PART I

GENERAL REVIEW OF ACTIVITIES

1. STRENGTHENING OF HEALTH SERVICES

1.1 Planning and Development of Hea l th S e r v i c e s

Governments i n t h e Region have been fo rmula t ing annua l , medium-term and /o r long-term p l a n s f o r o v e r a l l socio-economic development, i n c l u d i n g h e a l t h . WHO con t inues t o c o l l a b o r a t e i n t h e formulat ion of t h e s e h e a l t h p l a n s th.rough t h e a p p l i c a t i o n of s y s t e m a t i c p lanning, which aims a t maximizing t h e e f f i c i e n c y , e f f e c t i v e n e s s and coverage of t h e h e a l t h s e r v i c e s w i t h i n t h e u s u a l l y meagre resources made a v a i l a b l e t o t h e h e a l t h s e c t o r . The low p r i o r i t y be ing given t o t h e s o c i a l s e c t o r , i n c l u d i n g h e a l t h , con t inues , however, t o be a major c o n s t r a i n t i n most c o u n t r i e s .

Country h e a l t h programming (CHP), which recogn izes t h i s and o t h e r c o n s t r a i n t s and which invo lves o t h e r s e c t o r s i n t h e fo rmula t ion of h e a l t h p l a n s , i s i n c r e a s i n g l y accep ted and a p p l i e d and t h u s is c o n t i n u a l l y evo lv ing and b e i n g improved. Organ iza t ions of t h e United Nat ions system such a s UNICEF and UNDP, and b i l a t e r a l and m u l t i l a t e r a l agenc ies which a l s o c o n t r i b u t e t o t h e development of h e a l t h , have taken p a r t , w i t h WHO, i n t h e s e e x e r c i s e s .

Desp i t e cont inued governmental e f f o r t s t o s t r e n g t h e n and expand r u r a l h e a l t h s e r v i c e s , t h e i n f r a s t r u c t u r e of t h e s e r v i c e s i n r u r a l a r e a s and t h e i r coverage of t h e r u r a l popu la t ion i n t h e Region (which t o t a l s about 770 m i l l i o n ) remain ve ry l i m i t e d . It i s now recognized, a s a r e s u l t of country h e a l t h p r o g r a m i n g , t h a t t h i s major problem is due mainly t o t h e d e p l e t i o n of meagre manpower and c a p i t a l r e sources by s e r v i c e s which were b u i l t on t h e p a t t e r n of t h o s e i n developed c o u n t r i e s , which a r e u s u a l l y urban-based and most ly o r i e n t e d towards c u r a t i v e medicine. A l l governments i n t h e Region now acknowledge t h a t t h e on ly way t o overcome t h i s l a c k of manpower and resources is through t h e primary h e a l t h c a r e approach. A t t h e same t ime a s primary h e a l t h c a r e i s b e i n g developed, i t i s f e l t t h a t t h e i n f r a s t r u c t u r e of t h e h e a l t h s e r v i c e s should be s t r eng thened and expanded t o p rov ide t h e necessa ry suppor t i n t r a i n i n g , l o g i s t i c s , r e f e r r a l and s u p e r v i s i o n , s o t h a t eve ry c i t i z e n can enjoy t h e r i g h t t o t h e f u l l range of promotive, p r e v e n t i v e , c u r a t i v e and r e h a b i l i t a t i v e h e a l t h s e r v i c e s . I n t h i s connexion, t h e growing t r e n d of i n t e g r a t i n g t h e s e s e r v i c e s and t h e i r v e r t i c a l programmes a t t h e community l e v e l i s ga in ing momentum i n most c o u n t r i e s .

1.1.1 Health Planning, Progrme FormuZation and EvaZuation

I n a l l c o u n t r i e s of t h e Region, s t e a d y p r o g r e s s cont inued t o be made i n t h e f i e l d s of h e a l t h p lann ing , programme fo rmula t ion and e v a l u a t i o n . E a r l i e r promotive e f f o r t s had r e s u l t e d i n t h e s e t t i n g up of h e a l t h p lann ing c e l l s o r u n i t s i n n a t i o n a l h e a l t h a d m i n i s t r a t i o n s , t h e development of p lann ing and management c a p a b i l i t i e s and t h e e s t a b l i s h - ment of n a t i o n a l h e a l t h in fo rmat ion systems o r sub-systems f o r p lann ing , management, moni tor ing and e v a l u a t i o n . The Regional O f f i c e

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has provided t h e necessary expe r t i s e , o n a long-termor short-term b a s i s , as wel l as fellowships and suppl ies and equipment through country and inter-country p ro jec t s . It i s s a t i s f y i n g t o note t h a t the count r ies of t h e Region recognize t h e importance of eva lua t ing t h e i r programmes; some a r e now conducting eva lua t ion exerc ises which, i n genera l , follow t h e guidel ines developed by WHO, adapted t o t h e l o c a l s i t u a t i o n .

Bangladesh, which i n 1973, was t h e f i r s t country i n t h i s region t o conduct a country h e a l t h programming (CHP) exe rc i se , undertook t h e second cycle of CHP i n 1977. A comprehensive country hea l th p r o f i l e was completed. This exerc ise was most t imely, a s t h e Government was preparing a two-year consolidated programme f o r 1978 and 1979 and the Second Five-Year Plan (1980-1985) as wel l as long-term plans up t o the year 2000. The CHP exerc ise i d e n t i f i e d ten p r i o r i t y a reas f o r inc lus ion i n t h e Second Five-Year Plan, among which a r e primary hea l th ca re , i n s t i t u t i o n a l h e a l t h ca re , environmental hea l th , con t ro l of communicable d iseases , population con t ro l , and hea l th manpower development. The formulation of t h e primary hea l th care programme, including t h e expanded programme on immunization, was expected t o be completed by June 1978, t o be followed by t h a t of t h e environmental hea l th and o ther programmes. WHO provided a s s i s t ance i n these e f f o r t s t o formulate programmes.

