ofthe WHO Regional Committee for South-East Asia - WHO ...

Forty-fourth Sessior~ ofthe WHO Regional Committee for South-East Asia

Kummba Village, Maldives, 22-28 September ZYYI

World Health Organization Regional Office for South-East Asia Ncw Dclhi. India

Final Report and Minutes

Final Report and Minutes

Forty-fourth Session of the WHO Regional Committee for South-East Asia

Kurumba Kllage, Maldives, 22-28 September 1991

World Health Organization Regional Office for South-East Asia New Delhi, India November 1991

CONTENTS

Page

SECTION I - REPORT OF THE REGIONAL COMMIlTEE

lntmduction 1

Part I - Resolutions 3

SEAJRC44fil Forty-third Annual Report of the Regional Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 SEAIKC44m2 Selection of a Topic for the Technical Discussions ... . . . .. . . . . . . . . . . . . .. . . . . . . . . . . 3 SEAJRC44iR3 Resolution of Thanks SEAJRC44K4 Time and Place of the SEAJRC44B5 Disaster Preparedness SEAJRC44iR6 Evaluation of the Stra . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 SEAJRCl44iR7 Water Supply and Sa S E M C 4 4 m 8 AIDS . . . . . . .. . . .... . . . . .... . . . ..... . . .- ...... . . . ... .. , , , ..... , , . . . . . . . . . . . . . . . 7 SEAjRC44iR9 Sustainable Development

I'nrt I1 - Discussions on the Forty-third Annual Report of the Regional Director . . . . . . . . . . . . . . . . . . 10

I'nrt 111 - I)iscussions on the Report of the Sub-committee on Programme Budget.. . . . . . . . . . . . . . . . 15

Inart N - Discussions on Other Matters 16

1. Review of the Draft Provisional Agenda of the Eighty-ninth Session of the Executive Board and of the Forty-fifth World Health Assembly . . . . . . . . . . ... . . . . . . . . . ... . . . . . 16

2. Technical 1)iscus~ions on "Disaster Preparedness" . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

3. N I X 19

4. Review of the Second Evaluation of the Regional Strategies for Health for All . . . . . . . . . . . . 20

5. WHO Special Programme for Research and Training in Tropical Diseases . . . . . . . . . . . . . . . . . 21

6. WHO Special Programme for Research, Development and Research Training in Human Reproductio 21

7. Management Advisory Committee (MAC) on the Action Programme on k e n t i a l Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

8. Evaluation of the International Drinking Water Supply and Sanitation Decade

10. Consideration of Resolutions of Regional Interest Adopted by the World Health Assembly and the Executive Board 25

iii

Page

. . . . . . . . . . . . . . . . . . . 11. Time and Place of Forthcoming Sessions of the Regional Committee. 2 6

12. Selection of a Subject for the Technical Discussions at the Forty-fifth Session of the Regional Committee.. . . . . . . . . . . . .. .... ... ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 6

Annexes

1. List of Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

2. Agenda I

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Report of the Sub-Committee on Programme Budget 3 3

4. Recommendations Arising out of the Technical Discussions on Disaster Preparedness . 3 5

5. Report of the Twentieth Meeting of the C~nsultative Committee for Programme Development and Management

6. List of Official Documents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

SECTION I1 - MINUTES OF THE SESSION

First Meeting. 22 September 1991, 9.30 am

Second Meeting, 22 September 1991, 2.30 pm

Third Meeting, 23 September 1991, 8.00 am

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Fourth Meeting, 23 September 1991, 11.30 am 1 1 9

Fifth Meeting, 25 September 1991, 8.00 am

Sixth Meeting, 25 September 1991, 11.30 am

Seventh Meeting, 26 September 1991, 8.30 am

Eighth Meeting, 28 September 1991, 8.00 a

1 SECTION I

/ REPORT OF THE REGIONAL C O M M I ~ E E ' i

'0riginally issued as "Draft Final Repori of the Forty-fou~h Session of the WHO Regional Committee for South-East

Asia" (dwument SEAJRCMIZZ, dated 27 September 1991)

INTRODUCTION

H E forty-fourth session of the Regional Committee for South-East Asia was held T. m Kurumba Village Resort, Maldives, from 22 to 28 September 1591. It was attended by the representatives of the eleven Member States of the Region. The United Nations Development Programme and UNICEF, four nongovernmental organizations having official relations with WHO, and an observer from a voluntary agency also attended.

The Regional Committee meeting was declared open by the Regional Director in the absence of the outgoing Chairman and the Vice-Chairman of the forty-third session. His Excellency Mr Abdul Sattar Moosa Didi, Minister of Health and Welfare, Republic of Maldives, inaugurated the meeting.

A Sub-committee on Credentials, consisting of representatives from Bhutan, Mongolia and Sri Lanka, was constituted. The representative of Mongolia was elected Chairman of the Sub-committee which held one meeting and presented its report (SEA/RC44/19), based on which the Regional Committee recognized the validity of the credentials presented by all the representatives.

The Regional Committee elected the following office-bearers:

Chairman .. Dr Abdul Sattar Yoosuf (Maldives)

Vice-Chairman .. Dr Md. Khalilullah (Bangladesh)

The Committee revicwed the draft provisional agenda of the eighty-ninth session of the Executive Board and of the Forty-fifth session of the World Health Assembly (SEA/RC44/15 Rev.1). It established a Sub-committee on Programme Budget consisting of representatives from all Member States, and adopted its terms of reference (SEAIRC4413). Under the chairmanship of Dr Narendra Bahadur Rana (Nepal), the Sub-committee held two meetings and submitted a report (SEA/RC44/20), which was endorsed by the Regional Committee.

The Committee elected Dr Gandung Hartono as Chairman of the Technical Discussions on Disaster Preparedness, and adopted the annotated agenda for these discussions (SEA/RC44/4 and Add.1). The conclusions and recommendations arising out of these discussions, which were held on 24 September 1591 (SEA/RC44/21), were presented to the Regional Committee which endorsed the recommendations and adopted a resolution (SEA/RC44/RS).

REPORTOFTMIHE PORTY.POURTM REOIONAL WMMIITEe

The key-note address of the Director-General of WHO, Dr Hiroshi Nakajima, was read out by the Regional Director on the opening day.

A Sub-committee consisting of representatives from India, Maldives, Myanmar, Nepal and Thailand was formed to draft resolutions. AAer deliberations in eight plenary sessions, the Regional Committee adopted nine resolutions, which have been issued separately in the resolution series, and also incorporated in Part I of this report.

The Regional Committee nominated:

(1) Myanmar to the Management Committee of the Global Programme on AIDS, for three years from 1 January 1992,

(2) Indonesia to the Policy and Coordination Committee of the WHO Special Programme for Research, Development and Research Training in Human Reproduction for three years from 1 January 1992, and

(3) Thailand to the Joint Coordinating Board of the WHOSpecial Programme of Research and Training in Tropical Diseases, for three years from 1 January 1992.

Indonesia was renominated to the Management Advisory Committee of the Action Programme on Essential Drugs for three years from 1 January 1992.

The Committee decided to hold its forty-fifth session in Nepal in 1992, its forty-sixih session in the Regional Office in 1993 and noted with appreciation the offer of the Government of Mongolia to host the forty-seventh session in Mongolia in 1994.

The Committee decided to hold Technical Discussions on the subject of "Balance and Relevance in Human Resources for Health for HF.412000" during its forty-fifth session.

Part I of the report contains the resolutions adopted by the Committee. Parts 11, 111 and IV of the report are devoted to summaries of the Committee's discussions on important matters.

Part I

RESOLUTIONS

T HE following nine resolutions were adopted by the Regional Committee (the references to the 'Handbook' are to the Hondbohk of RerdutioPrr mld Decirionr ofthe WHO R&nd

Commitlee for South-Em h a , Volume 2, Tenth edition, 1976-19)0, and its supplements):

SENRC44lRl FORTY-THIRD ANNUAL REPORT OF THE REGIONAL DIRECTOR

The Regional Committee,

Having considered and discussed the Forty-third Annual Report of the Regional Director, which covers the activities of WHO in the South-East Asia Region during the period 1 July 1990 to 30 June 1991 (document SEAIRC44R and Corr.l),

1. NOTES with appreciation the progress made during the period in implementing WHO'S programme of collaborative activities in the South-East Asia Region, and

2. CONGRATULATES the Regional Director and his staff on bringing out a lucid and comprehensive report.

Handbook 9 Page 54

Eighth Mecting, 28 September 1991 SEAIRC41IMin.8

SENRC44lRZ SELECTION OF A TOPIC FOR TECHNICAL DISCUSSIONS


1. DECIDES to hold technical discussions during the forty-fifth session in 1992 on the subject of "Balance and relevance in human resources for health for HFA,%IW, and

2. REQUESTS the Regional Director to take appropriate steps to arrange for these discussions and to place this item on the agenda of the forty-fifth session.

Handbook 1.2.2 Page 6

SENRC44lR3 RESOLUTION OF THANKS


Eighth Meeting, 28 Septcmber 1991 SEWRC44/Min.8

Having brought its forty-fourth session to a successful conclusion,

1. WISHES to convey its sincere gratitude and thanks to the Government of the Republic of Maldives, particularly the Miniistry of Health and Welfare, for the warm and generous hospitality extended to the participants and members of the WHO Secretariat, as well as for the excellent arrangements made for the session;

2. PLACES on record its deep appreciation to His Excellency Mr Abdul Sattar Moosa Didi for his thought-provoking and inspiring inaugural address, and

3. EXPRESSES its appreciation to the Regional Director for his effective contribution and to his staff for their efforts in making this session a success.

Handbook 1.2.YZ) Page 8

Eighth Meetin& 28 September 1991 SEA/RC44/Min.8

SWRC44JR4 TIME AND PLACE OF THE FORTY-FIFTH, FORTY-SIXTH AND FORTY-SEVENTH SESSIONS


1. THANKS His Majesty's Government of Nepal for its invitation to host the forty-fifth session of the Regional Committee in Nepal;

2. DECIDES to hold the forty-fifth session in Nepal in September 1992, and the forty-sixth session at the Regional Office in New Delhi in September 1993, and

3. NOTES with thanks the invitation of the Government of Mongolia to host the forty-seventh session of the Regional Committee in Mongolia in 1994.

Handbook 1.2.1 page 4

Eighth Meeting. 28 September 1991 SeAmC44/Min.8

SENRC44IR5 DISASTER PREPAREDNESS


Recalling its resolution SEA/RC42/R6 on the subject of "Disaster Preparedness",

Noting the &kg frequency of natural disasters and the emergence of chemical, industrial and other man-made disasters in recent years affecting countries of the South-East Asia Region,

Being aware that the United Nations has declared the 1990s as the International Decade for Natural Disaster Reduction (IDNDR),

Having considered the report on the Technical Discussions held during the forty-fourth session,

1. URGES Member States:

(a) To formulate national plans for health emergency preparedness as an integral component of overall national disaster control plans, with effective

internal coordination within the health sector and close cooperation with the other concerned sectors;

(b) To designate and strengthen national centres for health emergency preparedness and response capable of undertaking epidemiological studies of disasters, mapping, training and research;

(c) To create mechanisms for the establishment of national and regional networks;

(d) To decentralize health emergency preparedness and response management with adequate resources and with active community involvement, and to strive to create a high level of public awareness and cooperation, and

(e) To cooperate with one another in the mitigation of disaster impact within the context of IDNDR, and

2. REQUESTS the Regional Director:

(a) To extend technical support to Member States in formulating national health plans for disaster preparedness, including epidemiological studies of disasters, mapping, training and research;

(b) To facilitate international cooperation, including mobilization of external resources, to strengthen disaster preparedness and to improve national capabilities for health emergency preparedness and response;

(c) To support human resources development in disaster preparedness at all levels in the Member States, and

(d) To support the establishment and strengthening of national centres of excellence on emergency preparedness, with particular reference to health, and promote their recognition as WHO collaborating centres.

Handbook 4.7 Page 36

Eighth Meeting. 28 September 1991 SE.4lRC441Min.8

SEAJRC44lR6 EVALUATION OF THE STRATEGIES FOR HEALTH FOR ALL


Recalling World Health Assembly resolution WHA34.36 and its own resolution SEA/RC43/R2 urging Member States to monitor progress and to undertake the evaluation of their Health for All strategies and report the results in the agreed common framework,

Appreciating the responses of all Member States in completing the second evaluation of the Health for All strategies, reporting therein the strengths and weaknesses of the strategies and the implementation processes,

REPORT OPTHE PORTY.WORTH aeOIONALCOMMTlXE

Reiterating the need for Member States to integrate the monitoring and evaluation processes of the Health for All strategies into the national health development processes in general and into the GovenunenlAKHO collaborative actions in particular,

1. ENDORSES the renew of the second evaluation of the strategies for Health for All and the submission of the same as the regional contribution to the Eighth World Health Situation Report;


(a) To continue to assess their Health for AU policies and strategies in the l i t of the results of the evaluation and to modify or strengthen them as necessry;

(b) To strengthen their health information systems, with particular reference to the underserved and disadvantaged sections of the woulation in a - spirit of equity and social justice;

(c) To strengthen the health management systems and improve community participation by adopting social mobilization strategies, and

(d) To strengthen their evaluation processes by involving other sectors where necessary, and

3. REQUESTS the Regional Director to support Member States for further improving the monitoring and evaluation of their Health for All strategies.

Handbook 2.2.1 Pap 15

Eighlh Meeting, 28 September 1991 SEAlRC44/Min.8

SEAlRC441R7 WATER SUPPLY AND SANITATION FOR THE 1990s


Recalling its resolutions SEA/RC3UR4, SEA/RC33/R9 and SEA/RC41/R6 on the subject of safe water supply and sanitation,

Having considered the document "General Overview of the International Drinking Water Supply and Sanitation Decade in the South-East Asia Region" (SEA/RC44/11),

Recognizing the cmcial importance of safe drinking water and sanitation for the protection of health and environment as well as improvement of the quality of life,

Noting the considerable progress made in rural water supply coverage, but also the widening gap in urban water supply coverage between the sewed and the unserved populations due to rapid population increase, and the fact that sanitation lags far behind water supply in both urban and rural areas, which call for increased and improved action in the 1990s,

Realizing that the countries will need considerable resources to meet their decade targets for safe water and sanitation,

Recalling the statement of "Some for all, rather than more for some", adopted by Member States at the Global Consultation on Safe Water and Sanitation, held in New Delhi in September 1990,


(a) To reaffirm the priority accorded to programmes for safe and reliable water supply and sanitation essential for the prevention of water-borne and other diseases and to stress the human aspeds and importance of community participation by undertaking psychosocial and behavioural studies and intensive health education activities, with particular focus on meeting the needs of the poor, both in rural and urban areas;

(b) To review their water supply and sanitation strategies for the 1990s and to adopt programmes to attain the target of universal coverage by the year 2000 so as to meet the goal of Health for AU,

(c) To mobilize resources, both national and international, and to ensure full participation of the people, particularly women, at all levels, and

(d) To improve the information system in the area of water supply and sanitation to effectively monitor and evaluate the progress made, and

2. REQUESTS the Regional Director to continue WHO'S support to Member States in their efforts to accelerate the implementation of water supply and sanitation programmes in the 1990s.

Handbook 6 Page 46

Eighth Meeting, 28 Scptembcr 1991 SEAJRC44lMin.8

SEA/RC44/R8 AIDS


Recalling resolutions WHA39.29, WHA40.26, WHA42.33, SEA/RC40/Rl, SEAiRC42jR2 and SEAIRC43jR5,

Recognizing the increasingly serious situation with regard to HIV infection/AIDS in countries of the Region,

Noting with concern the impact of HIV infectiodAIDS on a family through heterosexual transmission, which is now becoming a major mode of spread in the countries of the Region,

Realizing that availability of effective measures for the prevention and control of AIDS may take a long time,

Appreciating the increased external funding and the establishment of control programmes in all countries of the Region, including those where HIV infectionIAIDS prevalence are still relatively low,

Being aware of the potential benefits to be derived from close collaboration among countries in the Region,


(a) To make all possible efforts to include in their programmes all aspects of prevention and control activities, as mentioned in resolution SEA/RC43/R5, keeping a good balance between these efforts and those for the country's general health development aiming at sustainability by concentrating on strengthening national health systems and capabilities;

(b) To continue to play a leading role in the mobilization of all government, nongovernmental and private sectors in the control of HIV infection, and

(c) To build up, if necessary, intercountry collaboration in controlling the transmission of HIV infection, and

2. REQUESTS the Regional Director to continue to give technical support to Member States in their efforts for prevention and control of HIV infection and to mobilize extrabudgetary resources for intensifying national programme activities within the framework of the Global Programme on AIDS.

Handbook 5.1.6 Page 42

Eighth Meeting. 28 September 1991 SEAIRWIMin.8

SEA/RC44/R9 SUSTAINABLE DEVELOPMENT


Recalling World Health Assembly resolutions WHA29.45 and WHA42.26, and its own resolution SEAIRC38/R11,

Having considered the document "WHO'S Contribution to the International Efforts Towards Sustainable Development" (SEA/RC44/10),

Recognizing that sustainable socioeconomic development is essential to ensure the health and quality of life of future generations,

Concerned that uncontrolled and unsound development activities without environmental safeguard pose a threat to human health and the sustainability of the process of development itself,

Emphasizing that environmental protection and improvement should be inseparable from the total health and development effort,


(a) To establish, evaluate and update their health policies and strategies for preventing adverse effects of development on human health and the environment;

(b) To emphasize greater concern for human-centred development and the use of social mobilization strategies in the implementation of primary health care, and

(c) To strengthen cooperation between the health and other development sectors in order to address the health implications of development activities, and

2. REQUESTS the Regional Director:

(a) To lay emphasis on the interdependence of development, health and environment in WHO'S programmes, and

(b) To continue to collaborate with other international agencies and to support Member States in the formulation and implementation of regional and national policies and strategies for sustainable and environmentally-sound development.

Eighth Meeting. 28 September 1991 SEAIRC44iMin.8

Part I1

DISCUSSIONS ON THE FORTY-THIRD ANNUAL REPORT

OF THE REGIONAL DIRECTOR

RESENTING his Annual Report for the period 1 July 1990 to U) June 1991, the P . Reg~onal Dlrector . highlighted the significant collaborative activities of WHO in the South-East Asia Region. The challenging task before the Member States was the translation of the health policies into effective strategies and programmes to respond to the dynamics of current and emerging health problems in the Region. The Region had achieved significant progress in health development, as reflected in a decline in the crude death rate and the infant mortality rate, accompaniedby an overall improvement in the health status of the peoples. WHO continued to support the Member States in their efforts to improve health manpower management. The Organization had taken steps to develop a conceptual and operational framework for health development of the underprivileged.

Most of the countries in the Region were affected by natural disasters. WHO provided support to the countries, especially for developing national capabilities for disaster preparedness and emergency response.

The Regional Advisory Committee on Health Research, during its seventeenth session, held in April 1991, stressed the need for a strategic plan on health research in the strategies for HFA, and further strengthening of research capabilities in the countries of the Region. WHO continued tosupport research in DHFvaccine production, Hepatitis B, malaria, tuberculosis and in MCH and family planning, including safe mothethood, and in the development of a Regional Nutrition Research-cum-Action network.

Provision of safe water and basic sanitation as part of the goal of HFA/20aO was another area where WHO support to Member States continued. Member States also developed programmes on essential drugs and vaccines, particularly on drug management programmes, with support from WHO.

The malaria situation had remained somewhat static over the last few years, while HIV infections and AIDS had assumed epidemic proportions in a few countries.

The incidence of noncommunicable, chronic and degenerative diseases was rising due to increased life expectancy and changes in lifestyle and behaviour.

Stressing the importance of using the limited resources available more effectively to support the real priorities of the countries, the Regional Director drew the attention of the Committee to the health "paradigm", propounded by the Director-General whereby health should be seen as the centre of development. The Director-General laid emphasis on five broad programme areas for WHO collaboration during 1992-1993 and 1W4-1W5. These areas are: (1) health of man in a changing environment, (2) proper food and nutrition for healthy life and health development, (3) integrated disease control, (4) dissemination of information for advocacy as well as for scientific, managerial and educational purposes, and (5) intensified health development action and support to countries in the greatest need.

In conclusion, the Regional Director stated that despite economic, social and political constraints, significant progress had been achieved by the Member States in improving the quality of life of the people. He expressed the hope that the Regional Committee would continue to provide the South-East Asia Regional Office with valuable guidance and directions for technical collaboration with the Member States.

In its in-depth review of the Regional Director's Annual Report, the Regional Committee made significant comments on the various subjects contained in the report, which are mentioned below.

Regarding Health System Development and the Organization of Health Systems based on Primary Health Care, the Regional Committee noted with satisfaction the ovcrall progress made by the Member States. The Committee observed that the question of intcrnational collaboration and coordination among agencies in the field of health systcm development needed fresh consideration in the context of health policy and planning. Areas such as health systems research, health economic research, financing of health services and alternate financing required WHO support. Noting the efforts made by the countries to promote the integration of health services, the Regional Committee, while agreeing with the principle of integration, cautioned that all relevant factors such as availability of health infrastructure, epidemiological situation, etc.should be taken into account to determine the feasibility of integration.

Concerning the development of human resources for health, the Committee noted that this was one of the important factors in health development. While some countries had undertaken studies to assess health manpower requirements, others were engaged in dcveloping training courses to impart the required skills and technology. Efforts were continuing to reorient medical education to serve better the needs of the people through health-rclcvant service systcms. The Committee observed that the percentage of rcgional fellowships had been increasing because of the availability of expertise at the regional level. The Member States appreciated the need to start forward planning of the fellowships programme so as to improve its implementation. The Regional Committee also noted that the optimum mix of health manpower along with sound managerial process and planning of manpower should be studied for more effective implementation.

Referring to public information and education for health, the Regional Committee felt that there was a strong need to improve communication in health through interpersonal communication techniques.

The Committee felt that with increasing privatization in health care, there was a greater need to improve the quality of health care delivery systems and to thoroughly study the trend towards privatization, and factors that may influence the system and its effectiveness.

The Regional Committee noted the deliberations of the South-East Asia Regional Advisory Committee on Health Research (SEA/ACHR), which held its seventeenth session in Yangon in April 1991. The Committee appreciated WHO'S health research strategy at the global and regional levels in collaboration with national MRCs and analogous bodies. Research in DHF vaccine production, research-cum-action on nutrition, liver cancer and hepatitis studies, community participation in DHF control, health economics and financing of health care were continuing. Information support for research was being provided through the WHO HELLIS network. The Committee noted that World Health Assembly resolution WHA43.19 would be the basis for the identification of future research, research capability strengthening, training and other operational aspects.

The Committee noted with satisfaction that the JNSP programme in Myanmar and the integrated child development senice project in India had received international recognition. It was happy to note the various measures that had been taken by the Member States to reduce tobacco consumption and to create awareness on the ill-effects of cigarette smoking.

Considering that maternal mortality continued to be unacceptably high in some countries, the Regional Committee appreciated the steps now being taken by Member States to improve maternal health care. There was keen interest in the safe motherhood programme which attracted support from WHO, UNICEF, UNFPA, and the World Bank. Most of the countries had formulated strategies and action plans for functional integration of EPI, Diarrhoea1 Diseases and ARI with MCH programmes to achieve better child health and development.

Although two Member States expressed concern over the increasing incidence of traffic accidents, the Committee felt that accident prevention had not yet become a viable programme in the Region. Programmes on workers' health, on the other hand, had received priority in some countries already, but the interest seemed to be declining at present.

The Member States expressed keen interest in the development of nutrition programmes to reduce malnutrition. While recognizing the complexity of the nutrition problem in the Region, the Committee endorsed the need to undertake studies, and

cautioned against overdependence on imported food supplements, iron and vitamin pills etc. to combat malnutrition.

The Regional Committee noted that drug management programmes had been progressing well in a few countries with WHO support. The Committee, however, felt that even if health ministries were not coordinating the programme, they should play an active role in its implementation and coordinate with other departments. The Committee also endorsed collaboration in the spirit of TCDC and the use of international and bilateral assistance taking examples from the achievements of the ASEAN drug programme funded by UNDP and executed by WHO.

The Regional Committee was gratified to note that the majority of the countries have achieved at least 80 per cent immunization coverage due mainly to political will, commitment and sustained efforts of the Member States with financial support from donor agencies. There was a significant decrease in the reported cases of polio, diphtheria and pertussis. The countries of the Region had set the targets of eradicating polio by the year 2000, elimination 01 neonatal tetanus, and reducing measles by 90 per cent by 1995. The stage had come when EPI should be fully integrated into the health system infrastructure. However, its sustainability must be ensured throughout the process.

In the view of the Committee, concerted action was necessary to avoid deterioration of the malaria situation. Drug-resistant malaria parasites and insecticide resistance in vcctors with changing exophilic and exophagic habits of the main malaria vectors, were the main technical bottlenecks which needed to bc dealt with on solid scientific ground. The Committee also noted the prevalence of Kala-Azar and its recent exacerbation in the border areas adjoining Bangladesh, India and Nepal which needed to be dealt with jointly by the concerned Member States in a concerted and coordinated manner with WHO support.

The epidemiological approach with stratified operational methods for relevant and cffectivc technology for each geographical population group seemed to be the most promising strategy.

Acute respiratory infections coupled with diarrhoea1 diseases and malnutrition were still responsible for significant mortality among children. Better epidemiological studies and surveillance were needed to control and prevent Japanese encephalitis which constitutes a major problem in some countries.

The Committce noted that multidrug therapy for leprosy control was gaining momcntum in affected countries and felt optimistic that leprosy could be eradicated or at lcast eliminated in two or three countries of the Region in the near future.

AlDS was threatening to assume epidemic proportions in some countries, while in others, it was still at a low level. The AlDS situation does not permit complacency. The Committee noted with satisfaction that all Member States had initiated prevention

REPORTOFTHE PORN-FOURTH RUGIONAL WMMIllEE

and control measures through short-term or medium-term plans supported by WHO and other agencies. Since AIDS was going to be a long-drawn out battle, countries were advised to systematically build up their infrastructures and capabilities without slackening their surveillance and educational efforts.

Cardiovascular diseases, cancer, blindness and diabetes were becoming major public health problems as their incidence was on the increase with the increase in life expectancy and changcs in lifestyle. Since a large investment of resources would be needed for effective therapeutic control of these diseases, primary prevention through the PHC approach and early detection should be the strategy of choice.

The Regional Committee endorsed the recommendation of the nineteenth meeting of the Consultative Committee on Programme Development and Management (CCPDM) to maintain the status quo regarding the period of reporting for the Regional Director's Annual Report i.e., a twelve-month period for short reports in even-numbered years and a 24-month period for long reports in odd-numbered years.

The Committee adopted a resolution approving the Annual Report (SEA/RC44/Rl).

Part 111

DISCUSSIONS ON THE REPORT OF THE SUB-COMMITTEE

ON PROGRAMME BUDGET

T HE Sub-committee on Programme Budget, consisting of representatives from eleven Member States, met on 24 September 1991 and submitted its report (SEARC44120)

to the Regional Committee.

In accordance with its tcrms of reference, the Sub-commitlee reviewed the working paper relating to the implementation of the Organization's collaborative programme in Member States during the first eighteen months of the current biennium under the Regular Budget as well as the extrabudgetary resources. While noting the discussions of the twentieth meeting of the Consultative Committee on Programme Development and Management on this subject, the Sub-committee stressed the importance of WHO'S role as a lead agency and coordinating authority on international health work. It also noted that the costing for the long-term staff (LTS) was being done on an aggregated basis globally and was meant to be used for planning purposes only. While unforeseen situations during the implementation phase might alter this costing, such changes were adjusted in accordance with certain principles and guidelines on a regional basis in order to make the implementation of the LTS component more appropriate. It then endorsed the recommendations made by CCPDM.

The Sub-committec, while reviewing the salient features of the guidelines for the preparation of thc programme budget for 1994-1995, noted that Member States should, if possible, give special attention to five programme areas identified by the Director- General through a budgetary increase, in real terms, by an average of five per cent altogether, considering country-specific situations and trends for individual countries. The Committee agreed with the recommendations of CCPDM on this subject and stressed the need for exploring and evolving a mechanicm to increase the allocations to countries which at present had a rclativcly smaller share under the Regular Budget of WHO.

The Sub-committee fell that the South-East Asia Regional Office should take into account the collaborative activities being undertaken by Member States under the TCDC mcchanism within the framework of the report of the Second Meeting of Ministers of Health of the Countries of the South-East Asia Region (SEARIMMIMeet.2) and World Health Assembly resolution WHA43.9. Adequate efforts should also be made to mobilize extrabudgetary resources in furtherance of bilateral and multilateral collaboration.

Part IV

DISCUSSIONS ON OTHER MATTERS

1. Review of the Draft Provisional Agenda of the Eighty-ninth Session of the Executive Board and of the Forty-fifth World Health Assembly

The Regional Committee took note of the draft provisional agenda of the eighty-ninth session of the Executive Board and of the Forty-fifth World Health Assembly. The subject for the Technical Discussions at the Forty-fifth World Health Assembly will be Women, Health and Development.

2. Technical Discussions on "Disaster Preparedness"

Technical discussions were held on the subject of "Disaster Preparedness". During the discussions, the participants reviewed the disaster experiences in the countries of the Region, with particular concern for the more frequent and damaging types of disasters. Following the exchange of general experiences and deliberations on related matters, the group discussed several main areas of disaster preparedness and response and arrived at certain conclusions and recommendations.

The group concluded that the frequency of natural disasters had been on the increase in the past decade, and callcd for adequate disaster preparedness at the national, regional and global levels. A new qualitative dimension had been added due to the recent emergence of man-made or technological disasters. It was strwed that the period immediately after a disaster struck was a critical one when lives were endangered and the disruption of infrastructure and senices was at the highest leading to acute deprivation. Pro&ion of relief to overwme human misery and diitres in the first hours after a disaster had occurred was of ~Titical importance which the local resources - human, material and organizational - could and must endeavour to come up with before outsidc assistance could be mobilized. The group endorsed that besides immediate response and recovery, it was equally important to plan for longer tern reconstrudion and preparedness to meet future disasters. The group found the Manual on Emergency Preparedness and Response, prepared by the WHO Emergency Relief Operations Unit, as a useful guide to make a rapid assessment of the health effeds of diimters.

REPORTOPTHE FORTY-FOURTH R E G I O H A L C O M M ~ E

The group concluded that disaster mapping would be a valuable aid to disaster preparedness. It was understood to mean that disaster mapping would mainly concern itself with building up an epidemiological profile and a health resource inventory. The group reiterated the need for more effective international response and intensified coordination amongst the UN, bilateral and international voluntary organizations with responsibility for, and involvement in, disaster relief operations. It also agreed on the need for a greater degree of cohesion within the health emergency preparedness and response plan of the Ministry of Health and between the Health and other Ministries. This will make disaster control operations more effective and allow achievement of a higher impact by optimum utilization of limited resources.

Finally, the group concluded that, in order to be more effective, the health emergency preparedness and response plan should not only be well-known within the health sector but it should be integrated into the overall national plan for disaster control. While health alone could not coordinate the total national effort, it should nevertheless coordinate within its own sector. As a result of detailed discussions, the group made the following recommendations:

(1) In the context of the need for a broad regional or even global view of disasters, it was essential to expand the span of cooperation across the regions and globally, and, specifically, bi-regionally between the South-East Asia and the Western Pacific Regional Offices.

(2) Each country should prepare a health emergency preparedness and response plan within the national development plan. Health sector activities should be coordinated intrasectorally.

(3) The crucial factor of community involvement and self-reliance in disaster preparedness and management required that community organizations be supported with a high degree of public awareness of disasters and their prevention. UNEP, WMO and other international and bilateral organizations, which had sophisticated global intelligence network on environment and climate, should provide continuous information and early warning to countries that could not maintain costly facilities.

(4) All possible technical cooperation by concerned UN and other organizations, including WHO, should be provided to help countries with charting of disaster-prone areas and their charactcristics. A specific programme on emergency preparedness with WHO cooperation should immediately be established in countries that had not done so yet.

(5) Country-level studies on the social effects, particularly health effects, of rapid economic development should be supported along with drafting of rules and regulations that protected the fragile ecosystem. A long-term

REPORT OP 'MIHE PORTY.POURlU REGIONAL COMMllTEE

perspective dimension should be added in such legislation to ensure a sustainable environment for future generations.

(6) Each country should endeavour to set up a nodal centre of disaster preparedness and participate in a network of national centres. WHO and other concerned UN agencies should provide technical and financial support to the establishment of national centres and intercountry/regionaI network.

(7) To make a national plan of action effective, it was vital to develop a strong surveillance system, including an epidemiological system, which could provide mapping of disaster patterns. An effective mechanism for necessary services could be established within a certain time-frame. In addition, selected institutions at regional and state levels should be designated by countries and recognized by WHO to impart relevant training in health emergency preparedness and response. In this regard, cooperation between neighbouring countries should be fostered through bilateral meetings, especially to prepare for, and combat, disasters that take place on both sides of an international border. WHO should play a supportive and facilitating role in bringing this about.

(8) International and National Red Cross and Red Crescent Societies had traditionally played a significant role, especially in immediate disaster relief. These and other nongovernmental organizations should be utilized also for raising public awareness, particularly awareness amongst school-going children.

(9) All forms of international relief assistance should be combined with a longer term perspective of support through which national capabilities and institution-building and other forms of sustainable capabilities were promoted. An evaluation of the earlier disaster events and the usc of lessons learnt should be encouraged. A pool of educational case studies should be established in order to serve as resource material for teaching. In this context, appropriate operational research should also be conducted in order to build up appropriate methodologies that could be incorporated in training programmes at various levels.

(10) WHO should intensify its communication and coordination with UN and other agencies involved in various aspects of disaster management. WHO should continue to develop its own capacity to monitor and disseminate valid information on health aspects of disasters and also develop appropriate training for national staff development in cooperation with competent WHO collaborating centres. WHO should also provide technical cooperation to countries, particularly the vulnerable ones, in

order to be able to build up bilateral cooperation in disaster preparedness and management. WHO should m o b i i all possible extrabudgetary resources to help establish a nehvork of national centres and promote inter-regionaland regionalcooperation, training,research andinformation dissemination.

A resolution (SEA/RC44/RS) was adopted in support of theabove recommendations.

3. AIDS

The Committee considered the information contained in document SEA/RC44/8 and noted that the problem of HIV infection and AIDS had become greatly aggravated, with about one million adults and half-a-million children having been infected with AIDS globally during the past year alone. Although there were signs of the AIDS pandemic slowing down in the industrialized countries, it seemed to be spreading fast in the developing world. India, Myanmar and Thailand in the South-East Asia Region, which had reported zero or low prevalence of AIDS a few years ago, had now reported a large number of HIV infections and AIDS cases, with India and Thailand accounting for a major number of infections. The Committee felt that, in spite of the linancial support provided by extrabudgetary sources, the implementation of AIDS control programmes in some countries still left much to be desired. In addition to ensuring effective intersectoral coordination in most countries, it was imperative to mobilize effective support from all other concerned departments and institutions as we1 as NGOs. The Committee was then provided with an update on the situation prevailing in individual countries of the Region in the prevention and control of AIDS as well as the measures initiated by the countries to tackle the problem. The Committee stressed the importance of maintaining proper monitoring, better epidemiological approach, with passive surveillance in hospitals, active surveillance in high-risk groups, and sentinel surveillance since HIV infection/AIDS was becoming a very serious problem. The Member States should use appropriate methods available with them to deal with the problem of AIDS, taking into account the local customs, culture and epidemiological factors. The Committee expressed its apprehension that the interest now being shown by some international organizations might dccrease in due course when it was realized that, in the absence of an early breakthrough, the battle against AIDS might be a long one. The Committee, howcver, appreciated thc interest shown by UNDP, the World Bank and some other UN agencies who were actively supporting this programme and urged the Member States to use this support to strengthen national capabilities by developing their own infrastructure, manpower training programme, transfer and adaptation of technology and laboratory services in order to sustain their combat against the disease.

The Committee adopted a resolution on the subject (resolution SEAiRC44iRB).

Nnmlnatlno n l a member to the Management Committee nt the Global Programme on AIDS

The Regional Committee unanimously nominated Myanmar as a member of the Management Committee of the Global Programme on AIDS for a three-year term of office from January 1992 to December 1994.

4. Review of the Second Evaluation of the Regional Strategies for Health for All

All Member States of the South-East Asia Region completed the second evaluation of their Health for All strategies and reported the results using the Common Framework for Evaluation (CFED). The regional report, synthesized from country reports contained in document SEAmC44114, constituted the South-East Asia regional contribution to the Eighth World Health Situation Report.

The Committee noted the perceptible progress achieved since the first evaluation was carried out in 1985. The infant mortality rate had declined in most countries, but the lack of disaggregated data masked the variation in population groups and regions within countries. There had been marked improvement in life expectancy at birth. Community involvement in primary health care was stronger than before and more equitable distribution of resources for primary health care was noted. Despite the economic constraints and restricted growth of health budgets, some countries had earmarked more than half of the national health budget for local health care. Difficulties had emerged in some countries due to dynamic political and economic restructuring and adjustments, demanding a well-thought-out restructuring and orientation of health delivery systems and a fresh look at the methods of health care financing. The evaluation, inter alia, underscored the need for sustained efforts by countries to improve their capacities for health policy development, optimal resource allocation and mobilization of additional resources. These called for new orientation, new skills and sustained commitment to the goal of Health for All. Some of the priorities were promotion of health and protection of the environment, appropriate food and nutrition strategies, future health trend assessment, and integrated disease prevention and control. The evaluation was instrumental in improving the health information system and attending to the health problems of the underprivileged.

The need for disaggregated information was reiterated. It was felt that the range of values with regard to some indicators should be included in future evaluations. Difficulty was encountered in identifying actual expenditure on primary health care for which a methodology should be developed. In some countries with a better coverage in health care services, it was now necessary to improve the quality of health care. New methods of health care financing were being introduced to channel the considerable amount of personal and household health expenditure through an organized health

REPORTOPIHE FORTY-POURIM REGIONAL C O M M T R E

insurance or health maintenance scheme. An analysis of the quality and extent of community participation, including self-managed health care in village communities should be included in the next round of evaluation. Decentralization of development activities and fmances had resulted in local authorities planning the provision of health senices and had led to an increase in local health resources.

Transportatio~ communication and logistics were impeding the efficacy of primary health care, specially in countries with difficult topography. Several innovative experimental approaches to overcome the obstacles arising from social, economic and cultural factors were reported, with varying degrees of success.

It was also apprehended that the transition from a command economy to an open market economy may cause deterioration of certain health indicators. The most striking issues included the apparent gap between the HFA strategy and national development plans, which required close convergence, and also the need for closer involvement of other health-related sectors and effective intersectoral coordination.

The Committee adopted a resolution on the subject (SEAIRC44R6).

5. WHO Special Programme for Research and Training in Tropical Diseases

Report on the Joint Coordinating Board (JCB) Session

Dr U Kao Tun (Myanmar) reported on behalf of Indonesia and Myanmar on their participation in the fourteenth session of the Joint Coordinating Board held in June 1991.

Nomination of a Member to the Joint Coordinating Board

The Regional Committee unanimously nominated Thailand to the Joint Coordinating Board (JCB) in place of Indonesia under Section 2.2.2 of the Memorandum of Understanding for representation at the Joint Coordinating Board for a period of three years commencing from 1 January 1992.

6. WHO Special Programme for Research, Development and Research Training in Human Reproduction

Report on the Policy and Coordination Committee (PCC) Session

Dr Vitura Sangsingkeo (Thailand) reported on behalf of three countries of the Region represented at the fourth session of the Policy and Coordination Committee held in June 1991.

Nomination of a member to the Policy and Coordination Committee

The Regional Committee unanimously nominated Indonesia under category 2 as a member of the Policy and Coordination Committee for a period of three years from 1 January 1992.

7. Management Advisory Committee (MAC) of the Action Programme on Essential Drugs

Report on the Session of the Management Advisory Committee of the Action Programme on Essential Drugs

Dr Gandung Hartono (Indonesia) highlighted some of the important recommendations made by MAC which had held three meetings during 1989-1991. The complete report of MAC would be available soon.

Nomination of a Member to the Management Advisory Committee

The Regional Committee unanimously renominated Indonesia as a regional representative for the membership of the Management Advisory Committee for a period of three years from 1 January 1992.

8. Evaluation of the International Drinking Water Supply and Sanitation Decade (IDWSSD)

Consequent to the efforts of the United Nations General Assembly identifying the availability of potable water and sanitation as important factors for improving the health of the people, and adopting water supply and sanitation as one of the important elements of primary health care at Alma-Ata in 1978, the decade of 1981-1990 was declared the International Drinking Water Supply and Sanitation Decade. WHO was given the mandate to monitor the progress and achievement of the targets that were set for the Decade. The purpose of the mid-term reviews of 1983, 1985 and 1988 was not only to review the progress but also to undertake mid-course corrections. The forty-first session of the South-East Asia Regional Committee urged its Member States to further review the progress, mobilize resources, accelerate implementation and revise targets and strategies so as to meet the goal of HFNUXX).

The Committee took note of the progress, particularly the coverage of unserved urban and rural populations, with respect to the availability of water and sanitation. On the basis of the reports available and the analysis thereof, the Committee noted the gaps that still existed between the served and the unserved segments of the population,

both urban and rural. It was a matter of concern that this gap was widening, particularly in the unserved urban population. The members expressed concern about the enormous resources that would be required to ensure achievement of the desired goals by the year UWXl and requested WHO to further mobilize extrabudgetary resources to meet the resource needs.

The Committee appreciated the various innovative approaches being adopted by Member States in their efforts to meet the needs of the poor people, in both rural and urban areas. Governmental subsidies, involvement of nongovernmental organizations, community mobilization, advancement of subsidies and loans, creation of facilities for training and health education were being supported and encouraged. It was realized that achievement of the targets should not only be seen from the purely technological and health engineering angles, but that also there was also a need for a qualitative approach so that the diseases associated with water and sanitation could be tackled simultaneously and effectively. It was realized that there was a great need to undertake extensive community health education and research in knowledge, altitudes and psychosocial behaviour so that fhe facilities provided were used appropriately and in a sustained manner.

