develop a more strategic approach to work with countries In addi tion, the project will have a role in establishing more influential partnerships A MORE STRATEGIC APPROACH TO OUR WORK IN AND WITH COUNTRIES The financial resources for health lie overwhelmingly within countries. Responsibility for success(or failure) thus lies ultimately with governments. Only a tiny fraction of re sources for health in low and middle income countries originates in the international system-development banks, bilateral development assistance agencies, international nongovernmental organizations, foundations and WHO. Health spending in low and mid dle income countries in 1994 totalled about $250 billion, of which only $2 or 3 billion was from development assistance. We also need to recognize that WHO is not a donor agency. Its prime resources are knowledge and people In thinking about our relationships with Member States, we need to think not just about what we spend but about what we do
Message from the Director-General xv Europe and elsewhere. But the very countries that have relied heavily on market mechanisms to achieve the high incomes they enjoy today are the same countries that rely most heavily on governments to finance health services. With the exception of only the United States, the high income market-oriented democracies mandate universal coverage. Their health outcomes are very high. They have contained expenditures to a much smaller fraction of GDP than has the USA (7–10% versus 14%). In the one country where it was studied – Canada – introduction of National Health Insurance resulted in increased wages, reduced unemployment and improved health outcomes. Therein lies a lesson. This report advocates a “new universalism” that recognizes governments’ limits but retains government responsibility for leadership, regulation and finance of health systems. The new universalism welcomes diversity and, subject to appropriate guidelines, competition in the provision of services. At the same time it recognizes that if services are to be provided for all then not all services can be provided. The most cost-effective services should be provided first. The new universalism welcomes private sector involvement in supplying service providers with drugs and equipment, and encourages increased public and private investment in generating the new drugs, equipment and vaccines that will underpin long-term improvements in health. But it entrusts the public sector with the fundamental responsibility of ensuring solidarity in financing health care for all. It further calls for a strategic reorientation of ministries of health towards stewardship of the entire system through participatory, fair and efficient regulation. Countries approach WHO with concerns about health finance broadly defined, more than on any other question. Our thinking in this area generally reflects this new universalism. We are rapidly building internal capacity to learn about health finance and to respond more effectively to questions concerning it. Regaining our place at the centre of the health sector development agenda is a challenge for the whole of WHO; it is one reason why I have launched a project under the title of Partnerships for Health Sector Development. The project will be working to advance our strategic agenda on several fronts. It will work throughout the Organization to establish a health sector development perspective in all aspects of our work. It will also be concerned to help to develop a more strategic approach to work with countries. In addition, the project will have a role in establishing more influential partnerships. A MORE STRATEGIC APPROACH TO OUR WORK IN AND WITH COUNTRIES The financial resources for health lie overwhelmingly within countries. Responsibility for success (or failure) thus lies ultimately with governments. Only a tiny fraction of resources for health in low and middle income countries originates in the international system – development banks, bilateral development assistance agencies, international nongovernmental organizations, foundations and WHO. Health spending in low and middle income countries in 1994 totalled about $250 billion, of which only $2 or 3 billion was from development assistance. We also need to recognize that WHO is not a donor agency. Its prime resources are knowledge and people. In thinking about our relationships with Member States, we need to think not just about what we spend but about what we do