Assistance continued t o be provided t o Bhutan through t h e j o i n t UNDPI WHO p r o j e c t , f o r which t h e Government designated a na t iona l p ro jec t d i r ec to r . Progress was made i n implementing t h e 197711978 annual hea l th plan within t h e framework of t h e Fourth Five-Year Development Plan, which s t a r t e d i n 1976. The emphasis i s on expanding the coverage of i n t eg ra t ed r u r a l hea l th se rv ices and developing hea l th manpower f o r these serv ices . With WHO'S co l labora t ion the Goveqment formulated proposals f o r a s s i s t ance from UNICEF and the World Food Programme, and these have been accepted and a r e being implemented.

In Buma,a"People ' s Health Programmet'hasbeen developed on the bas i s of t h e country h e a l t h programming exerc ise ca r r i ed out i n 1975, and its implementation s t a r t e d i n Apr i l 1978. In tens ive preparatory a c t i v i t i e s took p lace during t h e period under review and included o r i e n t a t i o n courses on t h e programmes formulated and t h e i r phased implementation. These courses were at tended by programme managers, s t a t e l d i v i s i o n a l h e a l t h d i r e c t o r s and township hea l th o f f i c i a l s and and t h e i r s t a f f . Training was given t o t r a i n e r s and r u r a l hea l th cent re s t a f f . Training manuals were a l so developed. As t h e imple- mentation of the programmes necess i t a t ed the appl ica t ion of systematic management techniques f o r monitoring, con t ro l and evalua t ion , a s s i s t ance was given t o two workshops on evaluat ion methods. These workshops were attended by a l l s en io r h e a l t h o f f i c i a l s a t t h e c e n t r a l and s t a t e l d i v i s i o n l e v e l s and r e su l t ed i n t h e development of a method of eva lua t ion based on t h e guide l ines developed by WHO.

In Ind ia , t echn ica l cooperation continued t o be extended t o the National I n s t i t u t e of Health and Family Welfare, one of the main

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a c t i v i t i e s being t h e study of t h e Multi-purpose Health Workers' Scheme. In co l labora t ion with an inter-country p ro jec t (ICP PPS 002) a case study was completed i n t h e S t a t e of Haryana and is being used by the I n s t i t u t e f o r t r a i n i n g i n hea l th planning. Assistance was given i n the planning, implementation and evaluat ion of r u r a l hea l th serv ices and t h e development of the hea l th information system. A plan of operat ion f o r r u r a l hea l th u n i t s and the implementation of other planned a c t i v i t i e s has been prepared. These a c t i v i t i e s a r e expected t o cont r ibute significantly t o t h e s trengthening of r u r a l hea l th se rv ices , and e spec ia l ly t h e multi-purpose hea l th worker and cornunity hea l th worker schemes. The l a t t e r scheme was launched i n October 1977 i n 28 d i s t r i c t s and i s being sys temat ica l ly evaluated by theGovernment p r i o r t o its extension t o cover the whole country (see a l s o sub- sec t ion 1.1.4).

I n Indonesia, t h e core p ro jec t , "Strengthening of National Health Services" (IN0 HSD 001), has a team cons is t ing of a senior public hea l th administrator , a s t a t i s t i c i a n and a hea l th economist. Under t h e h e a l t h planning and evaluat ion component of the pro jec t , in tens ive hea l th planning a c t i v i t i e s continued f o r formulating the hea l th plan of PELITA I11 ( the Third Five-Year Development Plan) . These included the following: s i t u a t i o n ana lys is , d e f i n i t i o n of hea l th problems, s e t t i n g of objec t ives f o r hea l th improvement, s t r a t egy design, problem planning, organizat ion of a workshop on hea l th planning, and the submission of a programe proposal. The pro jec t formulation phase i s scheduled t o s t a r t i n August 1978. Assistance was provided i n preparing t h e annual plan of t h e Ministry of Health, i n s t rengthening t h e co l l ec t ion and processing of da ta on requirements f o r manpower and physical f a c i l i t i e s , and i n improving t h e hea l th planning and evalua t ion methods. P ro jec t s t a f f a s s i s t e d i n reviewing and updating t h e country p r o f i l e and i n formulating a d r a f t plan of ac t ion f o r hea l th planning and evaluat ion. The Bureau of Planning i n the Ministry of Health, which has four sub-divisions and has a s t a f f of 12 profess ionals and a l a rge number of support s t a f f , contr ibuted g rea t ly t o these a c t i v i t i e s . In addi t ion , planning c e l l s were e s t ab l i shed i n t h e d i f f e r e n t Direc tora tes General. The PELITA I11 programme plan f o r the period 1979-1983 was submitted t o the Annual Health Conference i n January 1978. US A I D ass i s tance f o r the t r a in ing of s e l ec t ed provinc ia l hea l th planning personnel i s envisaged.

In MongoZia, which has a long experience i n hea l th planning, an annual plan, a medium-term plan (within t h e Sixth Five-Year Development Plan) and a long-term plan (1976-1990) have been formulated. There i s growing i n t e r e s t i n t h e appl ica t ion of country hea l th programming f o r formu- l a t i n g medium-term plans. Two s t a f f members - one from the Regional Office and the o the r from WHO Headquarters - v i s i t e d Mongolia and advised on t h e development of a na t iona l hea l th information system a t a l l l eve l s .