Many countries were subject to the vagaries of nature. Mere availability of tubewells or latrines will not ensure their functioning throughout the year or their being used by the community. Conditions of drought and floods often inhibited round-the-year use of tubewells and latrines. Management of water resources and prcvention of land pollution by insanitary practices, therefore, gained importance. It was realized that, whereas the ministries of health were involved in testing of water and identifying the quality of the water supply, it was often not within their domain to ensure that corrective measures were also taken at the same time since this involved a number of other health-related sectors. There was need to bring in greater coordination and cooperation between various sectors to ensure supply of safe water and maintenance of sanitation.

Taking the example of a special situation, it was noted that the Republic of Maldives, being composed of atolls, had very specific problems of its own, particularly in regard to water supply and disposal of human waste. Attention, however, was being given to ensuring that the capital island of Ma16 had better systems of water supply and disposal of human waste so that a disease-free environment could be created.

Conccrn was expressed by some members at the increasing use of pesticides and chemical fcrtilizers to enhance agricultural production. These often tended to accumulate in water-logged fields and percolated to the subsoil water resources, often finding their way into drinking water supplies, thereby posing chemical hazards to health. This aspect of chemical pollution had to be monitored more closely and efforts were needed to ensure that these were kept under control.

The Committee felt that there was a need to create centres of excellence within Member States in the field of safe water supply and sanitation which wuld form national networks and wuld subsequently be recognized as WHO collaborating centres.

Finally, the Committee appreciated the need to adopt not only innovative but also scientifically-sound approaches so that not only the people in urban and rural areas, but also the poorer sections of communities were provided with safe water and sanitation. The facilities thus created should be used and maintained in a sustained manner. The Committee adopted a resolution (SEA/RC44/R7) emphasizing the need to take concerted measures to meet the needs for water and sanitation in the 1990s.

9. WHO'S Contribution to the International Efforts towards Sustainable Development

WHO's policies and strategies for Health for All had, from the very outset, stressed the close linkage between health and overall development. In the second half of this century, pollution, deforestation and industrialization had posed serious challenges to the survival of our planet and to the quality of life of all people. It was recognized that the needs of the present generation should be met in such a manner so as not to jeopardize human life for posterity. This necessitated the rational use of natural resources and protection of the ecosystem so as to ensure the preservation and promotion of health in a human-centred development effort.

WHO had established a high-level commission on health and environment to explore the health consequences of socioeconomic development. The commission produced its report underlining the links between health, environment, development, population growth, affluence and poverty as well as the wst of neglecting health in the process of development. The commission also outlined a strategy to achieve development without undermining the quality of the environment, which would be an input for WHO's new global environmental health strategy.

The Committee noted that economic and social development in the Region could not be achieved without some effect on the environment. The countries of the Region are faced with the dilemma of improving human health and protecting the quality of the environment while attempting faster economic development on a sustainable basis.

Efforts at the country level to rationalize economic development in terms of environmental protection were outlined. Many countries have welwmed the concept of sustainable development and are of the opinion that the 1990s should form a turning point in the whole process of human development. In almost all countries, development plans are now required to take environmental impact into account, and in some countries separate ministries of environment have been set up. increasing attention is being given to afforestation, environmental protection and bio-diversity. The Committee felt that there was a need to

REWRTOP THE PORTY.FOURTH RUilONALCOMMTlEE

look at the long-term effeds of man-made disasters. Many u)&es have also set up pollution mntrol boards and are giving dase attention to waste dispcd, particularly in urban settings

A reference was made to a Ministerial Summit on environment and development held in Bangkok in October 1990. In this regard, the Regional Director informed the Committee that a health component was included in the Bangkok Declaration of the Summit at the insistence of WHO supported by some sympathetic delegations. The Committee was urged to ensure that, at the forthcoming U.N. Conference in Brazil in 1992, their country delegations were adequately briefed on health aspects of environment and that the health emphasis was fully highlighted. To protect the environment and achieve sustainable development, the technological approach hitherto followed should give way to a socioeconomic, human-centred approach.

The Committee adopted a resolution on sustainable development (SEA/RC44/R9) laying emphasis on the inter-dependance of development, health and environment in WHO'S programmes.

10. Consideration of Resolutions of Regional Interest Adopted by the World Health Assembly and the Executive Board Eleven resolutions of regional interest adopted by the Forty-fourth World Health Assembly and six by the eighty-seventh session of the Executive Board were brought to the attention of the Regional Committee. These were noted.

(1) Research and development in the field of children's vaccines (WHA44.4 and EB87.R6)

(2) Tuberculosis control programme (WHA44.8)

(3) Leprosy (WHA44.9 and EB87.R5)

(4) Health promotion for the development of the least developed countries (WHA44.24 and EB87.R9)

(5) Smoking and travel (WHA44.26 and EB87.R8)

(6) Urban health development (WHA44.27)

(7) Water and environmental sanitation (WHA44.28)

(8) Method of work of the Health Asscmbly (WHA44.30)

(9) Traditional medicine and modern health care (WHA44.34 and EB87.R24)

(10) Emergency relief operations (WHA44.41)

(11) Women, health and development (WHA44.42)

(12) Collaboration within the United Nations System (EB87.R20)

REPORTOP THE FORTY.FOURTH ReGlONALCOMMWEE

Following deliberations on resolution EBS7.R24l, the Committee noted the conclusions and recommendations of the forty-third session of the Regional Committee with reference to UNGA resolution 441211 and endorsed its recommendations.

11. Time and Place of Forthcoming Sessions of the Regional Committee

The Regional Committee decided to hold its forty-fifth session in Nepal in September 1992, and its forty-sixth session in 1993 in the Regional Ofice for South-East Asia, New Delhi (resolution SEA/RC44/R4). The Regional Committee also noted the invitation of the Mongolian People's Republic to hold its forty-seventh session in 1994 in Mongolia (resolution SEA/RC44/R4)

12. Selection of a Subject for the Technical Discussions at the Forty-fifth Session of the Regional Committee

The Regional Committee decided to hold Technical Discussions on the subject of 'Balance and Relevance in Human Resources for Health for Health for All by the Year 2000' during its forty-fifth session in 1992 (resolution SEA/RC44/R2).

The Regional Committee endorsed the recommendation of the nineteenth meeting of CCPDM that Technical Discussions should continue to be held every year at the sessions of the Regional Committee on topics of regional interest.

Annex I

1. Representatives, Alternates and Advisers

BANGLADESH

Representalive : Dr Md. Khalilullah Joint Scrrctary (Cmrdination and Planning) Ministry of Hcalth and Family Welfare Dhaka

BI IUTAN

Representalive : Dr Jigmi Singay Joint Director Department of Health Services Ministry of Social SeMces Iltimphu

l)EMOCRA'IlC PEOPLES WPUBL.IC O F K O R M

Representalive : Dr Li Chang khm Chief Medical Officer Department of Science and Technologv Ministry of Public Health Pyongyang

Interpreter : Mr Kwon Sung Yon WHO National Programme Officer Pyongyang

INDIA

Representative : Dr A.K. Mukhe j e c Additional Direetor-General (PII) Directorate General of Heallh Services New Dclhi

INDONESIA

Representative : Dr Fandung Hartono Dirertor-Gcncral Communicable Diseases Control and Environmental llealth Jakana

Allcrnate : Dr N. Kurnara Rai Chief, Bureau of Planning Ministry of Health Jakana

'originally issued as document SEARC44nS (Rw.2) on 24 Scplembpr 1991

Representative : Dr Abdul Sattar Y m u f Deputy Minister Ministv of Health and Welfare Mali

Alternates : MI Mohamed Rashced Deputy D i w t o r of Planning and Cmrdination Ministry of Health and Welfare Malt

: Ms Huana Razee Deputy Director of Health Promotion and

Disease Control Dcpanmcnt of Puhlir tlcalth Ministry of Health and Welfare Malt

Advisers Dr Naila lbrahim Didi Medical Advlscr Ministry of Health and Welfare Malt

Dr T.13. Firdous Executive Direclor Central Hospital Malt

1.8. Col. Shawkalh lbrahim Ministry of Defence and Nal~onal Security Male

M r Mohamcd lbrahim Director Maldives Water and Sanitation Authority Malt

Mr Hussain Shihah Director of Environmental Affain Ministry of Planning and Environment Malt

Mr Hamdaon lfameed Under Secretary Ministry of Planning and Environment Mall6

Mr Abdullah Masech Assistant Under Secretary Ministry of Foreign Affain Male

Mr Abdul Muhusin Assistant Forecaster Department of Meteorology Male

REWRTOPTHE WRTY-FOURW REOIOHALCOMMTIEE

MONGOLIA

Representative

Alternate

MYANMAR

Representative

Alternate

NEPAL

Representative

Alternate

SRI LANKA

Representative

11IAIIAND

Representative

: H.E. Dr G. Dashzevcg Vim-Minister of Health Ulaanbaatar

: Dr R h l a n Senior Medical Officer Ministry of Health Ulaanbaatar

: Dr Kyaw Win Director, Department of Health Yangon

: Dr U Kan Tun Deputy Director, International Health Division Ministry of Health Yangon

: Dr Narendla Bahadur Rana Additional Secretary Ministry of Hcalth Kathmandu

: Dr B.D. Chataut Regional Director Regional Directorate of Hcalth Eastern Development Region Dhankuta

: Dr U.HS de Silva Deputy Director-General (Planning) Ministry of ilcalth Colomho

Dr Vitura Sangsingkeo Deputy Permanent Secretary Ministry of Public Health Bangkok

Dr Suthas Vcjcho Chief Medical Officer Offiec of the Pennancnt Secretary Ministry of Public Health Bangkok

Dr Somsak Chunhalas Director. Health Statistics Division Ministry of Public Health Bangkok

RBWRTOFTHE FORT-FOURTH ROGlONALCOMMnlEE

2. Representatives ofthe United Nations and Specialized Agencies

Unitcd Nations Development Pmgramme

United Nations Children's Fund

lntcrnational Confedcratian of Midwives

International Planned Parenthood Federation

World Federation of Occupational Therapists

World Rehabilitation Fund, lnr.

Soeiety lor Health Wucation

: Mr Mohammed Fnmhuddin Resident R e p ~ c n t a t i v e United Nations Devclopmcnt Pmgrammc P.O. Bm 2058 Oakvilla. 4 Kvlhidharhumagu Ma14

: Mr Ahmad Musanna Assistant Rcprucntative Unitcd Na t i on r~ i l d r en ' s Fund M. Maav+hs Huge Malt

4. Representatives of Noripventnrerrtal Organizatiotis

: M n Ruth Wong Senior Lecturer. Department of Health Studies Hong Kong Polytechnic Hung Hom Kwlloon. Hong Kong

Mr KA. Rahman Chairman, Regional Council for South Asia International Planned Parenthood Federation C/O Family Planning Association of Bangladesh (FF'AB) 2 Naya Paltan Dhaka-2. Bangladesh

M n Suchada Sakornsatian Occupational Therapist 174, Chareonakorn Road Soi Chareonakorn 6, Klonpasan Bangkok, Thailand

: Dr M. Arulpitchai Narayanan President. ARMA Hospitals and

Assistant Director Regional Of f i s for India World Rehabilitation Fund, Ine. 34 First Main Road. Gandhi Nagar, Adayar. Madras4Nl020, lndia

5. Observers

: Dr Naila lbrahim Didi Founder Member Soeicty for Health Education Male, Maldives

1. Opening of the Session

2. Subcommittee on Credentials

2.1 Appointment of the Sub-committee

2.2 Approval of the report of the Sub-committee

3. Election of Chairman and Vice-Chairman

4. Adoption of the Provisional Agenda and Supplementary Agenda, if any (SEAIRC4411)

5. Appointment of the Sub-committee on Programme Budget and adoption (SEAiRC4413) of its terms of reference, and election of the Chairman of the Subcommittee

6. Adoption of Agenda and election of Chairman for the Technical (SEIVRC4414 and Add.1) Discussions

7. Review of the draft provisional agenda of the eighty-ninth session of (SEAIRC44/15) the Fxecutivc Board and of the Forly-fifth World Health k w m b l y

8. Addrcs.5 by the Director-General, WHO

9. Forty-third Annual Report of the Regional Director (SENRC44f2)

10. Technical Discussions on "Disaster Preparedness" (SEA/RC44/17)

11. Sub-committee on Programme Budget

11.1 Cnnsideration of the reporl of the Sub-commiltee on Programme (Sl':NRC44120) Hudget

12. Consideration of the recommendations arising out of the Technical (SEAiRC44121) Discussions

13. AIDS

13.1 Update (SEAiRC44B and SEAIRC44nnf.2)

13.2 Report of the Management Committee of the Global Programme on AIDS

13.3 Nomination of a member to the Management Committee of the (sEmC44n2) Global Programme on AIDS in place of India whose term expires on 31 December 1991

'originally issued as dorument SEARC4411 on 18 July 1991

Renew of the second evaluation of the Regional Strategies for Health for All

WHO Special Programme for Research and Training in Tropical Diseases

15.1 Report on the Joint Coordinating Board (JCB) session

15.2 Nomination of a member to JCB in place of Indonesia whose term expires on 31 December 1991

WHO Special Programme for Research, Development and Research Training in Human Reproduction

16.1 Report on the Policy and Coordination Committee (PCC) session

16.2 Nomination of a member to the Policy and Coordination Committee in place of Nepal whose term expires on 31 December 1991

Management Advisory Committee (MAC) of the Action Programme on Essential Drugs

17.1 Report on the session of the Management Advisory Committee of the Action Programme on Essential Drugs

17.2 Nominat~onofamember tothe Management Advisory Committee in place of Indonesia whose term expires on 31 December 1991

Evaluation of the International Drinking Water Supply and Sanitation Decade (IDWSSD)

WHO'S contribution to the international efforts towards sustainable development

Consideration of resolutions of regional interest adopted by the World Ilealth M m h l y and the Executive Board

l ime and place of forthcoming sessions of the Regional Committee

Selection of a subject for the Technical 1)iscussions at the forty-fihh session of the Regional Committee

Adoption of the final report of the forty-fourth session of the Regional Committee

Adjournment

(SENRCWIII and SErVRC44flnf.4)

(SEA/RC44/10 and SFmWfln1.3)

Anna 3

REPORT OF THE SUB-COMMITJEE ON PROGRAMME BUDGET

1. Introduction

The Sub-committee on Programme Budget held a pre l imiw meeting on 22 September 1991 under the chairmanship of Dr Narendra Bahadur Rana (Nepal). The Sub-committee reviewed its t e r n of reference (document SEAmC44i3) and the two working papers (documents SEAIRC~~PBIWPI and SEA/RC44PBW2). The salient points wntained in the two working papers were highlighted for the benefit of the members of the Sub committee. The Sub-committee noted that the two working papers were part of the report of the twentieth meeting of the Consultative Committee for Programme Development and Management (CCPDM) which met in Maldives on 19 and 20 September 1991. The S u b committee met hvice again on 24 September 1991 to consider the two w o r m papers and fmakz its report to be presented to the Reional Committee. The meetings were attended by

Bangladesh Bhutan DPR Korea

India Indonesia Maldives Mongolia Myanmar Nepal Sri Lanka Thailand

Dr Md. Khalilullah Dr Jigmi Singay Dr Li Chang Bom Mr Kwon Sung Yon Dr A.K. Mukherjee Dr N. Kumara Rai Mr Mohmed Rasheed Dr R. Arslan Dr Kan Tun Dr Narendra Bahadur Rana Dr U.H.S. de Silva Dr Somsak Chunharas

2. Review of the Implementation of WHO'S Collaborative Programmes in the Member Countries during the First Eighteen Months of the Biennium 1990-1991

The Sub-committee reviewed the working paper contained in document SEAIRC~~A'BIWPI relating to the delivery of the Organization's collaborative programmes in the Member

'originally issued aa dcxument SEARC44rZO on 24 September 1991.

States and under the intercountry programme during the current biennium, both under the regular budget and under extrabudgetary funds. The Sub-committee, noting the discussions of the twentieth meeting of CCPDM on this subject, stressed the importance of WHO'S role as a lead agency and coordinating authority on international health work (Article 2(a) of the Constitution of WHO).

The Sub-committee also noted that the costing for long-term staff (LTS) component was being done on an aggregated basis globally by WHO headquarters. These are only tentative figures for planning purposes. In fact, during the course of implementation, unforeseen situations may alter this costing. Any discrepancies arising during the course of implementation need be adjusted on certain principles and guidelines so as to make the implementation of the LTS component more appropriate. Since the LTS component is looked upon as an aggregated basis, the need for additional costs to the country may ordinarily not arise. However, in case of unforeseen circumstances, these are to he adjusted in consultation with the respective country on a regional basis.

The Sub-committee then fully endorsed the recommendations made by CCPDM, as given in document No. SEA/PDM/Meet.m/8, page 4.

3. Guidelines for the Preparation of the Programme Budget for 1994-1995

The Sub-committee reviewed the working paper (document SEAIRC~~IPBIWPZ) and noted the programmeguidance memorandum issued by the Director-General, particularly the ncw approaches introduced in the formulation of the programme budget proposals for 1994-1995. The Sub-committee particularly noted that in the formulation of the programme budget proposals for 1994-1995, the Member States should give, if possible, special and greater attention to the five programme areas through a budgetary increase, in real terms, by at least 5 per cent taken together.

While agreeing with the recommendations of CCPDM as contained in document SEAIPDM/Meet.U)/6, page 8, the Sub-committee stressed the need to devise ways and means of effecting appropriate increases in the allocations to countrics which at present have a relatively smaller allocation under the regular budget of WHO.

4. Any Other Issue

The Sub-committee felt that the South-East Asia Regional Office should take into consideration the collaborative activities being undertaken by Member States under the mechanism of TCDC. Adequate efforts should be made to mobilize extrabudgetary resources in furtherance of such bilateral and multilateral activities?

'~cmlutioa SWHM Mccr2 adopled at thc Ssmnd Meeting d Minisma of Health of Cwnnir. d WHO South-!%I Asia R+o, a d rrsolution WHA43.9 refer

Annex 4

RECOMMENDATIONS ARISING OUT OF THE TECHNICAL DISCiUSSIONS

ON DISASTER PREPAREDNESS

1. Introduction The Technical Discussions on the subject of "Disaster Preparedness" were held in the main Conference Hall on 24 September 1991 under the chairmanship of Dr Gandung Hartono, Director-General, Communicable Diseases Control and Environmental Health, Ministry of Health, Jakarta, Indonesia. Dr B.D. Chataut, Regional Director, Regional Directorate of Health S e ~ c e s , Eastern Development Region, Dhankuta, Nepal, was elected as Rapporteur. The working paper for the Technical Discussions (document SEA/RC44/17), along with the Annotated Agenda (document SEAIRC444 Add.l), formed the basic for the Technical Discussions and the conclusions and recommendations drawn.

1.1 Introduction by the Chairman

The Chairman opened the meeting by welcoming the participants. The subject chosen for this year's Technical Discussions, namely, disaster preparedness, was highly relevant and extremely important in the light of past experience of natural and man-made disasters in the countries of the South-East Asia Region. Individual countries were facing various types of natural and other disasters resulting in varying degrees of disruption, dislocation, and loss of life and property, which required concerted action within the countries and increased intercountry cooperation in order to enhance the level of preparedness and response in the event of disasters. The Chairman invited the ~articipants to engage in discussions on the various aspects of disaster focusing particularly on the preparedness aspect. Much of disaster preparedness control and management dcpcndcd on close cooperation and coordination amongst the health and other sectors, and called for joint action, both nationally and internationally. Hc recalled that the Regional Committee had, at its forty-third session, selected disaster preparedness as thc subject for Tcchnical Discussions at its forty-fourth session.

12 lntrnductinn of the Working Paper

Dr M.Z. Husain, Director, PCUSEARO, introduced the working paper (document SEA/RC44/17) and recalled that these technical discussions were being held against the background of increasing magnitude and frequency of disasters in some countries of the Region. It was imperative to effectively prepare for, and deal with, disasters, and preparedness was the key element. He pointed out that the Annotated Agenda and the connected working paper comprehensively covered aspects of the subject under discussion. Although the main focus of debate and discussion should be on preparedness, which was crucial for enhancing national capabilities, it was also necessary to minimise the effects of natural or technological disasters.

In order to facilitate the start of the discussions he highlighted five different areas, viz. disaster trends and future projections, disaster preparedness, post-impact response, training and capacity building, and international action. He also referred to the particular concern and mandate of WHO to coordinate the health aspects of disaster preparedness and response in the international community. He referred to the role of WHO in helping countries enhance their capacities through technical cooperation at the country level, and through coordinating regional and international cooperation.

2. Discussions

The discussions commenced and all members of the Committee contribuled accounts of the general experiences in their countries, especially referring to the types of disaster that were frequent. The participant from Thailand felt that there was not enough experience in dealing with disasters in his country, but that disasters were becoming more frequent in recent years. To deal with this a National Committee had been constituted and it met every month. In his opinion, it was important to prepare people for meeting disasters with confidence. He also felt that countries with experience, both from the South-East Asia and the Western Pacific Regions, should join together and develop short bi-regional training courses in disaster preparedness.

The representative from Myanmar felt that an operational debition of disaster oould be as follms ''m of human emlogy which communities onnd m r m or ahrorb within their own resources''. In Myanmar, cydones, floods rainfall, fire hazards during dry d e r , and accidents w r e the annmon types of disasters He also felt that keeping people prepared for disasters was impottant and that in the prc-disaster phase, mcst &en there was no warning Community partidpation and self-help were key issues since people in communities we almost always the th to provide shelter, food and drinking water to an alTeded populatim 'Ilk, of cmw, did not predude relief from national and international agencies for alfeded people. Plans w r e m o r d i n a t e d n o [ ~ a t t h e ~ l e v e ~ b u t a l s o a t t h e d i s t r i d a n d t o u m s h p l e v e I s . ~ health sedor had sp& mpomibility for the health of the people. A video presentation prepared by Myanmar on the flooding of the lrrawady Basin was also made during the intermksbn.

The representative from Maldives stated that the situation in his country had changed dramatically during the last ten years. In April 1987, storms with high waves caused colossal damage to property amounting to $40 million, and, in May 1991, strong winds, in some places up to 95 knots per hour, resulted in damage to more than 10 000 houses and other structures, particularly in the southern atolls. This was also the first time that Maldives had appealed for international aid for disaster relief. Another cause of concern for Maldives was global warming and the anticipated rise in sea level since most of the islands were only one to two metres above sea level. He also referred to the ongoing SAARC study on the causes and consequences of natural disasters and pointed out that, while the study was in progress, there had been a change of perception in Maldives about the character of disasters. A National Committee, which had been constituted earlier, had now been coverted into a National Commission for Protection of the Environment. There was also a Ministerial Committee which supervised the development of plans for disaster relief and management. It was essential, in his new, to increase the awareness of the public and to adequately prepare them, to establish early warning systems and to act in a coordinated manner. He also felt that it was difficult for small countries with scarce resources to establish highly sophisticated infrastructures for monitoring weather and climatic changes. He felt that UN agencies like WMO and UNEP should support the infrastructure, and help establish a network for relaying sensitive information to countries that do not have thcir own monitoring systcms. It was also felt that WHO could assist Maldives in developing a programme lor disaster preparedness which, in the initial stages, should include disasters that were particularly dangerous to human health. Man-made disasters such as due to over- exploitation of water resources, were becoming more common and thii, in the case of Maldives, could be particularly damaging. Water conservation technology was crucial since the aquifer in Male was precariously balanced. International assistance was essential. A point was also made that whiie there were general aspects of dealing with dicasters, there were also individual country-specific issues which needed to be carefully considered.

The representative from Nepal referred to the unique geographical position of his country and stated that many of the disasters related to the topographical character, namely, landslides, earthquakes, floods, etc., had become common in recent years. Accidents, fires and such other disasters due to deforestation, road building, etc. were also becoming common. Nepal had had an earthquake about three years earlier which caused substantial damage. A committee under the chairmanship of the Home Minister had been set up and il included a representative of the Ministry of Health. A master plan to deal with disasters was under preparation. The health seclor had proposed to sct up trauma units in various parts of the country.

The representative from lndonesia said that in the past decade lndonesia had recorded nearly all kinds of disasters, including volcanic eruptions, lava floods, flooding by water, accidents, fires, landslides, storms, food poisoning and outbreaks of communicable diseases. Disaster management in lndonesia was complicated by the

REWRTOFTHE FORTY.FOURlH REOIONALCOMMWIRE

variety and frequency of occurrence of hazards as also by its size, the diversity of local culture, and the unequal population distribution. His country had considerable experience in disaster management, but this had been compartmentdised and did not realize the benefits of an integrated approach. In 1990, the President of Indonesia issued a decree setting up an institutional framework for disaster management at the national level which focused on relief at the local level. However, pre-disaster protection had yet to be emphasized. The Inter-departmental Coordination Board covered prevention, preparation, relief, rehabilitation and reconstruction for both natural and man-made disasters. It was chaired by the Coordination Minister for People's Welfare, and recently the Health Minister had become a member of the Board. Indonesia had specialized facilities located in Jakarta called the Indonesia D i i t e r Management Centre. Provincial Governors and District Chiefs had responsibility for the coordination and management of disasters. The Government of Indonesia had currently proposed a project to strengthen disaster preparedness and disaster management. It hoped to build up on previous assistance from UNDP in different aspects of disaster preparedness and management.

The representative from India said that, with the wide variation in the physical environment of India, the country had always been vulnerable to the whole range of disasters. With industrialization, man-made disasters had also increased. Deforestation in various parts of India had added to the problem of floods. The country very heavily depended on an unstable monsoon season, which resulted in floods as well as droughts. Drought, as a natural disaster, had plagued India, and not only caused loss of agricultural production but also much avoidable hardship. While efforts had been made to control floods, India lost a very large amount of its agricultural production in floods. Tropical cyclones were common in April-May and in September to December, particularly on the eastern coast. In recent times, cyclones had struck the eastern coast of India and caused very great destruction of property. India was also prone to soil erosion and desertification. It had also been affected by a number of earthquakes, some with severe consequences. The population density aggravated the effects. Though the administrative machinery was well prepared to deal with routine natural disasters, industrialization had gone on apace, and technological disasters had compelled the Government of India to take a new look. A scientific approach had become necessary because such disasters often arrived with unexpected severity and suddenness. The health sector was very often caught unawares. A notable example was the Bhopal gas leak tragedy, which led to 2 000 deaths and 20 000 casualties. It was a grim reminder of the fragility of the system. There was a need for specific control measures, including epidemiological surveillance, setting up of statistical units at the district level, research for disaster planning, case studies, and manpower development. He also referred to the use of local (State) institutions for training people in disaster management. In this context, he referred to the need for countries with common borders to coordinate their efforts in disasters affecting people across borders, since, like epidemics, disasters also did not recognize international boundaries.

The representative from Bangladesh stated that the WHO definition of 'disaster' appeared incomplete unless social disruption was added in addition to economic disruption. He then gave a country statement with particular reference to cyclonic storms that occurred in April 1991 in which over 140 000 human lives were lost, a large number of infrastructures, including 1.8 million houses destroyed, and extensive damage caused to ports and industries, and to crops and livestock. He said that since floods and cyclones were a recurrent phenomenon in the Lives of the people of Bangladesh, they were gradually gaining experience in dealing with disasters and paying attention to better management. He felt that mapping wouldbe useful since it provided information about areas likely to be hit by cyclones and flood-prone areas. The forecasting and broadcasting information system needed to be strengthened so that management and provisional senices could be organized and coordinated. He felt that there was a specific need to identify resources, train personnel, particularly health and community leaders and workers, improve managerial skill and provide logistics and materials to areas likely to be affected, particulaly water, food and cash. Besides, he advocated the need for bilateral collaboration with neighbouring countries.

The representative from Bhutan stated that a National Environmental Commission had been set up in his country in 1990, which was undertaking a number of studies. His country had rwgnized that rapid development could lead to calamity and this had already been seen with the increasing number of road construction activities which had caused landslides. It was necessary to sustain the fragile ecosystem for which specific provisions wcrc being made. There was a recognition that it was no1 always easy to enforce conservation rules in the face of the need to develop the economy at a rapid pace. His country would welcome joint efforts for disaster management and preparedness.

The representative from Sri Lanka stated that the situation was different in his country. Common disasters, such as floods and cyclones, continued lo exist, but the armed conllict that had afflicted his country in recent years had led to a number of serious consequences. It was also not possible to map vulnerable areas or to have emergency preparedness for dealing with such unpredictable situations. However, the Gencral Hospital in Colombo had an emergency preparedness plan and had been able to deal remarkably well with casualties from bomb explosions in recent events. Similar plans for other hospitals wcre in the process of being drawn up. One of the issues emerging was the rehabilitation of disabled persons. Anothcr concern was the need to give attention to special areas, since migration and establishment of refugee camps wcre creating new situations because of the draining of resources of local and adjoining areas and the resultant adverse health consequences. This was particularly because of the ethnic composition of refugees and the epidemiological diversities in refugee populations. While a strong coordination mechanism should work in providing the necessary services from both government and nongovernmental orgimizationr, focal points for health, both at national and distrid levels, have to be identified Training of health workers at &ous levels should be undertaken.

The representative from Mongolia, referring to the sparse population in his wuntry, stated that Mongolia had faced different natural disasters such as fue, flood, drought, etc. For example, there was a heavy flood in 1983 in Ulaanbaatar and, in 1990, fires due to drought covered a very large area in the eastern part of the wuntry and caused losses of over 100 000 head of cattle.

3. Conclusions

Following the exchange of wuntry experiences and views, the participants discussed several main areas and arrived at the following conclusions:

(1) It was concluded that the frequency of natural disasters had been on the increase in the past decade and called for more attention and adequate disaster preparedness at national, regional and global levels. However, a new qualitative dimension had been added due to the emergence of man-made or technological disasters. While assessment of the past trend remained important, a number of global threats arising from the greenhouse effect, atmospheric ozone depletion, and threat of global climatic change with a rise. in temperature had to be reckoned with. This called for a great deal of international cooperation at the global level with sharing of knowledge and information and scientifically sound projections behveen wuntries with a capacity to monitor and generate information and countries that were potentially at risk.

(2) With regard to the area of post-impact response, it was felt that the period immediately after disasters struck was a critical one when Eves were endangered and disruption of infrastructure and services leading to acute deprivation was at the highest. Relief to human misery and distress in the fust hours after a disaster were the most critical, when the local resources - human, material and organizational - wuld and must play the major role before outside assistance wuld be mobilized. The participants also endorsed the idea that besides immediate response and recovely, it was equally important to plan for longer term rmnstrudion and preparedness to meet future disasters. Longer term measures were also indispensable for enhancing the capabilities of the health infrastructure and health personnel in cooperation with community organizations to prepare for, and respond to, disaster situations.

(3) A Manual on Emergency Preparedness and Response, prepared by the WHO Emergency Relief Operations Unit of WHO headquarters, was made available to the meeting. It was found to be a useful guide to make a rapid assessment of the health effects of disasters of various types.

(4) The meeting agreed that disaster mapping would be a valuable aid to disaster preparedness. It was understood to mean that disaster mapping would mainly wncern itself with building up an epidemiological profile and a health resource inventory. But this would need to be based on an earlier established geographical mapping of disaster-prone areas, perhaps by the relief or interior ministry. Also,

disaster mapping would be less applicable to industrial disasters. The information gathered by disaster mapping would become more useful when used to establish a plan for disaster relief at the local level. However, in man-made disasters it is not easy to foresee and establish a disaster map except perhaps in a few instances, such as concentration of chemical industries. It was also observed that there was a lack of comprehensive or authentic dt~uments published on man-made disasters.

(5) The meeting reiteratred the need for more effective international response and more intensified coordination amongst the UN, bilateral and international voluntary organizations with responsibility for, and involvement in, disaster relief operations. The meeting agreed on the need for a greater degree of cohesion within health emergency preparedness and response plan and between the health and other ministries in order to render disaster relief operations more effective and to achieve a higher impact by optimum utilization of limited resources.

(6) In order to be more effective, the health emergency prcparcdncss and response plan should not only be well known, within the health sector but, more importantly, the plan should be integrated into the overall national plan for disaster control. While health alone could not coordinate the total national effort, it should nevertheless coordinate within its own sector.

4. Recommendations

Based on the conclusions drawn, the meeting made the following recommendations:

(1) In the context of the need for a broad regional or even global view of disasters, it was essential to expand the span of cooperation across the regions and globally, and, specifically, bi-regionally between the South-East Asia and the Western Pacific Regional Offices.

(2) Each country should prepare a health emergency preparedness and response plan within the national development plan. Health sectoral activities should be coordinated intrasectorally.

(3) The crucial factor of community involvement and self-reliance in disaster preparedness and management required that strong community organizations be supported with a high degree of public awareness of disasters and their prevention. UNEP and other international and bilateral organizations, which had sophisticated global intelligence on environment and climate, should provide continuous information and early warning to countries that could not maintain costly facilities.

(4) AU possible technical cooperation by concerned UN and other organi7ations, including WHO, should be provided to help wuntries with charting of disaster-prone areas and their characteristics. A specific programme on emergency preparedness with WHO cooperation should immediately be established in countries that had not done so yet.

(5) Each country should endeavour to set up a nodal centre of disaster preparedness and participate in a network of national centres. WHO and other wncerned UN agencies should provide technical and fmancial support to the establishment of national centres and interwuntrylregional network.

(6) Country-level studies on the sodal eBects, particularly health effects, of rapid economic development should be supported along with drafting of rules and regulations that protected the fragile ecosystem. A long-term perspective dimension should be added in such legislations to ensure a sustainable enkonment for future generations.

(7) To make a national plan of action effective, it is M'tal to develop a strong surveillance system including an epidemiological system which provides mapping of disaster patterns. An effective mechanism for necessary s e ~ c e s wuld be established within a certain time-frame. In addition, seleded institutions at regional and state levels should be designated by countries and recognized by WHO to impart relevant training in health emergency preparedness and response. In this regard, cooperation between neighbouring countries should be fostered through bilateral meetings, especially to prepare for, and combat, disasters that take place on both sides of an international border. WHO should play a supportive and facilitating role in bringing this about.

(8) International and National Red Cross and Red Crescent Societies have traditionally played a significant role, especially in immediate disaster relief. These and other nongovernmental organizations should be utilized also for raising public awareness, particularly awareness amongst school-going children.

(9) All forms of international relief assistance should be combined with a longer term perspective of support through which national capabilities and institution building and other forms of sustained capabilities were promoted. An evaluation of earlier disaster events and the use of lessons learnt should be encouraged. A pool of educational case studies should be established in order to serve as resource material for teaching. In this context, appropriate operational research should also be conducted in order to build up appropriate methodologies that could be incorporated in training programmes at various levels.

(10) WHO should intensify its communication and coordination with UN and other agencies involved in various aspects of disaster management. WHO should continue to develop its own capacity to monitor and disseminate valid information on health aspects of disasters and also develop appropriate training for national staff development in cooperation with competent WHO collaborating centrcs. WHO should also provide technical cooperation to countries, particularly the vulnerable ones, in order to be able to build up bilateral cooperation in disaster preparedness and management. WHO should mobilize all possible extrabudgetary resources to help establish a network of national centres and promote inter-regional and regional cooperation, training, research and information dissemination.

REPORT OF THE TWENTIETH MEETING OF THE CONSULTATIVE C O M M m E FOR P R O G W M E

DEVELOPMENT AND MANAGEMENT

INTRODUCTION

PURSUANT to the decision of the thirty-fifth session of the Regional Committee that the Consultative Committee for Programme Development and Management (CCPDM) should meet every six months to undertake a review of the implementation of WHO'S collaborative programmes in the Member States of the Region, the Regional Director convened the twentieth meeting of the CCPDM at Kurumba Village Resort, Kurumba, Maldives, on 19 and 7.0 September 1991, with the following terms of reference:

(1) To review the implementation of WHO'S collaborative programmes in the Member States during eighteen months of the biennium 1990-1991, i.e., 1 January 1990 to 30 June 1991;

(2) To report on the preparation of annual detailed plans of action for implementation during 1992;

(3) To provide guidelines for the preparation of the 1994-1995 programme budget; and

(4) To make recommendations concerning the working group study on improvement of programme management.

In his introductory remarks, Dr D.B. Bisht, Director, Programme Management in the WHO South-East Asia Regional Office, briefly mentioned the background to the establishment of the CCPDM and said that the prime task of the CCPDM was to undertake a periodic review of the implementation of the Organization's collaborative programmes in the Member States of the Region. The Committee had also been assigned

Originally issued as document SFMDMMcermB on 23 Scplenkr 1991

other important tasks relating to programme development and management during the past few years by the Regional Committee and by the Regional Director and its recommendations had been found useful both by the Member States and the Organization. The Member States had effectively utilized the mechanism of the CCPDM to participate in the development and management of the Organization's collaborative programmes, which had further strengthened the cooperative partnership existing between them and WHO in their joint endeavour for the attainment of the social objective of health for all by the year uXM. Referring to the agenda items included for the current session of the Committee, he expressed the hope that the suggestions and guidance provided by the Committee on these matters would facilitate the work of WHO.

Dr U Kan Tun of Myanmar was elected as Chairman and Dr Jigmi Singay of Bhutan as Rapporteur. The list of participants is given in the Appendix.

The Committee then adopted the provisional agenda (document SEA/PDM/Meet.20/1). The introduction of each agenda item by the Director, Programme Management, was followed by discussions and observations, which led to the formulation of recommendations by the Committee.

REVIEW OF THE IMPLEMENTATION OF WHO'S COLLABORATIVE PROGRAMMES IN THE MEMBER STATES DURING EIGHTEEN

MONTHS OF THE BIENNIUM 1990-1991, i.e. 1 January 1990 to 30 June 1991

THE working paper on the implementation of the Organization's collaborative programmes in the Member States during eighteen months of the biennium 1990-1991 (document SEA/PDM/Meet.U)/3) reflected a delivery rate of 65% for the Region as a whole in financial terms under the Regular Budget, and a delivery rate of 76% if the earmarkings were included. The Committee was informed that, as of 16 September 1991, the overall programme delivery rate had already reached 75% in terms of actual obligations, and 87% if earmarkings were included.

The Committee noted with concern that WHO'S collaborative programmes with Member States during the 1990-1991 biennium had not shown much improvement when compared to the previous biennium. It further observed that, as in the past, unsatisfactory implementation of fellowships, LCS and CSA components still continued to be major contributory factor to low programme implementation. The Committee, therefore, considered it imperative that the Member States and WHO should make concerted efforts to achieve full implementation of the 19%-1991 programme budgct during the rcmaining period of the biennium.

The following points emerged from the discussions on the subject:

(1) Delays in programme implementation in a few countries had occurred due to extraneous administrative factors.

(2) The programmes funded by the WHO regular budgct and other agcncies such as UNDP and UNFPA have different budgetary cycles as well as different processing procedures. Earlier, WHO, as the executing agency, had morc flexibility in the formulation and implementation of programme activities funded under extrabudgetary resources. However, over the years, some of the funding agencies had been assuming a technical role, and WHO had run into some difficulties due to changed modalities of programme development and operation. This should not, however, deter WHO from playing its technical role effectively, and the funding agencies should appreciate the mandatory role of WHO and facilitate programme implementation at country level.

(3) As more funds are being mobilized by countries themselves from various funding agencies, it would be advisable for the countries to have regular review meetings to monitor the progress and for the WRs to be involved with the mechanism established for monitoring these programmes by the countries.

(4) There isapparent discrepancy in the information on programme delivery as recorded at the country level and as shown on PDM cards by the Regional Office.

(5) Some countries experienced difficulties in securing timely release of funds to undertake activities under the LCS component as they are channelled through the Ministry of Finance. This also contributed to delays in programme implementation.

(6) Implementation of the fellowships programme had been discussed by the Committee on several occasions before. However, it still needed considerable improvement in terms of funding. In this contea, the Committee noted Thailand's approach to implementation of the fellowships programme through a process of underbudgeting and over-planning to safeguard against any unforeseen cost increase as well as to ensure smooth implementation of country programme activities, with a view to avoiding any last minute reprogramming of funds.

(7) According to the new financial rules in regard to fellowships, which had come into effect in 1991, financial obligations for a fellowship starting in the current biennium could eaend only up to the first year of the next biennium and not beyond. Thus, in the event of a fellowship extending beyond this period, the financial obligations would have to be met from the next biennial budget.

(8) Concern was expressed that the application of this new rule might create problems in securing placements in institutions in the absence of a firm financial commitment for the entire duration of the fellowship. The concept of a rolling plan might be adopted for implementation of the fellowships programme.

(9) it would be useful for the countries to have information on the available courses of study and appropriate institutions, both within and outside the region.

Taking into consideration the above observations, thecommittee made the following recommendations:

(1) For the 1990-1991 biennium, Member States should make concerted efforts to identify programme activities and accelerate programme implementation during the remaining three months of 1991, with a view to ensuring full delivery.

(2) The Regional Office should further improve its mechanism for processing requests received from the countries in order to facilitate timely implementation of planned activities.

(3) The Regional Office should improve informatics support to Member States in order to reduce the discrepancy between the financial information recorded at the country level and that recorded at the Regional Office on PDM cards.

(4) Member States should develop alternative andlor parallel programme implementation plans from the commencement of the biennium, especially where a country has a large fellowships programme, so that in case of failure to secure

REFORTOFTHE FORTY-FOURTH REGIONALCOMMITEE

placement for a fellowship the money could be automatically diverted to finance these parallel or alternative programme activities such as in-country fellowships, national group educational activities, etc.

(5) Member States shouldgive special attention to improving the delivery of programmes funded by extrabudgetary resources in the context of the increasing requirements for funds to implement national HFA strategies.

(6) Member States should initiate timely action to identify and nominate suitable candidates for fellowships, especially long-term fellowships, in order to improve the delivery of the fellowships programme. In this connection, the recommendations made by the Tenth CCPDM in September 1986 should be borne in mind.

(7) In cases of long-term fellowships extending over two or more biennial periods, Member States should ensure commitment of adequate funds to cover the entire duration of the fellowship in both the biennia before deciding on new fellowships.

(8) The existing coordination mechanisms between the planning and the implementing units at the country level and between the countries and the Regional Office should - be strengthened and further improved.

(9) WHO should extend support to Member States in the drawing up of realistic country programme implementation plans.

REPORTOFTHE FORR.fOURlH REGIONALCOMMmE

REPORT ON THE PREPARATION OF ANNUAL DETAILED PLANS OF ACTION FOR IMPLEMENTATION DURING 1992

PURSUANT to the decision of the Regional Committee on the preparation of annual detailed plans of action (POA) replacing the detailed programme budget, the CCPDM, at its eighteenth meeting hel$in September 1990, approved the format and contents of the framework for use by the Member States in the preparation of POA. The Committee then reviewed the information provided in the working paper (document SEAPDMIMeet.2014) on the steps initiated by the Member States for the preparation of POA in the light of the guidance from the CCPDM and the Regional Committee.

The Committee noted that these POA would form the basis of an agreement between the Member States and WHO for implementation of the 1992-1993 programme budget, and expressed the hope that these POA would become an important tool for programme managers, both at the country and regional levels, to monitor timely implementation of collaborative activities.

During the discussions, the delegates informed the Committee about the methods and approaches adopted by their respectivc countries in the preparation of the annual POA as well as their salient features. In this connection, the framework for POA approved by the CCPDM at its eighteenth meeting had been found quite useful by the Mcmber States. While appreciating the cfforts made by the countries in the preparation of POA for implementation of collaborative activities during the 1992-1993 biennium, the Committee recommended that:

(1) All cfforts should be made by the Member States to complete the POA in accordance with the framework approved by the CCPDM and submit them to the Regional Office by the end of October 1991;

(2) The Regional Office, on receipt of the POA, should take the necessary action to conclude an agreement with the Member States with a view to facilitating implementation of the 1992-1993 programme budget;

(3) Member States should provide the Regional Office some time next year with feedback from their experiences in the use of the framework for the preparation of POA for the 1992-1993 biennium; and

(4) If any support was required by Member States from the CST mechanism for completion of POA, this should be conveyed to the Regional Office at an early date.

GUIDELINES FOR THE PREPARATION OF THE 1994-1995 PROGRAMME BUDGET

THE Managerial Process for WHO'S Programme Development required the preparation of WHO's biennial programme budget within the framework of its General Programme of Work and the &b&ission of a-consolidated global budget to the world-~ealth Assembly for approval. The Committee noted that the Director-General had already issued programme guidance for the preparation 'of the 1994-1995 programme budget proposals. The Regional Director had forwarded the Director-General's programme guidance to the WHO Representatives for use in the formulation of preliminary programme proposals.

While reviewing the Director-General's programme guidance (document DGO/PCO/9l.I), which had been brought to the attention of the CCPDM for information, the Committee noted that the formulation of programme budget proposals for the 1994-1995 biennium would entail adoption of certain new approaches, namely:

(1) Application of criteria for determining priorities in the formulation of programme budget proposals for 1994-1995, as recommended by the WHO Executive Board vide its resolution EB87.R25;

(2) Use of the "rolling concept" in the preparation of programme statements with a view to covering, in addition to description of the evolution of national health situations, a period of four biennia. The programme statements would provide a summary of experiences gained during the implementation of the 1990-1991 and the 1992-1993 programme budgets, along with proposals for WHO collaboration during 1994-1995 and anticipated developments in 1996-1997; and

(3) Special emphasis laid on five programme areas, which should receive budgetary increase, in real terms, by at least 5% altogether, using the approved allocation for the 1992-1993 programme budget as a base.

During the discussions, the Committee welcomed, in general, the Director-General's guidelines on priority setting and thrust in the five priority programmes for the formulation of the 1994-1995 programme budget, which were by and large in linc with the national priorities. The following points emerged from the discussions:

(1) The fivc priority areas identified in the Director-General's guidance letter should bc seen in thc light of country-specific situations since a global indication in terms of thrust areas might not be suitable at the regional or country level.

(2) Support to the five priority areas should not be viewed in isolation but seen in the overall context of the national health development plan. As WHO's collaboration

with Member States aimed at enhancing the efforts of the national governments, support to these five priority programmes should be taken into consideration in the national perspective so that they could supplement the national activities.

It was advisable to develop a country plan for programmes supported by WHO and extrabudgetary resources which could also take into consideration the five priority programmes.

The 5% real increase envisaged is for all the five programmes taken together, and not necessarily for each individual programme.

Many countries in the Region had made tremendous progress in their health development activities. At the moment, many important programmes had been initiated and consolidation and extension of these programme activities were taking place in order to achieve the HFA goals. Ways and means should be found to enhance allocations under the Regular Budget to countries which have a relatively small allocation but have demonstrated a higher absorption capacity.

As the WHO funds are utilized for catalytic purposes, there should be some flexibility in the use of these funds for developing health services models which can later be replicated by the countries.

Concern was expressed that any increase in real terms to the five priority areas would result in reductions in other programme areas which may have a higher priority in the country-specific situation.

Regarding criteria for determining priorities, the country priorities would have preference over other criteria.

While noting the time-table for the formulation of the 1994-1995 programme budget, : CCPDM recommended that:

Member States should undertake, through the joint Government/WHO coordination mechanism, a review of implementation of national HFA strategies as well as of WHO collaboration during the 1990-1991 and the 1992-1993 biennia with a view to identifying ~riority programmes for WHO support during the 1994-1995 biennium;

The criteria for determining priorities as recommended by the WHO Executive Board (Annex 11 of document DGO/PCO/91.1) should be used by Member States in a flexible manner for selecting priority programmes for WHO collaboration, in accordance with the conditions and requirements specific to the country;

Special emphasis should be given to the following five programme areas, through a budgetary increase, in real terms, by at least 5% altogether, if possible:

3.2 Managera1 process for national health development (ercluding provisions for WHO Representative's ofice);

REPORTOFTHE FORT-POURTH REGIONAL COMMWEE

4.0 Organization of Health Systems based on Primary Health Care for intensified health development in counties most in need);

8.1 Nuhition;

11.0 Promotion of Environmental Health;

13.0 Disease prevention and control for integrated disease control);

and

(4) Member States should formulate programme budget proposals for 1994-1995 and programme statements in accordance with the guidelimes and time-table provided in the Director-General's programme guidance memorandum (document DGOIPCOI~I .I).

WORKING GROUP S'TUDY ON 1MPROVEMElVT OF PROGRAMME MANAGEMENT

THE Committee, during its review of programme implementation at its nineteenth meeting in April 1991, recommended that a study should be undertaken by a small working group to look into the question of persistently low programme delivery in the South-East Asia Region as compared to that in other WHO regions. In pursuance of this recommendation, the Regional Office had developed a paper outlining the modaIities for undertaking the proposed study.

'Ike main objectives d the proposed study were, inrerdia, to review in-depth the content and prmss d implementation of WHO'S cdlaborative programmes at muntry and regional levels with a view to identifying the issues and problems which led to delayed or non-delivery of programme activities at those levels. The study was en-ed to be undertaken in tw phace~ involving country and regimal lerels, including visits to the Regional Offices for the Eastern Mediterranean and Western PaciGc. Detailed protocds wwld be developed for each phace d the study, which was expeded to be completed over a period of two years.

The representatives from countries welcomed in general the proposed study on improvement of programme implementation, but felt that the duration of the study should be reduced and the results of the study should be available to the CCPDM some time in 1992. Since the proposed study was expected to identify the factors responsible for slow programme implementation, it should focus mainly on the process and contents of implementation, such as the planning process, managerial mechanism, implementation process, etc. It would also be advisable to undertake the study in a single phase rather than dividing it into two phases as proposed in the working paper (document SEAmDMIMeet.U)/6).

After further discussions, the Committee made the following recommendations:

(1) A study should be undertaken to identify the factors responsible for slow programme delivery, but the duration of the study should be short, particularly in the light of the fact that each country knew exactly where delays occurred;

(2) Every country should undertake its own study and submit a status report for consideration by the CCPDM at its meeting in April 1992. The study reports from Member States will be compiled into a regional report by the Regional Office;

(3) A common format should be evolved by the Regional Ofice for undertaking the studies in indi\idual Member Stata, providing for a certain degree of flexibility and balancing of bdh the content and implementation processes for use at the local level; and

(4) If required by Member States, support should be provided by the Regional Office for undertaking this study at the counlry level.

REPORTOP THE FORTY.FOURTH RFOIONAL COMMlTniE

Appendir

LIST OF PARTICIPANTS

B A N G 1 A I l P i S H

D r Md. Khalilullah Joint Secrebry (Planning rod Cmrdioation) Minirlry of Health and Family Welfare Dhaka

U I I U T A N

Dr Jigmi Singay Joint I)ir<c,or Dcpartmmt of ilealth Services 'lhimphu

Dr R Arslan Senior Med ia l Officer Mioistry o f H u l t b UIaaabaaur

1 MYANMAR Dr U Kyrw Win Dimtor, k p r n m c n t o f Heallh Ministry o f Health Y a n ~ o a

Dr U K.n Tun Dcpuly Direelor. International Health Division

DEMOCRA' l lC PEOI'I.E'S R E P U B L I C O F K O R E A Mxnnslry of Ileallh Yangon

Dr LI Chrne Rom ('hlcf \.lcJ~.al tllfnrcr I ) c l~~nmrn t af kiclcncr and Icchn.,lop M,",,!,, .>I I'"h1,. ll*al,h

M r Kwnn Sung Yon W l l O National Programme Office, Minislw of Public Ileallh

P~onmanb

I N D I A

Ncw 6 l h i

Ms Sujntha Kao Director (Intcrnationrl tlcalth) Monirtry of kleallh and Family Welfare N w I k l h i

I N D O N E S I A

Dr N. Kumara Rai Chiet Rvreav o f Planoing Ministry of Health Jakana

MAI.DIVES

M r Mohamed Kashrrd Deputy Direclor of Planning m d (iurdinnlion Ministry of l l ral th and Welfare Male

M O N G O L I A

H E Dr G. Darlueveg F in t Vice-Minister of llealth Ulaanhnalar

1 N E P A L

Dr 0. D. Chataul Regional Director, Regional Directorate of llealth Scrvim Eastern h e l o o m c n t Rccion

I SIU LANKA Dr U.H.S. dc Silva Depuly Director-General (Planning) Ministry of Health and Women's Affain Colombo

'THAILAND Dr Somsak Chunharas Director, Health Statisliu Division Office of the Pcmancnt Secretary Ministry of Puhlic Ileslth Bangkok

W l i O Secn(nr1sl

D r D L . Lishc Direelor, Pmgnmmr Management Dr MZHusain, Director, P lann in~ Cmrdinalion and -

Information M r D. Sanviocenti. Director, Suppon Programme Dr D+v Ray. Chief, Governing Bodies and Proloeol,

WI IO lieadouarters Geoevr . ~. Dr (Mr) N. M a t l a k R e p * and Davmentr Oflircr M r S.L Khatri. Acting Budget and Finance Officer M r 1 f .L Monga. Administrative Services Officer M r R V . Nararinhan, Special As i runt to

Director. Programme Management M r S. Vcdanamyanro, Spc i r l Asistan1

Pmgrrmme Cmrdinstion M r S K V a m r Adminirtrativc Assirtanl M r M.R. ffinagarzjan. Sccrctarial Assistant M r B.L. Tancia, Ten-Pmessor

SEAIRC4411 SEAIRC44R and C o n

SEA/RCbl/3

s m C 4 4 1 4 SEA/RC44/4 Add.1 SENRCA415

SEAIRC44114 and Con. 1, 2 and 3

SEAiRC44115 (Rev.1)

LIST OF OFFICIAL DOCUMENTS

Agenda . I Forty-third Annual Report of the Regional Director

Suggested terms of reference of the Subsommillee on Programme Budget D i t e r preparednes - Agenda Disaster preparedness - Annotated Agenda UNDPlWord BankiWHO Special Programme for Research and Training in Tropical Diseases - Report on the Joint Coordinating Board (JCB) session and nomination of a member to the Board in place of Indonesia Special Programme of Research, Development and Research Training in Human Reproduction -Report on the Policy and Coordination Committee (FCC) session and nomination of a member to PCC in place of Nepal Management Advisory Committee of the Action Programme on Essential Drugs - Nomination of a member lo MAC in place of Indonesia AIDS - Update Selection of a subject for the Technical Discussions at the forty-fifth session of the Regional Committee WHO'S contribution to the international efforts towards sustainable development (with particular reference to South-East Asia) General weniew of the International Drinking Water Supply and Sanitation Decade in the South-East Asia Region Nomination of a member to the Management Committee of the Global Programme on AIDS in place of India Consideration of resolutions of regional interest adopted by the World Health Assembly and the Fxecutive Board Review of the second evaluation of the regional strategies for Health for All Review of the Draft Provisional Agenda of the eighty-ninth session of the Executive Board and of the Forty-fifth World Health h?embly Time and place of forthcoming sessions of the Regional Committee Disaster preparedness (Working paper for the Technical Discussions) List of participants Report of the Sub-committee on Credentials Report of the Sub-committee on Programme Budget Remmmendatima&gout oftheTedmical ~ o n D $ a F l e r P r e p r e d n e s s Draft final report of the forty-fourth session of the Regional Committee for South-East Asia List of official documents

REWRTOFIHE PORTY~FOlJRlH REGlONALCOMMITIEf?

Information Documents

SEAiRC44Min. l and &".I

SENRC44IMin.Z and Corrl

SliNRCMlMin.3 SENKC44lMin.4 Sf:NRCl44/M~n.5 SENRCMiMin.6 SE.WRC44IM#n.7 SEAIRC44IMin.X

List of technical reports issued and meetings and courses organized during I ~ u l y 1990 - 30 June 1991 Situation of HWiAlDS in the countries of the South-East Asia Region (Compilation of unedited reports received from countries) Environmental ljealth aspects of Development - Cross-sectoral issues (Report of the Secretary-General of the UN CAnference on Environment and Development) Evaluation of the International Drinking Water Supply and Sanitation Decade in the South-Fat Asia Region (A background information document) Regional overview of EPI in the South-East k3ia Kegion (An information document) Saitama 1)cclaration - A call for new Public Health Action llcalth of the underprivileged

Minutes

First Meeting, 22 September 1991, 9.30 am


.Third Mecting, 20 September 1991, 8.00 am 1:ourth Mceting, 23 September 1991, 11.30 am Fifth Meeting, 25 Seplemlxr 1991, 8.00 am Sixth Meeting, 25 September 1991, 11.30 am Seventh Meeting, 26 September 1991, 8.00 am Eighth Meeting, 28 September 1991, 8.00 am

Resolutions

Forly-third Annual Report of the Regional 1)irector Selection of a topic for the Technical Discussions Resolution of thanks Time and place of the forty-fifth, forty-sixth and forty-seventh sessions Disaster preparedness Evaluati~n of the strategies for Ilealth for All Watcr supply and sanitation for the 199% All)S Sustainable development

SECTION II MINUTES OF THE SESSION

First Meeting, 22 September 1991, 9.30 am

TABLE OF CONTENTS

I . Opening of the session

Address hy the Deput Address hy the llegio Inaugural address by

2. Appointment of the Sub-committee on Credentials

3. Approval of the report of the Sub-wmmittee on C:redenlials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

4. Election of Chairman and Vice-chairman . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62

5. Statement by the Representative of UNDP 62

6 . Statement by the llepresentative of UNlC 63

7. Adoption of Provisional and Supplementary Agenda and Review of Draft Provis~onal Agcnda of thc Eighty-ninth Session of the fieculive Board and of the Forty-fifth World lIealth Assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

8. Timing of the Session . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

9. Appointment of the Sub-committee on Programme Budget and adoption of its terms of reference, and election of the

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Chairman of the Sub-committee . 6 5

10. Adopt~on of agenda and election crf Chairmzln for the Technical i)iscussions . . . . . . . . . . . . 65

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I I . Address by the 1)irector-General, Wl lO 65

12. Fortythird Annual Report of the Regional Director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68

13. Adjournment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

Annexes

1. Text of address by the Keg~onal Oirector 2. Text of address hy the 3. Text of address hy the Director-Genera 4. Text of Regional Director's addres intr

for the year 1990-1W1

'Originally iswed as document SEARC441Min.l ctn 22 September 1 9 1

1. OPENING OF THE SESSION (11m I )

The forty-fourth session of the Regional Committee was opened by Dr U Ko KO, Regional Director, in the absence of the outgoing Chairman and Vice-Chairman of thc forty-third session, in accordance with rule 12 of the Rules of Procedure of the Regional Committee.

Address by the Deputy Minister of Health and Welfare, Maldives

H.E. DR ABDUL SATTAR YOOSUF, Deputy Minister of Health and Wellire, Maldives, welcomed the participants, and recalled that eleven years ago Maldives had hosted the thirty-third session of the Regional Committee. It was the first occasion for his country to host a session. It was a momentous session in that the Regional Committee elected Dr U Ko Ko as the Regional Director for the ensuing five years. Dr U Ko Ko had, in his working, established a participatory type of relationship with all Member Countries, which greatly appreciated the work done by him during the past decadc.

On hchalf of the National Organbing Committee, he assured all possible hclp to rcprcscntatives for making their stay as satisfying as possible. He said that the agenda of the meeting included important topics demanding concentrated attention on the part of the representatives. He wished them all success in their deliberations and a pleasant stay in the country.

Address by the Regional Director

The REGIONAL DIRECTOR wclcomed H.E. the Ministcr of Health and Welfare of the Republic of Maldives, representatives of the Member Countries of the Region, representatives of the UN agencies and other international organizations, and other dignitaries. He expressed his gratitude to the Government of Maldives for hosting this session of the Regional Committee in Maldives which offered a unique atmosphere ol beauty and tranquillity. He also commended the progress made by the country in improving the health of its people through the primary health care approach. Thc Government of Maldives, under thc able guidance and leadership of H.E. the President, had stecred the country towards the expansion of the health infrastructure and implementation of the health programmes. He particularly referred to the success achieved in the prevention and control of malaria and leprosy and in the reduction of the crude death rate and the infant mortality rate.

The Regional Director referred to the scwnd evaluation of the HFAIuXX) strategies, carried out by the Mcmber Countries, and said that while progress in health development was satisfactory, as indicated by the results, the evaluation had also identified some problems and obstacles hampering the implementation of programmes. He urged the Member Countries to review and revise their health policies and strategies in the light of these problems within the context of the prevailing economic and political situations.

Referring to the concern expressed by the Consultative Committee on Programme Development and Management (CCPDM) about the low rate of programme implementation in the first year of the 1990-1991 biennium, the Regional Director assured the Member States that WHO would take the necessary steps to improve its programme delivery. At the same time, he solicited the cooperation of the Member States in adopting suitable measures in their own systems to improve programme delivery in the futurc.

The Regional Director haid that the South-East Asia Region had bccn allocated US$ 87 million from the WHO Global Programme Budget of US$ 808 million during 1992-93. Based on the annual detailed plan of action for the implementation of WHO'S collaborative programmes in 1992, which were to be finalized soon, agreements between WHO and individual Member Countries would be concluded. He hoped that the countries would prepare their plans rationally and implement them expeditiously.

Referring to thc glohal economic situation, the Regional Director pointed out that WHO was facing severe financial constraints. Its regular budget had registered zero-growth for the past six years. This called for the mobilization of more extrabudgetary resources and voluntary contributions. These resources, which, at present, almost matched the WHO regular budget, were being used for specific programmes such as AIDS, TDR, HRP and EPI. There was an urgent need for joint efforts by Member Countries and WHO to explore avenues for additional funds for sustaining the health development effort. In this context, the WHO Director-General's initiative of Intensified WHO Cooperation (IWC) with countries in the greatest need, taken in pursuance of World Health Assembly resolution WHA42.3, would prove to be an important mechanism for the mobilization of extrabudgetary resources.

The second United Nations Conference on the Least Developed Countries, held in 1Wl in Paris, had formulated a Programme of Action which had recogni7sd that, without improvements in the health standards, all measures of social and economic developmenl would remain ineffective. The U N General Assembly, while launching the Fourth UN Development Decade, had adopted the International Development Strategy (1991-1999) to strengthen development cooperation. This Strategy also laid stress on the goal of Health for All. Both these events, the Regional Director pointed out, provided opportunities for incorporating an adequate health dimension into the overall development process.

The implementation by Member States of the World Declaration on the Survival, Protection and Development of Children, adopted by the World Summit for Children, had been urged by the Forty-fourth World Health Assembly. WHO, along with UNDP, UNICEF and others, would collaborate with Member States in this Region in developing appropriate plans of action for activities cmcrging out of this Declaration.

Stressing the importance of nutrition which remained an important indicator of overall dcvclopmcnt, the Regional Director said that WHO and FAO, in collaboration with other UN agcncics, would organize an International Conference on Nutrition in December 1992 to draw the attention of governments and others to the problems relating to food and nutrition.

To intensify WHO's technical support to Member States and to cvolvc a global strategy for malaria control, three inter-rcgional meetings had been planned, one of which would bc held in Ncw Delhi in February 1%2. These would be followcd hy a Ministerial Confcrcncc on Malaria in Octohcr 1'992.

The Director-Cieneral of WHO, while addressing the Forty-fourth World Health Assembly and the eighty-seventh session of the Executive Board, had expressed concern at the slow progress in the achievement of health for all and urged the realization of a "new paradigm" for health which stressed the vital significance of health in human development. This "new paradigm" should help in the review and reorientation of the strategies and approaches for futurc hcalth dcvclopment and for the preparation of the Ninth General Programme of Work of WHO covering the pcriod lm-2001.

The Regional Dircctor stressed the sigtiificance of the annual meeting of Ministers of Health of the Region which rcaffirmcd its political commitment to the social goal of Health for All. It also provided guidance and support to WHO's collaborative efforts.

In conclusion, the Regional Dircctor reiterated WHO's appreciation of thecontinucd involvement and support of the Membcr Statcs in its functioning. The Regional Committee as wcll as CCPDM played an activc rolc in dctcrmining the Organization's policies and programmes and in its collaborative efforts. He expressed the hope that these bonds would be further strengthened in the march towards health for all in the Region (for full text, see Annex 1).

Inaugural Address by the Minister of Health and Welfare, Maldives

H.E. MR ABDUL SATTAR MOOSA DIDI, Minister of Health and Wclfare, Maldives, welcomed thc Regional Director and thc participants to the forty-fourth session of thc Regional Committee of the South-East Asia Region, and hoped that the arrangcmcnts for their stay and for the meeting would bc comfortable and satisfactory.

He said that this was the second time that the Regional Committee was meeting in Maldives. During the course of the week, the representatives would be discussing

topics of such vital importance as AIDS, disaster preparedness, strategy for Health for All and research and training in tropical diseases as they related to the Region, besides considering the Programme Budget.

H e said that maintenance of an adequate level of expenditure on health and related arcas of human development was recognized as a major factor for sustained economic growth. Expenditures on health were valuable economic investments and the pursuit of health and improvcd productivity through cost-effective primary health care actions, improvcd cconomic cfficiency and greater social justice should go hand in hand. H e emphasized that the powerful linkages between health and development must be recognized and acted upon, and that the investment on health should be accorded high priority by development planners and financial agencies, both in the developing countries and by the international community.

The W H O South-East Asia Region, with a population of 1.3 billion, had a variety of health problems, and thcrc was a need to give very careful thought to the ncw paradigm for health, initiated by the Director-Gcneral of WHO, kccping in view at all times that the goal of the Member Countries and WHO was the attainment of Health for All by the Year 2000. What had been achieved so far deserved considerable credit, but much more remained to be accomplished. No single approach could be prescribed for the attainment of the goal. Two important aspects had to be borne in mind in this regard. Firstly, that the health sector could not work alone and required the involvement of many othcr scctors. Secondly, it was essential to ensure community participation without which the health sector could not achieve the desired results.

The Regional CommittCc meeting brought together key figures involvcd in the implementation of health programmes. H e said that exchanges of experiences among representatives were bencfici;rl to Member Countries and extended the cooperation of his (iovernmcnt in making thcir task as easy as possible.

H e thanked thc Rcgional Director for his important address which covered all the vital issues related to the World Health Organization, and wished the deliberations all success (for full text, see Annex 2)

2. APPOINTMENT OF THE SUB-COMMITTEE ON CREDENTIALS (I lo?l 2 1 J

Thc Regional Committee agrccd that the representatives of Bhutan, Mongolia and Sri Lanka should constitute the Sub-committee on Crcdcntials.

The meeting was then temporarily adjourned.

3. APPROVAL OF THE REPORT OF THE SUB-COMMITTEE ON CREDENTIALS (ilm 2 2)

On resumption of the meeting, the representative of Mongolia, who had been elected Chairman of the Sub-committee on Credentials, read out the report of the Sub-committee recommending recognition of the validity of the credentials presented by the representatives of Bangladesh, Bhutan, Democratic People's Republic of Korea, India, Indonesia, Maldives, Mongolia, Myanmar, Nepal, Sri Lanka and Thailand.

The report of the Sub-committee was then approved.

4. ELECTION OF CHAIRMAN AND VICE-CHAIRMAN (Rem 3)

DR ABDUL SATTAR YOOSUF (Maldives), proposed by DR A.K. MUKHERJEE (India), and seconded by DR MD. KHALILULAH (Bangladesh), was elected Chairman of the session.

Taking the chair, Dr Yoosuf expressed his gratitude to the representatives far electing him as Chairman, which was a great honour for himself and his country. He hoped that he would be able to steer the Regional Committee smoothly in its deliberations during the next few days. He requested the representatives to be brief in their comments, in view of the fact that the Committee had a number of items for discussion.

On the proposal of MR MOHAMED RASHEED (Maldives), seconded by DR KAN TUN (Myanmar), DR KHALILULLAH (Bangladesh) was elected Vice-Chairman.

5. STATEMENT BY THE REPRESENTATIVE OF UNDP

MR MOHAMMED FARASHUDDIN (Resident Representative, UNDP) greeted thc Chairman and the Vice-Chairman on their election and thanked the Regional Dircctor for providing him with the opportunity Lo address the Regional Committee. He hoped that under the mature and dynamic lcadcrship of Dr Yoosuf, the Regional Committee would have fruitful deliberations and hoped that under the able stewardship of Dr U Ko KO, WHO would continue to forgc ahead towards its goal of HFA/2MW.

He stated that UNDP, in conjunction with WHO and Member Countries, had undertaken a number of constructive activities for human development in the Region. CJNDP had, time and again, stressed that it was necessary to translate econon~ic advancement into human development. Thc UNDP Human Development Reports of 1!Wl and 1991 had clearly demonstrated that economic development was the only means to achieve the ultimate end of human development, which meant improvement of ihc quality of life of human beings. He said that the Human Development Report had prepared what was called the human development index, which was a composite of three characteristics, viz., per capita income, life expectancy and literacy. For Maldives,

the ranking in human development index was 93 which was M points better than the figure for per capita income.

The emphasis on human and social development was singularly substantive and important in this country. As a result, Maldives had been classified as one of the medium human development indexed countries. Referring to the role of WHO, UNICEF and other UN agencies and Member Countries in the collaborative programmes in the areas of PHC, AIDS, water and sanitation and nutrition, he hoped that mutual cooperation would see these programmes come to fruition. He said that with the concurrence of the Member Countries, it was proposed to make human development the cornerstone of the UNDP Fifth Country Programme Cycle commencing in January 1992.

6. STATEMENT BY THE REPRESENTATIVE OF UNICEF

MR AHMED MUSANNA (Assistant Representative, UNICEF), thanked the Regional Director for being given an opportunity to attend the session. He reiterated the commitment of UNICEF to WHO and the Member Countries for close collaboration in improving the health of women and children. He recalled the mutually supportive role of the two agencies at global and country levels in the areas of universal child immunization, diarrhoea1 disease control, maternal and child health, family planning and nutrition, acute respiratory infections, essential drugs, training of health workers and the newly-emergent problem of AIDS. He stressed that the attention of the Committee was needed for strengthening existing mechanisms of collaboration and cooperation with WHO in order to provide increased support to the ongoing maternal and child health care and family planning programmes.

Expressing his concern at the health situation in these areas in the least developed countries, he called for enhanced support and improved coordination for optimum utilization of the limited financial and human resources available. This was particularly important in view of the economic crisis being faced by most countries and the threat of the AIDS pandemic which further jeopardized the prospects of development in the health sector.

He underlined the complementary nature of the shared goals of the various UN agencies to achieve Health for All by the Year UMO. Referring to the Dcclaration and Plan of Action adopted at the WorldSummit for Children, he reminded the representalivcs of the mandate given by the General Assembly to collectively support national government efforts in the implementation of national action plans within the next decade. Following the World Summit, Maldives had declared 1991 as the Year of the Maldivian Child. A National Conference on the Maldivian Child was held in Male in July this year to adopt a National Declaration and a Plan of Action for survival, protection and development of Maldivian children. Detailed national programmes of action, including budgetary

resources, implementation strategies and monitoring mechanisms, were expected to he finalized by the end of the year 1991.

Summing up, he said that although mortality rates were still high, it was satisfying to note that Maldives had already achieved some of the goals adopted by the World Summit of Children.

7. ADOPTION OF PROVISIONAL AND SUYYLEhlENTARY AGENDA , / ton 4, and REVIEW OF THE DRAR PROVISIONAL AGENDA OF THE EIGHTY-NINTH SESSION OF THE EXECUTlVE ROARD AND OF THE FORTY-FIFTH SESSION OF THE WORLD HEALTH ASSEMBLY (Im 7)

The Chairman referred to the provisional agenda (document SEA/RC44/1) which, hc said, had been developed in consultation with the Chairman of the forty-third session of the Regional Committee, the Director-General of WHO and the Member Countrics. He said that while considering the provisional agenda, it would be useful for the Committee to consider agenda item 7 "Review of the draft provisional agenda of the eighty-ninth session of the Executive Board and of the Forty-fifth World Health Assembly" (SENRC44115 Rev.1).

The REGIONAL DIRECTOR, referring to document SENRC44IlS Rev.], said that a revision of the document had been necessitated by recent changes in the agendas of the eighty-ninth session of the Excculive Board and the Forty-fifth World Health Assembly. He drew the attention of the representatives to the subject for Technical Discussions at the forty-fifth World Health Assembly session in May 1992, viz., Women, Health and Development. WHD dealt with the complex relationship between women, their social, political, cultural and economic situations and their contribution to health and overall development. More specifically, it would cover women's health and women as bcncficiaries of health programmes, women as providers of health care and women's health education as factors in the health sector which were crucial for women'? development. He hoped that the Member Countries would ensure that delegations were appropriately briefed on this important subject.

The provisional agenda was then adopted, after taking note of the provisional agendas of the eighty-ninth session of the Executive Board and the Forty-fifth World Health Assembly.

8. TIMING OF THE SESSION

The Regional Committee decided to work from 8.W am to 2.00 pm from 23 September 1Wl.

9. APYOINThlEN'I'Ok'TllE SUR-COMMITTEEON PROGRAMhlE RUDGE'T .All) AI)OPTION OF ITS TERMS 01.' REFERENCE. AND ELECTION OF THE CHAIRMAN O F THE SUB-COMMITIEE (Ilem \) Thc REGIONAL DIRECTOR, introducing the agenda item, said that in the past, the practice had been to present the broad programme budget in even-numbered years and thc detailed programme budget in odd-numbered years. In both cases, the Sub-committee on Programme Budget had been examining the detailed programme budget prior to its presentation to the Regional Committee. At its forty-second session, the Regional Committee had decided that only a single programme budget need be prepared for endorsement in even-numbered years, which meant that there would be no detailed programme budget for examination by the Sub-committee in the current year. The Sub-committee would undertake a review, based on an in-depth analysis made by CCPDM, of the implemcntation of the programme during the first 18 months of thc current biennium. The Sub-committee would also discuss the conclusions of the Twenticth CCPDM on the principles and steps to be taken in relation to the guidelines for preparation of the programme budget for 1994-1995. Thc feedback from the Sub-committec would provide useful guidance in formulating the programme budget proposal for the biennium 1Y)4-1995, to be undertaken from October 1991 to March 1992.

On the proposal of DR JIGMI SINCIAY (Bhutan), seconded by DR R. ARSLAN (Mongolia), DR NARENDRA BAHADUR RANA (Ncpal) was elected Chairman of thc Sub-Committee on Programme Budget.

10. ADOPTION O F AGENDA AND ELECTION O F CHAIRMAN FOR THE TECHNICAL DISCUSSIONS (Iron 6)

On thc proposal of DR SOMSAK CHUNHARAS (Thailand), sccondcd by DR B.D. CHATAUT (Ncpal), DR CANDUNG HARTONO (Indoncsia) was elccrcd Chairman for thc Technical Discussions on Disaster Preparcdness. The agcnda for the Technical Discussions was then adopted.

11. ADDRESS BY THE DIRECTOR-GENERAL, WHO (iron 8)

The Regional Director read out a message from the Director-Gcncral, WHO. In his addrcss, DR H. NAKAJIMA, rccalled the momentous cvcnts of thc past year which had witnessed an armed conflict with serious consequences worldwide. H c said that it was now for the local populations, supported by the intcrnational development community with its limited resources, to repair the damage. Eastern and central Europe, too, had witnessed far-reaching political and socioeconomicchanges. Man-madedisasters, accentuated by natural disasters like tornadoes, floods, outbreaks of cholera, malaria,

tuberculosis and the AIDS pandemic, were all signs of the "eternal ebb and flow of human misery" and indicated the edent of socioeconomic deterioration.

The sweeping changes in health and socioeconomic conditions all over the world called for global cooperation and global as well as local solutions. Health was becoming central to overall national development and newly-emerging health problems posed a challenge to the hitherto understood relationship between health and economics. Changes in development policies and strategies had not kept pace with these dramatic changes. The 1970s were witness to the adoption of the goal of HFADUM and the Declaration of Alma-Ata, whiie the 1980s were characterized by increased emphasis on monetary policies, a global deficit in fmancial resources, and a reversal of the centrally planned economies. These changes led to the marginalization of sustainable social development and the resultant breakdown of the normal coherence between economic and social policy. The failure to invest in people had resulted in the absence of a workable model for sociocconomic development, that is, a "paradigm".

Recent changes in the health and socioeconomic scene called for a new and coherent understanding of the relationship between economic and human development, within social development, in accordance with the sustainable development policies of the fourth United Nations Development Decade. The new emphasis implied that WHO and the Member States should pay more attention to the fundamental questions of (a) individual and community rights, (b) indicators of human need, health development and quality of life, and (c) the application of resources for overall health and human development. The fact could not be overlooked that the gap between the rich and the poor was widening, both within and between countries, and the attainment of equity in health development was often slow or even negative. This trend was discernible in indicators such as overall life expectancy, infant mortality, immunization, availability of essential drugs, per capita gross national product, balance of trade, food and nutritional status, availability of resources, disparity in infrastructure and logistics capabilities. Health was a human right and could not be left entirely to market forces.

The Director-General emphasized that WHO'S resources for technical cooperation in countries were not to be decided solely on the basis of national priorities but that they must reflect international health development policies and priorities. Critical questions like intended outcomes had to be answered, and it was this quest which called for a paradigm for health. This paradigm was not to replace the goal of health for all, but to help define a workable framework within which to develop a feasible and effective programme of work and to ensure its implementation through the correct use ofprimary health care. WHO'S collaborative programme with countries focused on the eight essentials of primary health care, the achievement of which called for pragmatic modcs of action that would include the development of human, technical and financial resources.

At the same time, new realities, new demands and new opportunities had to be kept in view. The proposed programme budget for 1994-1995 was expected to lay

emphasis on ensuring a significant increase in real terms in the regional allocations addressing five areas, namely, (1) the relationship between the state of the world economy and sustainable health development, as it affects the less developed countries; (2) the health of man in a deteriorating physical environment; (3) proper food and nutrition for health development; (4) an integrated approach to disease control; and (5) dissemination of information for advocacy, and for education, managerial and scientific purposes. These five areas merited the particular attention of representatives from Member States in their joint programmingwith W H O in the ensuing year. WHO'resources were the joint resourccs of all Member States and there was a need for flexibility in the deployment of WHO's resources within countries or between countries and regions if global needs and priorities so required it. Member States must make every effort to mobili7e additional resources. Extrabudgetary contributions without undue strings were needed to run special campaigns. Such contributions should not have any adverse financial implications for the regular budget. The crucial factor in this respect was WHO'S rcsponsivcness to Member Slates.

The Director-General said that priorities for WHO's technical cooperation must be based not only on the current health situation and immediate needs of a country, but must reflect forward-looking objectives and strategies for sustainable health and social development. Health for all was now beginning to encompass the entire life span of an individual, and the qucstion was how to generate and distribute needed resources to solve the emerging health problcms of each phase of the life cycle. The essential principles for decision-making must involve harmony among peoples in the community, and creativity in the use of technology and resourccs. Cost-efficiency of outputs and the effeclivcness of outcomes, in terms of impact on human health and overall sociocconomic development. needed to be monitored and evaluated continuously.

Recalling John Donne':, dictum that 'no man is an island cntirc of itself, everyone is a piccc of thc continent, a part of the main', the Director-Gcncral clnphasizcd the role of international solidarity in achieving progrcss. Hc said that the United Nations offered a potential framework for such action, but regretted that the UN and its Security Council were often left out when economic decisions were taken while social action was entrusted to specialized agencies like WHO for implementation in isolation. It was time lo define and set up a working relationship among the United Nations family for sustainable sociocconomic devclopmcnt ccntcred on human dcvclopmenr (for full tcxi, scc Annex 1).

The CHAIRMAN requested the Rcgional Dircctor to convey to the Director-General the appreciation of the Regional Committce for his erudite exposition which had provided food for thought and was singular in encompassing all the important activities in the field of health, and had also suggested various ways and means of tackling the problems in this field. H e was confident that the valuable ideas and actions

M I N l m 5 01 IHE FIRST MEEllNG

in the forceful address of the Director-General would help the countries in formulating their stand to meet the challenges facing them.

12. FORTY-THIRD ANNUAL REPORT OF THE REGIONAL DIRECTOR (Iron 9)

The REGIONAL DIRECTOR, while introducing the Annual Report for the period 1 July 1990 to 30 June 1991 (document SEAIRC44R and Corr.l), highlighted the details of the collaborative activities of WHO with the Member States.

He said that the most important challenge for the Member Countries was the formulation of health policies and their translation into effective strategies and programmes to deal with the dynamics of the current and emerging health problems in the Region. A Regional Consultation, held in June 1991, had adopted a regional action plan and identified future needs for strengthening national capabilities in health policy formulation and health planning. Subsequently, a Regional Consultation in Health Economics, held in October 1990, had prepared a regional programme of action in this rcgard.

There had been significant progress in health development in the Member Countrics - the crude death rate and the infant mortality rate had declined, the overall health status of the populations had improved, and the life expectancy at birth had increased. The health infrastructure had expanded and improved its coverage, including the quality of care, through training of community health workers and involvement of the community in the management of local health services.

The Regional Director said that the major expenditure in the management of the health infrastructure was on human resources, and WHO continued to support national efforts aimed at improving health manpower management. The Member Countries were in the process of strengthening and reorienting educational systems in order to achievc a quantitative balance and systematic relevance to their health manpower requirements.

He said that, as recommended by the Regional Committee in 1990, the focus of health development efforts in the last decade of this century should be on the health of the underprivileged through a holistic strategy and approach. An Intercountry Consultation on Health of the Underprivileged, held in August 1991, developed a framework for action in this important area.

The South-East Asia Advisory Committee on Health Research, at its meeting held in April 1991, discussed the need to formulate a strategic plan for the next fivc years in pursuance of the World Health Assembly resolution on the role of health research in the strategies for health for all and agreed to lay greater emphasis on the strength of research capabilities. A consultative meeting was held in April 1991 to identify a set of scientifically sound and relevant criteria for the appraisal of HSR project proposals that would be useful to funding agencies as well as researchers. The meeting of the

M I t J l l T E OFTHF F I M MEETING

Directors of Medical Research Councils, held in November 1990, endorsed the World Health Assembly resolution on the role of health research in the strategies for health for all and recommended the formulation of a plan for national action. The meeting also discussed thz role of traditional systems of medicine in health care delivery.

An Intercountry Consultation on Health Education Strategics in South-East Asia in the Context of HFA/2(KK), held in December 1990, provided the basis for defining thc functions and role of hcalth educators. Emphasis on maternal and child health was revived and stratcgics and plans of action were formulated in most of the countries for functional intcgraiion oflhe senices provided by EPI, CDD, ARI and MCH programmes. WHO also continued to support research in MCH and family planning, including safe motherhood. With a view to bringing together centres of excellence in the field of nutrition research relevant to local nutritional problems, WHO supported the dcvclopment of a Regional Nutrition Research-cum-Action Nctwork.

In the field of environmental health, WHO continued to pursue the targets for safe water and basic sanitation as part of the goal of HFtV2000. Some countries had launched activities for the improvement of environmental health, including prevention and control of health hazards from environmental pollution.

Essential drugs and vaccines, particularly the Drug Management Programme, had heen progrcssivcly developed with support from WHO. A majority of the countries had achieved immunimtion coverage of at least 80 per cent. The positive impact of WHO assistance on the immunization programme was the reduction of childhood diseases, especially poliomyelitis, diphtheria and pertussis. WHO had striven to promote self-reliance in vaccines by supporting local production in many countries, while efforts were made to develop national quality control systems to ensure that the vaccines used conformed to WHO standards.

The malaria situation in the Region had remained somewhat static during the past 5-6 years. All countries with endemic malaria were implementing the revised control strategy through the primary health care approach. Malaria control activities at intermediate and peripheral levels had been fully integrated into the basic health s e ~ c e s , and, at the national level, a core group of specialists was entrusted with the tasks of planning, supervision, training, research and coordination.

AIDS had assumed epidemic proportions in some countries. All countries of the Region had initiated prevention and control measures through short- and medium-term plans with support from WHO and other international and bilateral agencies. In thc absence of a curative drug or preventive vaccine, the emphasis had been on information, education and communication. H e reiterated that there was no room for complacency since AIDS had the potential of becoming a devastating threat if it was not contained with appropriate measures.

Acute respiratory infections were the leading causes of death among children. Tuberculosis continued to be a major health problem in the Region, and had been further accentuated by the emergence of AIDS. The leprosy control programme was gaining momentum and coverage with MDT was increasing in all the countries. Maldives was now in the process of eradicating leprosy, while two or three more countries of the Region were expected to do so in the near future.