In NepaZ, following t h e Government's approval of t h e long-term heal th plan (1975-1990) fo r upgrading t h e hea l th f a c i l i t i e s and serv ices i n

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the country, t h e plan of operat ion of t h e p ro jec t f o r e s t ab l i sh ing planning and programming systems a t the c e n t r a l , reg ional and d i s t r i c t l e v e l s of t h e h e a l t h se rv ices adminis t ra t ion was signed i n 1977. This p ro jec t , which, among o the r th ings , w i l l ca r ry out pol icy ana lys is and s t r a t e g i c and t a c t i c a l planning and evaluat ion, receives a s s i s t ance from a WHO team cons i s t ing of a h e a l t h planner and a s t a t i s t i c i a n ; US AID assigned a management o f f i c e r i n 1977. WHO, UNICEF and US A I D provide support f o r t h e eva lua t ion o r mid-term review of t h e hea l th plan. Assis tance was provided i n t h e organizat ion of plan evaluat ion. WHO a l s o col laborated i n t h e preparat ion of a country p r o f i l e , and t h i s i s expected t o lead t o improved coordination of the inputs of various ex te rna l sources and among t h e d i f f e r e n t departments of t h e Government. With t h e help of t h e p ro jec t na t iona l t r a i n i n g courses on h e a l t h planning f o r t h e s t a f f of t h e Ministry of Health have been developed.

The GoverIUO~t of Sri L m k a has formulated its hea l th pol icy , which includes t h e provision of a high s tandard of hea l th care with emphasis on d isease prevention and the f u r t h e r upgrading of hea l th se rv ices , p a r t i c u l a r l y i n t h e r u r a l areas. Assis tance continued t o be provided t o the h e a l t h planning u n i t i n t h e Ministry of Health. The s t a f f of t h e u n i t , i n co l labora t ion wi th WHO s t a f f (of t h e inter-country p ro jec t ICP PPS 002) he ld a second course on hea l th planning and medical care adminis t ra t ion i n December 1977. The Government has decided t o conduct a country hea l th programming exe rc i se i n co l la - bora t ion with WHO.

In T h a i Z m d , t h e hea l th planning u n i t continued t o play an a c t i v e and growing r o l e i n a l l matters r e l a t e d t o planning, management and information i n support of t h e implementation of h e a l t h programmes formulated i n 1975 during t h e country h e a l t h programming exercise. The planning u n i t a s we l l as s en io r adminis t ra tors i n t h e Ministry of Publ ic Health a r e tak ing a keen i n t e r e s t i n evaluat ing and fu r the r developing t h e CHP method. The s t rengthening of hea l th se rv ices administrat ion through t r a i n i n g i n planning and management a t c e n t r a l , p rovinc ia l and d i s t r i c t l e v e l s is rece iv ing p r i o r i t y a t t e n t i o n , and in tens ive t r a i n i n g a c t i v i t i e s a r e under way. There a r e plans f o r decent ra l iz ing h e a l t h planning t o t h e p rov inc ia l l e v e l , using t h e CHP method; an i n i t i a l t r i a l i n one of the northern provinces is planned f o r l a t e r 1978. Consequent on such a c t i v i t i e s and i n t e r e s t , t h e Government, i n co l labora t ion wi th WHO, i s examining t h e f e a s i b i l i t y of e s t ab l i sh ing a CHP t r a i n i n g cent re i n Thailand. A na t iona l i n t e r - s e c t o r a l conference on t r a i n i n g i n h e a l t h management involving m i n i s t r i e s , u n i v e r s i t i e s and i n s t i t u t i o n s concerned with hea l th a c t i v i t i e s , was he ld i n Apr i l 1978 with t h e p a r t i c i p a t i o n of WHO s t a f f . With i ts ever-growing r e s p o n s i b i l i t i e s and a c t i v i t i e s , t h e planning u n i t needs t o be s trengthened f u r t h e r s o a s t o avoid delays i n and rescheduling of some p ro jec t milestones.

The i n t e r c o u n t r y p ro jec t on t h e s trengthening of hea l th serv ices adminis t ra t ion through t r a i n i n g i n planning, e s t ab l i shed with UNDP

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ass i s tance , aims a t f u r t h e r developing na t iona l c a p a b i l i t i e s i n hea l th planning and management through t r a i n i n g i n s t i t u t i o n s i n the countr ies ( f o r example, schools of publ ic hea l th ) , and by conducting regional and country group educat ional a c t i v i t i e s . Of a t o t a l of t h r e e regional and 22 country courses planned under t h e pro jec t f o r t h e years 1975- 1980, two regional and 12 country courses had been organized as of the end of June 1978. Assistance was a l s o provided t o t h e countr ies of t h e Region i n reviewing t h e objec t ives and content of teaching cu r r i cu la , i n formulating educat ional objec t ives based on modern educat ional technology, i n developing guidel ines f o r teaching modules and i n designing specimen modules. A management o f f i c e r was recru i ted , and two short-term consul tants v i s i t e d t r a in ing i n s t i t u t i o n s i n d i f f e r e n t countr ies t o follow up t h e progress made s ince the basel ine review undertaken by a consul tant i n 1975. Another consultant a s s i s t ed with a Regional Seminar on Health Manpower Studies i n Relation t o Health Care Delivery, which was attended by 21 pa r t i c ipan t s from seven countr ies . National courses were he ld i n Indonesia, S r i Lanka and Thailand, involving a t o t a l of 118 pa r t i c ipan t s . The inter-country pro jec t maintained c lose l i n k s with and support t o country pro jec ts involved i n hea l th planning and management, as wel l as with t r a in ing i n s t i t u t i o n s . A mid-term t r i p a r t i t e review of t h e p ro jec t , undertaken i n March 1978, evaluated t h e progress made and recommended extension of t h e pro jec t up t o 1981, with emphasis on s trengthening hea l th planning i n four countr ies and the provision of a s s i s t ance t o the Asian and P a c i f i c Development I n s t i t u t e , Bangkok, i n a c t i v i t i e s of common i n t e r e s t .