WHO promoted an integrated approach through primary health care to achieve cost-effective control of communicable diseases. The incidence of noncommunicable and chronic and degenerative diseases had increased with higher life expectancy and changes in lifestyle. In view of the harmful effects of tobacco use, WHO had been supporting Member States in counteracting its use through information and education, and by encouraging health legislation.

Many countries had rcccntly cxpcricnced disastrous situations such as cyclones, floods, earthquakes, volcanic eruptions, and lirc. WHO had providcd support for developing national capabilities in disaster preparedness and emergency response.

The Regional Director said that although the mid-point of the road leading to the goal of Health for All had passed, problems still persisted. It was essential that the limitcd resources available were used effectively by supporting only the real priority needs for health development. The Dircctor-General of WHO had suggested five broad areas to be emphasized in WHO'S collaboration during 1W2-1093 and 1994-1%5. Thcsc were: (1) health of man in a changing environment, (2) proper food and nutrition for healthy life and health development, (3) integrated disease control, (4) dissemination of information for advocacy as well as for scientific, managerial and educational purposes, and (5) intensified health development action and support to countries in the greatest need.

In conclusion, the Regional Director reiterated that in spite of the overwhelming economic, social and political constraints and problems relating to human and financial resources, commendable progress had bccn made by the Member States with the ultimate aim of improving the quality of life of their people. He felt confident that the Regional Committee, through its collective wisdom, would continue to provide the Regional Office with valuable guidance and directions for future collaboration (for full text, see Annex 4).

The CHAIRMAN invited gcneral commcnts from the representatives on the Annual Report of the Regional Director. He added that specific comments relating to individual topics could be made later while discussing the relevant chapters. He further said that representatives of nongovernmental organizations were welcome to make observations on matters relating to their areas of interest, but that they should not raise issues relating to implementation of the programmes by the governments since government representatives were present.

MR KWON SUNG YON (DPR Korea), speaking on behalf of his country's delegation, congratulated the Chairman and the Vice-Chairman on their election. He also congratulated the Regional Director for his excellent report and for the efforts made for the improvement of the health programmes in the Region. He referred to the measures taken to implement the decisions taken by the previous sessions of the Regional Committee and expressed appreciation of the efforts to strengthen the organilation and management of district health systems as a key to primary health care.

Mr Kwon stated that the Government of DPR Korea had taken measures to further improve the 'section-doctor system'. His Government had also reviewed the national strategy for Health for All by the Year uXX) and taken necessary action for the future. He hoped that the RegionalOffice would continue to providesupport for the improvement of primary health care, including district health systems.

DR KHALILULLAH (Bangladesh) congratulated the Chairman on his election and expressed appreciation of the report presented by the Regional Director. He expressed appreciation for the emergency relief supplies provided by WHO to Bangladesh for disaster relief during the recent cyclone.

Referring to a meeting held at ESCAP on environmental health, Dr Khalilullah stressed the need for various agencies, such as WHO, UNICEF and WFP, lo coordinate their efforts with UNEP. He specifically requested WHO for increased involvement with UNEP in this important area.

MR RASHEED (Maldives) congratulated the Chairman and the Vice-Chairman on their election. He felicitated the Regional Director on his excellent report and expressed the appreciation of his country for the support received from WHO for the control of leprosy and hoped that such support would continue to enable them to achieve their targets.

DR U KYAW WIN (Myanmar) expressed apprecialion to the Regional Director for his excellent report. He said that communicable diseases and nutrition-related problems were on the increase in Myanmar, and requested WHO'S support to overcome these problems. He also emphasized that there should be coordinated programmes to fight malaria, HIV infection, luberculosis, etc. The national health plan had been adopted for 1991-92. It laid special emphasis on health programmes for the north-eastern border areas which had hitherto been unsewed. He expressed the hope that the help of UN agencies and nongovernmental organizations would be forthcoming.

DR SINGAY (Bhutan) joined the other representatives in congratulating the Chairman and the Vice-Chairman on their election as well as in felicitating the Regional Director on a comprehensivc and erudite report.

DR U.H.S. DE SlLVA (Sri Lanka) congratulated the Chairman and the Vice-Chairman on their election and also the Regional Director for an excellent report.

He said that Sri Lanka had focused attention on populations belonging to the low-income group who were provided with health care facilities under the 'Jan Saviya' (poverty alleviation) programme for the underpriuileged. He was happy to see the inclusion of activities on health economics in the report at a time when countries in the Region were trying hard to obtain extra finances for the health sector.

DR ARSLAN (Mongolia) congratulated the Chairman and the Vice-Chairman on their election and expressed satisfaction over the extensive work done by the Regional Office, particularly with regard to the improvement of managerial capabilities for national health development in the countries. He said that despite the consequences of regional conflicts, natural calamities and financial constraints hampering overall development in the developing countries, there was a common need for more efforts to strengthen the countries' own capabilities and promote regional self-sufficiency and self-reliance for the achievement of the goal of Health for All by the Year uXX). He hoped that this session would provide an opportunity for the representatives to have an exchange of views and to learn from each other's experiences.

DR MUKHERJEE (India) congratulated the Chairman and the Vice-Chairman on their election, and thanked the Regional Director for the Annual Report which covered all the major issues related to the Region. India had started discussions on its Eighth Five-Year Plan and its national priorities matched those of WHO. He also emphasized the grcat relevance of the topic of health economics. He noted with appreciation the excellent work being done in the Region with regard to the strengthening of training institutions and manpower development and said that lndia would keep international health issues in view while designing national plans.

DR HARTONO (Indonesia) extended his congratulations to the Chairman and the Vice-Chairman on their election and thanked the Regional Director for his excellent report. He stressed the need for extra efforts to strengthen the strategies for the achievement of Health for All by way of controlling communicable diseases combined with environmental hygiene.

DR RANA (Nepal) also congratulated the Chairman and the Vice-chairman on their election and the Regional Diector on his Annual Report. He referred to the launching of a new health policy by the Government of Nepal which envisaged that the benefits of health programmes should reach people in remote areas of the country. His Government was trying to establish sub-health posts in all those areas so that people living there, who ofhemi% laced a bt of hardship, could have access to health care. The ratio of hcallh personnel to population was low in Nepal. While acknowledging the help of other Member Countries, he sought their further support as well as continued WHO assistance in the training and development of health manpower to overcome the shortages in Nepal.

The CHAIRMAN concluded by expressing his thanks to the Regional Diector for a comprehensive report highlighting the main issues being faced by Member Countries in

the development of health policies. Despite various conflicting issues, the need for the training of health personnel, adoption of community-based approaches, health economics, and some others were the issues common to all Member Countries.

The REGIONAL DIRECTOR, responding to the observations made by the reprcscntativcs, said that the implementation of the collaborative programmes was a joint endeavour by WHO and the Member Countries. He suggested that, while taking up the topic of disaster preparedness duringthe Technical Discussions, the representatives might dwell more on the programme for disaster preparedness rather than on the relief provided following disasters in the countries, although such relief remained an urgent need in countries where disasters had occurred. WHO maintained that more emphasis was to be laid on preparing the countries for unforeseen disasters.

13. ADJOURNMENT

The meeting was adjourned.

TEXT OF ADDRESS BY THE REGIONAL DIRECTOR

Your Excellency, distinguished delegates, representatives of UN agencies and international organizations, ladies and gentlemen,

At the outset, I wish to extend my sincere and grateful appreciation to the Government of the Republic of Maldives for graciously hosting this session of the Regional Committee. I am especially grateful to Your Excellency for having graced this inaugural function in spite of the numerous demands on your precious time. On behalf of the World Health Organization and on my own behalf, I have great pleasure in extending to you greetings and a warm welcome on the occasion of the forty-fourth session of the Regional Committee being held in the mapscent ambience of the Republic of Maldives.

The Republic of Maldives, with its unique geographical features, its scenic beauty and tranquillity, and the homogeneity of its people, offers an unequalled backdrop for this august gathering of distinguished representatives from the Member Countries of the WHO South-East Asia Region. The counlry's commitment to improve the health and welfare of all its people through the primary health care approach has already achieved outstanding results, as reflected by the changes in the health status and other health and socio-economic indicators.

Excellency, the achievements of your country in expanding the health infrastructure and in implementing health programmes under the able guidance of your Government, and of His Excellency, the President, have gone hand in hand with your tireless efforts to mobilize the communities in the atolls and island5 for health development. The succcss achieved in the prevention and control of malaria and leprosy is indeed remarkable. With sigdcant reductions in the crude death rate and the infant mortality rate, the Republic of Maldives is well on its way to achieving the social goal of Health for AU.

Distinguished representatives, ladies and gentlemen, all Member Countries of the Region have carried out the second evaluation of their strategies for Health for All by the Year 2000. The results of this evaluation show that all countries have made satisfactory progress in their health development effons towards better health for all within the framework of equity and social justice. However, much more remains to be done if the social goal of Health for AU is to be f d y realized. Problems and obstacles in the implementation of such strategies have been identified through this evaluation process. These should be used as the basis for the Member Countries and WHO to re-examine and revise their health policies and strategies to improve operational results keeping in new the current and projected economic and political situation in the countries, the Region and the world as a whole.

While reviewing the implementation of the WHO'S collaborative programme at its nineteenth meeting in April 1991, the Consultative Committee for Programme Development and Management (CCPDM), which consists of representatives of all Member Countries of the Region, expressed its particular concern at the low rate of programme delivery during the f i s t year of the 1990-1991 biennium. In this connection, I can assure you that WHO will spare no effort to improve the management of programme activities. However, at the same time, I would like to urge the Member States to critically review their own procedures and take appropriate measures to expedite the implementation process in order to improve the efficiency and effectiveness of the WHO programme delivery at the country level in the ensuing biennia.

The Forty-fourth World Health Assembly, held in May this year, approved an appropriation, from the WHO global programme budget during the 1992-1M biennium, of an amount of USlE808 million, out of which US$ 87 million has been allocated to the South-East Asia Region. We are now in the process of completing the annual detailed plan of action for the implementation of WHO'S collaborative programmes in 1992 which w i U form the basis of agreements between WHO and individual Member Countries. I hope that the countries will prepare the plans rationally and implement them expeditiously.

The worldwide economic situation has placed severe limitations on the resources and hence the activities of the World Health Organization. For the past six years, the Organization has operated within the constraint of a zero-growth regular budget. It would be unrealistic to expert a better donor climate and an increase in the assessed contributions to WHO in the near future. WHO, therefore, has to mobilize more extrabudgetary resources and other voluntary contributions for supporting its collaborative programmes, particularly in the priority areas. These resources, which are now nearly of the same magnitude as the WHO'S regular budget at the global level, are being used to finance specific programmes such as the Global Programme on AIDS, Special Programme for Research and Training in Tropical Diseases, Special Programme for Research, Development and Training in Human Reproduction, and Expanded Programme on Immunization. It is imperative that more intensive efforts be made both by the Member States and WHO to mobilize additional funds from bilateral, multilateral and other agencies for sustaining the momentum of health development efforts in the countries. Through close cooperation and joint management between WHO and Member States, the Organization's collaborative programmes continue to be the most relevant, efficient and cost effective.

In the context of this issue, the Director-General's forward looking initiative of Intensified WHO Cooperation (IWC) with countries in the greatest need will be an important mechanism for the mobilization of extrabudgetary resources. This initiative, launched in pursuance of the World Health Assembly resolution WHA42.3, aims at promoting effective partnership between Member Countries on the one hand, and UN agencies and multilateral, bilateral and other international organizations cooperating in

the achievement of health for all through primary health care, on the other. Thus, the thrust of WHO'S regular budget needs to be targeted to where it will be most effective in supporting the mainstream of countries' health development activities.

The Second United Nations Conference on the Least Developed Countries, held in Paris in 1990, adopted the Paris Declaration and Programme of Action for the 1990s. The Programme recognizes, inter alia, that without profound improvements in the health standards in the least developed countries, other measures of social and economic development will remain ineffective. The Forty-fourth World Health Assembly was concerned with the issue, and adopted a resolution requesting Member States to take into account the outcome of the Conference, especially the need to include the health component in their socioeconomic development programmes, when formulating national development policies and plans.

The United Nations General Assembly has also launched the Fourth United Nations Development Decade, and adopted an International Development Strategy for the period 1991.1999 in order to strengthen international development cooperation. With regard to human resource development, which has the closest interaction with the process af economic and technological transformation, the Strategy lays emphasis on the goal of Health for All, including primary health care, prevention of chronic diseases, environmental health including sanitation and safe drinking water, nutrition, and the health needs of women and children. It also reaffirms the need for action in the control and prevention of AIDS as well as prevention of the spread of epidemics and other diseases that are endemic in many developing countries. The Strategy provides yet another opportunity to incorporate adequate health dimension into the overall development process.

The Forty-fourth World Health Assembly considered the follow-up action on the World Summit for Children, which adopted the World Declaration on the Survival, Protection and Development of Children. The Assembly invited Member States to accord political and economic priority necessary for the successful implementation of the Declaration, particularly the sections dealing with action that countries might wish to take to assure a better future for every child. The South-East Asia Region is committed to the follow-up of activities arising out of this Declaration, and, along with UNDP, UNICEF and others, will collaborate with Member States to develop the relevant plans of action in the context of HFA strategies and International Development Strategy.

Nutritional status remains an important indicator of human and other aspects of social development. WHO accords a high priority to nutrition in its collaborative activities with Member States. FA0 and WHO, in collaboration with other UN agencies, have decided to organize an International Conference on Nutrition in December 1992 to revive the interest of governments and international development agencies on problems relating to food and nutrition worldwide.

Malaria still remains one of the most important tropical diseases threatening 40 per cent of the world population. In order to intensify its technical support to Member States, and to enunciate a global strategy for malaria control, WHO will convene a Ministerial Conference on Malaria in October 1992. Prior to that there will be three inter-regional meetings to prepare for the Conference and to help achieve technical and political consensus among Member States. One of these meetings will take place in New Delhi, India, in February 1992.

Distinguished representatives, ladies and gentlemen, concerned at the slow and uneven progress toward-, the achic~ment of health for all, the Director-General of WHO, in his addresses to the eighty-seventh session of the Executive Board and the Forty-fourth World Health Assembly, called for the realization of a "new paradigm" for health, in which health is to be seen as central to human development and quality of life. This is in order to see clearly and comprchemively thc dramatic impact of the rapid and often unpredidable changes in political, economic and social conditions in this interdependent world on health developmcnt. With careful and extensive analysis of the Mlious interading factors having a bearing on people's health, this new paradigm will help in the re-examination and reorientation of strategies and approaches for future health development, and contribute to the preparation of the Ninth General Programme of Work of WHO for the period 1996-2001.

Thc Hcalth Ministers of h e WHO South-East Asia Region meet every year to r e a r m their political resolve and commitment to the social goal of Health for All, as well as to provide guidana: and support to the umperative efforts of the Organi~ation Their next meeting will bc held in thc Republic of Maldives in the coming week. The diredion and response provided by the Member States in various fora have also greatly helped in maintaining a high degree of relevance in WHO'S collaborative policy and programme in the Region.

In order to improve health status and quality of life of all peoples in the Region, the Member States and WHO have established close liaison and partnership. The consistent support and involvement of Membcr Statcs have immensely contributed to the smooth working of thc Organi~ation. The Regional Committee is always fully involved in determining the policy and programmes for WHO collaboration in the Region. The Consultative Committee for Programme Development and Management, which was established in pursuance of a mandate from the Regional Committee, has also evolved as an important mechanism in this collaborative process. With strong bonds having been established bctwcen the Member Countries and WHO, I am confident that our march towards health for all will progress smoothly with multiplied momentum.

Mr Chairman, ladies and gentlemen, let me once again welcome you all and express my sincere gratitude to thc Government of the Republic of Maldives for hosting this session of the WHO Regional Committee for South-East Asia in these beautiful and enchanting surroundings.

I thank you all.

TEXT OF ADDRESS BY THE MINISTER OF HEALTH AND WELFARE, MALDIVES

Regional Director of the WHO South-East Asia Region, Mr Chief Justice, Mr Speakcr, Honourable Ministers, Your Excellencies, Heads of Diplomatic Missions in Maldives, distinguished delegates to the forty-fourth session of the Regional Committee for South-East Asia, colleagues in the health sector, ladies and gentlemen,

It gives me great pleasure to welcome Dr U Ko KO, Regional Director of thc WHO South-East Asia Region, and the distinguished participants of the forty-fourth Regional Committee for South-East Asia. I hope that the arrangements made for your stay and for the meeting are comfortable and satisfactory.

This is the second time that the Regional Committee is meeting in Maldives. The week ahead of you is full of a heay agenda. During the course of the week, you will be giving your attention, among other topics, to such vital issues as AIDS, Disaster Preparedness, Strategies for Health for All, and Research and Training in Tropical Diseases, as they relate to our region, besides considering the Programme Budget. You will also be evaluating the status of the very important question of the International Drinking Water Supply and Sanitation Decade. While considering these issues, I havc no doubt that you will bear in mind the new paradigm for health, called for by the Director-General of the World Health Organization in his address to the last World Health Assembly and to the eighty-seventh and eighty-eighth sessions of the Executive Board.

Building and maintaining adequate levels of expenditures on health and related arcas of human dcvclopment is recognized a a major factor behind sustained economic growth.

Expenditures on health are valuable economic investments, comparable in tcrms of social rate of return with investment in other sectors. There can be little doubt that we have under-invested on carefully targeted health programmes, and there arc untapped opportunities to pursue health and improved productivity simultaneously through cost-effective primary health care actions. Improved economic efficiency and greater social justice can go hand in hand.

As highlighted in thc report of the Commission of Health Research for Development, the powerful linkages between health and development must be recognized and acted upon. Health investment should be accorded high priority by development planners and financial agencies, both in the developing countries and by the international community. Health, like education, is often perceived as a soft consumption sector which will only follow advances in harder sectors like industry and agriculture.

Investing wisely in health will build human capital, enabling people on a more equitable basis to contribute to and gain from economic productivity. Unlike investments in factories and roads, investment in health can generate returns that do not depreciate and that can bring significant social benefits for a Lifetime and into the next generation.

The WHO South-Eact Asia Region, with its population of 1.3 billion, has a variety of health problems. We, therefore, certainly need to give very careful thought to the new paradigm, remembering at all times the goal that members of the World Health organiration set to attain Health for AU by the year 2000. What has been achieved to date deserves considerable credit. However, much more remains to be accomplished. To attain the goal we set, no single approach can be prescribed to all the Member Countries of the Region. Neverthe1e.y there are two important factors that are essential in every country. The fust, is the realization that the health sector cannot work alone. It reauires the involvement of many other sectors and support of several government departments lo conduct its functions. The scwnd important factor kcommunity participation. Without whole-hearted participation . . by the community in health programmes and support by other related government ministries or departments, no amount of expenditure by the State or effort by the health sector alone can achieve the desired results.

Thic annual meeting brings together the key fgures involved in implementing the health programmes planned for the citiz~ns of the respectiw countries of our Region. Set in vastly diTfcrcnt geographical locations, your problemc and your solutions to same may vary. Howcver, every wuntry's experience is ol immense value to the other members of the Region. T h q while you diqpose of the items on the agenda couectively, exchanges of news carried out at the personal level are equally important, n d only to two individual countries, but, quite often, also to the whole Region. Therefore, as hosts to the forty-fourth session of the Regional Committee, we in Maldives wish to assure you of our readiness to cooperate with all the dclcgates to make their tasks at thic meeting a$ easy and succwful as possible.

To our Regional Director, Dr U KO KO and his dedicated staff, I would like to extend our sincere thanks for the readiness with which our requests are always heard and considered.

With these remarks, I have the honour and pleasure of inaugurating the forty-fourth session of the Regional Committee of the WHO South-East Asia Region and wish the very best for this session's proceedings.

I thank you.

TEXT OF ADDRESS OF THE DIRECTOR-GENERAL, WHO

Mr Chairman, excellencies, honourable representatives, ladies and gentlemen, colleagues and friends,

When I addressed this Regional Committee last year, I spoke of the need to convert the 1990s from a "decade of debt and poverty" to a "decade of opportunity". At the same time, I warned that without leadership, innovation and preparedness, this could turn out to be a decade of crisis and disaster. One year ago, the world stood at the brink of yet another armed conflict - ostensibly "regional" in character. But, as we have seen, the crisis was truly "global" in its causes and consequences. Now the chariots of war have come and gone, leaving in their wake the usual trail of despoliation and desolation. Once again, it is for the local populations, supported by the international development community, with their limited resources, to do what they can to repair the damage and carry on. Similarly, we are seeing momentous political and socioeconomic upheavals in central and eastern Europe, and in many countries in all regions of the world.

These are but more examples of "the eternal ebb and flow of human misery". We see the same pattern in all natural and man-made disasters. We see it in the tornadoes and floods that have struck Bangladesh and China this year. We see it in the current outbreaks of cholera in Africa and South America. And we see it in the global AIDS pandemic which has become a serious problem on all continents. The increased incidence of malaria and tuberculosis also demonstrates this socioeconomic deterioration.While each Member State must assume full responsibility for sustained, self-reliant health development within its borders, it is evident that the sweeping changes in hcalth and sociocconomic conditions, taking place today, transcend the borders of individual countries and even regions, and call for global cooperation and global as well as local solutions. The solutions to the health challenges of today and tomorrow extend beyond the boundaries of the conventional health "sector", and challenge our understanding of the relationship between health and economics. Health, in its fullest sense, is becoming central to overall national development.

These dramatic changes in the political and economic fundamentals have taken place with or without coherent development policies and strategies to them. In the 1970s. the goal of Health for All by the Year U X W ) and the Declaration of Alma-Ata were conceived and premised on the assumption of a dynamic balance between economic conditions, scientific advances and social schemes for human wellbeing. However, in the 1980s, the Western-style open market systems shifted more to supply-side economics,

with increased emphasis, in industrialized countries, on monetary policies, and with a global deficit in the availability of financial resources. At the same time, there was retrenchment of the centrally-planned economies, with their focus on production rather than on consumption. The changes in both these systems resulted in the removal of their built-in safety nets. When social conditionalities were no longer protected these changes had the effect of marginalizing sustainable social development. Thus there was a hrcakdown in the normal coherence between economic and social policy. Meanwhile, many nations of the so-called "third w o r l d were suffering from economic deterioration and were offered structural adjustment "solutions" that inhibited social development. The salient feature of economic policies in the 1980s has been the failure to invest in people. The world has been left without a pragmatic solution or a workable model for socioeconomic development, in other words a "paradigm".

If l havc rcsortcd to such economic terms as "fundamentals", "structural adjustment", "marginali~ation" and "paradigm" in relation to human developmcnt, it has becn to cmphasizc thc magnitude of the change, the interrelationship between the underlying economic and social issues, and the significance of the challenging opportunities and solutions that lie before us. I have stressed the issues of resources availability, allocation and utilization. I have attempted to redefine in a pragmatic and realistic way the basis for our work towards sustainable development, that is to say, the search for equity in hcalth status, justicc in access to health care, and a more equitable distribution of rcsourccs to mcct human needs. In short, I have called for a new, coherent understanding of the rclation between economic and human development, within overall social dcvclopmcnt, in accordance with the sustainable development policics of the fourth United Nations Development Decade.

The implications of this for WHO and for each Member State are that we have to devote more attention to fundamental questions of (a) individual and community rights; (b) indicators of human need, health development and quality of life; and (c) the application of rcsourccs lor overall health and human developmcnt. Much as we havc sccn progrcss in overall avcragc health status in the world in rccent ycars, the sad fact is that the disparity, that is to say the gap, betwecn rich and poor is widcning, both within and between countries. Attainment of equity in health devclopment is often slow or even downward in direction. We see this in such indicators as overall life expectancy, disability-free life expectancy, infant mortality, immunization, disability, availability of csscntial drugs, per capita gross national product, balance of trade, food and nutritiorlal status, environmental deterioration, disposable income and the availability of resources. Wc also see this in the disparity in infrastructure and logistics capabilities. Furthcrmorc, cvcn thc claims made for the superiority of a centrally planned economy arc bcing questioned. At the same timc, if health is a human right, it cannot be left entirely to market forces. In addition, we have to answer questions such as who pays, how much and for what, to ensure personal health. Is there any country today that has all the answers?

All of us, in WHO as in countries, have to focus more sharply on how we administer the technical, material, human and financial resources that we have. The use of WHO'S resources for technical cooperation in countries is not to be decided solely on the basis of exclusively national priorities but also must reflect international health development policies and priorities. We must be responsive to critical questions. What are our intended products or "outputs"? What are the intended "outcomes" that we seek, for our people to benefit, and for the health system to be effective and efficient. It is to define this quest that I have spoken of the need for a "paradigm for health. Such a "paradigm" is not to replace our common goal of health for all; it is to help define a workable framework within which to develop a feasible, effective programme of work, and how to ensure its implementation through the correct use of primary health care. I stress the word "correct" because many developing countries are still at the stage of regarding primary health care as only a "special initiative" with "selective" implementation and have yet to put in place a national health care system which is based on integrated and comprehensive primary health care.

In WHO'S technical cooperation with countries, we are continuing to focus on the eight essentials of primary health care, in response to nationally defined priorities. Thesc include at least: education concerning prevailing health problems and the methods of preventing and controlling them; promotion of fwd supply and proper nutrition; an adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunization against the major infectious diseases; prevention and control of locally endemic diseases; appropriate treatment of common discascs and injuries; and provision of essential drugs. In support of these we must concentrate on modes of action which will include human, technical and financial resources development. A new pragmatism is necessary and we need to search for entry points to build upon.

At the same time, we are having to adjust to new realities, new demands and ncw opportunities. After listening to these issues debated in the six WHO regional committees, the Executive Board and the World Health Assembly, I have sought to identify a fcw major areas requiring special attention. In my instructions for the preparation of the proposed programme budget for the financial period 1994-1905, I have asked each Regional Director to show a significant increase in real terms (of at least 5 per cent) in the regional allocation to programmes addressing five areas, namely: (1) the relationship between the state of the world economy and sustainable health development, as it affects the less developed countries; (2) the hcalth of man in a deteriorating physical environment; (3) propcr food and nutrition for health development; (4) an integrated approach lo disease control; and (5) dissemination of information for advocacy, and for education, managerial and scientific purposes.

Therefore, representatives and friends from Member States of the South-East Asia Region, as you begin your joint programming with WHO in the coming year, I am asking you to pay particular attention to these five areas. The tentative country planning

figures for technical cooperation with WHO, which will be communicated to you by the Regional Director, constitute a starting point for joint discussions. But I must reiterate that all WHO'S resources, including the country allocations, are the joint resources of all Member States; they do not belong to one individual country. I must have the flexibility to be able to recall, reprogramme or redeploy WHO'S resources within countries, between programmes, or even between countries and regions, if global needs and priorities so require it. At the same time, your thinking should not be limited to activities that can be accommodated only through WHO'S small regular budget. Every effort must be made to mobilize additional resources from all possible sources, as the need arises. When calling on WHO for technical cooperation and support, I ask you to make use of the collectively agreed criteria for determining programme priorities.

As Director-General, 1 am constantly under pressure from proponents of different priorities. If you read the 22 obligatory functions of WHO contained in its Constitution, you will see that thc Organi7ation is called on, as the directing and coordinating technical agency, to cover the whole world and the entire field of health - holistically defined. Everyone is ready to advise me on additional "high" priorities, but few will advise me on "low" priorities. I am often asked, why doesn't WHO select just a few, maybe five or ten, highly visible, attractive priority programmes, and do them really well, forgetting the rest? Well, I would gladly take on a few highly visible crusades, as we did with the eradication of smallpox. Is not our war on AIDS one such crusade? But, if forced to stay within a limited regular budget, such additional efforts could only be at the expense of other important health problems. Therefore, for additional crusades we need extrabudgetary contributions, without undue strings attached. However, we must not be "donor driven"; we must he responsive to you, the Member States. And increased cdrabudgctary funding should not have adverse financial implications for the regular budget.

Thc priorities for WHO'S technical cooperation must be based not only on the current health situation and immediate needs of a country, but must reflect forward-looking objectives and strategies for sustainable health and social development. Health for all is happily coming to be interpreted as meaning that the entire life-cycle of an individual must be taken into consideration - through safe motherhood, child survival and development, adolescent health, health throughout the span of his or her productive life, and finally, a disability-free old age. We are faced with the question of how to generate and distribute the resourccs needed to solve, by promotive, corrective and rchabilitativc mcans, tha emerging health problems of each phase of this life-cycle. For this, special efforts must be made to determine the major existing health problcms and how they can be addressed. The basic principle for decision-making for health for all must seek harmony, that 1s equity and involvement among peoples in the community, and creativity in the use of technology and resources to these ends. We must continuously monitor and evaluate the cost-efficiency of outputs, and ultimately the effectiveness of outcomes, in terms of impact on human health and overall socioeconomic development.

As John Donne said, "No man is an island entire of itself, everyone is a piecc oT the continent, a part of the main". It is only by maintaining international solidarity, from regional groupings to global action, that progress will be made. The United Nation5 offers a potential framework for such action. But, too often, we see the United Nations and its Security Council bypassed by major political events, with economic decisions bcing taken outside its arena, and social action left to the specialized agencies, such as WHO, to carry out in isolation. Thcn we ourselves must take up the gauntlet to ensure that investment in our future is investment in people. It is the time to define and set up a working framework among the United Nations family, including UNDP, the World Bank, IMF and GA'IT, for sustainable socioeconomic development centred on human dcvelopment.

Distinguished represcntativcs, you have a heavy agenda before you. I know your Chairman will steer you through your work, with the able support of Dr Ko KO and his staff. I look fonvard with grcat interest to the results of your debate.

TEXT O F REGIONAL DIRECTOR'S ADDRESS INTRODUCING HIS ANNUAL REPORT FOR T H E YEAR 1W-91

Mr Chairman, distinguished representatives, ladies and gentlemen,

It is my great pleasure to present to you the Regional Director's Annual Report on the Work of WHO in the South-East Asia Region for the period 1 July 1990 to 30 June 1091, as contained in the document SEAIRC4412. Since this document already provides details of the collaborative activities of WHO with the Member States during the period undcr review, I would just highlight only a few salient features of this collaborative work in health dcvclopmcnt.

The formulation of health policies and their translation into effective strategies and programmes to deal with the dynamics of the current and emerging health problems in the South-East Asia Region constitute the most important challenge for the governmcnls of the Mcmhcr States and WHO. T o support the strengthcningolthe national capabilities in hcalth policy formulation and health planning in the light of the changing political, economic and social climatc, a Regional Consultation was held in Bangkok in Junc 1991 to review the current situation and identify future needs for such strengthening. The meeting adopted a regional action plan to be used as a framework for initiating action in Membcr Countries. Keeping in view the global economic situation and the financial constraints being faced by Member States, a Regional Consultation in Health Economics, held at the Regional Office in Ocloher 1990, prepared a regional programme of action to address the iqsucs in health economics and health care financing.

According to the second evaluation of HFN2000 strategies, concluded in the first half of this year, there has heen demonstrable progress in health development in the Membcr Countries. The crude death rate has declined in almost all countries of the Region, though it is still somewhat high in a few of them. The overall health status of the populations has improvcd in most countries. Infant mortality rate, which is an important health indicator, also declined (with five countries reporting less than 50 per 1MX) live births and only two abovc 100 per 1OOO live births. The life expectancy at birth, for both males and females, has increased in almost all countries, and now cxcceds M years in six of thcm.

In all countries of the Region, the health infrastructure has expanded and improved its coverage. The organization and management of the district health system has been further strengthened through decentralization. Training and utilization of community

health workers and involvement of the community in the management of local health services has helped improve coverage, including the quality of care.

The major item of expenditure in any health system k on human resources to manage the health infrastructure. In order to achieve health for all through the primary health care approach, efficient planning, production, and deployment of health personnel at all levels assume paramount importance. Toward this end, WHO continued to support national efforts aimed at improving health manpower management. Progress was observed in Member Countries in the strengthening and reorientation of educational systems to achieve a quantitative balance and systematic relevance to their health manpower requirements. At the undergraduate level, the trends noted in the past decade were further reinforced with greater community orientation of the curricula, introduction of innovative educational strategies, and strengthening of educational management mechanisms.

A pragmatic approach that takes into account the weaknesses and constraints 111 the health system, and utilizes opportunities and resources as and when they become available, with due concern for human rights and equity, is the hallmark of a coordinated and cogent effort in health development. Attention is being focused on those pockets of the population whose health parameters are far below the national averages. Thus, in line with the recommendations of the Technical Discussions held during the forty-third scssion of the Regional Committee in IYM, the focus of health development efforts in the last decade of this century should be on health of the underprivileged through a holistic strategy and approach. With a new to developing a framework for action in this important area, an intercountry consultation on health of the underprivileged was held in August 1991.

The seventeenth session of the WHOISEAR Advisory Committee on Health Research was held in Yangon, Myanmar, in April 1991. The Committee reviewed the regional research programme as well as other matters relating to research promotion and devclopment in the Region. A consultative meeting was held in April 1991 to identify a set of scientifically-sound and relevant criteria for the appraisal of health services research project proposals that would be useful to funding agencies as well as researchers. In pursuance of the World Health Assembly resolution on the role of health research in the strategies for health for all, the Committee also discussed the need to formulate a strategic plan for the next five years, and in this connection, agreed to put greater emphasis on the strengthening of research capabilities, especially in translating the research aims and objectives into practical programmes and actions.

In November lYN, the seventh meeting of the Directors of Medical Rescarch Councils or Analagous Bodies and Concerned Research Foci in the Relevant Ministries was held in Kathmandu, Nepal. The meeting reviewed the research collaboration between Member Countries and WHO, endorsed the call for action embodied in the World Health Assembly resolution on the role of health research in the strategies for

health for all, and recommended the formulation of a plan for national action in response to this resolution. The meeting also discussed mechanisms to promote national capabilities for self-sustained research and the role of traditional systems of medicine in health care delivery.

Information and education for health has been further strengthened through WHO'S collaborative efforts in Member Countries. The recommendations made at the lntcrcountry Consultation on Health Education Strategies in South-East Asia in the Context of HFAIUMa, held in the Regional Office in December 1990, provided, among other things, the basis for defining the functions and role of health educators. At the country level, WHO'S collaborative activities were aimed at strengthening the health education infrastructure, training of health staff, production and use of health education materials, and involvement of media. Thcre is a need to improve interpersonal communication techniques, make wider and incrcascd use of the mass media, and build alliances with other development sectors, including nongovernmental organizations and women and youth groups.

There was a new orientation to the delivery of maternal and child health services, including family planning, through the primary health care approach. Resulting from the International Conference on Safe Motherhood, emphasis was revived on maternal care in all the countries of the Region. To achieve better child health, strategies and plans of action were formulated in most of the countries for functional integration of the services provided by EPI, Diarrhoea] Diseases, ARI and MCH programmes. Support was also provided to countries for research in MCH and family planning, including safe motherhood, operational research, and a multicentre study on low birth-weight and infant morbidity and mortality. A study on child development and testing of techniques for monitoring physical growth and psychosocial development of children was also carried out.

WHO also supported the development 01 a Regional Nutrition Rcscarch-cum- Action Network in order to bring together centres of excellence in the field of nutrition research relevant to local nutritional problems. Countries of the Region are in a transitional period with regard to nutritional problems. While protein-energy malnutrition remains a serious impediment to human development, its epidemiology is changing. Millions of poor people, who move to a cash economy in urban areas, have to adapt thcmsclves to new foods and food habits. The increase in female employment is altering thc pattcrn of breast-feeding and weaning practiccs.

There is a growing awareness of environmental problems and their close links with health and socioeconomic development, particularly in the countries experiencing rapid urbanization and industrialization. While continuing to pursue the targets of safe water and basic sanitation as part of the goal of HFAL!GCO, some countries launched activities for the improvement of environmental health in both rural and urban areas, including prevention and control of health hazards from environmental pollutions. Attention was

also givcn to chemical safety and control of poisoning, health risk assessment and management, environmental epidemiology, and food safety.

Under the DTR programme, health laboratory services, along with laboratory technology, has been given close attention at the country level. With strong support in the WHO Executive Board, and the interest shown by donors, Essential Drugs and Vaccines, particularly the Drug Management Programme with all its components, such as drug policies, essential drugs and rational use of drugs, has been progressively developed. The UNDP-supported ASEAN pharmaceutical project is completing Phase 111 and is now planning for Phase IV.

During the period under review, a majority of the countries achieved immunization covcrage of at least 80 per cent. In some countries, the positive impact of immunization on the reduction of childhood diseases, especially poliomyelitis, diphtheria and pertussis, hecame cvidcnt. It is recognized that a strong health service infrastructure and adequatc financial and managerial support are indispensable for sustaining the gains already achieved. WHO strove to promote self-reliance in vaccine supply in many countries by supporting their local production. Efforts were also made to develop national quality control systems to ensure that vaccines used conform to the WHO standards.

Thc malaria situation in the Rcgion has remained somewhat static during the past 5-6 ycars, with the incidence ranging between 2.5 to 2.8 million reported cases. The proportion of P. folcipanrm infections was about 40 per cent of the total malaria cases. All countries with endemic malaria were implementing the revised control strategy through the primary health care approach. Stratification had been widely accepted in the Region since it had proved to be useful, particularly in the light of limited resources. In several countries, malaria control activities at intermediate and peripheral levels have bcen fully integrated into the basic health services, while, at the national level, a core group of specialists was entrusted with the task of planning, supervision, training, research and coordination.

AIDS assumed epidemic proportions in some countries, while in others it was still at a low endemic level. In view of the peculiar epidemiology of the disease, no country should be considered as safe. The major mode of transmission is now known to be sexual contact, followed by the use of infected syringes by intravenous drug users. All countries in the Region have initiated prevention and control measures through short- or medium-term plans which have been supported by WHO and other international and bilatcral agencies. In thc absence of a curative drug or a preventive vaccine, thc emphasis has been on information, education and communication. There is no room For complacency, even in countries that at present have a low prevalence of HIV infection. Current wisdom suggests that AIDS, if not contained with appropriate measures, could become a devastating threat.

Acute respiratory infections, particularly pneumonia together with diarrhoeal diseases and malnutrition, are still the leading causes of death among children, and result in the largest number of attendance at out-patient units of health care facilities. Case management strategy in diarrhoeal diseases has greatly reduced mortality in children. In order to reduce morbidity caused by diarrhoea, interventions such as exclusive breast-feeding and improved weaning practices have bewme relevant. Tuberculosis continues to be a major health problem in the Region. It has further been accentuated by the emergence of AIDS. It has therefore bewme imperative to strengthen national tuberculosis control programmes under the overall umbrella of the primary health care approach.

It is gratifying to note that leprosy control programme is gaining momentum and coverage with multidrug therapy is increasing in all the countries every year. The number of leprosy cases released are also increasing. Consequently, Maldives is now in the process of cradication of leprosy, and, with concerted efforts, this dreadful disease can be eradicatedleliminated from two or three more countries in the near future.

With a view to achieving cost-effective control of communicable diseases, WHO promoted an integrated approach through primary health care. A study carried out in one country indicated that integration was feasible, beneficial, sustainable and effective. Satisfactory progress was noted during the first phase of the study in the control of selected communicable diseases. While significant features of this study were being documented, a framework for an integrated approach was being reviewed and prepared for in-depth analysis and further testing.

It is ironic that while the Region is still under a heavy load of infectious diseases, noncommunicable diseases, such as cardiovascular diseases and cancer, are becoming major public health concerns. The incidence of noncommunicable and chronic and degenerative diseases has increased with higher life expectancy, changes in lifestyle, and environmental pollutions. Control of these health problems require relatively higher capital and running costs, posing a difficult choice to countries with limited resources. WHO, therefore, advocates and supports primary prevention through the primary health care approach, and early detection, as well as prevention and control of health risk factors. It is well recognized that among other things, the use of tobacco is directly or indirectly responsible for the increase in these diseases in most countries. WHO has been very active in supporting Member States to counteract the use of tobacco through information and education, and by encouraging health legislation. Activities have been undertaken to promote people's awareness about the harmful effects of tobacco use.

Most countries of the South-East Asia Region are prone to natural disasters. Many of them have recently experienced disaster situations such as cyclone, flood, earthquake, volcanic eruptions and fire. WHO has been providing support to both immediate relief and long-term efforts to develop national capabilities in disaster preparedness and emergency response. WHO'S thrust in this area has been towards integrating the health

preparedness and response component into the overall national disaster preparedness plan and programme in order to achieve collective coordination among concerned agencies and institutions.

We have witnessed successes in raising the health status of the population. However, some old problems still remain, and new problems have emerged. Although the approach to some of them appears to be common in most countries, yet there are issues requiring country-specific solutions within the framework of a country's social, cultural, political and economic situation. We have come beyond the mid-point of the road leading to the goal of Health for All, but there are many daunting problems and obstacles still lo be overcome in the coming years. Taking the economic and political realities into account, we have to use our limited resources effectively by supporting only the real priority needs for health development. Keeping in mind the complex and interconnected nature of health problems worldwide, the Director-General of WHO has suggested five broad areas to be emphasized in WHO'S collaboration during 1992-1993 and 1994-1Y)S. These arc: (1) health of man in a changing environment, (2) proper food and nutrition for healthy life and health developmcnt, (3) integrated disease control, (4) dissemination of information for advocacy as well as for scientific, managerial and educational purposes, and (5) intensified health development action and support to countries in the greatest need.

I have outlined to you only a few salient health development activities during thc period under review in which WHO closely collaborated with the Member States in the South-East Asia Region. I must reiterate that, in spite of overwhelming economic, social and political constraints, and problems relating to human and financial resources, Member States have made commendable progress in health development with the ultimate aim of improving the quality of life of their people so that they could effectively contribute to the social and economic development of their countries.

I am confident that the Regional Committee, through its collective wisdom, would continue to provide us with valuable guidance and directions for our future wllaboradon.

Thank you.