1.1.2 Hea Zth Service Information

The growing awareness t h a t hea l th information and s t a t i s t i c s must provide meaningful support i n the planning, management, and evaluat ion of na t iona l hea l th serv ices has brought about changes i n t h e hea l th informationlheal th s t a t i s t i c s programes i n t h e Region. Instead of independent p ro jec t s , t he present p r a c t i c e is t o provide ass i s tance a s a component of more broadly based p ro jec t s on the planning, management and the s trengthening of hea l th serv ices . This is intended t o f a c i l i t a t e b e t t e r i n t eg ra t ion of hea l th information and s t a t i s t i c s i n t o t h e planning and management of hea l th sen t i ces and thus reduce t h e gap between producers and users of information.

,I Health information systems with spec ia l reference t o primary hea l th care and r u r a l development" was t h e subjec t of the technica l discussions held during t h e t h i r t i e t h se s s ion of t h e RegionalCommittee i n August 1977. The r e s u l t i n g reconnnendations s t r e s s e d the importance of the development of hea l th information sub-systems appropriate t o t h e primary hea l th care l e v e l . The need t o ensure t h a t the data co l lec ted a t t h e primary hea l th care l e v e l a r e re levant t o management purposes, and t h e importance of l inking PHC with voluntary hea l th workers, v i l l a g e councils o r s i m i l a r organizat ions, were a l s o s t r e s sed .

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implementation of t h e P e o p l e ' s Hea l th Programme, which s t a r t e d i n A p r i l , w i l l a c c e l e r a t e f u l f i l m e n t of t h e o p e r a t i o n a l r e s e a r c h p r i o r i t i e s i d e n t i f i e d f o r each programme.

A number of o p e r a t i o n a l r e s e a r c h s t u d i e s a r e under way i n Ind ia , w i t h WHO c o l l a b o r a t i o n , f o r example, c o n t r o l l e d t r i a l s of chemotherapy i n t u b e r c u l o s i s , o p e r a t i o n a l s t u d i e s on m a l a r i a r e s i s t a n c e , f i l a r i a epidemiology and f i e l d t r i a l s on t h e c o n t r o l of human f e r t i l i t y . A s tudy of t h e mult i-purpose h e a l t h worker s t r a t e g y i s p r o g r e s s i n g and i s expected t o be completed b e f o r e September 1978. Various n a t i o n a l i n s t i t u t i o n s ( h e a l t h , s o c i a l , management and s t a t i s t i c a l ) a r e c o l l a b o r a t i n g w i t h t h e Min i s t ry of Hea l th and Family Welfare i n c a r r y i n g o u t a thorough e v a l u a t i o n of t h e community h e a l t h workers ' scheme.

I n Indonesia, t h e Hea l th S e w i c e s Research and Development I n s t i t u t e i n Surabaya was des igna ted a s a WHO C o l l a b o r a t i n g Cen t re . The r e s e a r c h and development component of p r o j e c t I N 0 HSD 001 cont inued t o c o l l a b o r a t e w i t h t h e Research and Development I n s t i t u t e s i n J a k a r t a and Surabaya. A WHO systems a n a l y s t cont inued h i s a s s i s t a n c e t o o p e r a t i o n a l r e s e a r c h and systems a n a l y s i s (ORSA) and d i v e r s e a c t i - v i t i e s , geared mainly t o t r a i n i n g and r e s e a r c h .

The Regional O f f i c e i s a r r a n g i n g t o p r i n t 200 c o p i e s of t h e Eng l i sh v e r s i o n of t h e management s c i e n c e s manual which has been developed by t h e p r o j e c t , f o r d i s t r i b u t i o n t o o t h e r c o u n t r i e s i n t h e Region. US A I D has provided f i n a n c i a l a s s i s t a n c e f o r t h e o r g a n i z a t i o n of t r a i n i n g courses . The Research and Development I n s t i t u t e s i n J a k a r t a and Surabaya cont inued t o des ign and conduct a number of o p e r a t i o n a l s t u d i e s r e l e v a n t t o upgrading t h e e f f e c t i v e n e s s and e f f i c i e n c y of t h e h e a l t h s e w i c e s and t h e development of primary h e a l t h c a r e .

I n MaZdives, o p e r a t i o n a l r e s e a r c h a c t i v i t i e s a r e i n p rogress . Work on mass t u b e r c u l o s i s and l e p r o s y case - f ind ing and immunization cont inued w i t h a s s i s t a n c e from a c o n s u l t a n t , and d a t a on s a n i t a t i o n were be ing c o l l e c t e d from t h e o u t e r a t o l l s .

The I n s t i t u t e of Hygiene, Microbiology and Epidemiology i n MongoZia cont inued i t s o p e r a t i o n a l s t u d i e s , ep idemio log ica l su rveys and f i e l d t r i a l s f o r s t r e n g t h e n i n g ep idemio log ica l s u r v e i l l a n c e . UNFPA i s a s s i s t i n g i n t h e ep idemio log ica l s t u d i e s of popu la t ion growth, which i n c l u d e s t u d i e s on i n f a n t and c h i l d m o r t a l i t y , ma te rna l morb id i ty , i n f a n t n u t r i t i o n , p e r i n a t a l m o r t a l i t y and f e r t i l i t y p a t t e r n s . A n a t i o n a l committee was appo in ted t o p r e p a r e a s t u d y of t h e s t a t e of h e a l t h of t h e popu la t ion . T h i s s t u d y , t o be under taken j o i n t l y w i t h t h e USSR, i s planned t o s t a r t i n 1979, c o i n c i d i n g w i t h t h e c o u n t r y ' s census , and w i l l c o n t i n u e f o r s e v e r a l y e a r s .

I n NepaZ, a Demographic Sample Survey has provided r e l i a b l e e s t i m a t e s of t h e popu la t ion s t r u c t u r e and dynamics, i n c l u d i n g crude and s p e c i f i c v i t a l s t a t i s t i c s . The n u t r i t i o n su rvey conducted under p r o j e c t

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NEP NUT 003 i n 1976, and t h e e a r l i e r "Nepal Nu t r i t i ona l S ta tus Survey", ca r r i ed out wi th US A I D a s s i s t ance i n 1975, provided the bas i s f o r a mult i -sectoral n u t r i t i o n programme i n col laborat ion with WHO, UNICEF, FAO, WFP and US AID. The current CHP mid-term evaluat ion using the country p r o f i l e as an o v e r a l l information/evaluation base, w i l l cont r ibute t o t h e eva lua t ion method being worked out f o r developing count r ies a t WHO Headquarters. The I n s t i t u t e of Medicine car r ied out an opera t ional s tudy on r u r a l hea l th needs e n t i t l e d "Study i n a P r ima~y Health Care Unit , D i s t r i c t of Tanahu", t h e f indings of which a r e of g rea t i n t e r e s t and opera t ional value. The na t iona l family planninglmatemal and ch i ld hea l th pro jec t completed o r i s conducting t h e following s tud ie s : a fou r -d i s t r i c t KAPIfert i l i ty survey, a Nepal f e r t i l i t y survey, t h e t e s t i n g and organizat ion of a s impl i f ied repor t ing system, t h e fou r th round of the KAPIfert i l i ty survey in s i x d i s t r i c t s , a f e r t i l i t y , morbidity and mor ta l i ty survey, a laparoscopic follow-up survey, a maternal n u t r i t i o n survey and a study of n u t r i t i o n education f o r mothers.

In Sri Lanka, a na t iona l inventory of research s tud ie s on hea l th s e n i c e s was developed. A proposal f o r "Field Research and Management Studies i n Family Health" was designed and i s under consideration. The Nutr i t ion Department of the Medical Research I n s t i t u t e continued with i ts opera t ional s t u d i e s , i n order t o develop n u t r i t i o n a l a c t i v i t i e s within the framework of bas i c hea l th serv ices .

In ThuiZmzd, seve ra l opera t ional pro jec ts have been evolved applying innovative a l t e r n a t i v e s t r a t e g i e s f o r t h e development of primary hea l th ca re , f o r example, t h e Sarapee, Korat, DEIDS, and Songkhla p ro jec t s , the p ro jec t s using malaria co l labora t ing volunteers and the community-based family planning workers. In t h i s connexion the following research s tud ie s o r p ro jec t s a r e i n progress: preliminary evaluat ion of v i l l a g e hea l th volunteer work f o r primary hea l th care ( jo in t ly by WHO pro jec t THA HED 001 and the I n s t i t u t e of Social S tudies) ; an experimental study of t h e impact of t h e age and sex of v i l l a g e leaders on t h e implementation of hea l th programmes i n Korat Province (WHO projec t THA HED 001); cost-analysis and evaluat ion s tud ie s of t h e Lampang DEIDS p ro jec t (US AID and t h e American Public Health Associat ion); the nut r i t ion- in tegra ted primary hea l th care p ro jec t , Samerng D i s t r i c t (WHO~IPPF); primary hea l th care supervision and supply systems (Royal Thai GovernmentlWHO Coordinating Committee); t h e r o l e of t h e Buddhist monk i n r u r a l socio-economic development, including primary hea l th care (RTGIWHO Coordinating Committee), t h e education of v i l l a g e volunteers i n se l ec t ed communities (RTGIWHO Coordinating Committee), and the Songkhla in tegra ted model of r u r a l development (UNICEF).

1.1.4 Organization of Basic Health Services

Governments i n t h e Region continued t o s t rengthen and expand the i n f r a s t r u c t u r e of t h e i r bas i c hea l th se rv ices , espec ia l ly i n rura l a reas , with t h e aim of increas ing t h e coverage and improving the

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q u a l i t y of these serv ices . A t rend towards reformulating na t iona l p o l i c i e s i n l i n e wi th these objec t ives has been evident . Recognizing t h e l imi ted se rv ices ava i l ab le t o t h e r u r a l population and those l i v i n g i n urban slums, a l l governments have now accepted i t as a policy t o support primary hea l th care programmes by increas ing the numbers and se rv ices of h e a l t h cent res and sub-centres. The aim is t o provide promotive, preventive, cu ra t ive , and r e h a b i l i t a t i v e serv ices i n a balanced manner and t o i n t e g r a t e spec ia l i zed v e r t i c a l programmes gradual ly i n t o these h e a l t h serv ices . Technical cooperation was extended to these e f f o r t s through country and inter-country p ro jec t s .

Assistance was provided f o r the development of task and action-oriented job descr ip t ions f o r t h e members of t h e h e a l t h team s t a f f i n g the i n f r a s t r u c t u r e of b a s i c h e a l t h serv ices . It was a l s o given f o r the development of t r a i n i n g c u r r i c u l a , t h e provision of continuing education and t h e imparting of t h e necessary knowledge, s k i l l s and a t t i t u d e s t o h e a l t h workers,the development of teaching and opera t ional manuals, and t h e r e t r a i n i n g of uni-purpose personnel f o r multi-purpose h e a l t h work. In co l labora t ion with UNICEF, suppl ies and equipment were provided. These a c t i v i t i e s were intended t o support the current changing r o l e s of t h e various ca tegor ies of workers i n the hea l th team i n order t o improve t h e e f f ec t iveness and e f f i c i ency of t h e hea l th serv ices . Fur ther , support was given t o t h e promotion and development of a two-way r e f e r r a l system and the s trengthening of supervisory a c t i v i t i e s t o ensure proper u t i l i z a t i o n of resources - both f i n a n c i a l and manpower - a t a l l l eve l s .