MINUE5 OFTHESECOND MEEIlNG

SUMMARY MINUTES'


TABLE OF CONTENTS

page

I . I:orly-third Annual 1lcp)rt of the Kegional Ilirector (conid) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92

2. Adjournmcnr . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102

10riginally issued as dcxurncnl SJ3RCAJMin.2 on 23 September 1991

1. FORTY-THIRD ANNUAL REPORT OF THE REGIONAL DIRECTOR (nm 9, conrd)

Executive Summary (pp.x-mi)

On resumption of the meeting, the Chairman expressed the hope that the Committee, during the course of the discussions on the Regional Director's Annual Report, would have time to discuss the new health paradigm advocated by the Director-General of WHO, which put health at the centre of development and went into the question of how health policies could be designed to achieve the goal of health for all. He then invited discussion on the Regional Director's Annual Report chaptenvise.

DR N. KUMARA RAI (Indonesia) questioned the validity of the statement that more than 90 per cent of pregnant mothers were provided with appropriate health care. He said that this was not true of Indonesia, where such coverage was less than 60 per cent.

The REGIONAL DIRECTOR agreed with the observation of the representativc from Indonesia and said that the mistake could have occurred while collating the information received from the countries. He said that the figure of 90 per cent would perhaps be true in selected types of services in some countries.

DR KHALILULLAH (Bangladesh) expressed his reservations about the statistics on immunization, provision of basic sanitation facilities, etc. quoted in the Annual Report. Raising the question of coordination between WHO and other multilateral and bilateral agencies as well as nongovernmental organizations, he said that since thcse agencies and WHO had common objectives as far as the health sector was concerned, and also in view of the fact that these agencies were able to mobilize additional resources, WHO should take more initiative to involve these agencies in health activities. The role of nongovernmental organizations was of particular importance in the field of training. Without their active participation, achievement of the goal of HFA might not be feasible.

The REGIONAL DIRECTOR said that WHO had always maintained a policy of close collaboration with other UN agencies. The cxtent of involvement of these agencics in national health development depended on the countries' own policies and prcfercnces and on the capabilities of the national coordinating mechanisms. As far as support from NGOs was concerned, some of the countries were more liberal in accepting active involvement of the NGOs, while others were not so open. He assured support to those countries who were prepared to allow active participation of NGOs in their health activities.

DR MUKHERJEE (India) stated that, although information on diagnostic technologies was reflected wrrectly in the report, there was no mention of rehabilitative technology. He suggested that this should be given priority. He appreciated WHO'S support for the health information system, which had enabled India to network all the districts in the country via satellite and had given a new impetus to bettering health care.

The REGIONAL DIRECTOR drew the attention of the representatives to agenda item 20 (document SEA/RC44113) which wntained resolutions of regional interest adopted by the World Health Assembly and the Executive Board, and said that, while taking up specific chapters of the Annual Report for discussion, the relevant resolutions could also he considered. HI: further mentioned that a representative each from two countries of the Region had been elected as President of the Forty-fourth World Health Assembly and Chairman of the Executive Board.

The Rcgional Director, replying to the question raised by the representative from Bhutan about developments on UN General Assembly Resolution 44/211, said that this subject would be discussed while considering the EB resolution EB98.Ru) under agenda item 20 "Resolutions of Regional interest" (document SEAiRC44113). The Executive Board had felt that though the original UNGA resolution was technically sound, there were operational difficulties in implementing it. These related to the channelling of funds through UNDP and through their counterpart, i.e., the departmcnt of economic affairs or planning, and not through the ministries of health. The Executive Board had apprised lhc Director-General of this, who would, in turn, report the same to the United Nations.

Health System Development (pp. 23-32) Organization of Health Systems based on Primary Health Care (pp. 33-37)

The Chairman invited comments from distinguished delegates on these two chapters.

DR KAN TUN (Myanmar) said that a number of changes had taken place in the field of health in Myanmar recently, in tune with the changing socioeconomic policies of the country. A national health committee had been formed to provide necessary guidance and direction. A national health plan had heen formulated and a new population policy enunciated, which was a departure from the earlier policies. A new drug policy had also been adopted and a drug law promulgated. The health sector was now encouraged to deal directly with NGOs, and organizations such as Family Planning International and World Vision were now participating in health activities in Myanmar. A new Intensified WHO Cooperation (IWC) initiative had been launched. The new initiative was geared to the specific needs of Myanmar and permitted partnership between governments and collaborating agencies.

MR KWON (DPR Korea) stated that it was planned to strengthen the district health system in DPR Korea for successful implementation of the health-for-all strategy and to improve the quality of primary health care. He thanked WHO for its continued support to the development of the district health system. His government had initiated important measures to upgrade the section-doctor system into a 'household-doctor system' under which each doctor would take care of 130-150 families. The system aimed at reducing the number of households under each doctor by increasing the number of doctors. He expressed the hope that continued support from WHO will be available to his country in its efforts at strengthening its health system.

DR HARTONO (Indonesia), referring to the subject of collaborating centres for HFA, said that WHO had designated national centres also in Indonesia as WHO collaborating centres. He clarified that the assessment of health system research was intended to be carried out throughout the country and not only in Surabaya province.

DR MUKHERJEE (India) appreciated the reference to India's programmes for promoting epidemiological surveillance. His country had recently launched a long-term training programme in field epidemiology and 444 districts were expected to have an epidemiologist each in the near future.

MS HUSNA RAZEE (Maldives) felt that epidemiological surveillance was indeed crucial to all health programmes, and more so in the area of communicable diseases. This, in turn, called for the strengthening of the laboratory support services. Maldives found it difficult to carry out effective epidemiological surveillance in the absence of an adequate laboratory system.

DR CHATAUT (Nepal), referring to developments in Nepal in the field of health systems infrastructure, said that recent political changes in the country had their effect on the health strategies. Ncpal had decided to expand health care coverage in thc districts. It was proposed to have one sub-health post for each village, and this meant the setting up of 3,199 sub-health posts during the next five years. It was proposed to have a primary health care centre in each of the 205 electoral constituencies. Medical doctors and paramedical personnel would staff the primary health care centres. He hoped that WHO and other organizations would assist his country in preparing the required health manpower. In health research development, Nepal had taken animportant step by upgrading and renaming the Nepal Medical Research Council as the Nepal Health Research Council and conferring a semi-autonomous status on it.

DR ARSLAN (Mongolia) felt that the question of allocation of scarce resources for the most effective utilization had gained added importance in Mongolia, primarily following changes in the political climate. The transition from a centrally-planned economy to a market-oriented economy was not smooth. Real income had begun to decline in Mongolia because of the abrupt change in its relationship with East European partners in trade and aid. The transition period had imposed new burdens upon the

country, which found it difficult to wpe with them. Mongolia was grateful to donor countries and international organizations, including WHO, which appreciated the situation in the wuntry and had rushed aid supplies, including drugs and medicines, to overcome shortages. Mongolia was reviewing its health policy and was changing procedures for the management and planning of the health budget, and more powers were being bestowed upon local authorities. As a result of these changes, health institutions now enjoyed greater autonomy. A new system of health insurance was being put into operation and the cost of health services was being assessed and health legislation was to be amended appropriately.

DR DE SILVA (Sri Lanka) stated that Sri Lanka had devolved the functions and powers of the Ministry of Health down to eight provinces with a new to bringing the health structure of the Government closer to the people.

DR KHALILULLAH (Bangladesh) felt that malaria, tuberculosis and rheumatic fever needed greater surveillance in Bangladesh. The lack of laboratory facilities at the local level was a factor inhibiting control and treatment of these diseases. The cost of drugs had risen tremendously. The country could usefully include the treatment of these diseases in its primary health care system. This would, in turn, call for the strengthening of its laboratory system. Chlorofluorocarbons (CFC) and other halogens had an ozone-depletion effect. There was a need to transfer technology for the production of chcaper and less toxic chemicals to developing countries. He felt that the subject of health legislation had not received the attention it merited from organizations like WHO. As regards thc provision of primary health care, laboratory and logistic support were surely needed. The production and quality control of vaccines within the country needed to be encouraged and he requested WHO support in this regard.

MR RASHEED (Maldives) recalled the comments of the representatives in favour of strengthening of health economics. Quite often, planning for health led to undue emphasis on targcts in contrast to cost-effectiveness of the programme, and this rendered the sustainability of the programme questionable. The question of social services versus economic returns deserved careful consideration by health planners. Health care was, no doubt, a basic human need but what was required was a health system which could be sustained by the available resources.

DR SOMSAK CHUNHARAS (Thailand) said that Thailand had placed greater emphasis on methodological approaches and did not limit its emphasis to disease surveillance. This was one crucial concept in the Thai health programme. The slow dcvclopment of assessment effort was discussed in a meeting on health planning and management in Thailand in June 1991 and his country looked forward to WHO to provide leadership in this area. As regards ICD-10, little progress seemed to have been made at regional and global levels though the new classification was expected to begin in the next two years. Thailand had, therefore, introduced a modified ICD-10 list to facilitate the classification of diseases at the hospital level. Most of the efforts towards

MINIIIT.? O F M E SECOND M E m N G

improving the health reporting system had been made possible because of WHO contributions. Thailand had recently introduced compulsory insurance covering about 2.5 million workers in the country. The scheme was however facing difficulties and his country needed to learn from the experience of other countries where health insurance systems were better developed. Health financing was an important factor and his country would bt: glad to share its experience with other countries. Thailand had added four new elements to the current ten in its primary health care programme. These were: AIDS prevention and control, accident prevention and community safety promotion as well as rehabilitation of victims; consumer protection including food, drugs, cosmetics and chemicals used in agriculture, and prevention and control of pollution of fhc environment.

DR SINGAY (Bhutan) felt that the question of integration needed to be looked at carefully. Integration, according to him, was a 'catchword' which made the funding agencies happy and the collaborating agencies comfortable. In his country, health services had been integrated since inception. He felt that the process of integration should not overburden the health system as this might, in turn, affect the quality of services. As an example, he referred to the control of leprosy in which integration could not be achieved in certain categories of work and beyond particular levels even while his country was a pioneer in the implementation of multidrug leprosy therapy. While he supported the principle of integration of health services, he cautioned that this should be carefully weighed before it was introduced.

Hc referred to the success of the Mongar project, which was implemented with support from WHO. This project had become self-sustaining and a recent review had shown that the health parameters had improved considerably compared to those two years ago.

DR KHALILULLAH (Bangladesh), referring to the statement appearing undcr sub-para 3 of para 3.2 on page 27, pointed out that it was the national 'health policy', and not the national 'health and population policy', which was drafted and subjertcd to public debate. He added that this was latcr abandoned.

The REGIONAL DIRECTOR, referring to the extensive discussions that had taken place on the topic of health system development, said that the questions of international collaboration and coordination among agencies as well as collaboration and support that had been sought from thc planning commission needed to be lookcd into in the context of health system planning and policy. The Eighth General Programme of Work of WHO had two main components, viz. hcalth system infrastructure and hcalth scicnce and technology. He said that observations made by the representatives had been noted.

He favoured WHO support being provided for health systems research, health economic research, financing of health services and alternate financing. Health planning

and management had an important place in the call made by the Director-General for future concentrated effort. Better health planning and management at the country level would ensure that the health ministries could defend their plans and programmes with the finance ministries. He referred to the Mongar district and the Huvsgul Aimak projects, and said that more concentrated efforts were needed in future to replicate such projects. He also referred to similar projects in India and Thailand. Countries should undertake more health systems research projects.

Referring to the comments made on primary health care, the Regional Director said that health did not mean only public health, but included medical care as well as preventive, promotive and rehabilitative care. Regarding the 10th revision of the International Classification of Diseases (ICD), he said that this would become operational in 1993. Even though the finalization of the 10th ICD had taken longer than expected, it would obviate the need for another revision for at least the next 20 to 25 years. As regards medical care statistics, he said that efforts at medical sophistication, the system of registration in a country, and the medical certification of death, etc., had to be taken into consideration. Without meaning to lessen the importance of ICD, he also referred to other statistical and epidemiological tools, viz. sample survey methods, sentinel surveys for EPI and AIDS, and lay reporting.

The Regional Director said that WHO accepted and promoted the principle of integration of health services, but cautioned that integration should be thoroughly worked out taking into consideration various factors such as the availability of health infrastructure, the epidemiological situation, etc. However, integration could not be achieved in the absence of a health infrastructure to integrate into. He agreed with the views of the representative from Bhutan that the integration of health services needed to be implemented with caution and realism.

Development of Human Resources lor Health (pp.38-SO)

DR MUKHERJEE (India) said that human resources for health wasone ofthe important facets of the health development programme. A study had been undertaken in India to understand the health manpower requirements, and many more studies would be necessary to look into the need not only of medical but also of paramedical personnel. Community-based and problem-based learning needed to be introduced in the undergraduate and postgraduate medical curricula. The primary health care strategies should also be endorsed very strongly in the curriculum as 60 per cent of the diseases at the primary health care level could be diagnosed and treated successfully by the paramedical group. There was also an acute shortage of nursing personnel.

MS RAZEE (Maldives) said that some of the countries of the Region had already developed manpower plans and were updating them to focus on the need for human resources for the health sector. In Maldives, manpower was a critical issue due to its

acute shortage. She felt that it was very important to focus not only on training and retraining of health workers but also on retaining those who had been trained. Emphasis should also be laid on the quality of training and production of quality learning materials.

DR CHATAUT (Nepal), referring to page 38 where it had been mentioned that support was provided for a review of the health manpower situation in the context of the health care system, said that this particular activity had not been undertaken in Nepal. However, the country-level resources utilization workshop, supported by WHO, was quite useful in this regard. In the context of planned expansion of the health coverage in Nepal, there was a need for situation analysis of health manpower and health manpower planning in the near future. At present, there was only one university teaching hospital for medical training. India had agreed to assist in the expansion of Bir Hospital, and with support from WHO, it would be possible to train more postgraduate students at this hospital.

Referring to the table on page 48 relating lo the distribution of fellowships under the WHO regular budget, he said that Nepal also had awarded a few fellowships in the clinical sciences. These could be included in the table if placements had been arranged.

DR KHALILULLAH (Bangladesh) said that his country had initiated a scheme on human resources for health as part of health manpower development, which did not link up with career development. This scheme needed careful study. He felt that health care delivery should expand with the development of human resources for health which should include other categories of human resources. In order to extend primary health care at the grassroots level, he felt that the syllabi of school children should includc nutrition, family planning, and diarrhoea1 disease control. In Bangladesh, orientation of medical p e r s o ~ e l had not been really effective. Leadership development was essential since clinical doctors did not know about community participation, social behaviour with patients, or the economics of health care. It was also necessary to develop institutions within the Region for the development of health manpower. Most people from Bangladesh were going to American and European regions while only a few wcrc going to the South-East Asian countries. Transfer of technology within the Region was essential to develop the Region's own resources, and the import of foreign technology from America or Europe should be resorted to only where regional expertise was not available.

There was a need to develop teacher training courses in order to provide important tools and technologies. Sincc fellowships were not helpful in the long run, career development planning along with human resources development should be closely linked UP.

DR ARSLAN (Mongolia) said that his country was facing a new socioeconomic situation because of which medical education required some reorientation. A new educational law had been approved on the basis of which the ministries of health and

MINlIlFS OFTHESECOND MEmN(i

education had decided to upgrade the existing State Medical Institute to the level of medical university with two medical colleges in rural areas, while a new postgraduate training institute for physicians and health workers had been established. The number of medical students was decreasing, and a new type of undergraduate training, paid by cooperative or private companies and enterprises, had been introduced in order to produce doctors and health workers who were socially relevant and responsive.

Educational programmes and curriculum for postgraduate training needed to be modified and furthcr developed to ensure community-oriented and problem-solving medical education to meet the health needs of the society. Mongolian traditional medicine, English language and other subjects were included in the curriculum for undergraduates in the State Medical University. He hoped that it would be possible to prepare teachers for medical education institutions using WHO collaborative programmes, and to improve teaching curriculum and modules.

DR DE SILVA (Sri Lanka) said that there was a great need for paramedical staff for deployment in basic health senices in his country. It was planned to provide basic laboratory facilities and improve essential drugs management in rural institutions for which paramedical staff were required. In view of the shortage of this category of health manpower, it was proposed to develop training courses in the universities, including medical laboratory technologists and pharmacists to ensure better delivery of primary health care.

He added that his government had decided to employ one auxiliary hcalth worker per 1000 population. Towards this end, it was proposed to train 17 000 auxiliary health workers for which training institutions were being identified. It was also planned to activate and use the regional training centres for this training. Thereafter, the auxiliary health workers would be abqorbed as public health midwives after suitable training. Although the field staff were well-oriented in primary health care, they needed orientation programmes in health education. There was also a need to strengthen school health education programmes in counselling for school children, especially girls, so that the targeted populations had greater awareness of maternal conditions and family planning.

DR SOMSAK (Thailand) said that in his country much of the WHO country budget was being spent on overseas training of fellows. Management training was imparted under the project on national health development. Thailand had organized several intercountry workshops and meetings on health manpower dcvclopment in the past. One of thc basic tenets advocated by WHO was the interrelationship between health manpower development and health services development. Although logical in the context of thc hcalth sector, it was being constantly challenged by the private sector in view of the rapidly growing economy of the country. The sewnd concept was the balance of health manpower which was especially relevant in the context of the next Five-Year Plan starting in October 1992. Its main emphasis was on the development of skilled health manpower at the health centre level. On the other hand, there was a

MINW-5 O F l l l E SECOND MEETlNG

demand for doctors and nurses in big hospitals competing with the health centres. So a balance had to be maintained between the different categories of health manpower. The queslion to be considered was whether health centres should be strengthened at the cost of big hospitals. The health manpower situation in the country was affected by market mechanisms. Thailand was facing problems in health manpower distribution system in the public and private sectors. Medical doctors were deployed successfully lo rural areas through the compulsory service scheme after graduation, introduced twenty years ago. It was felt that the standard of health care in the public sector was not very high. Due to pressure from the public, there was an outflow of much-needed categories of medical manpower, such as nurses, from public to private hospitals which, in turn, jeopardized the balanced distribution of health manpower. A clear understanding of the market powers and forces affecting health manpower was needed.

The poor standard of health care delivery in public hospitals compelled even the lcss affluent to seek medical care in the private health sector. This called for producing more doctors in order to rectify the imbalance between the private and public sectors. However, the production of more doctors might worsen the situation rather than improve it.

Constant efforts were made by his Government to reorient medical schools to serve the health services system. Continuous and regular meetings were conducted, including the conference on medical education, which was held every seven years. The next medical education conference was scheduled to take place in 1993. This conference was expected to focus attention on problem-based medical education and emergent needs of the health system. It was sought to improve the health senices system through the reorientation of medical education.

Public Information and Education for Health (pps1.55)

DR KAN TUN (Myanmar) felt that there was a strong need for communication in health through inter-personal communication techniques. In Myanmar, two areas were considered important - one was AIDSIHIV infection, which was increasing; the second related to the birth-spacing programme for married couples. The thrust of the family planning programme would not be on technology, but on effective information. Myanmar intended to approach WHO for providing such a communication technology.

MS RAZEE (Maldives) noted that thc concept of intersectoral collaboration for school hcalth education was an accepted principle. In Maldives, cooperation eldstcd bctween the health and education sectors in the implementation of health programmes. The school health education programme was being implemented by the Ministry of Education with the assistance of the Ministry of Health. Various aspects of health education had been incorporated in the school curriculum for the under-fives to ensure that the next generation of Maldivian children grew up with greater awareness of the

principles of basic health and hygiene. Recently, a revision of the curriculum for environmental studies had also been undertaken. Thus, aspects of health in other sectors were being included in the school health education programme.

She felt that, in addition to intersectoral collaboration, there was a need for intercountry cooperation as well to establish a regional centre for the exchange of materials and information. Since much time and money were invested in producing educational materials, it would be helpful if different countries could exchange materials that could be adapted and translated for educational purposes. This would also minimize the time involved in the preparation of such materials. She also stressed the need to monitor the quality of the messages targeted at various sections of the population in order to ensure their effectiveness. She felt that, due to the lack of trained manpower, educational materials were often not produced scientifically, resulting in a waste of effort and rcsources.

DR SINGAY (Bhutan) said that a Bureau for Information, Education and Communication for Health had been established in his country and it had already started functioning. In Bhutan, World Health Day, World AIDS Day and No Tobacco Day had generated a lot of interest. Activities such as workshops, seminars, exhibitions, poster competitions, debates and essay competitions to observe these days were planned well in advance and were included in the annual work plans at the district level. The Regional Director's messagc and radio broadcast on World Health Day were received very well and translated into some of the local languages. He requested WHO to continue supplying health education materials for the dissemination of information.

TheREGIONALDIRECTOR, in response to the observationsof the representatives on the health manpower development programme, said that the percentage of regional fellowships was being increased every year and now stood at 40 per cent. The main reason for this was the availability of expertise at the regional level. The basic purpose of WHO fellowships was to provide training opportunities for personnel. However, there was no need to thrust rcgional fellowships on the countries if appropriate training facilities were not available in a particular ficld. In such cases, placement outside the Region should be tried. He suggested forward planning in the implementation of fellowships since the objectives of the fellowships and the terms of reference were already available. He requested the representatives to start planning for the 1992-1993 fellowships by selecting candidates and sending their fellowships application forms for placement. Since academic courses tended to start in September or January in most universities institutions, placements could be secured only if applications wcre sent early enough.

The Regional Director said that an optimum mix of health manpower along with the managerial process and planning of manpower could be achieved. Different countries had different manpower needs and there could be no global standard. Each country had to estimate its requirement in its own context. However, a pyramidal structure was

the ideal one, and top-heavy structures were undesirable. Referring to the increasing privati7ation in health care, he said that the poor quality of health care delivery in the public sector had led to rapid expansion of private health care establishments. The need of the hour was to strengthen the public sector health care delivery system and it was necessary to thoroughly study the various factors influencing the trend towards privatization.

He said that in the late 1970s, regional reference centres had been established. However, with the establishment of WHO collaborating centres, it was decided to promote national centres of expertise with a regional network for the exchange of information and for intercountry collaborative activities.

2. ADJOURNMENT

After somc announcements, the meeting was adjourned

SUMMARY MINUTES'

Third Meeting, 23 September 1991, 8.00 am

TABLE OF CONTENTS

page

I. Forty-third Annual Report of the Regional Direclor ( c m r d ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

2. Adjournment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

rigin in ally issued i s document SFMC44lMin.3 on 24 Septenkr 1 9 1

Opening the meeting, the CHAIRMAN introduced Dr Vitura Sangsingkeo and Dr Chakradharm Dharmasakti, representatives from Thailand, who had just arrived to attend the Regional Committee, and invited them to make a statement.

DR VITURA (Thailand)> speaking on behalf of the Thai delegation, congratulated the Chairman and the Vice-Chairman on their election. He conveyed his appreciation ro the Regional Director and his staff for the innovative support provided tohis country in creating better health conditions for its people. The efforts of the Regional Director were all the more laudable in view of the resource constraint faced by the Organilation. The discontinuance of the detailed programme budgct and the use of detailed plans of action in its place wcrc indications of the efforts made by WHO to streamline and accelerate the progress towards better health development. He expressed the hope that these changes in the planning and budgetary process would benefit Member Countries in the implementation of WHO'S collaborative programmes and allow the utilization of WHO'S resources in the most appropriate manner. In Thailand, although the WHO regular budget accounted for 0.3 per cent of the total annual national programme budget in health, the Governmcnt was trying to use it optimally. The collaboration between WHO and Memhcr Countries had been crucial for their health development initiatives. He singled out WHO as the only external agency in Thailand to have the maximum involvement and participation in their health development programmes despite the comparatively small financial inputs, and hoped that this collaboration would continue.

1. FORTY-THIRD ANNUAL REPORT OF THE REGIONAL DIRECTOR (Ircrn 9, cr,,zrd)

Research Promotion and Development Including Research on Health-Promotion Hehaviour (pp.5741)

The REGIONAL DIRECTOR, introducing the subject, made a brief presentation on research development, and on the report of the South-East Asia Advisory Committee on Health Research (SEAIACHR) in the absence of the Chairman. He said that SEAIACHR was the main advisory body to the Regional Director on matters concerning regional rescarch policy and direction. Thc seventeenth session of SEAIACHR was held in Yangon from 21 to 27 April 1991 and was attended, among others, by staff from WHO hcadquartcrs.

Scientific meetings, strengthening of rescarch capabilities, award of visitingscientists grants and research training grants and the status of WHO collaborating centres were

somc of thc RPD activities undertaken during the past year. A total of 12 scientific mectings were supported. The participants of the seventh meeting of Directors of Medical Research Councils or Analogous Bodies and concerned Research Foci in the Rclcvant Ministries, held in Nepal in November 1990, recommended the generation of a climate conducive to the development of research, the cctablishment or strengthening of rcsearch coordination mechanisms at the country level and thc formulation of a plan of action for implementing the World Health Assembly rcsolution on the subject of defining the role of health rescarch in HFA strategies.

A si7eable amount of the RPD budget was allocated for direct financial support to individual research projects in the countries. A two-tier system for the review of proposals for research grant? - one at the country level and another at the Regional Oflicc level - was in practice. At present, 67 rescarch projects were being conducted by countries in collaboration with the Regional Officc, in addition to the research activitics supportcd by Global Special Programmes. Several multiccntre and multicountry rescarch projects were operating in the areas of D H F vaccine production, the rcscarch-cum-action on nutrition programme, liver cancer and Hepatitis C studies, community participation in D H F control, health economics, financing of health services, ctc. Information support for research and hcalth systems research also received considerable attention through WHO'S HELLIS nctwork. S E N A C H R made a number of recommendations which includcd strcngthcning of coordination betwcen focal point libraries and other libraries in the countries.

Four counlrics in thc Region had received institutional strcngthening grants and activities were to be initiated in some of them. This point had been elaborated in Section 3.3 "Health Systems Research and Development" (pp. 3-32).

Matters arising out of the Thirtieth scssion of the Global ACHR, held in IYM, and thc Technical Discussions of the World Hcalth Assembly held in 1990, were considcrcd hy SEAJACHR as well as by the meeting of MRCs. The task forccs and sub-commitlccs convcncd by thc Global ACHR in response to World Health Assembly rcsolulion WHA43.19 on the Role of Health Research in the Strategy for HFN2000, were on health development research, emcrging problems of critical significance to health science and technology, and on research capability strcngthcning.

A full report was givcn to SEAIACHR on the Technical Discussions held at the Forty-third World Health Assembly in 1990. It urged national MRCs and analogous bodies, scientists and scientific institutions in the countries to respond to the challenges, as mentioned in resolution WHA43.19. WHO would be revising and updating its hcalth research strategy at global and regional Icvels, in collaboration with national MRCs and analogous bodies. Global Special Programmes, such as the UNDPWorld BanklWHO Special Programme on Research and Training in Tropical Diseases (TDR), the WHO Special Programme for Research Development and Research Training in Human

Reproduction (HRP), CDDIARI and GPA provided support to research activities in the Region.

The CHAIRMAN invited the representatives to make their observations.

DR MUKHERJEE (India) expressed his agreement with the major thrust areas of the programme in the field of research. He sought more details about the outcome of the seventh meeting of Directors of Medical Research Councils or Analogous Bodics and Concerned Research Foci in the Relevant Ministries held in Kathmandu, Nepal, from 4 to 9 November 19W.

DR KWON (DPR Korea) thanked the Regional Office for sending a high-level consultant to DPR Korea to assist in its research programme. A staff member from the WHO Regional Office also visited DPR Korea and provided guidance and discussion on research proposals and other research activities, which was considered very useful. He urged that the support be continued in the future.

DR CHATAUT (Nepal) stated that Nepal was lagging behind in research activities. The Nepal Health Research Council was established last year and the Government had allocated approximately % 100 000 in its regular budget for the development of the infrastructure. There was a need to enhance research capability at the national level. He sought WHO'S support for research promotion activities under the regular budget and through extrabudgetary resources in the form of professional expert staff and short-term consultants to strengthen research activities and scrutinize research proposals. The ultimate aim was to develop research expertise within the country.

DR KHALILULLAH (Bangladesh) said that, despite having research potential, Bangladesh could not achieve much due to the lack of manpower. He emphasized the need for further research in the fields of malaria and non-communicable diseases such as cancer. Community participation, continuing education and resource mobilization were the other areas to receive additional attention. Referring to the efficacy of the drug used for treatment of tuberculosis, he anticipated that the time needed for therapy could be further reduced after conducting appropriate research.

Much research was being conducted by Unani and Ayurvedic researchers. He urged that such research should include health systems research. Some very good research was being conducted at the Research Institute of the University of Dhaka. This deserved the attention of WHO.

DR SOMSAK (Thailand) thanked thc Regional Director for his continued support in the area of health systems research. He stressed the significance of involving research institutions and premier policy organizations in strengthening the research mechanism. The Ministry of Public Health would set up a Health Systems Research Institute in the future. He hoped that the functioning of this institute would be strengthened with support from WHO.

DR DE SlLVA (Sri Lanka) stated that research was getting special attention in Sri Lanka. Most research work was carried out by individual institutions and the results did not reach the Ministry. Therefore, there was an urgent need for a mechanism to coordinate the various research activities being undertaken under the HSR project. Preparation of a bibliography was also under way.

DR YOUSUF, speaking in his capacity as representative of Maldives, mentioned that hcalth services research should be made revolutionary for purposes of health resourcc mobilization and improvement of health services delivery. In Maldives, research had been carried out, with WHO'S support, on the productivity of health workers and promotion of health behaviour. Using the approach of "training and visitation" prevalent in the agriculture sector, whereby the community health worker periodically visited the field, there was pcrccptible improvement in public health awareness. Efforts were being made to create a hcalth s c ~ c e s research section in the Ministry of Health. Collaboration with othcr agcncics and other ministries such as the Ministry of Planning was also sought to help overcome thc problem of shortage of manpower.

The REGIONAL DIRECTOR, thanking the representatives for their positive responses which had led to the emergence of a number of issues, mentioned that the priority research topics had first been identified by ACHR held in 1986. At this meeting, research on diseases such as malaria, nutrition and diarrhoea1 diseases was idcntitied as priority, but, later on, with the advcnt of the Alma-Ata declaration, ACHR relooked into the issuc of prioriti7ation and produced two Regional Publications on rcsearch, viz. (1) Research Need for HFA by the Year 2000, and (2) Concept of HSR. The countries should look into the question of whether this research would solve the ambient problems and whether better methodologies could be developed. Research on diseases such as tuberculosis, malaria, etc., was continuing. Regarding tuberculosis, two consultations had been held, and ACHR had discussed research on malaria in Chiang Mai. With guidancc from ACHR and using the RPD funds, various study methods and (cst kits had bccn dcvclopcd for drug-resistant Plasmodium. Further production of thcsc kits was being undertaken with assistance from TDR and WPRO.

The HQ document "Research Strategies for Health for All" contained general guidclines for rcsearch and the global approach to research. The World Health Assembly resolution on research could also be taken as a basis for the identification of future research, research capability strengthening, training and other operational aspects. ACHR considered research management and capability to be the main area which should be developed.

Though the countries possessed the potential and manpower for carrying out rcsearch, they could get only meagre funds from sources such as TDR and HRP because their proposals lacked proper design and content and were poorly documented. Towards this end, WHO had been supporting countries such as Mongolia and DPR Korea by way of consultants to conduct workshopslseminars so that good research proposals

could be developed for funding. The same thing applied regarding the mobilization of extrabudgetary funds for research. Except Bhutan and Maldives, some type of coordination mechanism for research management existed in all the countries.

General Health Protection and Promotion (pp. 6266)

Proteetion and Promotion olHealth olSpoellic Population Groups (pp.67-74) Protection and Promotion of Mental Health (pp. 75.78)

The CHAIRMAN suggested that, while considering Chapter 8 under Sub-section 8.1 "Tobacco or Health", the Committee might also examine resolutions WHA44.26 and EB87.R8 "Smoking and Travel". Ako, under Sub-section 9.1 "Maternal and Child Health, Including Family Planning", resolution WHA44.42 "Women, Health and Development" could be taken up (document SEA/RC44/13).

DR KUMARA RAI (Indonesia), noting the deteriorating oral health situation in the Region, said that Indonesia was striving to promote oral health. Provision of better dental equipment and increasing the ratio of dentists to the population were planned. The present situation was that there was dentist for 3-4 health centres with ill-equipped dental units.

From October 1991, all cigarette packets in Indonesia would carry the slogan "Smoking is injurious to health, which was only one aspect of the anti-smoking campaign.

The maternal mortality rate in Indonesia was as high as 4.5 per 1 000 and efforts were being made to place one midwife in each village so that by the end of 1992 around 20 000 villages would have midwives. Community participation in MCH had improved with the establishment of "maternity huts" and "mother awareness groups" at the village Icvel, where 10-12 pregnant or lactating mothers gathered to discuss childbirth and lactation.

DR KAN TUN (Myanmar) stated that the JNSP programme in Myanmar had been selected, along with the integrated child development senice project in India, fi)r the Liquria International Technology for Development Prize. The project was launched on a national scale since its inception in 1984 and it laid emphasis on the training of village-level health workers and district health workers, besides aiming at strengthening nutrition units at the central and regional levels.

DR MUKHERJEE (India) rcferred to page 65 of the Report wherein it was stated that the fatality rate of road accidents in India was 5.9 per I 000 vehicles, with an overall accident rate of more than 30 per 1 WO population. He felt that the fatality rate in a city such as New Delhi might be much higher, with pedestrians being the mosl accident-prone. There was a need to ascertain whether the statistics quoted were based on official data. In the sphere of nutrition, extensive studies of protein-energy malnutrition (PEM) had been conducted in India. It was the implementation of new programmes

which posed difficulties. The National Institute of Nutrition had made a major contribution to the promotion of understanding of the problems of iron deficiency and anaemia. He hoped that the outcome of the programme would be successful.

DR SINGAY (Bhutan) joined other delegates in expressing his appreciation to the Regional Director and his team for the excellent Annual Report. He stated that the iodine dcficiency disorders control programme in Bhutan was one of the best. Its impact had been excellent and a recent study of 3 000 children did not detect a single casc of goitre. It was proposed to start a nationwide assessment of the IDD control programme in which WHO was providing collaboration and cooperation, especially through technical guidance. Bhutan was convinced that unless the agriculture sector shifted its cmphasis from a production-based policy to one based on nutrition, the problem of malnutrition was likely to continue irrespective of the quantity of food produced. The proper and equitable distribution of available food was no less important in thc control of malnutrition. As regards maternal and child hcalth, while much progress had been achieved in child health, this was not so in the field of maternal health. The seventh five-year plan (1W2-1997) laid greater emphasis on the maternal health component and had set an ambitious target of providing health care to every pregnant mother and ensuring that each delivery was under the supervision of a skilled health worker. Bhutan's programme for the control of tobacco use was progressing very well and the wmmunity itself waz fighting again51 the use of tobacco, though in some parts of thc country such a campaign had lcd to sales of cigarettes and tobacco going underground.

DR DE SILVA (Sri Lanka) felt that Sri Lanka needed some special programmes to combat malnutrition in general and to lower the incidence of low birth-weight babies in particular through timely identification of malnourished mothers and interventions to correct the condition. His country was, therefore, hoping to get WHO assistance to develop an anthropometric chart for mothers to monitor weight gain during pregancy. Programmes like 'triposha' (distribution of food to selected beneficiaries) had given cmphasis to nutritional supplementation, but the use of locally-prepared foods for supplementation should be encouraged. He hoped that nutrition research network, recently launched by WHO, would provide useful information about nutrition research in all the countries. The newsletter issued by the Network needed to be more frequent. Sri Lanka had implemented a programe to integrate oral health within the routine functions of primary health workers. His country had a national committee on accident prcvcntion and WHO would provided assistance to produce a vidco on pesticide poisoning with vast improvements in coverage. More attention was being devoted to monitoring the quality of matcrnal and child health services in the country. There should bc increased awareness of adolescent health among school and post-school children. The family card proposed to be introduced would contain useful information regarding health conditions in the family. A reporting system had been developed for occupational diseases and the country needed assistance in developing an information system for the identification of ha7ardous industries.

DR RANA (Nepal) stated that more than 40 per cent of Nepal's poor lived in remote areas and that the problem of poverty was largely one of lack of resources rather than distribution. Given the fact that the vast majority of the poor were subsistence farmers, any programme for poverty alleviation would have to focus on agricultural productivity and employment in order to have an impact on health, nutrition and population control. Nepal planned to achieve a substantial reduction in the rate of population growth by the turn of the century and would be requiring major assistance in improving the service delivery, concentrating on outreach to the periphery, mainly accelerating on family planning and maternal and chid health services.

MS RAZEE (Maldives) stated that though some progress had been achieved in Maldives in promoting awareness of malnutrition and change of dietary habits of people, there was a need to obtain a clear picture of the nutrition situation in the country so that interventions to combat malnutrition could he suitably targeted. In the field of oral health, WHO'S collaboration was mainly focused on training national personnel and improving services through better utilization of existing facilities. She commended the SEAR countries on the work that they had done in reducing tobacco consumption, though Maldives had not done much in this field. There was a need to strengthen awareness regarding tobacco use, besides taking legislative and administrative measures to control this habit, particularly by banning advertisements. Maternal mortality continued to be a major problem in the country and a workshop on safe motherhood had been held in 1'990. The strengthening of regional hospitals, with facilities and trained personnel, was essential to reduce maternal mortality. Another recommendation of this workshop was to make guidance on child spacing available at the island level, which the Government had decided to implement. Building of women's centres in islands was an innovative approach adopted by Maldives, and delivery homes with well-ventilated rooms and trained staff were being provided.

DR ARSLAN (Mongolia) stated that Mongolia did not have a WHO-supported programme in nutrition, but this did not imply the absence of any nutritional dcficicncy in the country. It was possible that the type of nutritional deficiency prevalent in the country was different from that obtaining in other countries. What Mongolia faced was not protein-energy malnutrition but anaemia among pregnant women, vitamin deficiency and iron deficiency in some parts of the country. Because of its extreme climate, Mongolia faced seasonal scarcities of essential food items, and this led to the lack of vitamin-rich and high-energy food, particularly among children and other vulnerable groups of population. The need was to initiate studies and formulate research-cum-action projects. A research project with UNICEF support had been launched, a situation analysis of the nutritional status of mothers and children had been carried out and project proposals formulated. The prevailing economic crisis in the country had adversely affected the people and the need of the hour was to ensure an adequate supply of minimum food to them. Since tackling the problem called for intersectoral cooperation, various ministries were working on a national programme for food, with special emphasis

on children's nutrition. The experience of other countries in the Region in implementation of nutritional programmes could be useful for Mongolia.

On the subject of maternal and child health, including family planning Dr Arslan stated that a national conference on family planning had been held in Mongolia in August 1991, which podded a forum for the exchange of experiences in family planning and safe motherhood and facilitated the formulation of a new programme in Mongolia. The country attached great importance to the provision of MCH and family planning services considering that the mortality rate among women and children was ralher high and the interval between births in many parts of the country was short. About 40 per cent of pregnant women suffered from anaemia and similar disorders. In contrast to earlier times, Mongolia now laid emphasis on family planning through birth spacing in a hid to reduce infant and maternal mortality while, at the same time, taking care not to retard population growth. Mongolia could benefit from the experiences of other countries in the Rcgion in this field.

DR SOMSAK (Thailand), expressing concern over the increasing incidence of traffic accidents, especially those caused by truck drivers owing to drug abuse, said that his Government had been considering the initiation of serious measures to control the menace of drug abuse anlong truck drivers. Truck drivers suspected of taking psychoactive drugs were being subjected to urine and blood tests to identify drug abuse, which he hoped would prove a deterrent to those taking psychoactive drugs.

Referring to the unparalleled tobacco consumption situation in his country, he stated that funds provided by WHO in the form of seed money for tobacco control programmes would be a significant springboard for subsequent national contributions. An office for tobacco consumption control had been set up in his country, which involved various sectors apart from the Ministry of Public Health and had high-level government officials as members. Funds for the stafting and activities of this office had been allocated by the Govcrnmcnt for the current fiscal year, and a similar allocation of funds was cxpec~cd in the next fiscal year. Assistance from relaled governmcntai sectors as wcll as from nongovernmental organizations would be useful in the implementation of the programme for the control of tobacco consumption. The Government was reviewing the proposal to restrict the import of externally-produced tobacco into the country as part of its combined action against smoking. The Government would also shortly be enacting legislation for the control of tobacco consumption, which would include a ban on advcrtiscments, a consumer protection ad , legal restrictions on the sale and consumption of tobacco, and the declaration of public places ac smoking-free.

Dr Somsak said that psychosocial factors for health development cncompasscd a much wider area than just mental hcalth promotion. Behavioural improvement would not only lead to mental health but physical health as well. He suggested that the subject of behavioural health should receive adequate attention under the mental health promotion programme. Even though the programme was titled Promotion and Protection

of Mental Health, most activities in this area were of a rehabilitative nature. His country was making efforts for the reorientation of the existing health infrastructure and manpower for the promotion of mental health. He felt that such activities might differ from the programme classification of WHO as this would relate to various groups of population. He cited three important groups of population for the reorientation of mental health services, viz. infants, adolescents and the elderly.

DR KHALILULLAH (Bangladesh) said that poverty, malnutrition and disease was a vicious cycle, and his country was no exception. Nutrition per se could not be isolated from development and, apart from health action, more developmental action was required. In his country, 15 per cent of children weresuffering from acute malnutrition, and one-third of maternal deaths was attributable to malnutrition and its consequences. Nutrition had been given priority in sectoral development, particularly in the national economic development. Eighty-five per cent of the population lived below subsistence level, i.e., had an intake of less than 2 100 kilocalories per day. He sought WHO assistance, in a broader framework, in combating malnutrition and the consequent health effccts.

Abortion and related complications caused one-third of total maternal mortality, with malnutrition accounting for another one-third. It was hoped to provide free access to health centres for cases of abortion. He said that EPI and family planning had a direct relationship and that the coverage of 85 per cent of the population with EPI would have a direct impact on maternal health. Adequate attention was being given to mothers and children in rural areas with oral rehydration therapy and provision of iron supplements. The incidence of iodine-deficiency disorders varied from 10 to 50 per cent in different geographical areas. In order to overcome this problem, iodizatiob of salt had been undertaken wiih UNICEF assistance and legislation had also been enacted in this regard, which had resulted in eight of the 100 industries taking up iodization of salt.