In BangZadesh, t h e s trengthening and expansion of the i n f r a s t r u c t u r e of r u r a l hea l th se rv ices continued. The programming phase of the second country h e a l t h programming exe rc i se , completed i n 1977, i d e n t i f i e d a ,1 S t a t i c Health Care Programme" i n support of primary hea l th care as a p r i o r i t y for programme formulation. The s t a t i c h e a l t h c a r e programe includes a l l s e rv ices del ivered by i n s t i t u t i o n s a t t h e thana and more l o c a l l e v e l s , p r imar i ly t h e thana hea l th complexes and union sub-centres, toge ther with a l l o the r government hea l th i n s t i t u t i o n s , such a s under-five c l i n i c s , eye camps, medical care , maternal and chi ld h e a l t h and o ther h e a l t h and n u t r i t i o n education a c t i v i t i e s . The programme proposal envisages an increase i n t h e number of thana h e a l t h complexes from t h e present 150 t o 356 by 1985 and of union hea l th cent res from t h e present 400 t o 2000.

In Bhutan, t h e WHO/UNDP pro jec t has been cooperating with the Government i n expanding t h e coverage of i n t eg ra t ed r u r a l hea l th se rv ices . Progress was made i n converting d ispensar ies i n t o in tegra ted bas i c hea l th u n i t s - out of t h e t o t a l of 61 d ispensar ies , 2 1 have thus been converted. Several s ec t ions of t h e opera t ional manual f o r t h e bas ic hea l th u n i t s were f ina l i zed and t e s t ed . Following the success of t h e f i e l d t e s t , the use of the manual is being extended t o a l l bas i c hea l th u n i t s and t o maternal and ch i ld hea l th a c t i v i t i e s i n hosp i t a l s . Zonal hea l th supervisory systems were es tab l i shed i n

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three out of the country's seven zones, and the supervision of communicable-disease surve i l lance and cont ro l a c t i v i t i e s strengthened. The Health School continued t o receive support i n the t r a in ing of hea l th a s s i s t a n t s , bas ic hea l th workers and aux i l i a ry nurse-midwives; 45 of these workers graduated during t h e report ing period, bringing the t o t a l number of graduates t o 67. The school hea l th programme was strengthened and a post of school hea l th o f f i c e r was es tab l i shed . In co l labora t ion with WFP and UNICEF, the pro jec t took pa r t i n the planning, conduct and evaluat ion of a mult i -discipl inary t r a in ing course i n n u t r i t i o n i n May 1978 (see a l so Section 1 .6) .

In Burma, t h e People's Health Programme, which was formulated through the country hea l th programming exerc ise i n 1976, gives f i r s t p r i o r i t y t o primary hea l th care and the bas ic hea l th serv ices . In order t o develop primary heal th care , the i n f r a s t r u c t u r e of the bas i c hea l th serv ices needs t o be strengthened and increased so as t o provide t h e necessary support t o and cope with the addi t ional workload expected to r e s u l t from the implementation of primary heal th care and o ther s e rv ice programmes. Accordingly, the present inf ra- s t r u c t u r e of r u r a l bas ic hea l th se rv ices , which includes 5235 un i t s (169 s t a t i o n h o s p i t a l s , 1077 r u r a l hea l th centres and 3989 sub-centres)

w i l l be increased by about 18% by 1982 ( to about 6180 u n i t s ) . A number of preparatory a c t i v i t i e s were ca r r i ed out during the year, including the t r a i n i n g of t r a i n e r s and t r a inees a t various l eve l s . This involved t r a i n i n g a l l ca tegor ies of bas ic hea l th serv ice s t a f f i n order t o prepare them f o r t h e i r changing ro l e s a s supervisors and t r a i n e r s and/ o r t o become multi-purpose hea l th workers. A manual was developed and d i s t r ibu ted t o a l l b a s i c hea l th workers i n t h e townships se lec ted f o r t h e implementation of t h e programme. UNICEF and WHO provided the necessary suppl ies and equipment. As t h e programme a l so involves the phased in t eg ra t ion of spec ia l ized v e r t i c a l campaigns a t the l o c a l l e v e l , unipurpose workers i n such programmes were re t ra ined f o r multi- purpose work.

In India, t h e Government accords the highest p r i o r i t y t o in tegra ted development i n r u r a l a r eas , where 80% of the population l i ves . With t h i s end i n view, t h e Ministry of Health and Family Welfare launched a r u r a l hea l th scheme i n October 1977 with t h e aim of br inging simple hea l th ca re within t h e reach of every c i t i z e n by organizing cadres of medical, paramedical and community hea l th workers. The emphasis is on t h e promotive and preventive aspects of hea l th . Since 1974, the Government has been operat ing t h e multi-purpose hea l th workers' scheme with a s s i s t ance from UNFPA, UNICEF and WHO. Under t h i s scheme, unipurpose h e a l t h personnel of v e r t i c a l programmes such as smallpox vaccinators , malaria surve i l lance workers, family welfare hea l th a s s i s t a n t s and tuberculos is workers a r e t r a ined t o become multi-purpose workers s o a s t o provide in tegra ted hea l th serv ices t o the r u r a l community. The backbone of t h e scheme i s cons t i tu ted by teams each cons is t ing of one male and one female multi-purpose worker supported by t h e s t a f f i n t h e sub-centres and the primary hea l th centres .