His country accorded priority to human reproductive health and had been supporting research in this area. He solicited WHO assistance in further promoting research in human reproduction.

He said that drug abuse caused more traffic accidents. Control of drug trafficking had also assumed importance since the route for drug trafficking passed through his country.

As regards workers' health, thc Safety Act had not been sufficiently implcmcnted in industries. Occupational accidents were more common among industrial workers, especially in the textile and jute industries. Chemical poisoning and the use of artificial fertilizers and insecticides were also causing problems. He wished to learn from the experiences of India in the control of poisoning due to insecticides and fertilizers.

DR CHATAUT (Nepal), referring to page 63 in which mention was made to JNSP in his country, clarified that, apart from the Ministry of Health, the ministries of Agriculture, Education and Local Development hadalso been involved in nutrition-related activities. JNSP, which was undertaken with the support of WHO and the Italian Government, no longer existcd.

At this stage, thc CHAIRMAN invited the representatives of nongovernmental organizations to make statements of a general nature.

MR K.A. RAHMAN (International Planned Parenthood Federation), congratulated the Chairman and the Vice-Chairman on their election, and the Regional Director for presenting an excellent and concise report. The objective of his organization was to cnsure bettcr health for mothers and children. lPPF consisted of six regions and 136 mcmbcrs. He presented data on social indicators in various countries in the South Asian Region and also in developed countries like the UK and the USA. He highlighted the importance of nongovernmelital organizations in health development and pledged his Federation's assistance to the national governments and international organizations. He also called upon the countries of the WHO South-East Asia Region who were not already members of lPPF to consider enrolling themselves as members. He said that his organi~ation had been in close collaboration with WHO in the areas of maternal and child health and AIDS, and expressed the hope that the contribution of lPPF in these areas would hc rccognizcd.

MRS RUTH WONG (lnternalional Conrederation of Midwives) thanked the Regional Dircctor for inviting the International Confederation of Midwives to attend the Regional Committce session. She said that ICM consisted of over 60 member associations throughout the world. Countries with midwifery associations or midwifery branches of nursing or medical associations were eligible to apply for membership. One of the aims of ICM was to assist member organizations address issues and problems, and i t aimcd to facilitate the provision of effective and efficient care for mothers and babies through thc sharing of information, updating of knowledge and dcvclopment of skills in practice, research and management. Support and advice given by member organizations to one another was another means of achieving this aim. Safe motherhood had been a priority in ICM activities, and regions were urged to hold seminars, workshops and conferences to address this issue. She also requested the Governments of Bangladesh, India and Sri Lanka to hold workshops to stimulate midwives to work out strategies and mcans of implementation to reduce maternal and infant mortality and morbidity. The role of midwives and morbidity indicators were some of the areas in which ICM was undertaking research. The curriculum for the training of midwives was gradually changing to include sociology and behavioural sciences as well as biological sciences, counselling and health teaching. The development of management training for midwives at all levels was essential. Effective and efficient use of resources was an important issue facing midwifery managers due to economic constraints.

Referring to the three chapters under discussion, the REGIONAL DIRECTOR said that some of the programmes were in various stages of development. Accident prevention had not become a viable programme although it had been in existence for some time. Some countries had evinced interest in workers' health and occupational health programmes, but many others did not give them a high priority.

Note had been made of the inaccuracies in statistics about accidents in India, malnutrition, etc. As regards maternal and child health, family planning and human reproduction, WHO was interested in the totality of development of the health system in order to include the health of the child and the mother. The programme on safe motherhood was a very useful inter-agency collaborative programme among WHO, UNFPA, the World Bank and UNICEF, covering mother, child, father and the family. MCH was a technology to improve the health of the mother and the child. He urged the countries of the Region to develop and implement this programme in totality.

With regard to nutrition, the Regional Director said that this was a very complex problem. He advocated the use of local foodstuffs and urged that dependence on imported foodstuffs, iron pills, etc., be avoided. The use of alcohol, tobacco, drugs and even water in some countries were major problems. Too much emphasis was laid on technology forgetting social behaviour. It was essential to try to change social behaviours and social attitudes. With regard to psychosocial aspects of alcohol, it was necessary to view the totality of human behaviour.

WHO had been collaborating with the countries in drug abuse programmes. In Thailand, the programme had been continuing for many years. In Myanmar, the programme was doing well, as also in Sri Lanka, to some extent. In other countries, health ministries were not involved in the drug programme. The drug abuse programme was a multisectoral activity and a multi-ministerial programme, which existed in India and Indonesia. In Nepal, a programme was being formulated, and it was recommended that the Ministry of Health should take an active part in its implementation.

The Regional Director drew the attention of the representatives to two WHO publications on health research, entitled Health Research Strategy and Research Programme - A Global Oveniew, as well as related documents.

Promotion Of Environmental Health (pp.7986)

Introducing the subject, the REGIONAL DIRECTOR said that a full discussion on two aspects of the environmental health programme could be held when agenda item 18 "Evaluation of the International Drinking Water Supply and Sanitation Decade", and item 19 "WHO'S Contribution to the International Efforts Towards Sustainable Development", were taken up for consideration.

The CHAIRMAN, agreeing with the comments of the Regional Director, urged the representatives to confine their comments to WHO collaboration in the SEA Region in the environmental health programme, and suggested that the other items might be discussed in detail when agenda items 18 and 19 were taken up.

Diagnostic, Therapeutic and Rehabilitative Technology (pp 87-95)

The CHAIRMAN said that resolutions WHA44.34 and EB 87.R24 relating toTraditiona1 Medicine and Modern Health Care (document SEA/RC44/13) be taken up for discussion along with this chapter.

DR MUKHERJEE (India) said that drug policies and programmes in India were controlled by the Department of Chemicals. A large number of drugs and pharmaceuticals were produced in India which catered to the needs of the national health programmes. An intersectoral approach was called for to ensure that the minimum drugs for common diseases were made available to the common man. Out of the 60 000 drugs produced in India, 8M) commonly-used drugs were identified for use by general practitioners and hospitals. Separate formats had been developed for drug use in small hospitals, dispensaries and big hospitals. This had led to rational use of drugs and had discouraged the consumption of various other drugs available in the market.

He said that the establishment of the National Institute of Biologicals had filled a long-felt need for a central referral laboratory. This Institute would be the nodal point in the country for quality assurance of drugs and biologicals.

He felt that the sub-section relating to rehabilitation did not contain enough information on the disability situation. He advocated the strengthening of rehabilitation senices through the primary health care network, which combined a promotive, preventive, rehabilitative and curative approach to health care. India had the largest primary health care network in the world, encompassing 20 MW primary health care ccntres and 102 000 sub-centres. This network could be effectively utilized to deliver rehabilitative care to the community. He felt that, without a synthesis of the primary health care approach with community-based rehabilitation, the rehabilitation programme could not be successful.

He said that significant contributions had been made by nongovernmental organizations in the field ofrehabilitation. A case in point was Rehabilitation Coordination India, which was affiliated to Rehabilitation International. The participation of such voluntary organiirations in WHO workshops and seminars on rehabilitation, held from time to time, would provide them with an opportunity to focus their attention on what needed to be done in the country. He sought WHO support for strengthening the development of low-cost appliances, prosthetics and rehabilitation aids.

DR SINGAY (Bhutan) said that there was a need for support services for clinical laboratories at the district level in his country, and that this had been identified as a priority area in the Seventh Plan. The essential drugs programme in Bhutan was progressing satisfactorily, although there was room for further improvement. The concept of rational use of drugs had been understood by the doctors and they were well oricntcd to it. Hc conveyed the gratitude of his Government to WHO and the reprcsentatives of India and Thailand for collaborating in drug quality testing in the absence of a drug quality control laboratory in Bhutan. However, he requested WHO lo develop a proper mechanism and procedures for vaccine quality control, particularly in retrieving the results of tests of suspected reactions to vaccines expeditiously.

DR KYAW WIN (Myanmar) informed the committee that the Myanmar Essential Drugs Programme had been launched in his country several years ago with technical assistance from WHO and financial inputs from bilateral agencies such as FINNIDA. Under this programme, essential drugs were provided to nine townships under a pilot project. The purpose of this pilot project was to strengthen the drug policy, quality assurance, procurement and distribution systems. Myanmar did not have drug control regulations at present and a lot of drugs were available on the free market, with the result that the public had free access to dangerous drugs. This was to be checked slowly so that in due course of time the inflow of drugs to the country would be regulated. To this end, general practitioners and basic health staff were being trained. Standard diagnostic kits had been distributcd with relevant information on the safe use of drugs and a national drug formulary had bccn developed. Health education was being disseminatcd by the distribution of pamphlets on essential drugs and there was good community response to it. However, the quality assurance programme in the Region had to be strengthened td ensure the safety and efficacy of vaccines.

Referring to the practice of traditional medicine, Dr Kyaw Win said that, in his country, fifty per cent of the population still used traditional systems of medicine to treat common ailments. He advocated promotion of the use of traditional medicine within the Region. In his country, a school of traditional medicine had been set up in Mandalay to impart knowledge handcd down over generations in a scientific manncr. The practitioners of traditional medicine were sent to city hospitals to work side by side with the staff. In this way, the traditional systems of medicine could be integrated with modern medicine to improve health care delivery. He said that quality assurance and research on traditional medicine would go a long way in improving its efficacy.

DR KHALILULLAH (Bangladesh) said that, in his country, storekeepers in medical stores needed to be exposed to some training programme in the proper storage of drugs to ensure their efficacy. He called for regional cooperation to control the flood of spurious drugs from indigenous and external sources. With the introduction of drug regulatory policies in the country, smuggling of drugs across the borders had become

a recurrent problem and speedy action was called for to control the situation. Drugs with less toxicity and more effectiveness needed to be produced within the Region.

Endorsing the remarks of the representative from India on the subject of rehabilitation, he said that the development of appropriate low-cost prosthetics should be encouraged so that handicapped persons were not deprived of income-generating activities that improved their quality of life.

Agreeing with the comments of the previous speakers, Dr Khalilullah said that traditional medicines normally had less toxicity than allopathic drugs and that their use should be encouraged. In his country, homoeopathic medicines were also very popular. Some research in the efficacy of these medicines and their application in the existing health system was therefore necessary.

DR DE SILVA (Sri Lanka) said that, in his country, drug use in the population was being monitored. However, there was a need to improve drug information to prescribers and users. WHO had supported a programme for the publication of drug information bulletins.

He said that Sri Lanka had a good community-based rehabilitation programme. Training was imparted to volunteers with the help of the WHO manual on community-based rehabilitation which was proposed to be translated into local languages for effective use by volunteers.

DR CHATAUT (Nepal) said that his country had an essential drugs policy. However, only 15 per cent of its total drug requirement was met by indigenous production. He sought technical assistance from WHO for increasing indigenous drug production to meet 60 per cent of the country's requirement by 1997 as targeted.

The demand for anti-rabies vaccine in Nepal was going up while local production had been discontinued for some time now. He requestcd WHO to arrange for regular and expeditious supply of anti-rabies vaccine to his country.

DR M.A. NARAYANAN (World Rehabilitation Fund) congratulated the Regional Director on his committed leadership to the governments and peoples of the Region in their march towards the goal of HFN2000. He said that in the last year of the Decade of the Disabled, it was necessary lo analyse whether the objectives of the comprehensive community-based rehabilitation programme outlined by WHO had bccn attained. Disability prevention and rehabilitation were crucial issues because harnessing the abilities of the disabled yielded a good harvest in terms of mobilizing human resources for sustainable development.

He informed the Committee that the World Rehabilitation Fund had conducted training programmes and developed appropriate technology for rehabilitation in the past. The Fund was dedicated to the promotion of leadership through professional training, international exchange of experts in rehabilitation, information dissemination

and mobilization of resources from developed countries and bilateral agencies in order to guarantee the rights of the disabled to the attainment of the goal of HFAIuXX).

Responding to the observations made by the representatives, the REGIONAL DIRECTOR said that most of the countries of the Region had a package programme for disability prevention and rehabilitation. In India, the programme received bilateral assistance from various agencies in addition to the planned funds from the health sector. In this connection, he referred to two consultations on disability prevention and rehabilitation that had recently taken place in the Regional Office to address the issues involved. He felt that the countries of the Region could have close collaboration in the spirit of TCDC or could benefit from bilateral assistance in the drug programme from the ASEAN countries who have shown their political cohesiveness. He said that the production of anti-rabies vaccine would require the setting up of the necessary infrastructure, availability of seed vaccine and trained personnel. WHO would be prepared to provide technical assistance to the countries in this regard.

2. ADJOURNMENT


MINUESOFTHE FOURTH MEEllNG

SUMMARY MINUTES'

Fourth Meeting, 23 September 1991, 11.30 am

TABLE OF CONTENTS

I. Forty-third Annual Kep)rt of the Regional Director (Conrd) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

2. Consideration of Resolutions of Regional Interest Adopled by the World Health hsernbly and the Executive Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,128

3. Adjournment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

l0rieinally irved as documrnt SEAIRC44IMin.4 on 21 September 1991

1. FORTY-THIRD ANNUAL REPORT OF THE REGIONAL DIRECTOR (~rm 9, conrd)

Disease Prevention and Control (pp.%-136)

The REGIONAL DIRECTOR said that various sub-sections under this Chapter could be grouped in three categories for the purpose of discussion. First, he took up the sections dealing with immunization and Malaria.

He said that, part from the impressive achievement of more than 80 per cent child immunization in 1990 (for BCG, DPT measles and OPV), there was also a decrease in the reported cases of polio, diphthcria and pertussis due to extraordinary commitment, political will and individual government's efforts as well as those of the donor agencies. Accordingly, WHO and UNICEF would officially announce, under the auspices of the UN Secretary-General, this achievement at the UN Headquarters, New York, on 8 October 1991.

Countries of the Region had set the target of polio eradication by 2000, neonatal tctanus elimination by 1995, and measles reduction of 90 per cent by 1995. Tetanus toxoid coverage of pregnant women lagged behind other EPI programmes.

Disease surveillance was also part of the priorities set for EPI targets for the IYWs. Member Countries were strengthening their surveillance systems with necessary support from the Regional Office. All countries realized the importance of improved disease-reporting, case investigation and finding, and appropriate control measurcs. Development of timely and complcte reporting by all countries to provide "information for action" for use in rapid disease investigation and control was essential. Considering the significance of disease surveillance, increased efforts were needed.

There was a need for periodical review at regional and country levels to meet the targets of this decade. Adequate training was crucial for strengthening basic curricula and developing problem-solving skills. Implementation of EPI as an integral part of the health system infrastructure was necessary as was coordination of all planning and management with all concerned departments and NGOs, UN and other donor agencics.

The situation wilh regard to malaria had not improved over the last 5-6 years. A concerted action was essential in order to avoid further deterioration of the situation.

P.falcipanmt resistance to antimalarials, vector resistance to insecticides, and the development of exophilic and exophagic habits by the main malaria vectors constituted the technical problems to malaria control in the Region, which were further aggravated by the increasing economic constraints, large-scale population movements, etc.

Countries with endemic malaria were implementing malarial control strategies through the primary health care approach with varying degrees of success. Dependence on any particular control measure had to be avoided.

Preparations were being made for an Inter-regional Malaria Pre-Summit Meeting in February 1092 in Delhi. The Pre-Summit Meeting, along with two such meetings held in Africa and Latin America, would lead to a Ministers' Global Conference on Malaria which will be held in October 1992. A global strategy on malaria control will be adopted at this meeting, which would also revive interest in malaria control among policy-makers.

The CHAIRMAN invited the representatives to express their views on the subject.

DR SINGAY (Bhutan) said that, under the able guidance of the Regional Director, Bhutan had been able to achieve universal child immuni7ation. Targets for the Seventh Plan 1992-lW7 had already been set. Surveillance and containment measures as well as EPI were part of the national health plan. He requested information on whether there was to be a policy change in EPI regarding vaccines in view of the costs involved.

MS RAZEE (Maldives) was happy to report that Maldives had achieved the universal child immunization targets before the target date with support from WHO and UNICEF. There had been no cases of poliomyelitis, diphtheria, pertussis or measles reportcd in thc last 7-8 years.

She pointed out that in document SEARC44nnf.5, in the table on page 3, which showed the number of cases countrywise, the cases in Maldives had been wrongly indicated, as no case had occurred since 1984.

DR SOMSAK (Thailand) requested more information about the countries which were reported (ref.page 100, first para) to have introduced a system of tetanus toxoid immunization among all women of child-bearing age so that such examples could be followed in other countries too, if found useful. There were a few problems in Thailand with regard to thc antenatal care of women. The results of having all women of child-bearing age vaccinated wcre satisfactory in all provinces and there had been a rcduction in neonatal tetanus. Japanese encephalitis vaccine had also been included in the EPI vaccination schedule and had resulted in a reduction in the number of cases. He wanted to share the experiences of other Member Countries in this regard.

DR HARTONO (Indonesia) acknowledged with thanks the support rcccivcd by Indonesia from WHO in the field of immunization. Efforts were being made to immunize even all brides-to-be women through a registration system with the cooperation of the Ministry of Religion, which had shown encouraging results. Indonesia had also achieved the target of universal child immunization nationally, although some provinces in the eastern region still needed intensified effort to be completed by the end of the Fifth Five-Year Plan. Several measures were being initiated to produce vaccines indigenously.

He asked whether financial assistance could be expected for the production of vaccines. Immunization programmes could be successfully linked with family planning programmes.

DR KYAW WIN (Myanmar) said that Myanmar had conducted a survey on universal child immunization and gave a picture of the results obtained. He appreciated the assistance received from WHO for this programme. He also stated that midwives contributed significantly to the EPI programme.

Malaria continued to be a cause of concern to Myanmar. Spraying of DDT was not very effective and there were also the complex problems of drug resistance of P,falcipamm and of changes in vector behaviour.

DR KHALlLULLAH (Bangladesh) congratulated the Regional Director on the well-documented chapter on discase prevention and control in the Annual Report. Although Bangladesh had not yet achieved the target of universal child immunization in two divisions, it had become a possibility in the other two divisions. Bangladesh was expected to achieve the target of 80 per cent coverage. There was no mechanism for the production of vaccines in the country although production of insecticides was done indigenously with a quality wntrol laboratory. There was a need to augment the national capacity in this respect. Follow-up of immunized children after three years was considered useful. Noncommunicable diseases control was also an important area in Bangladesh and should be included in the PHC: systcm.

DR RANA (Nepal) mentioncd the incidence of kala-azar in some parts of Nepal. Control measures, such as the use of insecticides, were still in the frontline, as reported in the Annual Report of the Regional Director. The Government had allocated a substantial amount of funds for insecticides under the malaria wntrol programme. Some assistance had also been expected from DANIDA. However, there was a need to bc self-sufficient in this area eventually. Recalling the assistance received for the control of kala-azar over the last two years and which had now stopped, he expressed the need to revive that programme.

DR DE SILVA (Sri Lanka) reported that in areas of armed conflict of the country the immunization coverage might not reach expected levels and that efforts were being made to realize the targets. Special surveillance in these areas had shown encouraging results.

The situation regarding malaria continucd to be dismal in Sri Lanka since cases were on the increase, and strategies for malaria control needed to be reviewed. Control of dengue haemorrhagic fever and Japanese encephalitis also needed urgent attention. An integrated vector control programme had to be implemented. The International Irrigation Management Institute had been designated as the WHO Collaborating Centre for Vector Control. More efforts were being made for the control of vector-borne diseases in Sri Lanka.

M I N W OPTHE FOURTH M E m N G

Support was required for the implementation of the immunization programme against Japanese encephalitis. He requested WHO to consider his Government's request in this regard.

DR MUKHERJEE (India) mentioned that WHO should provide to the countries a write-up on the various aspects of vaccine management such as production, availability, testing facilities, distribution logistics, etc. Polio vaccine coverage in lndia was more than 85 per cent and the name of India should be included amongst those on page 99 of the Annual Report in which the eradication of polio wuld be achieved by the year 2000. In the production of BCG vaccine, India was self-sufficient, and after the current revamping of the unit, India should be in a position to supply this vaccine to other countries of the Region. Clinical trials had been recently carried out on the Japanese encephalitis vaccine and production would start after getting the feedback. Dr Mukherjee said lndia had a serious problem in regard to leishmaniasis in the States of Bihar and West Bengal and appreciated the timely provision of drugs by WHO for this.

DR ARSLAN (Mongolia) said that, though a WHO-assisted diarrhoeal diseases control programme had existed in his country for many years, it was not effective because of the tendency of doctors to use antibiotics and parenteral rehydration therapy instead of oral rehydration therapy. The Government had reformulated its policy on diarrhoeal diseases management and with WHO'S support the new national manager, together with a consultant, had conducted a national workshop on diarrhoeal diseases control to bring about a change in the attitude of doctors. Mentioning that there was no reference to plague in the Annual Report, he said that Mongolia had had eleven cases last year and three cases this year. Two projects for the production of viral hepatitis vaccine, which were set up with assistance from WHO and UNDP, were progressing well.

DR KYAW WIN (Myanmar) suggested that filariasis should receive more attention in view of the fact that it took 5-10 years to detect the infection in a person and that the disease was incurable after this length of time.

The REGIONAL DIRECTOR mentioned that the question raised by the representative from Maldives would be answered during the course of the session. Regarding EPI, the available vaccines for the EPI diseases should be better utilized in spite of the logistics problems such as availability, transportation, cost, sustainability, etc. The issues of future research and development of a one-shot injection or quadruple vaccine wcrc highly technical and these were being effectively looked after by the Global Advisory Group on EPI at WHO headquarters. He suggested that political issues should not be mixed up with operational matters concerning the EPI campaign, and that the concept of EPI was different from the other mass vaccine campaigns. The important issue was to utilize the existing technology, methodology, etc., effectively. He suggested that the Member States should establish a system covering the manufacture infrastructure, logistics, etc. instead of obtaining small quantities from donors, so that even if these donor agencies disappeared from the scene it would be possible to sustain the EPI

MINUTE7 OFTME FOURTH MEETlNG

programme. The same applied to the mass distribution of Vitamin A. He also advocated the innovative activities in EPI which were being carried out in Thailand.

He mentioned that better surveillance and epidemiological studies should be carried out to combat Japanese encephalitis. Emphasizing that one single method was not enough to control malaria, he expressed the hope that the country representatives would bring their different experiences with malaria control to the forthcoming Regional Malaria Meeting, which would also constitute an input to the Amsterdam Summit on malaria.

He suggested that the dauntries concerned should try to continue the existing UNDP-funded intercountry programme on plague since this year was the terminal year. He suggested that Bangladesh, Myanmar and Nepal should have enough manpowcr and that TDR activities could bc stepped up in these countries.

The CHAIRMAN proposed discussion on Sub-sections 8 to 14 of Chapter 13 of the Report, covering the sections on Tuberculosis, Leprosy, Zoonoses, Sexually-transmitted Diseases, Research and Development in the Field of Vaccines, AIDS, and Other Communicable Diseases. He suggested that resolution WHA44.8 could be examined with the discussion on Tuberculosis, resolutions WHA44.9 and EB87.RS with the discussion on Leprosy, and resolutions WHA44.4 and EB87.R6 with the discussion on Research and Development in the Field of Vaccines. These resolutions formed part of document SEA/RC44/13 under agenda item 20. Since the subject of AlDS was to be discussed under agenda item 13, he suggested that discussion on this sub-section might be combined with the discussion on the relevant agenda item. He then invited comments from the representatives.

DR VITURA SANGSINGKEO (Thailand) stated that recent epidemiological data indicated that Thailand was faced with increasing number of deaths resulting from noncommunicable diseases, including traffic accidents. It was well known that heterosexual transmission was the major means of spread of AlDS in the country. Efforts had been made to control the spread by emphasizing health education and promoting the use of condoms. The development of vaccines against rheumatic fever had made encouraging progress. The 1990 epidemic of dengue haemorrhagic fever (DHF) was now undcr control and the successful trials of DHF vaccine would continue in the near future which would definitely contribute to the control of the disease in the country.

DR KAN TUN (Myanmar) stated that multi-drug thcrapy had provcd to bc ihc turning point in the history of leprosy control in Myanmar and it was hoped the problcm would be eliminated completely by the year 2000. MDT was commenced in 1988 and a total of SUXM cases had so far been successfully treated, with 23000 being treated in 1990 alone. Hidden cases of leprosy posed a problem and efforts to detect such cases had been accelerated. A related problem was the physical and mental rehabilitation of

MINVTTSOFTTiE FOURTH MEFI1NG

leprosy patients in the years ahead and the Government planned to take active steps in this direction.

DR SINGAY (Bhutan) stated that acute respiratory infections had superseded diarrhoea1 diseases in importance in Bhutan, and that the Government proposed to tacklc this problem seriously. Bhutan had fully implemented the recommendation of the TB task force by switching over nationwide to short course chemotherapy technology. With the advancement of effective leprosy control programme, case detection was becoming very difficult thus calling for morc efforts, resources and parallel advancement in the skill of manpower which was often not understood by the Government.

MS RAZEE (Maldives) stated that Maldives had made considerable progress in controlling malaria and leprosy, while not much had been achieved in the control of tuberculosis. A fresh look and new strategies were called for to tackle this health problem. She called for close WHO collaboration with Maldives in this vital area. The resolution on the subject called for greater collaboration and she hopcd that countrics of the Region would be able to make greater headway in their tuberculosis control programmes.

D R MUKHERJEE (India) recalled the recent national-level consultation on tuberculosis to evaluate the strategies adopted in India's tuberculosis control programme. India, too, was faced with thc difficulty of estimating the precise number of TB patients in the country, and this was one reason why it was not possible to influence policy-makers in the Govcrnmcnt on this programme. New strategies were being evolved to make thc programme more effective. The drop-out rate of patients had shown a rising trend. Chemotherapy had an important role in the management of the tuberculosis programme. lndia would be keen to learn from the experiences of other countries in this field. The concept of multidrug therapy had recently been introduced in India for the control of leprosy. The leprosy control programme was one of the best-managed health programmes in the country even though $cant attention was being devoted to the rehabilitation of patients. Advances in surgery could play an aclive, promotive role in the lattcr aspect. Three vaccines of indigenous origin, besides the WHO vaccine for leprosy, were now under trial, and lndia would welcome more information on the development of vaccines in other countries in order to determine the place of vaccines in leprosy control.

DR HARTONO (Indonesia) recalled that a WHO-sponsored International Meeting on Epidemiology of Leprosy had been held in Jakarta from 17 to 22 June 1'990 with the aim of lowering the prcvalence of leprosy to one per I OM1 of population and that morc than 70 experts from 35 countrics had attended it.

DR DE SILVA (Sri Lanka) stated that the Sri Lankan experience in the control of leprosy had indicated a rise from 10 to 60 per cent in the number of persons coming for self-treatment following public awareness programmes. This had given rise to the hope that the country would be successful in eradicating leprosy.

M I N W S O F M B FOURTH MEEnNG

The REGIONAL DIRECTOR assured the representatives that their comments and views had been noted and that WHO could now proceed with the programme confidently. Trials of vaccines had been proceeding well in India under the auspices of the Indian Council of Medical Research. Elsewhere, vaccines for malaria and EPI as also children's vaccines were being developed. Scientists had been hoping to find vaccines which were effective, stable and portable. The use of multidrug therapy, with proper epidemiological studies and social marketing, etc., could lead to eradication of leprosy in countries such as Sri Lanka, Maldives, India and Thailand. This did not, however, mean that the work had to stop after this goal was achieved. Malaria parasites were of several species and the evolution of new drugs for control might take a long time. The vaccine now in use had not proved very effective.

The CHAIRMAN proposed discussion on Blindness and Deafness, Cancer, Cardiovascular Diseases, and Other Noncommunicable Diseases Prevention and Control Activities. He invited comments from the representatives.

DR SOMSAK (Thailand) stated thal Thailand proposed to surmount the problem of noncommunicable diseases by advocating healthy behaviour, besides early detection and treatment. The most serious challenge to health was posed by smoking and alcohol consumption. The results of the no-smoking campaign in the country had been encouraging, while controlling the consumption of alcohol was proving to be difficult. As regards cancer prevention and control, emphasis was on early detection coupled with provision of treatment facilities, and improving the capacity of the provincial health facilities. Thailand would be happy to share with other countries its experiences on various models for prevention and control of major noncommunicable diseases.

The REGIONAL DIRECTOR said that with the number of ageing people growing in the Region, action by the countries was essential to tackle the emerging problems. Based on the knowledge and information available from epidemiological studies, good programmes and projects could be formulated and donors contacted. Once the commitment for funding was available, problems could be identified through surveys, research and development and the relevant programmes could be implemented.

Health Information Support (pp.137-140) Support Services (pp.141.147)

The Committee took up these chapters, along with their sub-sections, for discussion.

DR KHALILULLAH (Bangladesh) wished to place on record the appreciation of his country for the quick and timely assistance provided by WHO by way of supply of medicines, particularly at times of disaster.

DR CHATAUT (Nepal) referring to Annex 1 - Organizational Structure - said that efforts were under way in his country for organizational restructuring. He

MINlJl€5 OFTHE FOURTH MEETlNG

acknowledged the assistance provided by WHO in this regard by making available the senices of a short-term consultant. H e wished to know whether information on the organizational structures of countries of the Region could also be included as part of the Annex in the Regional Director's Annual Report in subsequent years, which he thought would be bcneficial.

I)R SOMSAK (Thailand) referred to the recent establishment of a RTGIWHO Documentation Centre and expressed the hope that relevant and essential documents would be made available for use and reference purposes at the country level. H e requested WHO assistance for providing additional documentation support to this Centre. H e also suggested that W H O fellows who sought placement in his country could make use of the services of this Centre. Any suggestion in this regard was welcome.

DR D E SILVA (Sri Lanka) said that the existing libraries in the Ministry of Health and in the office of the WHO Representative should be strengthened.

The REGIONAL DIRECTOR referred to the WHO Publication 'Health Care in South-East Asia' which provided information, among other things, on the administrative structure of countries of the Region. H e did not favour the inclusion of the organizational structures of the countries in the Region as part of the Annex in the Regional Director's Annual Report. Noting the establishment of the Documentation Centre in Thailand, he referred to the distribution system of WHO documents to countries. WHO documents were made available to countrics in three groups, viz. documents relating to the World Health Assembly and the Executive Board, which were provided to the governments; technical reports on individual programme areas, which were distributed to the respective departments in the government; and other WHO publications which were distributed through sales. W H O had been strengthening libraries in countries and had identified one library in each country to act as the national focal point for the supply of publications and documents.

DR KHALILULLAH (Bangladcsh) refcrrcd to the Chapter on Promotion of Environmental Health, discussion on which was deferred, and raised the issues of supply of drinking watcr and pollution. H e said that deforestation and the resultant imbalance in the bio-levels was a problem in his country. H e also expressed concern over the dumping of chemical wastes from industries and of nuclear wastes through downstream river Ganges from neighbouring countries into his country. This would have harmful effects on the ecology of the country. Due to the lack of forests, food chains were a[kctcd and some animal spccics were on thc verge of extinction.

DR MUKHERJEE (India) endorsed the concern expressed by the representative from Bangladesh and said that his Government had been taking steps to prevent pollution of the Ganges. The Operation Ganga project was specifically meant to prevent pollution of the river thereby preventing industrial and other wastes from flowing into the ncighbouring countries.

MlHVrCSOFTl1E FOURTH MPEllNG

The CHAIRMAN congratulated the Regional Director on his presenting an exhaustive report and suggested the drafting of a resolution adopting the annual report as a whole. He suggested that the representatives from India, Maldives, Myanmar, Nepal and Thailand form a drafting committee to draft resolutions, including the one on the Regional Director's Annual Report. This was agreed to.

2. CONSIDERATION OF RESOLUTIONS OF REGIONAL INTEREST ADOFTED BY THE WORLD HEALTH ASSEMBLY AND THE EXECUTIVE BOARD (Iran 20)

The REGIONAL DIRECTOR referred to the document SEA/RC44/13 on the subject and said that 17 resolutions were listed therein. The write-ups consisted of the main points in the resolution. Eleven of these resolutions had already been considered while discussing the Annual Report of the Regional Director, and two would be taken up while discussing agenda item 18 on Evaluation of the International Drinking Water Supply and Sanitation Decade (IDWSSD) and agenda item 19 on WHO'S contribution to the international efforts towards sustainable development. As such, only four resolutions remained to be considered.

The CHAIRMAN invited observations of the representatives on the following resolutions:

(1) Health promotion for the development of the least developed countries (WHA44.24 and EB87.R9).

There were no comments.

(2) Method of work of the Health Assembly (WHA44.30)

The REGIONAL DIRECTOR said that the main point was that the work of the World Health Assembly had been reviewed periodically, and the Executive Board meeting in January 1991 had gone into various aspects of improving its working and making the Assembly more effective. The Board had recommended that the Assembly should not consider resolutions unless there had been a full debate on those items in the Executive Board or that they had been the subject of prior consideration by the Assembly, in order to ensure that there was no proliferation of resolutions. Secondly, until recently, Technical Discussions in the Assembly were being held every year. But now it had been decided by the Assembly itself that, from the Forty-sixth World Health Assembly, Technical Discussions would be held only in even-numbered years when there was no proposed programme budget to be discussed. During odd-numbered years, when the budget was discussed, there would be no Technical Discussions. The Technical Discussions in 1992 would be on the subject of Women, Health and Development. In 1993, there would be discussion on the budget, and thus there would be no Technical Discussions.

MINUIF5 OP THE FOURTH MEEllNG

(3) Collaboration within the United Nations System (EB87.RU))

The REGIONAL DIRECTOR said that this subject had been discussed at the forty-third session of the Regional Committee in great detail. The UN General Assembly resolution 441211 had been earlier referred to the Director-General. WHO, for comments. The Director-General had referred it to the Regional Committees for their comments in ordcr for him to respond. AU Regional Committees had discussed this matter and the Regional Directors submitted their viewpoints to the Director-General. On the basis of the views of the six WHO Regional Committees and the Programme Committee of the Executive Board, the Executive Board, at its eighty-seventh session, had prepared a resolution (EB87.RU)) on this subject for consideration by the Forty-fourth World Health Assembly. The Assembly, however, decided not to discuss the subject. The Director-Gcneral of WHO decided that the Regional Committees could review the subject in the Regional Committees before it was again taken up at the Executive Board in January 1992.

The Director-General was yet to report to the United Nations the reaction of WHO to this proposal. WHO recognized the need for good coordination among the agencies of the UN family. However, the resolution presented a few operational difficulties. For example, synchronization of the planning cycles of each agency and country was a difficult proposition. As it is, it was difficult for WHO to synchronize its biennial budgetary cycle with the different cycles of UNDP, UNICEF and UNFPA. Synchronizing its budgetary cycle with the different planning cycles of different countries would be even more difficult.

The resolutions further proposed centralized funding from UN for technical assistance to each country through its overall planning mechanism. WHO did not think this was desirable in the interest of health programmes which would be undermined. Since the subject had been discussed in detail at the Forty-third World Health Assembly, he suggested that thc Regional Committee, at its forty-fourth session, might endorse the discussions and conclusions of its Forty-third session without further elaboration.

DR SOMSAK (Thailand) expressed his surprise as lo why the Assembly decided not to discuss this important matter and returned it to the Director-General since many of the persons attending the Assembly were those who had attended the Executive Board Meeting.

The REGIONAL DIRECTOR informed the Committee of what had happened in thc Assembly when the resolution of the Executive Board was presented. Committee B decided not to consider it. A debate took place during which a numbcr of delegates made comments. When the resolution was voted, there were more abstentions than votes for the resolution, and no objections. He urged the representative to study the records of proceedings of Committee B of the Forty-fourth World Health Assembly to get a better feel of what actually happened.

MINVTTS O F l l i E FOURTH MEEllNG

In response to a query from DR SINGAY (Bhutan), the REGIONAL DIRECTOR informed the Committee that other Regions reacted somewhat differently. For example, PAHO had 60 per cent of its budget from sources other than WHO. In the EURO Region, there was a big intercountry programme with one WHO Representative in a country and small country programmes in some East European countries.

He further clarified that WHO (like FAO, ILO) was a special id agency of the United Nations with its own constitution and governing bodies, as distinct from UN funding agencies like UNICEF, UNDP and UNFPA, which did not have their own constitutions or specific governing bodies. With the ministries of health as the focal point for WHO in regard to national health programmes, the representatives, through the ministries of health, had to discuss these matters, UNGA resolution 441211 and operational problems within the Foreign, Planning and Economic and Coordination ministries to explain the situation. So far as the forty-fourth session of the Regional Committee was concerned, the Regional Director suggested that the Committee need not go into details again, but endorse the discussions and conclusions made at its forty-third session.

3. ADJOURNMENT


SUMMARY MINUTES'

Fifth Meeting, 25 September 1991, 8.00 am

TABLE OF CONTENTS

2 I l c p ~ r t 11f thc Managerncnt C*>mm~tlcc on the Global Programme on AIDS 140

3. Nomination of a member lo the Management Committee of the Global Programme on AIDS in place of India . . . . . . . . . . . . . . . . . . . .

4. Rcvicw of the second evaluation of' the Regional Strategies for I3ealth for All . . . . . . . . . . . . . . . 1 4 1

1. AIDS (Item 13)

Update (Irem 13.1)

In the absence of the Chairman, the Vice-Chairman called the meeting to order. He proposed a discussion on the agenda item relating to AIDS. Since there was a large number of items on the agenda, he solicited the cooperation of the representatives so that all the items could be dealt with. The Vice-Chairman suggested that while discussing AIDS Update, Section 13.13 (AIDS) of the Forty-third Annual Report of the Regional Director (pp. 126-129) might also be taken up.

The REGIONAL DIRECTOR, introducing the subject, stated that the problem of HIV infection and AIDS had become greatly aggravated. WHO estimated that about 8-10 million adults and about one million children were currently infected worldwide, with about one million adults and half a million children having been infected with AIDS during the past one year alone. While the AIDS pandemic had shown signs of slowing down in the industrialized countrics, it was spreading fast in the developing countries. India, Myanmar and Thailand in the South-East Asia Region had reported a signilicant number of HIV infections and cases of AIDS. It was estimated that about 250 000 and 200 000 HIV infections might have occurred in India and Thailand respectively. Half of these HIV-positive cases would develop AIDS symptoms in ten years and might die in the absence of a curative drug. The incidence of tuberculosis associated with HIV infection had shown an increase in the Region. This was another disturbing factor. The socioeconomic impact of the disease, which was already evident in subSaharan Africa, might be felt with the same intensity in our Regjon in 10-15 years from now if the present trend persisted. The fact that several wuntries in the Region still reported a low or zero prevalence should not lead to complacency. The Regional Director recalled that wuntries, such as India, Myanmar and Thailand, which had reported zero or low prevalence of AIDS a few years ago, were now faced with a serious public health problem due to HIV infections and AIDS. Ten countries of the Region had formulated national medium-term programmes (MTP) to combat AIDS, while Maldives was expected to formulate its MTP during the current year. Financial support was being provided to countries under WHO'S global programme of AIDS (GPA).

The Regional Director cautioned that, in spite of financial support provided by international and bilateral agencies, the implementation of AIDS control programmes in some countries still left much to be desired. There was an urgent need for effective intersectoral coordination in most countries. While the Ministry of Health should be the focal point for all activities relating to AIDS control, effective support was essential from all other concerned sectors, institutions and NGOs. Referring to the documents

M I N L m S O F l H E FIFTH MEtTlNG

SEAIRC4418 and SEA/RC44/Inf.2, which had been distributed, he invited comments, observations and suggestions from the representatives.

D R MUKHERJEE (India) drew particular attention to some salient aspects of the Indian scenario with a view to updating the information given in documcnt SEAJRC4411nf.2. The number of fatal cascs had increased from 65 to 68 since May 19'11 while 1 MK) seropositive cases had been detected in a single month. The number of AlDS cascs had incrcascd from 1 100 in 1989 to 2 (iOO in 1990, and twice that number again in 1W1. It was feared that the actual number might be much higher. The number of seropositive cascs had fluc~uated between 2.4 and 12.7 per 1 W, but this had now stabilized at 5.9. In this context, he was keen to know WHO'S projections of the likely AIDS cases in the South-East Asia Region as this information was of crucial importance to all countries in order to draw up their plans for its control.

Dr Mukhcrjee stated that as far as lndia was concerned, the cpidcmiological pattern of AlDS varied widely from State to State, with the north-eastern States, namely, Manipur and Nagaland, reporting as many as 43.7 cases per 1000 tested for seropositivity. India had launched a concertcd effort to develop a long-term programme of AIDS control with financial support from the World Bank to the tune of Rs. 130 crore. The country proposed to significantly widen the scope of seeking external assistance for its AlDS control programme. H e thanked WHO for the support it had given to his country.

Rcfcrring to the problcms being faced in the programme against AIDS, Dr Mukherjec referred to the important aspcct of legislation. A Bill rcccntly presented in the Indian Parliament was referred to the Subjects Committce, and had to be withdrawn for some reasons. Another issue was the foreign tourists and the large community of foreign students studying in India. The latter group numbered about 75 000. The question was how to evolve an effective testing methodology best suited to screen this large group. A hard look at medical ethics was also nccdcd to ensure that hospitals and doctors did not refuse to attend to suspccted AlDS cascs. This could perhaps he achieved by drawing up common guidelines for hospitals and medical and paramedical personnel. Another important question rclating to the AIDS control programme was the sterilization of injection needles, particularly in the primary hcalth centres in countries such as India, where it was economically not feasible to provide disposable syringes and needles. Suitable guidelines needed to be evolvcd in this respect.

DR KAN TUN (Myanmar) statcd that the first HIV infected case was rcported in Myanmar in 1088. The number had increased since thcn. Cross-scctional studies showed 2 743 HIV-positive cases out of a total sample of 103 051. The National Health Committee of Myanmar had taken up AIDS control as a priority health problem. In this respect, the situation in Myanmar was similar to that which obtained in neighbouring Thailand. In order to forge close coopcration between the two countries, necessary steps were bcing taken to form a joint committec to tackle health problems of common

concern. The two countries proposed to hold a joint meeting on AIDS, malaria, etc., in mid-November 1991.

DR DE SILVA (Sri Lanka) stated that in Sri Lanka, 39 HIV-positive cases were reported by August 1991, of whom nine were foreigners; these included one HIV-2 positive. A short-term plan of action had been implemented in Sri Lanka, an interim plan of action was currently being implemented, and a long-term plan, with an estimated budget of US$ 3.3 million, was being prepared. The Government was expected to contribute about US$ 0.75 million to this programme and the remaining funds were expected from UNDP. A project document had been signed with UNDP, providing for US$ 1.2 million towards the technical assistance wmponent alone.

He further stated that it had been decided to decentralize the IEC component of the AIDS control programme. There was a need to share the experiences and expertise in this respect with other countries of the Region. He expressed appreciation that Thailand had responded positively to a request made by Sri Lanka by arranging a study tour for two Sri Lankan policy-makers.

Another vital area of concern in AIDS prevention and control in Sri Lanka was male prostitution. He requested assistance from Thailand to combat this problem. The existing legislation in the country did not permit any legal action against this activity. There were also no legal measures available to restrain foreign prostitutes from operating in the country, for which suitable legislation was under preparation. Screening of blood samples was another necessary but expensive activity, and Sri Lanka had succeeded in reducing the expenditure on this activity by pooling the serum from blood donors. With a view to integrating AIDS control into the STD control programme, Sri Lanka planned to set up provincial AIDS committees in the eight provinces of the country. Five NGOs had expressed willingness to assist in the programme and this was welcome. No less crucial was the political commitment from the governments. A seminar for the parliamentarians was to be held nca month. The use of needles was equally important and Sri Lanka would welcome advice and suitable technology on sterilization and reuse of needles considering that disposable needles was an expensive proposition.

MS RAZEE (Maldives) mentioned that, though her country had not so far had any case of AIDS, there was no room for complacency. There was cause for concern because of the existence of factors such as high-risk behaviour groups, multiple sexual partners, a high divorce rate, and the regular inflow of foreign tourists and patients whounderwent treatment in countries where the standards of blood usage and transfusion facilities were questionable. 9 832 samples had been tested up to August 1991, out of which none was found positive. The samples were taken mainly from sailors, persons who came for medical check-ups, tuberculosis patients, children with thalassemia, and patients who were admitted for operations. To be ready to face the problem when it arose, it was essential that health personnel, such as doctors, nurses and laboratory technicians, were well-trained in the clinical management of AIDS. Due to the lack of

personnel trained in communication and public health education, health education strategies on AlDS could not be carried out effectively. In this regard, the national radio station of Maldives played a crucial role in imparting health education. It was running a weekly programme on AlDS in order to educate people in AIDS prevention and control. Ms Razee stressed the importance of involving nongovernmental organizations in the AIDS control programme because they were in a better position to cut across political and religious harriers. She wished to share the experiences of other countries in dealing with issues such as confidentiality of reported cases, since there would be a hue and cry once a case was reported and the affected family was likely to be harassed.

DR VITURA (Thailand) wanted to update the information contained in the document SEAiRC4418. He wanted paragraphs two and three on page 5 of the document to be replaced by the following to provide more precise and updated information about the situation of AIDS in his country.

"In Thailand, there is clear evidence that the direction and magnitude of the epidemic have changed over the past few years. The initial cases of AIDS were generally limited to imported cases of Thai homosexual males returning from foreign countries in 1984 and 1985. This was followed by an explosive spread of the AlDS virus among Thailand's intravenous drug users in 1987 and 1988. The virus then spread among male and female sex workers throughout the country, particularly in the northern provinces.

"The Ministry of PublicHealth has collectedextensive information documenting the spread of the HIV virus through its sentinel surveillance system in 1989 and 1990. It is now clear that heterosexual intercourse has become the single most important mode of transmission (male to female and female to male) in the expanding AIDS epidemic. Many provinces are also reporting cases of pcrinatal transmission (mother to child). It is expected that the AIDS epidemic in Thailand will continue to expand, with heterosexual intercourse being the major mode of transmission."

Dr Vitura also wanted the heading of sub-paragraph 21.2 on page 22 to be changed from "Year 1 Review of Medium-Term Plans of Thailand" to "Medium-Term Programme Review Conducted in Thailand".

Table 2 appearing on page 3 of the document should be corrected to incorporate the following latest figures relating to Thailand:

"As of 31 August 1991, the present situation of AIDS and HIV infec~ion in Thailand includes 167 AlDS cases, 429 cases of ARC and 33 607 HIV infections reported to the Ministry of Public Health. Information on AIDS and HIV in Thailand is gathered through routine reporting as well as through sentinel surveillance surveys conducted twice each year.

"Thailand has also begun efforts to establish estimates of the actual number of HIV infected persons in the country. It is believed that approximately u)0 000 persons were infected with HIV by the end of 1990. This figure is revised as time goes on, and as of 31 August 1991, it was believed that the number was somewhere between 2.50 000 to 300 000 persons.

On page 12, in the area of Counselling, Thailand conducted an Informal Consultation on HIVIAIDS Counselling from 17 to 21 September 1990, with technical and financial assistance from WHO headquarters. This subsequently resulted in national training manuals being developed and anonymously tested and counselling sites being established in Bangkok and provincial cities.

Dr Vitura mentioned that, in Thailand, apart from disseminating information to the general public on possible modes of transmission of AIDS and advocation of desirable - sexual behaviour, the Ministry of Public Health had worked closely with the Ministry of Interior in limiting AIDS transmission through prostitution and service girls. Condoms were being distributed free of charge followed by regular check-ups for STD and HIV infection by provincial health authorities. Health personnel and police would in future work closely to contain the spread of STD and HIV transmission.

The Ministry of Public Health was able to persuade the Ministry of Education to set up three offices to deal with AIDS education for young people. A National Committee for the Prevention of AlDS had been created with the Prime Minister as the Chairman and the Permanent Secretary of Health as the Secretary.

It was difficult to change the situation overnight in spite of public education, and persuading people to stay away from prostitution while control of the transmission of the virus had to be undertaken right away by mobilizing all possible support. In disseminating information or introducing interventions about HIV infection, it was essential not to create any misunderstanding or misinterpretation by the public.

DR SINGAY (Bhutan) said that though no positive HIV case had been reported in Bhutan, a short-term plan for the prevention and control of AlDS had been successfully completed and the medium-term plan was in the process of implementation. The national AlDS prevention and control programme was a well-accepted programme and the Ministry of Foreign Affairs had issued pamphlets about AIDS to people who were travelling abroad. World AlDS Day was celebrated at the community level whereby more health education and dissemination of information had been possible. Through effective mobilization of resources, especially through the Global Programme on AIDS (GPA) and through the Regional Plan of Action, Bhutan was able to strengthen the STD control programme, and improve laboratory and sterilization services. A nationwide knowledge, attitude behaviour and Practice (KABP) survey had been conducted and the results were being analyscd. While thanking WHO for the support so far given, he

sought the Organization's assistance in training medical personnel in AIDS case management.

DR LI CHANG BOM (DPR Korea) thanked WHO for the assistance provided to his country in the prevention and control of AIDS. A National AIDS Control Committee in DPR Korea existed and a short-term project for the prevention and control of AIDS was in operation. Though no cases of AIDS had been reported in DPR Korea, the threat existed because of the fast spread of the disease the world over as well as the steady inflow of foreign tourists to the country. He sought assistance in the strengthening of screening facilities and sterilization of medical instruments. Though medical personnel possessed simple knowledge about AIDS through publications and health education materials, they needed to be trained in the clinical aspects and case management of AIDS. He sought from WHO more public health education material such as pamphlets, training modules, vidco cassettes and films. He wanted to share the experiences of other countries with regard to the legal and public health aspects of the prevention and control of AIDS.

DR HARTONO (Indonesia) stated that there was no reason for complacency in the matter of giving attention to the problem of AIDS. In Indonesia, approximately 133 000 people had been screened so far, out of which 35 were found seropositive and more than 16 full-blown AlDS cases detected. Of these 16 cases, 13 had already died and one had left the country. The mode of transmission in Indonesia was through homoscxuality, bisexuality, IV injection, blood transfusion and heterosexual behaviour. A study of scxual bchaviours in the country had revealed the relationship between AlDS and the social norms and values associated with sex among the population. Because of its geographical location, Indonesia had a tourist potential from countries with known high HIV prevalence which could lead to rapid spread of HIV infectiodAIDS

In response to the WHO Global Programme on AIDS, a Nalional AlDS Committee had been established. Thc national AIDS programme comprised of three phases - short-term plan (1988-89), interim period plan (1990-91)and medium-termplan (1992-94). Strengthening epidemiological surveillance, developing health education for all sections of the population, supporting laboratory facilities and monitoring and evaluation were of vital importance. Considerable financial resources would be required for implementation of the action plans. Since WHO funds were meagre, it would not be possible to sustain the programme as planned in the future without adequate financial support from other international, bilateral and multilateral sources.

Though there was initial resistance, the family planning programmc did not object to the promotion of condoms as an effective means of prevention of the spread of AIDS.

DR CHATAUT (Nepal) appreciated the support provided by WHO for the AIDS programme in Nepal in terms of technical and financial assistance. At present, the main

activity was health education. Inadequate transportation within the country poscd difficulties. The literacy rate was low and the availability of trained health manpower to build up the health education programme was insufficient. However, the increasing involvement of nongovernmental organizations in health education programme for AIDS was greatly welcome. Even NGOs with objectives other than health were participating in this programme. Two groups of social workers had formed an association with NGOs mainly for the control of AlDS and STD. They were keen to participate in the national activities and it was proposed to allocate for them financial resources under thc Government AIDS Control Programme.

DR KHALILULLAH (Bangladesh) reported that there was only one case of AIDS reported so far in his country, and that patient had died. No further case was reported. Bangladesh had an AIDS surveillance mechanism which operated through identified focal points. Appointmcnt of full-time project managers, establishment of laboratory facilities, training of doctors, nurses and paramedical staff were some of the measures taken under this programmc. Hcalth education for AIDS had been strengthened in the interim plan of action, which was expected to be completed by the end of 1991. Inclusion of training programmes, strengthening of laboratories, health education and isolation of AlDS patients were proposed to be included in the MTP. Expressing concern about transmission, Dr Khalilullah said that AIDS was a social disease and its patients feared the threat of isolation and social humiliation. Sometimes even the hcalth workers refused to attend them. Bangladesh shared the concern about the spread of this diseasc as expressed by representatives from other countries.

The REGIONAL DIRECTOR again stressed the importance of the subject. He said that minor discrepancies in the statistics as reported in the documents and thosc brought up by the representatives were due to the fact that the documents had been prepared in Junc 1W1. Therefore, up-to-date data could not be presented. He suggested that there was a need to maintain proper monitoring, better epidemiological approach, with passive surveillance in hospitals, active surveillance in high-risk groups, and sentincl surveillance since it was becoming a very scrious problem.

Regarding sterilization techniques, he said that skin-piercing methods should be avoided to the extent possible, and injections should be given only when absolutely neccssary and only using properly sterilized needles. For example, blood tests for malaria and filariasis parasites could be avoided. Instead, control methods, such as stratification. should be adopted. For sterilization tcchniques, WHO Publication AIDS Serics No. 2 - "Guidelines on Sterilization and Disinfection Methods Effective Against Human Immunodeficiency Virus (HIV)" - contained useful information, which had already been distributed to the national AIDS programme managers, and these could be referred to. The preferred method for sterilization was dry sterilization heating up to 170°C or boiling for 20 minutes for equipment to be sterilized for Hepatitis B or HIV.

The Regional Director requested that appropriate methods available in the countries should be used to deal with the problem of AIDS, taking into account the local customs, culture and epidemiological factors. Counselling and creating public awareness were essential parts of health education. Some useful documents for clinical management of AIDS could be used as health education materials. Measures could also be adopted in a manner similar to those applied in the case of tuberculosis some decades ago. In fact, a combination of measures was needed taking into consideration the local conditions and no coercive or preventive method should ever be adopted.

He expressed the apprehension that the tremendous interest now being shown by some international organizations all over the world in the AlDS programmes might not last long, and that the interest might decline in the absence of an early breakthrough and when it was realized that AlDS was going to be a long-drawn battle. At that stage, WHO might be the only agency left to deal with it. However, he felt happy that UNDP, the World Bank and some other UN agencies were actively coming forward in this programme. Some Scandinavian countries had also offered assistance. In view of this, he urged the Member Countries to use these supports to develop their own infrastructure, manpower training programmes and laboratory services in order to sustain their battle against the disease.

A global strategy had been adopted by WHO and a regional strategy for AIDS control and prevention also existed. He stressed the need for all concerned to work in a coordinated manner and to involve the NGOs in the totality of these efforts. These organizations might be allowed by the ministries of health to participate within the framework of national AIDS programmes.

At this point, the Regional Director requested the representatives from UNDP and UNICEF to make statements.

MR FARASHUDDlN (UNDP) thanked the Chairman for affording him the opportunity to make a statement. He said that UNDP had been in the forefront in the tight against AIDS, the gravity of which had been fully realized. WHO and UNDP had formed an alliance some years ago which had worked well so far. UNDP looked at the problem not from the medical or technical point of view, but more from the point of view of impact on social and economic development. He quoted the example of the Philippines (the country of his previous assignment) where measures to face the problem were initially postponed before it struck back and the country had to stand up and take noticc. Therefore, he urged that this problem could not and should not be wished away and the situation should be brought into sharp focus. UNDP was planning to help Maldives in organizing a sensitization workshop which would involve all the UNDP personnel and the nationals. This matter had already been discussed with the WHO Representative. He referred to a regional AIDS control project located in New Delhi, India. He invited the representatives to look at the project document which provided for awarenessgeneration workshops, training, and other activities.Thedocument

was available for review and he urged the representatives to give it a serious look. He said that in the overall programming of UNDP activities in the 1990s, HIVIAIDS would receive attention as a matter of special concern.

MR MUSANNA (UNICEF) said that his office concentrated on the creation of awareness of AIDS, and had supported the inclusion of this in the school curricula as well as in the training of paramedical staff. Translation of AIDS publicity materials into the local languages had also been undertaken. UNICEF had been cooperating with UNDP and WHO at the country level. He said that with combined efforts it should be possible to combat the problem of AIDS.

2. REPORT OF THE MANAGEMENT COMMIlTEE OF THE GLOBAL PROGRAMME ON AlDS ( I m 13.2)

The REGIONAL DIRECTOR introduced the subject and said that thc Management Committee of the Global Programme on AlDS represented the interest and responsibility of WHO'S external partners collaborating in the global strategy for the prevention and control of AIDS. As the advisory body to the Director-General of WHO, it recommended onmatters relating to the policy, strategy, finance, management, monitoring and evaluation of WHO'S Global Programme on AIDS. India and lndonesia represented the South-East Asia Region at the Global Management Committee (GMC) and two meetings of this Committee had been held in November 1990 and in April 1991. He requested the rcpresentatives from India and lndonesia to report jointly or individually on thcse meetings.

DR HARTONO (Indonesia) expressed his inability to report on the attendance of the Indonesian representative since he did not have advance information on this.

DR MUKHERJEE (India) also regretted his inability to present a report.

The REGIONAL DIRECTOR stated that the problem arose because the country rcpresentatives coming to the Regional Committee session might not be the same as those who had attended the Global Management Committee. The countries had been alerted in advance about the need to report to the Regional Committee. He, however, stated that the report of the meeting could be obtained from WHO headquarters and copies made available to the countries.

3. NOMINATION OF A MEMBER TO THE MANAGEMENT COMMIlTEE OF THE GLOBAL PROGRAMME ON AIDS IN PLACE OF INDIA (Item 13.3)

The REGIONAL DIRECTOR, introducing the item, said that India and Indonesia had been appointed members of the Management Committee of the Global Programme on AIDS for one and three-year terms respectively. India would be completing its tcrm

on 31 December 1991 and another country was to be nominated to the Committee for a three-year term from January 1992 to December 1994.

The Committee nominated Myanmar to the Management Committee of the Global Programme on AIDS in place of India for a period of three years from January 1992 to December 1994 and requested the Regional Director to inform WHO headquarters accordingly.

4. REVIEW OF THE SECOND EVALUATION OF THE REGIONAL STRATEGIES FOR HEALTH FOR ALL ( I m 14)

The VICE-CHAIRMAN invited Dr M. Zakir Husain, Director, Planning, Coordination and Information, to introduce the subject.

DR ZAKIR HUSAlN referred to the previous two monitorings of the strategies for Health for All in 1983 and 1988 and the first evaluation conducted in 1985. In compliance with World Health Assembly resolution WHA42.2, all the countries had completed their second evaluation and reported the results in the agreed common framework and format (CFED). These reports, covering information on socioeconomic developments, development of health systems, health situation and trends and outlook for the future, had been synthesized into a regional report which would constitute the regional contribution to the Eighth World Health Situation Report. Individual country reports had been presented in documents SEA/HSD/150 to SEA/HSD/lM. The regional review document presented the progress achieved in the Member Countries since the last evaluation, conducted in 1985, recounted the constraints and difficulties that had been faced in the implementation of the strategies, and indicated approaches to resolve issues of common concern.

Highlighting some of the findings from the second evaluation, Dr Husain said that most countries lacked a fully-operational and complete registration system for births and deaths, and demographic and related epidemiological data remained incomplete and therefore inconclusive. Infant mortality rate had declined in most countries, but in the absence of disaggregated data, geographical variation within countries could not be detected. There had been marked improvement in the life expectancy at birth, which had exceeded 60 years for males in six countries, with females having an edge over males in most countries.

Popular participation in the primary health care approach had emerged stronger and more equitable distribution of resources for primary health care had been noted. Despite the economic stagnation in the countries resulting in the restricted growth of health budget, more than 50 per cent of the national health expenditure had been earmarked for local health care in four countries. The adult literacy rate had exceeded 70 per cent in seven countries and was between 60 and 70 per cent in the rest.

New challenges and difficulties had emerged due to economic restructuring, adjustments and social transformation. The evaluation had underlined the need for sustained effort to improve the capacity for health policy analysis and health development planning, with optimal resource allocation and generation in the face of changing socioeconomic and political environment. The priorities identified were promotion of health and protection of environment in regard to the vector and disease control, food and nutrition strategies and sophisticated future trend assessment. The countries needed neworicntation, new skills and new commitment tosustain and accelerate implementation, where necessary, for the attainment of the goal of Health for AU in the current decade.

DR MUKHERJEE (India) congratulated WHO for comprehending the positive health development in the right spirit. Speaking about the Indian scenario, he complemented the information already provided in the background document. Therc had been wide variations in the infant mortality rate in different States in his country, with several States already having achieved the target set for the ycar 2CW. Thc birth rate had shown only a marginal difference. The Eighth Five-Year Plan (1992-1996) would lay stress on consolidation of the past achievements in the field of primary health care. The emphasis in the Plan would be on quality of services at the primary health centres and sub-centres rather than on increasing the number of such health facilities. As regards the 20-point parameters indicated in the document, he said that these had been under constant monitoring at the national level. Some of the States had already achieved the targets. He said that the new health paradigm would be an appropriate tool for achieving the targets set. He felt that the document could have prescntcd a more optimistic outlook for the future.

DR SINGAY (Bhutan) wished to associate himself with the views expressed by the representative from India and congratulated the Regional Director on his presentation of a lucid and comprehensive report on the Evaluation of HFA Strategies. He said that as regards indicators, there was a risk of masking of the situation when data wcre presented in an aggregated manner. He suggested that ranges of values for indicators be indicated in future, which would make the information more analytic. Referring to the social indicators which were presented by the representative of the International Planned Parenthood Federation, he said that some ofthe ratios, such as doctor-population, doctor-bed, could be misleading. Equity of distribution of health care facilities, both in urban and rural areas, was important and should find expilicit mention.

DR LI (interpreted by Dr Kwon) thanked the Regional Director for preparing a very comprehensive paper on the subject. He pointed out some discrepancies in the statistical data mentioned in the document in respect of DPR Korea. The Regional Director requested him to furnish the revised figures, indicating the source of information, which would be duly reflected in the summary records.

DR DE SILVA (Sri Lanka) complimented the Regional Office on producing the report on the second evaluation of regional strategies for health for all. He felt that it

was difficult to obtain figures in respect of expenditure on primary health care as no methodology for the purpose existed until recently. In the context of global indicator No. 4, he suggested that a methodology be provided to countries since most of them were not geared to collect this kind of information yet. With regard to the morbidity pattern, he said that delivery-related cases were not the leading cause of morbidity. Despite the armed conflid and a decline in the foreign exchange position, the health situation in his country continued to be good, except in regard to malnutrition, incidence of low birth-weight babies, malaria and anaemia in women. His Government was concerned about the occurrence of noncommunicable diseases, such as heart and cardiovascular diseases, caused by the changing Lifestyle of the people. His country was trying to overcome these problems within the available resources and with assistance from WHO. With the devolution of powers and functions to the provinces, each province was able to develop its own programmes and funds were obtainable for health from local authorities. A bottom-up planning process had been possible. The Poverty Alleviation (Janasaviya) Programme had opened up opportunities for local leadership and for joint actions by health with other development programmes. Through this mechanism the trained community was now ready to accept the health programmes and helped the Government to transfer its efforts in building up community involvement in health. Other countries could gain from successful experiences of mobilization of the community in a big way in the poverty alleviation programme. The health impact was under study. Indicators showed an improvement in the health status, but quality of care and quality assurance were subjects of special attention.

Hc said that the Management Development and Planning Unit of the Ministry of Development and Planning was strengthened to closely monitor the ongoing programmes, to effectively wordinate the management training activities, to develop an adequate health information system, and take steps for human resource development. He pointed out that there was a move towards private health care. The household expenditure survey showed that even though free health services wcre available, approximately 60 per cent of the total health cxpenditure was borne by the household. These resources that wcre in an unorganized sector could be mobilized through health insurance, etc.

DR KUMARA RAI (Indonesia) said that in order to improve the quantity as well as the quality of its health services, two Presidential Decrees had been passed for the implementation of two innovative approaches. The first related to new graduate doctors, which stipulates that, as from 1W2, all new doctors would be hired on a contractual basis only in order to make them work in remote areas. This would enable 100 per cent of the health centres to be headed by medical doctors, as against 90 per cent of the existing 5 600 health centres. This scheme would benefit not only doctors whose salaries would rise by four or five times, but also improve performance as only those doctors doing well as civil servants would be offered contracts after they had finished the three-year compulsory service. The second innovative approach was in the self-financing of hospitals, for which five government hospitals would be field-tested.

Through this approach people would be allowed to use their revenue directly in order to obtain better quality of senice from hospitals which would act as a referral for primary health care. With regard to the percentage of expenditure on health by the community, a situation similar to that in Sri Lanka existed, as 70 per cent of the health expenditure was being borne by the community. A health maintenance scheme was heing implemented for the community, which would enable it to use 70 per cent of the funds more uscfully to cover preventive as well as curative aspects of health care. The coverage under this scheme was only 12 per cent at present. It was hoped to covcr about 20 per cent of the population under this scheme by the end of 1994. With regard to health indicators, he stated that maternal mortality was of serious concern. His country intended to post midwives totalling about 20 000 by the end of 1994, and by the year 2000 it was hoped to have at least one midwife in each village.

DR ARSLAN (Mongolia) noted with satisfaction that the second evaluation showed improvement in the indicators used to evaluate the progress made. He said that in his country, owing to stagnation of economic development in the last decade, progress in the implementation of national HFA strategies had slowed down. In spite of the steady increase in the national budget for health over the years, proportionate increase in population and health problems connected with development together with inflation, devaluation of national currency and shortage of hard currency, budget deficit had affected health development. The situation was aggravated by a decrease in employment opportunities and social guarantees to pcople in health protection and education. As a result, health indicators of the population in the lirst half of 1991 had changed. The incidence of maternal morbidity continued to be high due to the high crude birth ratc, high-risk pregnancies, and lack of attention to child spacing under the then national demographic policy.

Traditionally, the main features of thc health senices system in his country were high accessibility, total population, coverage, introduction of the latcst advances in medical tcchnologies, practices and provision of health care free of cost.

Thc hcalth system infrastructure was now increasingly under the influence of market mechanisms, necessitating modification of the basic principles of the national health policy and evolution of new approaches to sustain health development in the country.

Though the country had a well-established health system infrastructure with 85 health workers per 10 000 population, the non-existence of a communications network, lack of proper roads, inaccessibility of certain sections of the population in remote area? and inadequate modes of transportation contributed to difficulties in hcalth care delivery. Innovative measures had been adopted to ameliorate the situation. The establishment of cooperativc and private hospitals was expected to fill this gap. The question of privatization of some segments of the health sector was under consideration by the Government. In order to improve accessibility of primary health care, the health care system was being decentralized at primary, secondary and tertiary levels. He hoped

that, with technical support from WHO and donor countries, the goal of HFA/;?000 would be realized.

D R SOMSAK (Thailand) noted that the evaluation of HFA strategies was a praiscworthy effort and was instrumental in stimulating and intensifying efforts at strengthening implementation of the strategies for HFAROOO and improved hcalth information system. H e said that the monitoring system provided indicators of improvcmcnt of the health status of the population. However, there was no room for complacency as now the health problems of the underprivileged populations had to be addressed. H e said that the inaccuracies in the statistics in respect of maternal and infant mortality in his country were due to lacunae in the reporting system rather than to the actual drop in maternal and child health coverage.

H e suggested that as an important component of PHC services, an in-depth analysis of community participation bc undertaken during the next evaluation. Underlining the importance of community participation in health development as the main strategy to achieve comprehensive health care, he said that the focus should be on encouraging community self-reliance in health care rather than on mere expansion of health care and the population coverage. H e said that in the next five-year plan, the emphasis would be on strengthening health centres to get a better interface with the village level, sclf-reliant and self-managcd primary health care.

H e complimcntcd thc Regional Director on the consolidated report on CFEJZ based on individual contributions from Member Countries and hoped that the lessons learnt during the second evaluation would be incorporated into the global report for submission to the forthcoming World Health Assembly.

Expressing his appreciation of the meticulously-documented report on the second evaluation of HFA strategies, DR KYAW WIN (Myanmar) fclt that HFA mcthodology, managerial process for national health development and community involvement in health care had shown a markcd improvement. lntersectoral coordination with other sectors and TCDC cfforts had also been strengthened.

Agreeing with the views expressed by the representative from Thailand, he said that community participation through better organization and dissemination of information for self-care in health was the key approach. The ten-household health workers scheme, under which ten houses wcre considered as one unit and placed under the responsibility of a PHC worker in Myanmar, had been very successful. This PHC workcr instructcd the residents on self-care methodologies, while there was activc participation of the more affluent citizens through contributions in cash and kind to build health facilities and hospitals.

MR RASHEED (Maldives) joined the other representatives in complimenting the Regional Director on presenting a comprehensive report. H e noted that the discrepancies in thc ligurrs in respect of Maldives were due to weaknesses in the information and

reporting system at the atoll level, which needed to be strengthened. He said that in his country, expenditure on health had grown in relation to GNP and had increased from 83 to 91 in a short time. He recommended that cost-effective systems of health care should be introduced to sustain this growth.

DR NAlLA IBRAHIM DID1 (Maldives) said that though maternal morbidity rates had come down in Maldives, infant and neonatal mortality continued to be high. This had relevance in terms of distance, isolation and climactic conditions of the islands and atolls in her country which caused logistic problems for transporting sick patients. She stressed the need to focus on these problems to prevent neonatal deaths caused by delays in transportation and provision of adequate medical care in time.

Similarly, family health workers were handicapped by the lack of transport to the remote islands and atolls to impart family planning education. With the assistance of WHO and UNFPA, a project had been established to provide family planning services. However, her country faced an acute shortage of trained manpower, and requested WHO assistance to address this problem. She said that there was a high incidence of hypertension in the younger age-group and suggested that prevention of noncommunicable diseasescould be integratedwith the PHC services for early case detection and prevention.

DR CHATAUT (Nepal) said that the CFEI2 document had proved to be an asset for health planning purposes in the context of the new political system in the country. The second evaluation exercise gave a catalytic impetus to the identification of national strategies for HFA. He felt that it was imperative that proper feedback was available to constantly monitor the progress. He said that the Eighth Five-Year Plan was about to be launched in his country. The thrust of the new health policy to be declared by the Government during the forthcoming Health Ministers' Meeting would be towards providing basic health care to the undersewed population in the rural areas by creating new health facilities in terms of sub-health posts and health centres.

The VICE-CHAIRMAN, speaking as the representative of Bangladcsh, said that health was a decentralized subject and was delivered through the local govcrnment system. In the absence of a clearly-enunciated health policy and health manpower plan, several impediments were encountered in the progress towards HFA/UMO. However, the Government was aware of the problem and the health sector had received a bigger share of the budget. He solicited continued support of WHO and other international organizations to sustain PHC development in a committed manner.

MS SUCHADA SAKORNSATIAN (World Federation of OccupationalTherapists) expressed her gratitude at being given the opportunity to inform the representatives regarding the work of her Federation in support of HFA. The World Federation of Occupational Therapists, a nongovernmental organization, acted as the official international organization for the promotion of occupational therapy, providing services to those afflicted by physical injury or illness, developmental problems, the ageing

process, and social or psychosocial problems. The Federation strongly supported WHO'S efforts at community-based rehabilitation programmes which might be beyond the means of the countries of the Region, and the Federation could assist WHO through specialized guidance on establishing occupational therapy training programmes, provision of expert advisers in community-based rehabilitation, and access to its worldwide network of information resources on occupational therapy.

MS RUTH WON(; (International Confederation of Midwives) noted with appreciation that the goal of Health for All had made progress in the Region. Fifty per cent of the world's population consisted of women, and a majority of the health services were meant for women and children. Still, women did not have any choice in making decisions on reproductive health, child spacing and family planning. A great deal of time and effort was being devoted to improving the health of women without recognii.ing that, as recipients of the outcome of these efforts, they could render valuable help with the programme. She implored the representatives to ensure that women wcrc affordcd the opportunity to share in decision-making, especially in view of the fact that there could be religious and cultural difficulties involved at the time of their implementation. Any amount of resource - economic, financial or manpower - devoted to the achievement of the Health for All objective would not be fruitful without the active involvement of women.

2. ADJOURNMENT

Thc meeting was adjourned.

Sivth Meeting, 25 September 1991, 11.30 a m

TABLE OF CONTENTS

llevicw o f the scu~nd evaluation of thc Regional Strategies for l-leallh for A11 . . . . . . . . . . . . . 150

Man;~gement Adv~sory Commillec (MAC:) o f the Acllon I'r(1grammc on . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I:c$cnlial Ilrugs . . . . . . .

W l l O Special I'rogramme of llesearch and Training in Tropical 1)iseases. . . . . . . . . . . . . . . . . . 1 5 2

WHO Special Programme for Research Development and Research Training in Human Reproduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . Sub-commitlee on Programme Budgel. . . . . . . . . . . . . . 155

(i1nsldcratlon 111 lhc rca~mmcndalions arising oul 11f lhe 'l'echnical l)lscus~ions on I lw~s t c r I'rcparcdness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

l<valuat~on of the international Drlnking Water Supply and Sanitation Decade. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

WHO'S Contribution to the lntcrnalional Efforts towards Sustainable Development . . . . . . . 160

Adjournment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163

1. REVIEW OF THE SECOND EVALUATION OF THE REGIONAL STRATEGIES FOR HEALTH FOR ALL ( I i m 14, conid)

The VICE-CHAIRMAN called the meeting to order and requested Dr Zakir Husain to respond to the points raised in the preceding discussion.

Dr ZAKlR HUSAIN assured the representatives that the interest, support and concern expressed by them regarding the necessity of refining data on health status and health situation through disaggregation had been noted. Such disaggregation was likely to reflect the inequity or the need for equity which was one of the principles of HFA. The extcnt to which the disaggregated data could be presented in future evaluation reports would depend on the degree of disaggregation reported by the individual country evaluations. The need for more accurate and updated data had been mentioned by representatives and he invited them to provide information regarding data on which they might have strong reservations so that they could be suitably reflected in the summary minutes. In doing so, they might wish to quote the source ofrevised information; the revised data could be incorporated in future reports.

The REGIONAL D I R E n O R stated that the evaluation had highlighted several achievements and successes. It was to be noted, however, that the HFA strategy should not be seen as distinct from the national health development plan. The HFA strategy a u l d not be independent of the national health policy, but the two constituted the same whole. Besides, the implementation of the health policies called for a multi-sectoral approach, with collaboration from various ministries, departments and organizations besides the Ministry of Health. Such an approach was not adequately reflected in the evaluation and this aspect deserved greater attention.

2. MANAGEMENT ADVISORY COMMI'ITEE (MAC) OF THE ACTION PROGRAMME ON ESSENTlAL DRUGS ( am 17)

Report on the session ofthe Management Advisory Committee of the Action Programme on Essential Drugs

The REGIONAL DIRECTOR, introducing the subject, stated that the Managemcnl Advisory Committee (MAC) had held three meetings so far and representatives from Bhutan and Indonesia had participated in them. He invited one of the representatives to present a report of the meeting.

The VICE-CHAIRMAN invited the representative from Indonesia to present the report of the Committee.

DR HARTONO (Indonesia) stated that the supply of essential drugs for primary health care called for the development and implementation of national drug policies in the context of csscntial drugs. The Action Programme on Essential Drugs (DAP) had providcd support for the implementation of country programmes on essential drugs, and developed guidelines in the areas of drug quantification and rational use of drugs. He recalled that the first meeting of MAC was held in October 1989, the second meeting in March 1990 and the third in February 1991. MAC had highlighted the four areas of intervention in WHO'S Action Programme on Essential Drugs, viz. policy and management, supply and logistics, thc rational use of drugs, and quality assurance.

Thc report of the latest meeting of MAC was still in its draft form and so were the recommendations. Rccapitulalingthc principal refommendationsof themccting, Dr Hartono stated that the Committee had stressed the importance of interaction between the Executive Board's Committee on Drug Policies and MAC, it stressed DAP collaboration with other WHO programmes as also programmes and institutions outside WHO; requested DAP to strengthen and deepen the research component of its programmes, and, in this perspective, to further strengthen its collahwation with expertise outside DAP and WHO by setting up ad lloc advkory groups. The meeting also proposed that the forthcoming meeting of MAC would have the theme of 'rati~inal use of drugs', and would include the use of antibiotics, research methodology, definition of research priorities and operational priorities, and the setting up of indicators, particularly at the country level.

Nomination of a member to the Management Advisory Committee of the Action Programme on Essential Drugs (MAC) in place of Indonesia whose term expires on 31 December 1991 (11cm 17.2)

Introducing the subject, the REGIONAL DIRECTOR drew the attention of the representatives to document SEA'RC4417, which contained detailed information on the background of MAC, its composition, its terms of reference and functioning. He requested the Regional Committee to elect a member for a period of three years in placc of Indonesia whose term would expire on 31 Deeembcr 1991.

DR KUMARA RAI (Indonesia) sought reappointment of Indonesia on MAC in view of its great interest in the subject and also due to the fact that it had been acting as the collaborating centre of ASEAN in Good Manufacturing Practices (GMP).

The REGIONAL DIRECTOR clarified that the terms of reference of MAC allowed reappointmcnt.

The Committee renominated Indonesia to the membership of MAC for another term of three years effective 1 January 1992. The Vice-Chairman requested the Regional Director to inform WHO headquarters accordingly.

3. WHO SPECIAL PROGRAMME OF RESEARCH AND TRAINING IN TROPICAL DISEASES ( I r o n 1 5 ,

Report on the Joint Coordinating Board (JCB) session (lfm I I I ) Nomination of a member to JCB in place of Indonesia whose term expires on 31 December 1991 flm rs.2)

Introducing the subject, the REGIONAL DIRECTOR said that this agenda item contained two parts: the first part related to a report by the current members from this Region on their attendance in JCB, and the second part related to the election of a member in place of Indonesia whose term would expire on 31 December 1991. Currently, lndonesia and Myanmar were the two members from this Region who attended the JCB session and he invited their report on the attendance.

Reporting on the participation in the fourteenth session of JCB from 25-26 June 1991, DR U KAN TUN (Myanmar), read out a joint statement on behalf of Indonesia and Myanmar. He highlighted the four terms of reference of the Board, viz. to revicw TDR in 1989-1990, the 1992-1993 budget, TDR and industry collaboration in product development, and community perspectives in accepting these technologies. He mentioned that the key-note address by the Honourable Minister for Health of Nigeria to the JCB session had stressed the importance of the infrastructure of the primary health care delivery system and community participation in the social sector. The matters relating to the thirteenth meeting of JCB and the Scientific and Technical Progress of the Director's Rcpr t and STAG report were discussed. Other presentations included reports on women and malaria, and on collaboration with industry. The report of the Standimg Committee was also presented. The Board approved the revised progamme budget for 1990-1991, the proposed programme budget for 1W-1993 and the estimated budget for 1994-1995.

The Regional Director drew the attention of the representatives to document SEAIRC4415, which contained detailed information on the background of JCB, its functions and composition. At present, Indonesia and Myanmar were the two members from the South-East Asia Region under paragraph 2.2.2 of the Memorandum of Understanding. The term of Indonesia (1989-1991) would be expiring on 31 December 1991. He requested the Regional Committee to elect a member for a period of threc years from 1 January 1992 to replace Indonesia.

The Committee nominated Thailand to the Joint Coordinating Board in place of Indonesia. The Vice-Chairman requested the Regional Director to inform WHO headquarters accordingly.

4. WHO SPECIAL PROGRAMME FOR RESEARCH, DEVELOPMENT AND RESEARCH TRAINING IN HUMAN REPRODUCTION (Item 16)

Report on the Policy and Coordination Committee (PCC) session (Item 1 6 1 ) Nomination of a member to PCC in place of Nepal whose term expires on 31 December 1991 ( I I ~ 16.2)

Introducing the subject, the REGIONAL DIRECTOR rcfcrrcd to document SEA/RC44/7 which contained detailed information on the background and composition of PCC. As was the usual practice, he invited one of the countries who had attended the PCC meeting recently to report on the attendance.

Reporting on the participation in the fourth session of thc Policy and Coordination Committee from 19 to 21 June 1991, DR VITURA (Thailand) said that the South-East Asia Rcgion was rcprcscntcd by Bangladesh, Ncpal and Thailand. Thc salient points discussed at thc meeting wcrc as follows:

(1)The Committee rcvicwed in dctail the proposcd programme budget for the 1992-1993 biennium and noted the proposed increase of USO7.1 million or 13.7 per cent over the approved budget for 1m-1991. The Committee also suggested that thc Programme should look for optimal ways to utilize its personnel resourccs given the fact that thc prcscnt exchange rates had led to an unavoidable incrcase in the tcchnical and administrative support costs. The Committee noted the incrcascd interest of the countries in seeking support from the Programme as also the incrcascd financial support for the Programme from its external donors and some new financial contributors, i.e. Argentina, USSR and Venezuela. It was also observed that the previous invcstment of thc Programme in strcngthcning research capabilities in developing countries was producing multiplier effects as highlighted by the External Impact Evaluation Team Study in 1W0, which bccamc the basis for formulating thc 1902-1093 programme budget.

(2)The Committee was briefed by the chairperson of thc Scientific and Technical Advisory Group (STAG) of the Programme on the work done by STAG. There were five areas of research and development under the Programme and also task forces set up for various tcchnical work. The Committee was briefed in dctail about rcscarch on post-ovulatory progestcnes known as mifeprestinc and agrccd that such research was important in order that the Organization could rcspond adequately to the requests for information and advice from Membcr States. The Committee noted that the Programme was not supporting clinical research on anti-progestenes in any country without explicit government approval, but, at the same time, reaffirmed the wish to continue its activity in this area.

(3)The Committee was briefed about the 'no-scalpel' vasectomy technique practised widely in China, and the long-term problems as a consequence of vasectomy possibly with regard to increased incidence of cardiovascular diseases and testicular cancer. A large retrospective study in China, and findings from studies in the USA and the UK, found no evidence that vasectomy increased the risk of cardiovascular diseases. As for the risk of cancer, the results of a study in Denmark would be available in 1992. Other techniques under study for fertility regulation in males were hormonal methods using the testosterone enanthrot and long-acting androgens, and non-hormonal drugs and plants.

(4) The Programme expected to stimulate more interest in the Committee for resources for this area in its 20th Anniversary activities, to be organized at the country and regional levels through its collaborating centres.

(5) The Committee was informed about the Programme initiative to highlight the impact of the environment on reproductive health through an international workshop organized in Copenhagen in September 1991.

The representative from Thailand proposed that the Programme look into care of the post-menopausal conditions of women as the quality of life decreased during this period. Knowledge from reproductive health research and activities could contribute significantly to improving the quality of this period. It was also suggested that it would be highly beneficial to set up collaboration between the developing and developed countries.

DR VITURA thanked the Regional Committee on behalf of the three countrics from the Region for the opportunity to attend the PCC session.

On a question from DR MUKHERJEE (India) as to whether there was any real concern in the PCC about vasectomy, anti-pregnancy vaccines and male contraceptives, DR SOMSAK (Thailand) mentioned that the Committee had been briefed and that according to the fmdings of the long-term follow-up studies done in the USA, the UK and Denmark, there were some possible side-effects of male contraceptives which were undesirable. If the hormone was stopped for a few months, the side-effects disappeared. The Programme was investigating the possibility of the use of non-hormonol drug, and the results were encouraging.

The VICE-CHATRMAN invited the country representatives to offer nominations for Membership of the Policy Cw~rdination Committee in place of Nepal whose term would expire on 31 December 1991.

DR U KAN TUN (Myanmar) proposed Indonesia to replace Nepal in PCC in view of Indonesia's technical capability to support this Special Programme on the basis of its enormous experience in family planning research and development in human reproduction.

DR CHATAUT (Nepal) seconded the nomination of Indonesia.

Indonesia was elected to the Policy Coordination Committee for a period of three years, i.e. from 1991 to 1994. The Vice-Chairman then requested the Regional Director to inform WHO headquarters about this nomination.

5. SUB-COMMI'ITEE ON PROGRAMME BUDGET (11m 11)

Consideration of the Report of the Sub-committee on Programme Budget (firm 11.1)

The VICE-CHAIRMAN said that the Sub-committee on Programme Budget had met under the Chairmanship of Dr Rana (Nepal) and requested him to present the report.