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The National I n s t i t u t e of Health and Family Welfare continued with its ope ra t iona l s tudy of t h e scheme t o assess t h e e f fec t iveness of t h e r eo r i en ta t ion t r a i n i n g programme, t o i d e n t i f y t h e problems assoc ia ted with r e t r a i n i n g f o r multi-purpose work and its f i e l d opera t ion , and t o develop an appropr ia te hea l th information system geared t o the decision-making process. Since 1977, t h e implementation of the scheme has been acce lera ted following t h e launching of t h e cormunity hea l th workers' scheme, t o which t h e multi-purpose workers a r e t o provide the necessary support. WHO and UNICEF col labora te with t h e Government i n achieving t h e objec t ives of t h e study. Technical cooperation was a l s o provided i n t h e planning, implementation and evalua t ion of the r u r a l h e a l t h se rv ices . A f u r t h e r p ro jec t (IND PPS 001) was s t a r t e d i n 1978 with t h e ob jec t ive of promoting t h e understanding of hea l th economics and i ts important cont r ibut ion t o improved h e a l t h planning and management. These p ro jec t s a r e expected t o con t r ibu te s i g n i f i c a n t l y t o t h e success of t h e r u r a l h e a l t h scheme.

I n Indonesia, t h e i n f r a s t r u c t u r e of t h e b a s i c hea l th se rv ices i n r u r a l a reas continued t o be expanded and strengthened according t o t h e PELITA I1 Plan. It i s an t i c ipa ted t h a t t h e t a r g e t of e s t ab l i sh ing a t l e a s t one h e a l t h cen t r e i n each d i s t r i c t w i l l be reached by 197811979. The Pres ident ' s s p e c i a l developmental "INPRES" funds supplemented the Government's budget f o r h e a l t h , t h e funds being used f o r e s t ab l i sh ing new h e a l t h cen t r e s and improving t h e q u a l i t y of s e r v i c e i n e x i s t i n g ones, f o r providing supp l i e s and drugs, and f o r improving r u r a l s a n i t a t i o n . Foreign a s s i s t ance i n support of t h i s governmental e f f o r t i s intended mainly f o r t h e improvement of r u r a l water supply f a c i l i t i e s and t h e development of h o s p i t a l s and n u t r i t i o n and community hea l th serv ices . The s trengthened i n f r a s t r u c t u r e of the r u r a l h e a l t h s e r v i c e s i s expected t o cont r ibute g r e a t l y t o t h e development of primary h e a l t h care. The component of t h e umbrella p ro jec t IN0 HSD 001 dea l ing with t h e h e a l t h care de l ivery system continued t o provide a s s i s t ance t o t h e Direc tora te General of Community Health and its four d i r e c t o r a t e s responsible respec t ive ly f o r community h e a l t h se rv ices , hea l th education, family planning and n u t r i t i o n . The WHO team cons is t ing of a publ ic hea l th adminis t ra tor and a pub l i c hea l th nurse i s cooperating i n carrying out a v a r i e t y of a c t i v i t i e s such as : t h e qua r t e r ly monitoring of t h e INPRES development programme i n r u r a l a r eas , t h e assessment of h e a l t h cen t r e funct ions , t h e s trengthening of t h e primary hea l th nurse (PK) t r a i n i n g programme, t h e eva lua t ion of the family h e a l t h programme i n r e l a t i o n t o primary hea l th ca re , t h e maternal mor ta l i ty s tudy, and t h e review of t h e r e f e r r a l system.

In NepaZ, where 96% of t h e population l i v e s i n r u r a l a r eas , t h e majori ty i n t h e northern h i l l y and mountainous regions, successive development plans have given p r i o r i t y t o t h e provision of hea l th ca re t o t h e maximum poss ib le number of people. The hea l th se rv ices , which were mainly i n urban areas and t h e t e r a i region, de l ivered mostly cu ra t ive medical care , rendered through h o s p i t a l s and o the r i n s t i t u t i o n s . By t h e end of 1977, and wi th in t h e framework of the F i f t h Development Plan (1975-1980),the i n f r a s t r u c t u r e of t h e hea l th

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se rv ices had been increased t o 177 medical care i n s t i t u t i o n s (61 a l lo- pa th i c hosp i t a l s , 31 h e a l t h cent res , 1 ayurvedic hospi ta l ,82 ayurvedic d ispensar ies , 1 homoeopathic h o s p i t a l , and 1 unani dispensary) and 433 hea l th posts de l iver ing preventive and cura t ive care t o the r u r a l population. Within a period of seven years the re has been a 77% increase i n medical i n s t i t u t i o n s and a 183% increase i n r u r a l hea l th f a c i l i t i e s . Most of t h e expansion i n t h e l a t t e r has been d i rec ted t o t h e un-served r u r a l population, thus s i g n i f i c a n t l y r e c t i f y i n g t h e e a r l i e r geographical imbalance i n t h e d i s t r i b u t i o n of hea l th serv ices . A f u r t h e r considerable expansion of the hea l th serv ices i s expected i n t h e next two years , as t h e F i f t h Development Plan envisages the i n f r a s t r u c t u r e of t h e hea l th serv ices i n r u r a l a reas t o cons is t of 810 hea l th posts e f f e c t i v e l y supervised by 48 d i s t r i c t h e a l t h o f f i c e s , with a r e f e r r a l system t o hosp i t a l s o r hea l th centres (one i n each of t h e 75 d i s t r i c t s ) , and administered by t h e four regional hea l th o f f i ces supported a t t h e na t iona l l e v e l by the Ministry of Health. The WHO team consis t ing of a public hea l th administrator , a public hea l th o f f i c e r , a medical s t o r e s management o f f i c e r , a publ ic hea l th nurse, a laboratory s p e c i a l i s t and a medical records o f f i c e r continues t o a s s i s t i n these e f f o r t s , i n c lose co l labora t ion with a US AID team. A wide range of a c t i v i t i e s i s expected t o be accomplished by mid-1978, including t h e construct ion o r conversion of more hea l th posts ; in-service t r a i n i n g of personnel i n hea l th posts and d i s t r i c t hea l th o f f i c e s ; t r a i n i n g of community leaders ; assessment of t h e n u t r i t i o n a l s t a t e of ch i ldren under f i v e , and expansion of t h e immunization programme.