DR RANA (Nepal), Chairman of the Sub-committee on Programme Budget, said that the Committee had met on 22 and 24 September to review its terms of reference, as mentioned in the document SEA/RC44/3 and the working papers SEAIRC44PBIWPIl and SEA/RC44PB/WP2. The Committee consisted of representatives of all the eleven Member Countries. He presented the report and also read out the conclusions and recommendations of the Sub-committee. The Sub-committee reviewed the working paper relating to the delivery of the Organization's collaborative programmes during the first 18 months of the 1990-1991 biennium and also noted the discussions of the twentieth meeting of CCPDM on this subject. He mentioned the following five as being in need of increased WHO support:

(1) Managerial process for national health development;

(2) Organization of health system infrastructure based on PHC (for intensified health development in countries most in need);

(3) Nutrition;

(4) Promotion of environmental health, and

(5) Integrated disease prevention and control.

The VICE-CHAIRMAN thanked Dr Rana for the report, as contained in the document SEA/RC44IU) submitted to the Regional Committee, and invited comments from the representatives. Since there were no comments, the report was adopted.

6. CONSIDERATION OF THE RECOhlhlENDATIONS ARISING OUT OF THE TECHNICAL DISCUSSIONS ON DISASTER PREPAREDNESS q11m 12,

The VICE-CHAIRMAN requested Dr Hartono, Chairman of the Technical Discussions on Disaster Preparedness, to present the report for the consideration of the Regional Committee.

DR HARTONO thanked the participants for their cooperation and contribution in the discussions. He also appreciated the support provided by the Secretariat and presented the report on the Technical Discussions on Disaster Preparedness (document SEA/RC44/21) to the Committee. DR CHATAUT (Nepal), Rapporteur, then read out the conclusions and recommendations arising out of the Technical Discussions.

The VICE-CHAIRMAN thanked the Chairman of the Technical Discussions group for an excellent report. He said that the subject was of great interest to all the countries of the Region. He hoped that the representatives would have gone into the details of the report which had already been circulated. He then invited them to express their news so that the recommendations arising out of the Technical Discussions could be finalized and the report adoptcd.

DR MUKHERJEE (India) expressed satisfaction with the report and referrcd to someerrors therein. He proposed that the words "all levels" appearingin recommendation No.9 be replaced with "various levels".

The REGIONAL DIRECTOR thanked the representative from India for pointing out the error and said that necessary corrections would be incorporated in the final version of the report.

The report was adopted,

7. E\'ALUATION OF THE INTERNATIONAL DRINKING WATER SUPPLY AND SANITATION DECADE (IDWSSD) (11m 18)

The VICE-CHAIRMAN referred to the documents SEA/RC44/11 and SEARC441lnf.4 dealing with this subject and suggested that the resolution WHA44.28 on Water and Environmental Sanitation, rcferrcd to in document SEAEC44113, be taken up for discussion along with this item. He then invited Dr D.B. Bisht, Dircctor, Programme Management, to introduce the subject.

DR BISHT, introducing the subject, said that the International Drinking Water Supply and Sanitation Decade (IDWSSD) had the main objective of stimulating and accelerating national water supply and sanitation coverage to ensure access to safe water supply and adequate sanitation facilities for the unsewed urban and rural populations. To attain these objectives, emphasis had been placed on the complementarity of water supply and sanitation. The importance of community participation at every stage of implementation had also been recognized. While significant progress could be claimed in the coverage of rural populations, the gap between the served and the unserved urban populations had been widening. Progress in sanitation coverage had lagged far behind the target set for the Decade. Intensified efforts were needed in order to realize universal coverage by the year Urn.

WHO had been supporting institutional and manpower development, convening of intercountry consultations, and preparation of national Decade Plans. Progress in these sectors had been closely monitored and mid-course corrections carried out in 1983, 1985 and 1988. The background document contained an overview of the water supply and sanitation situation and dwelt on the tasks that lay ahead in the post-Decade period. In conclusion, he said that the investments in new facilities and rehabilitation of the existing systems would have to be increased manifold along with human resource development, health education and community participation.

DR SOMSAK (Thailand) stated that the achievements of the Decade should be assessed against the incidence of water-borne diseases, especially diarrhoea1 diseases, which did not show any significant decline despite improved water supply and sanitation facilities. Thcir qualitative aspects ought to be looked at from an engineering angle, such as facilities for storage of drinking water in water tankers, piped water supply systems and sanitary latrines. Continuous availability of safe drinking water should be ensured. Maintenance of the most sophisticated facilities was another area for priority attention. He also underscored the importance of health education in promoting behavioural aspects of the people to ensure appropriate use of sanitary latrines and the role of safe drinking water because lack of awareness among the people had contributed to the spate of water-borne and other diseases due to insanitary conditions.

His country had embarked on a comprehensive package of sanitation development which includcd water supply and latrines as its components, and was aimed at reduction of water and sanitation-related diseases. Emphasis under this package would be laid on proper sanitation, disposal of wastes, sewerage systems, pest control and household cleanliness.

DR MUKHERJEE (India) said that water supply coverage in his country had reached 86 per cent in urban areas and 76 per cent in rural areas. Endorsing the views expressed by the representative from Thailand on behavioural aspects, he said that a change in the social system was essential in relation to the use of a better sanitation system. He referred to the indigenous low-cost sanitary system 'Sulabh Shauchalaya' in his country and felt that such efforts should be encouraged. He noted with concern that the health ministry had not been very active on the management of water supply and sanitation. More and more institutions for water supply and sanitation needed to be established.

DR KYAW WIN (Myanmar) highlighted the importance of safe drinking water, especially in the dry zones, and felt that rain water, if stored properly, would be the most hygienic. But if storage tanks were not covered properly, this might lead to breeding of mosquitoes. However, collection of rain water and storage under hygienic conditions should be promoted. As regards sanitation, building of sanitary latrines had been taken up on a large scale in his country. This could considerably reduce water-borne and excreta-borne diseases.

DR SINGAY (Bhutan) said that his wuntry, which accorded top priority to water supply and sanitation, had recently developed a policy paper on water supply and sanitation which had been passed by the cabinet and which would be debated in the forthcoming National Assembly. They had come across many hurdles and had realized the mistakes committed. Improvement in personal hygiene and behavioural aspects were of great importance. A lack of coordination had been noticed in laboratory testing of water and subsequent interventions. Running of water supply schemes without proper intervention did not serve the purpose of provision of drinking water free from E.Coli. The E.Coli content of water differed in different countries, and in different geographical areas and seasons in the same wuntry.

Maintenance of the water supply schemes had also been facing serious problems, because at the time of establishment of these schemes, the local capabilities were not taken into account. Funding had a vital role to play in the revival of these schemes with many of them proving extremely cxpensive, especially when coverage was extended to the outlying areas of the country. Added to this was the problem of lack of interest of donor agencies for continued funding of such schemes.

Speakingabout sanitation, Dr Jigmi Singay said that the introduction of sophisticated technology without preparing the society for accepting it, could be a futile exercise. Realizing this, his country had, in the Seventh Plan, emphasized the need for every household to have sanitary latrines. Once this was ensured, the next step would be to introduce the new technology.

LT. COL. IBRAHIM (Maldives) thanked the Regional Director and the WHO staff on their compilation of a very comprehensive report on water supply and sanitation. He said that in Male, which was a very densely populated island, the emphasis had been on urban water supply and sanitation. Groundwater pollution, diarrhoea1 disease, and cholera epidemics were prevalent there. Recently, a project on the Male Water Supply and Sewerage had been completcd in order to provide drinking water of the required quality to the public by implementing a distribution network from the collection of rainwater, minimizing the use of ground water. Though the target for drinking and cooking water had been achieved, there was not enough water for other purposes, i.e. bathing and washing, for which alternative sources were being explored. In the rural sector, about 33 per cent coverage had been achieved. It was being contemplated that charges for the supply of water to houses should be made.

Wirh regard to sanitation in the rural sector, since people used beachcs for defecation, which was very insanitary, a new scheme of septic tanks had been designed with assistance from WHO. The scheme would be implemented in the next Decadc.

DR HARTONO (Indonesia) said that his wuntry had recognized this problem long before IDWSSD, and the President of Indonesia had issued special instructions to the health sector to ensure water supply and sanitation facilities to the rural areas.

So far the coverage for water supply had increased from 19 to M) per cent in rural areas, and for sanitation from 16 to 42 per cent, which was good progress. More attention was now being paid to intersectoral cooperation and coordination. The Public Works Department had taken over the physical construction of all systems of water supply and sanitation, and the health sector was taking care of water supply control and health education, which were essential parts of community participation. The Interior Ministry would be responsible for the mobilization of local social communities in arranging the management of water supply. Administration would educate cadres and try to make real models for the neighbouring people. There was agreement on the level of water quality to be maintained and drinking water authorities had been demonstrating to the villagers the opening of new water taps and encouraging them to drink directly from the tap. However, a lot still needed to be done.

DR DE SILVA (Sri Lanka) said that his Government had allocated $ 1.0 million as subsidy for the construction of latrines, under which low-income households would be given subsidy after they had constructed the latrines. This scheme was under revision. Many latrines were not being used, especially in estate areas, since people were not attuned to it. This called for more interventions to change the behaviour of the people. In many areas, there was improvement in water supply and sanitation facilities. Water quality monitoring was also being done. The Central Environmental Authority monitored water quality in and around Colombo. There was a need to decentralize authority to provinces which would bring more quality control and quality assurance.

The VICE-CHAIRMAN, speaking as the representative of Bangladesh, said that there were two important issues with regard to water supply and sanitation. Since water was being taken out from the soil, charging for water was necessary. Concrete city buildings and chemical pollution of water were serious problems. Consumption of artificial fertilizers was increasing. In Bangladesh, there was water logging, which destroyed frogs and such other animals. His country was encouraging the private sector to produce latrines and tubewells. Assistance of WHO as well as that of other agencies would be required for improving water supply.

DR BISHT (Director, Programme Management) thanked the representatives who had expressed their views on the subject of water supply and sanitation, and enumerated their successes and failures as well as the approaches which they had made in their own countries. One of the difficulties that had been mentioned was the inability on the part of the health sector to take collective measures for the supply of potable water to the people and disposal of night soil which was an important sanitation problem. He recalled that even before the Alma-Ata Declaration in 1978, the UN General Assembly had directed that the monitoring of the Decade for water supply and sanitation should be the responsibility of WHO. It was then accepted as one of the key elements of the Alma-Ata Declaration.

He said that WHO had a mandate under which it had to function. In this connection, it was important for the countries to take strong legislative and administrative decisions to ensure the supply of potable water to the people.

He said that one of the eight elements of PHC was the provision of good quality water. This had to be carried out in a phased manner, and emphasis was to be laid where it was most required. Had there not been an increase in the total population, a shift of population from rural to urban areas, and growth of shanties in big urban centres, the result would have been even better. Areas in some towns were worse than in the countryside. It was essential to arrive at strategies for the 1990s both on ihe regional and national bases, and the inhibiting factors as well as steps to counteract them had been very nicely delineated. A Consultation Meeting was held in New Delhi on the subject. He requested the members to go through that report and fortify items which they would like to add and which had already been mentioned. He said that there was no doubt that the 1990s could be looked to with hope.

8. WHO'S CONTRIBUTION TO THE INTERNATIONAL EFFORTS TOWARDS SUSTAINABLE DEVELOPMENT (Irm 19)

DR BlSHT (Director, Programme Management), introducing the subject, said that pollution, deforestation and industrialization posed serious challenges to the survival of the planet. It was universally recognized that the needs of the present generation should be met with sustainable development without jeopardizing the lives of future generations. Rational use of natural resources and protection of the ecosystem were essential prerequisites for the preservation and promotion of health. Sustainable development was, therefore, essential for the welfare of all mankind.

He said that WHO'S policies and strategies for HFA had always stressed the close intersectoral linkage between health and overall development. Documents SEAIRC44110 and SEAiRC44ITnf.3 described some of the important events relevant to this.

In April 1990, the Director-General of WHO established a high-level Commission on Health and Environment to sustain the health consequences of socioeconomic development. In July this year, the Commission produced its draft report which underlined the link between health, environment, development and population growth, affluence and poverty as well as the cost of neglecting health in the process of development. This report included a strategy to achieve development without undermining the quality of the environment for future generations. The report would also be used to formulate WHO'S new global environmental health strategy for the next decade. In October tW, WHO participated in a Ministerial Summit on Environment and Development in Bangkok and the Regional Strategy for Asia and the Pacific was evolved after adopting the Bangkok Declaration.

The document gave an o v e ~ e w of the regional contribution to the current activities in the main areas of meeting the basic health needs relating to environmental health, family planning and health of the vulnerable groups, malnutrition and occupational health problems, control of parasitic and communicable diseases, mental health, health education and the role of women in health development. It was apparent that economic and social development in the Region could not and would not be achieved without paying a dear price in terms of environmental pollution and human health. There was a growing evidence of resource depletion, pollution of air and water and destruction of forests for cultivation as examples of the negative intluences on health and quality of life. The countries of the Region faced the dilemma of minimizing economic development necessary for immediate improvement of human health and protection of quality of environment on which human health and sustainable development critically depended.

The VICE-CHAIRMAN, speaking as the representative of Bangladesh, said that he had attended the Summit in Bangkok where he had stressed the need for closer coordination between the United Nations Environment Programme and WHO in view of WHO's fum commitment to the promotion of environmental health.

DR SUTHAS VEJCHO (Thailand) commended WHO's long-established and continuous advocacy of the concept of sustainable development, which was very much appreciated by his Government as it was a global as well as national concern. However, in his country, rapid industrialization and economic growth were leading to more pollution and uneven income distribution with deteriorating quality of life. He felt that development should be defined as sustainable use of resources, balance with ecology and biodiversity and sustainable impact on human beings without which there would only be advancement in material terms.

In his country, a national meeting on planning and management of industrialization and urbanization had been organized to focus the attention ofthe public and policy-makers on the benefits of industrialization. The Ministry of Health coordinated environmental issues with various authorities concerned. This concept was advocated through the mass media, resulting in increased awareness of environmental issues. He hoped that with WHO's leadership in the international arena, his country would have sustainable development.

DR SINGAY (Bhutan) said that with the adoption of the principle of sustainable development, the year 1990 marked a turning point for his country. Several national-level meetings and workshops on the subject had taken place to reinforce this idea. Beginning with 1990, all development programmes were reviewed seriously for sustainable development. He said that his country would welcome any suggestions for collaboration and cooperation towards successful implementation of this concept.

DR HARTONO (Indonesia) said that his country was very much concerned about the impact of environment on development. All development plans were required to take their environmental impact into account. A separate Commission on Environmental Impact Assessment had been established with governors of provinces chairing the local chapters. A deadline had been fuced for existing enterprises to submit a study of environmental impact assessment. In the health sector, it was compulsory for hospitals and pharmaceutical companies to assess their needs. With these measures, it was hoped to gradually increase environmental awareness and routinely incorporate sustainable development as a way of life.

DR DE SILVA (Sri Lanka) said that realizing the importance of environmental health, a separate Ministry of Environment had been formed. However, though a number of industries coming up in the free trade zone were generating a lot of income, some industries were assessed for environmental impact only after they had been established and the infrastructure had been built up. Hc felt that such industries should be assessed for environmental impact before they were established.

He said that a tree-planting campaign had been launched to overcome the problem of deforestation. Certain days had been identified as tree-planting days. All householders and voluntary organizations were involved in this campaign. He said that with increasing urbanization, deforestation had escalated to accommodate construction sites, leading to depletion of natural resources. Housing development was a sign of economic growth. However, a delicate balance had to be maintained at all times to have sustainable development.

DR MUKHERJEE (India) said that the document SEAIRC44110 was very informative and provided new insights into the inseparable relationship betwccn environmental protection and health for sustainable development.

Highlighting the active role played by the Ministry of Environment and Forests in his country in addressing issues concerning environmental pollution, he urgcd WHO to look critically at the long-term effects of man-made disasters. He said that the Central Pollution Control Board was the focal point for monitoring air, water and soil quality. The Ministry of Health was closely involved with the Department of Environment in matters relating to environmental health.

DR CHATAUT (Nepal) said that with the introduction of some industrial activities and the increasing transportation network, the problem of air pollution was reaching alarming proportions, especially in the capital city of Kathmandu. Due to inadequate facilities for solid waste disposal, water pollutionwas also on the increase. The Government was aware of these problems and, to this end, the Ministry of Forests and Soil Conservation had been renamed as the Ministry of Forests and Environment. It was hoped that, with WHO'S guidance, Nepal would be able to take the right steps to contain the problems of pollution.

Elaborating on the Ministerial Summit on Environment and Development organized by ESCAP, the REGIONAL DIRECTOR said that it was attended by all UN agencies and ministers of environment of Member Countries. An amount of US$ 4 billion was pledged for the countries in the Pacific region. In the Bangkok Declaration adopted at the Summit, the health component was included on the insistence of the Director-General of WHO, who was strongly supported by the Indian Minister of Environment. Referring to the regional mechanism of WHO ensuring close interaction with Member Countries, he urged the representatives to ensure that, in the forthcoming UN Conference at Brazzaville, their delegations were briefed to include a strong element of health in their programme. He pointed out that only by taking immediate initiative and developing a project could WHO secure funds for environmental health programmes from the amount pledged at the Summit. As regards IDWSSD, he said that the Decade target had not yet been achieved. Howevcr, a switchover to a socioeconomic approach instead of a technological approach would yield bcttcr results.

9. ADJOURNMENT

After a few announcements, the meeting was adjourned.

SUMMARY MINUTES'

Seventh Meeting, 26 September 1991, 8.30 am

TABLE OF CONTENTS

Page

I. Selection of a suhject for the Technical Discussions at the Forty-fifth Session of the Regional Committee (6

2. l'ime and place of forthcoming sessions of the Regional Committee . . . . . . . . . . . . . . . . . . . . . . . . 168

3. Discussion on draft resolutions 69

4. Adjournment.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172

I . SELECTION OF A SURJECT FOR THE TECHNICAL DISCUSSIONS AT THE FORTY-FIkTH SESSION OF THE REGIONAL COMMIITEE (/ten 22,

Introducing the subject, theREGlONALDIREffOR stated that document SEAIRC44F) listed the titles of the subjects for technical discussions during the last ten years as well as the four proposed for consideration by the Regional Committee for selection of one for the next Regional Committee session. These topics were not binding and some other subject could also be chosen if the Regional Committee so desired.

Thc CHAIRMAN invited comments and suggestions from the representatives. He also requested the Committee to decide if any of the four proposed topics was agreeable.

DR KHALILULLAH (Bangladesh) requested for a clarification if any morc topics could be included for consideration.

The REGIONAL DIRECTOR clarified that the total number of topics for consideration could not exceed five. The Regional Committee agreed to include one more topic

DR KHALILULLAH (Bangladesh) proposed two subjects viz., (1) Health services management, and (2) Equity in primary health care, for the consideration of the Commitlce.

DR MUKHERJEE (India) said that all the proposed topics were very relevant. In view of the approaching target of Health for All by the Year 2000, "Balance and relevance in human resources for health for HFA/2000" was the fust priority from his counlry's point of view. The topic "Financing of health care" was also of great sifi~cance considering the nccd for identifying investments to be made and expected returns in terms of health care. Financial aspects would be specifically relevant to India in view of the new industrial policy and other changes being introduced in the country. The accountability of the health department to the fmance and other departments was expected. Hence, he would give first ~riority to "Balance and relevance in human resources for health for HFA/2000" and his second choice would be: "Financing of health care".

DR KUMARA RAI (Indonesia) considered "Financing of health care" to be his country's first priority since he felt that, by discussing this subject, simultaneously the issues of equity and quality of primary health care, as proposed by the representative from Bangladesh, could also be dealt with. This topic was also relevant since a national workshop on primary health care and an intercountry workshop on quality assurance of primary health care were to be held in Indonesia.

DR CHATAUT (Nepal) expressed his preference for topic No.1 - Integrated approach for prevention and control of AIDS in the context of primary health care -

in view of the problem of AIDS in Nepal. The programme of AIDS prevention and control was in its initial stage in his country and it would be most appropriate to adopt an integrated approach within primary health care.

DR SOMSAK (Thailand) said that all topics were of interest from Thailand's point of view. However, he felt that some were no1 technical in nature. Discussion on these topics might deal with country-specilic situations and it might be dillicult to generate good technical discussions. He considered lopic N o 3 as very important but thought it might not lead to concrete conclusions or suggestions. With regard to topic No.3, he felt that the Regional Offioc would have to make sure that there was a good framework so thal after the cded ion of data had been completed, a good technical model wuld emerge from these discussions. He considered topic No. 4 to bc of higher priority, while topic No. 3 was also important.

DR D E SILVA (Sri Lanka) said that from Sri Lanka's point of view, topic No.4 should rcccive first priority, although he feared that not much information would be forthcoming on this subject. There was a need to conduct some studies to prepare for thc technical discussions n e a year.

DR SINGAY (Bhutan) endorsed the view expressed by other representatives and said that his choice of thc topic for Technical Discussions was No.3.

The CHAIRMAN, speaking on behalf of Maldives, expressed conncern about the organirational problems in the health systcm such as identifying the types of health workers, relevance of their work and the need to see how best to mobilize manpower in the health care system. He thought topic No. 3 to be of the highest priority from Maldives' point of view.

The REGIONAL DIRECTOR clarified that the concentration of the technical discussions was more on the general principles and guidance, which did not require operational aspccts to be dixus$cd in detail. He assured the Committee that some of the subjects would rcuivc adcqu;ctc attention olhcrwisc loo since S E A R 0 would be organi/ing seminars, workshops and conferences on these and related topics during 191-92.

From the discussions, the REGIONAL DIRECTOR thought that the topic receiving preference from most of the representatives was No.3 - Balance and relevance in human resources for health for HFN2000.

DR KHALILULLAH (Bangladesh) said that his country had adopted the system of health services management even before the Alma-Ata declaration. But, in the dccentralizcd set-up where health services were a part of the functions of the local government, the operationill system needed technical and financial support and mobilization of resources could be a management issue. Hence, the inclusion of health services management in the topic for Technical Discussions "Balance and relevance in human resources for health for HFA/2000" was essential to look into this issue.

DR SINGAY (Bhutan) said that since priority topics had already been identified, each topic could be taken up for Technical Discussions in subsequent years. He requested the Regional Director to prepare a sequence of the subjects which could be taken up in the future sessions of the Regional Committee.

DR SOMSAK (Thailand) said that 'assessing the performance of human resources for health' should also be included in discussions on topic No.3.

The REGIONAL DIRECTOR said that, without making the title longer, issues such as health systems management could be included under topic N o 3 For the other topics which were not chosen for Technical Diussiong there would be some other consultations or group educational activities which would cover these topics in one way or the other.

DR MUKHERJEE (India) suggested that, while the subject of Technical Discussionc was taken up at the RC meetings, the Programme Budget Sub-committee should not be scheduled at the same time as some countries which sent only one representative could not attend both these meetings. The REGIONAL DIRECTOR said that this problem would not arise next year as there would be a longer P.B. Sub-wmmittee session and a delegation of more than one member would allow attendance at both the meetings.

Summing up, the CHAIRMAN said that in new of the majority favouring topic No. 3 "Balance and relevance in human resources for health for HFAIUXX)", as contained in document SEAJRC4419, it was selected as the subject for the Technical Discussions at the forty-fifth session of the Regional Committee in 1992.

The REGIONAL DIRECTOR mentioned that the Regional Committee, at its forty-third session, had discussed the need and periodicity of the Technical Discussions. Subsequently, the Consultative Committee for Programme Development and Management (CCPDM) conducted an in-depth study at its nineteenth meeting, and recommended that Technical Discussions should be held every year.

The Regional Committee, at its forty-second session, had decided that the annual report of the Regional Director should be of two types - long and short - in view of the presentation of the budget document only in alternate years, and referred the question of the period to be covered to CCPDM. CCPDM, at its nineteenth meeting, recommended that the report should be short (12 months) in the year when the budget document was presented, and long (24 months) during the year when the budget document was not presented.

The Committee noted and endorsed the above recommendations of CCPDM.

2. TIME AND PLACE OF FORTHCOMING SESSIONS OF THE REGIONAL C O M M I r n E (Iron 21)

Introducing the subject, the REGIONAL DIRECTOR said that, in accordance with the procedure of the Regional Committee, it was necessary to decide the time and

place of forthcoming sessions. It was customary to hold alternate sessions of the Regional Committee at the Regional Office unless there was an invitation from a government to hold the session in one of the countries. At the forty-third session of the Regional Committee, held in the Regional Office, it had been decided, vide resolution SEAIRC43IR9, that the forty-fifth session would be held in Nepal. The Chairman might request the representative from Nepal to confirm HMC's invitation. He further mentioned that the forty-sixth scssion, to be held in 1993, coincided with the nomination of the Regional Director, and, as per the advice of the Director-General of WHO, it was now a tradition to hold such sessions in the Regional Offices. This was not a rule, and if the Committee decided to hold its session elsewhere, it could also be considered.

DR RANA (Nepal) confirmed the invitation of His Majesty's Government to hold the forty-fifth session in Nepal during September 1992 and mentioned that Dussehra holidays should he kept in mind while fuing the dates of the session.

Thc REGIONAL DIRECTOR, noting the statement of the representative from Nepal, assured that the Dussehra holidays would be kept in mind while taking up the question of the dates and the venue of the session with the HMG. The convenience of the Director-General, WHO, who customarily attended the sessions of all the Regional Committees, would also have to be considered while deciding about the dates.

The CHAIRMAN invited comments from the representatives on the proposal of the Regional Director to hold the forty-sixth session of the Regional Committec in 1993 in New Delhi.

DR ARSLAN (Mongolia) conveyed the invitation of the Government of the Mongolian People's Republic to host the forty-sixth session of the Regional Committee in Mongolia. The REGIONAL DIRECTOR recalled the advice of the Director-General o l WHO to hold at the Regional Office such sessions of the Regional Committee as had the nomination of the Rcgional Director on the agenda. In that case, DR ARSLAN said that his country would like to host the forty-seventh session of the Rcgional Committec in Mongolia in 1Y)4. There were no other suggestions from the representatives and the invitation of Mongolia was accepted.

3. 1)ISCUSSION O N DRAFT RESOLUTIONS

C~~mmcntingon the draft resolutions which were before thc Committee, thc REGZONAL DIRECTOR emphasized that these represented the conscnsus arrived at by the Drafting Committee but needed to be discussed and agreed to by the Regional Committee. The draft texts needed thorough study by the representatives. The draft texts agreed to by the representatives would be presented to the Regional Committee once again on Saturday, 28 September 1991, for formal adoption.

Digresing from the subject under dixuSSioII, the REGIONAL DIRECTOR informed the Committee that, in the context of the discussions on Seaion 7 of the Annual Report of the Regional Director ( R w c h Promotion and Development including Research on Health-Promoting BehaGour), the following new Collaborating Centres had been designated since the publication of the Directory of WHO Collaborating Centres: PUSDMLAT, Jakarta, as WHO Collaborating Centre for HFA Leadership Development; the International Irrigation Management Institute, Colombo, and the Faculty of Tropical Medicine, Mahidol University, Bangkok, as WHOIFAORTNEP Collaborating Centres for Environmental Management for Vedor Control and the Indian Institute of Technology, New Delhii as WHO Collaborating Centre for Safety Technology.

Resuming the discussion on draft resolutions, the Chairman read out the text of each draft resolution and invited comments from the representatives. Following the discussions, the Regional Committee endorsed the t ea of the following draft resolutions with some changes:

Provisional drop resolr~lion A: Forty-third Annual Report of the Regional Director

There was no comment from the representatives and the draft resolution was approved.

Provisional drap resolulion B: Selection of a Topic for the Technical Discussions

The words "Balance and relevance in human resources for health for HFAI2000" to be inserted in operative paragraph 1, within quotes.

Provisional drop resolulion C: Resolution of Thanks

The draft resolution was accepted without any modification.

Provisional Drafl resolution D: Time and Place of the Forty-fifth and Forty-sixth Sessions

The title of the resolution to be changed to read: "Time and place of the forty-fifth, forty-sixth and forty-seventh sessions".

A new operative paragraph 3 to be added: "3. NOTES with thanks the invitation of the Government of the Mongolian People's Republic to host the forty-seventh session of the Regional Committee in Mongolia in 1994".

Provisional drop resolrrfiort E: Disaster Preparedness

DR KHALILULLAH (Bangladesh) stated that the subject of the draft resolution was of interest and concerned most countries in the Region. He proposed a new clause 2(d) requesting the Regional Director to establish a regional collaborating centre for health emergency preparedness.

The REGIONAL DIRECTOR clarified that, following the decision of the WHO Executive Board in 1978, the title "regional collaborating centre" was no longer in use

and institutions were now designated either as National Centres of Excellence or WHO Collaborating Centres. DR MUKHERJEE (India) supported the proposal of the representative from Bangladesh and felt that the precise language could be decided by the Secretariat.

The CHAIRMAN expressed the consensus of the Committee that a sub-clause (d) be inserted to request the Regional Director to support the development of national centres of excellence and WHO Collaborating Centres in emergency preparedness.

DR HARTONO (Indonesia) wished to avoid the impression that the health sector was keen to become dae focal point for activities on disaster preparedness. me intention was to make everyone aware of the need for disaster preparedness and involve them in this task

The REGIONAL DIRECTOR felt that the intention should be to talk about disaster preparedness, with particular reference to health. DR D.B. BISHT, Director, Programme Management, suggested that a sub-clause could be added to clause (c) so as to read: "To support human resources development in disaster preparedness at all levels in the Member States including development of notjonul centres of ercelIe?~ce in t~ealtlr disaster preparedness wt~ich could also furtction as WHO collaborafing centres': This would obviate the need to have a new clause (d). As the representatives still expressed their preference for a new clause (d), the CHAIRMAN accepted their suggc5tion and requcstcd the Secretariat to do the needful. There were no comments on othcr paragraphs of the draft resolution.

Pr~?~,isiottol draJ resolutio!~ F: Evalualion of the Strategies for Health for All

The following modifications were agreed to:

(1) Operative paragraph 2(b) to read: "to strengthen their health information systems with particular reference to the underserved and disadvantaged sections of the populations in a spirit of equity and social justice".

(2) New operative parligraph 2(c) to be added:

"(c) strengthen the health management system and improve community participation by adopting a social mobilization strategy, a n d

(3) Operative paragraph 2(c) to be renumbered as 2(d)

Provisional drap resolutiorl G: Water Supply and Sanitation for the 1990s

(1) Thc following to bc added as the fifth paragraph of the preamble: "Realizing that the countries will need considerable resources to achieve their safe water and sanitation targets,"

(2) Operative paragraph l(a): replace "and the promotion of community health" with "to stress the human aspects and importance of community participation by undertaking KAPB studies for intensive health education activities".

(3) Operative paragraph (d) to read: "To improve the information system in the area of water supply and sanitation to effectively monitor and evaluate the progress made."

Provisional &afl resolution H: AIDS

The following to be added as fourth paragraph of the preamble:

"Realizing that availability of effective measures for the prevention and control of AIDS may take a long time,"

(1) The following to be added at the end of operative para 1 (a), after 'HIV infection':

"aiming at sustainability by concentrating on strengthening national health systems and capabilities"

Provisional dmfl resolution I: Sustainable Development

(1) Fourth paragraph of the preamble to be reworded as follows:

"Concerned that uncontrolled andunsounddevelopment activitieswithout environmental safeguards pose a threat to human health and the sustainability of the process of development itself,"

(2) A new operative paragraph l(b) to be added as follows:

(b) "to emphasize a greater concern for human-centered development and the use of social mobilization strategy to be applied in the implementation of primary health care,"

(3) The existing operative paragraph l(b) to be renumbered as l(c).

At this point, the REGIONAL DIRECTOR drew the attention of the representatives to information document SEAIRC44flnf.6 on the Saitama Declaration - A Call for New Public Health Action - and expressed the hope that they would find this document, which dealt with the future thinking on health and development, with particular emphasis on financing and health economics, useful.

4. ADJOURNMENT


M I N W OF THE EIGHTH MEETNO

SUMMARY MINUTES'

Eighth Meeting, 28 September 1991, 8.00 am

TABLE OF CONTENTS

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Adjournment 176

' ~ r i ~ i n a l l y issued as docurnenl SFWC44IMin.8 nn 15 Ortober 1991

Opening the meeting, the CHAIRMAN informed the Committee that the WHO Director-General, Dr H. Nakajima, would address the session shortly after his arrival.

1. ADOPTION OF RESOLUTlONS

The Regional Committee adopted the following resolutions with minor modifications:

1. Forty-third Annual Report of the Regional Director (Draft Resolution No. A)

2. Selection of a Topic for the Technical Discussions (Draft Resolution No. B)

3. Resolution of Thanks (Draft Resolution No. C)

4. Time and Place of the Forty-Fifth, Forty-Sixth and Forty-Seventh Sessions (Draft Resolution No. D)

5. Disaster Preparedness (Draft Resolution No. E)

6. Evaluation of the Strategies for Health for All (Draft Resolution No. F)

Operative paragraph 2, sub-paragraph (c), second line, "a" appearing between "adopting" and "social" to be deleted.

7. Water Supply and Sanitation for the 1990s (Draft Resolution No. G)

Operative pargraph l(a), fourth line, "KAPB" to be replaced with "psychosocial and behanoural studies".

8. AIDS (Draft Resolution No. H)

Operative paragraph l(b), " and to be added at the end.

9. Sustainable Development (Draft Resolution No. I)

Operative paragraph l(a), " and appearing at the end to be deleted and the comma to be replaced with a semi-colon.

Operative paragraph 1(b), to read:

"To emphasize a greater concern for human-centred development and the use of social mobilization strategies in the implementation of primary health care, a n d .

2. ADOPTION OF THE FINAL REPORT OF THE FORTY-FOURTH SESSION OF THE REGIONAL COMMITIEE (fim 23)

The CHAIRMAN suggested wnsideration of the report (document SEA,'RC44122), part by part.

Introduction

Page I MR C.-H. VICiNES (Legal Counsel, WHO/HQ) suggested replacing "Member Countries" with "Member States" in the first and fourth paragraphs in order to be in conformi~with the WHO Constitution.

Part I1 - Discussions on the Forth-Third Annual Report of the Regional Director

Poge 6 , second paragraph, first line, "the drug abuse" to bc replaced with "drug managemenl".

fourth paragraph to include at thc end a refcrencc to the prevalence of, and control activities relating to, kala-azar.

second paragraph from bottom, first line, "cancer and cataracts ..." to read "cancer, blindness and diabetes...".

Part 111 - Discussions on Programme Budget

Poge 7 The title of Part 111 to read: "Discussions on the Report of the Sub-committee on Programme Budget".

Part IV - Discussions on Other Matters

Poge 8, paragraph under item 1: The following sentence to be added at the end: "The subject for the Technical Discussions at the Forty-fifth World Health Assembly will be Women, Health and Development".

Puge 9, third paragraph, third line, "UNEP and other international and bilateral ...." to read: "UNEP, WMO and other international and bilateral ...." item (6), first line, "model" to read "nodal"

Page 10, first paragraph under item 3, third line " .... half-a-million children having been infected with AlDS during the past year alone" to read "....half-a-million children having been infected with AlDS globally during the past year alone".

Poge 12, paragraph undcr item 6, fus( line, "on his country's participation ..." to read "on behalf of the three countries of h e Region represented at the....".

Page 1.7, tifth l i e from top, "psychosocial" to be added between "and and "behaviour". Also, "(KAB)" appearing after "behaviour" to be deleted.

fust full paragraph, fourth line from bottom, to begin a new paragraph with the sentence "The Republic of Maldives ...." adding at the beginning 'Taking the example of a special situation, it was noted that....".

Page 14, second full paragraph, fourth line from bottom, the sentence "Attention is also being given to improving tree cover." to be replaced with "Increasing attention is being given to afforestation, environmental protection and bio-diversity.".

The Committee adopted the report after noting the above modifications.

3. ADJOURNMENT

The CHAIRMAN informed the meeting about the arrival of Dr Hiroshi Nakajima, Director-General, and stated that even though the important subject of the new health paradigm and social mobilization strategy had not been discussed in detail during the preceding meetings, the Committee had emphasized the need to redirect health policies and strategies in the countries of the Region. It was hoped that such new policies would stimulate community participation and generate knowledge among the people who were recipients of the services.

DR HIROSHI NAKAJIMA, Director-General, expressed his pleasure at being able to address the forty-fourth session of the Regional Committee. He said that thc Regional Committee for South-East Asia had always devoted considerable attention to health matters of regional importance. The meetings of Ministers of Health, which followed the Regional Committee meetings, afforded an opportunity to discuss technical matters and transmit the outcome of the meetings to health policy decision-makers in the Ministries of Health in order that common policies could be elaborated for the achievement of health for all by the year 2000 and beyond.

Referring to his inaugural message, which was read out by the Regional Director, he said that it highlighted the momentous political, social and economic upheaval in the world and described how WHO could best respond to the new challenges the health community was facing and address itself better to global health concerns. It was not an upheaval in terms of the Saitama Summit but was more a period of transition.

The Diredor-General stated that countries of the South-East Asia Region had always been at the forefront of much of the innovative work for health. These countries still faced challenges, old and new. The pcoplc of the Region had suffered greatly from natural disasters such as floods and storms, which slowed down the pace of progress towards equity in health status, equality and justice in access to health care, and more even distribution of resources to meet human needs. It was essential to be prepared to cope with disasters since they could strike at any time, and such opportunities would need to be considered as not only a time for rehabilitation but for further reconstrudion of the health systems.

MINUES OFTHE EIGHTH MEETING

Two countries of the Region - India and Thailand - were at grave risk from the scourge of AIDS and it was not a time to be complacent. Steps needed to be taken urgenlly to combat the pandemic since its implications for the health and economy of the countries wcre very grave indeed.

Much work still rcmaincd to be done in providing safe drinking water for the populations of the Region. (iivcn the pressures of population growth and population movcments due to immigration or refugee migration, it was barely possible to kecp up with coverage targets. He hoped that greater efforts would be forthcoming in the field of water supply and basic sanitation, given the commitment and dedication of the countries of the Region.

The Director-General emphasized that the lessons learnt during the review of the second evaluation of the implementation of national and regional strategies for hcalth for all would go a long way in building up future approaches in health devclopmcnt. There was a need to bring health into the arena of total devclopment, and he assured full coopcration of the Regional Director.

In conclusion, the Director-General congratulated the representatives on the successful conclusion of the session of the Regional Committee and extended to them WHO'S support and encouragement in what often seemed to be an insurmountable task of consolidating and integrating action for health for all.

Thc CHAIRMAN thankcd thc Director-General for his inspiring address. Echoing thc sentiments of all the participants, he expressed the hope that under Dr Nakajima's leadership WHO would move steadily towards the achievement of health for all. He thcn invited the representatives to express their views.

DR MUKHERJEE (India), speaking on behalf of all the participants, expressed his sinccre gratitude and thanks to the Government of the Republic of Maldives, particularly to the Minister of Hcalth and Welfare, for the gcnerous hospitality extended to them during their slay in Maldives. Hc said that special thanks wcre due to the Dcputy Minister of Hcalth and Welfarc and Chairman of the session, Dr Abdul Sattar Yoosuf, for his ablc support and astute handling of the issues debated in the forum. He thanked Dr H. Nakajima, Director-General, for his inspiring address, and Dr U KO KO, Rcgional Director, who had made everyone feel par1 of one big family. He also thankcd othcr members of staff of the WHO South-East Asia Region for their active involvement and positive contributions, and cxpressed his appreciation to all thosc who worked silcnrly behind (he scene to cement thc total programme in a very positive way.

The REGIONAL DIRECTOR, responding to thc sentiments expresscd by the representative from India, stated that a wide range of subjects had been covered in the past few days and there was no need to go over them once again. Countries of the Region had to be prepared for a long fight against AIDS. The evaluation of HFA stratcgies had highlighted several achievements as also certain issues and constraints.

There had been no Programme Budget document this year, but countries of the Region had developed, or were in the process of developing, a detailed plan of action for 1992 and they had to make serious efforts to implement their programmes. The slow delivery of programmes had been responsible for the South-East Asia Region suffering the largest cut in budget allocations. It was essential to implement as much of the programme as possible in the first year of the biennium itself.

Another important subject was the preparation of the 1994-1995 Programme Budget, which required a lot of thought and consultation. The WHO Representatives in the countries would be working out the national policy programmes for the 19941995 programme budget and would submit them to the next meeting of CCPDM in November 1991. He urged the representatives to devote attention to this subject.

The Regional Director expressed his happiness that the Director-General had found time to attend the concluding session. Reflecting the sentiments of the representatives, he thanked both the Chairman and the Vice-Chairman for ably guiding the proceedings of the session. He thanked the Chairmen of the Technical Discussions, the Sub-committee on Programme Budget and the Sub-committee on Credentials for their valuable contributions. H e also thanked the Hon'ble Minister of Health and Welfare of the Republic of Maldives for the excellent arrangements made for the session. He expressed his thanks to the country representatives, representatives of nongovernmental organizations and others for their active participation in the deliberations of the session.

The CHAIRMAN, speaking on behalf of the Vice-Chairman and on his own behalf, thanked the representatives for their kindness and cooperation which helped him to conduct the proceedings smoothly. He said that it reflected the assessment of the representatives that a convergence of thought had emerged on all important, and even controversial, subjects. The Region faced several common problems, but there were common social and cultural factors which facilitated communication between the countries. The true test of the utility of directions and programmes propounded during the discussions would be the kind of follow-up action taken by the countries concerned.

He thanked the members of the Secretariat for their untiring work in making the session a success and the organizers of the session and the management of the Kurumba Village Resort for the excellent arrangements and facilities. A very important aspect of the meeting had been the fellow feeling generated among those present, and he was sure that feelings of homeliness and congenial environment had been extended to everyone. Memories of kindness and helpfulness lasted long. He expressed the hope that the representatives would meet again in Nepal in 1992 and wished them 'bon voyage'.

The Chairman then declared the forty-fourth session closed.

ofthe WHO Regional Committee for South-East Asia - WHO ...

Documents

Transcript of ofthe WHO Regional Committee for South-East Asia - WHO ...