Bearing i n mind t h e cons t r a in t s posed by shortages of c a p i t a l and manpower resources, t h e Government has decided t o conduct a mid-term s i t u a t i o n ana lys is within t h e framework of t h e F i f t h Five-Year Development Plan i n co l labora t ion with WHO, UNICEF, UNFPA and US A I D . This w i l l be a s i g n i f i c a n t achievement, and preparatory work is i n progress , including t h e development of an updated country p r o f i l e . This eva lua t ive exe rc i se i s t imely, a s it coincides with preparat ions f o r implementing a v i l l a g e volunteer primary hea l th care scheme with t h e support of t h e bas ic hea l th serv ices .

In Thailand, t h e in t eg ra t ed r u r a l hea l th serv ices continued t o be strengthened and upgraded i n support of primary hea l th care. A t the end of 1977, t h e expanding in f r a s t ruc tu re of t h e r u r a l hea l th serv ices consis ted of 297 h o s p i t a l s , 3898 h e a l t h cent res and 1448 midwifery c l i n i c s . By 1981, t h e na t iona l plan envisages t h e expansion of the i n f r a s t r u c t u r e t o 350 hosp i t a l s , 4533 hea l th centres and 2956midwifery c l i n i c s .

Under the provinc ia l h e a l t h care development p ro jec t , the WHO management o f f i c e r continued t o provide a s s i s t ance t o t h e Rural Health Division. The p ro jec t a s s i s t e d i n preparing t h e annual hea l th budget and a l l o c a t i n g it t o t h e provinces and i n rev is ing t h e e x i s t i n g report ing procedures. Among o the r areas of cooperation were the development of task-oriented supervisory systems a t a l l administrat ive

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l e v e l s , management of the construct ion of hea l th f a c i l i t i e s i n the provinces, and t h e implementation of t h e primary hea l th care programme, inc luding i t s s i z a b l e t r a i n i n g component. The p ro jec t has been progressing s a t i s f a c t o r i l y and was very successfu l i n a t t r a c t i n g s u b s t a n t i a l extra-budgetary funds. The Regional Adviser on Community Health Services v i s i t e d the p ro jec t and reviewed i ts progress with t h e na t iona l a u t h o r i t i e s . The Royal Thai Government/WHO Coordinating Committee reviewed t h e p ro jec t document together with t h a t of t h e population p ro jec t i n Apr i l 1978.

A new p r o j e c t , "Urban Health Care Development" (THA HSD 001) was launched i n 1977. The ob jec t ives of t h e pro jec t a r e : (1) t o assis ' t i n t h e development of comprehensive hea l th se rv ices f o r the s l u m population i n Bangkok and 126 munic ipa l i t ies as an i n t e g r a l p a r t of town planning and urban management with emphasis on the preventive aspects of hea l th , e spec ia l ly environmental hea l th , family planning and i m u n i z a t i o n , and (2) t o improve the administrat ion and management of urban hosp i t a l s . A na t iona l temporary adviser was r ec ru i t ed t o a s s i s t i n t h e group educat ional and t r a i n i n g a c t i v i t i e s , which a r e supported by a WHO grant . Two t r a i n i n g courses i n urban public hea l th adminis t ra t ion and planning were organized, attended by hea l th o f f i c e r s from Bangkok and o t h e r munic ipa l i t ies . Training courses f o r school teachers i n t h e provinces a r e being given. The t a r g e t i s t o t r a i n 90 publ ic h e a l t h adminis t ra tors and 100 000 school teachers by 1980.

1 . 2 Primary Health Care

The primary h e a l t h care (PHC) approach i s now accepted by a l l governments and is gaining momentum i n South-East Asia. A l l the count r ies i n t h e Region a r e now aiming a t b e t t e r coverage through PHC, with simultaneous expansion of t h e support ing i n f r a s t r u c t u r e of t h e i r h e a l t h se rv ices .

The concensus among t h e count r ies i n accept ing primary hea l th care has been followed by s e v e r a l promotive a c t i v i t i e s a t na t iona l l eve l . These measures were d i r ec t ed towards c r y s t a l l i z i n g the concept and studying t h e most s u i t a b l e approaches from each country 's point of view. Several count r ies have made in-depth s t u d i e s of innovative p r o j e c t s , held na t iona l dialogues and exchanged information and experiences both on an in t r a - and an in t e r - sec to ra l bas i s . They have developed s t r a t e g i e s t o maximize the coverage i n order t o reach t h e under-served r u r a l population a s rap id ly a s poss ib l e , throughthe PHC approach, supported by t h e i n f r a s t r u c t u r e of the b a s i c h e a l t h s e r v i c e s . WHO and UNICEF have a s s i s t e d i n these e f f o r t s . The determination of t h e count r ies t o accept and implement t h e primary hea l th care approach was r e i t e r a t e d during t h e WHOIUNICEF Regional Meeting on PrimaryHealth Care, whichwas he ld i n t h e Regional Office i n November1977in prepara- t i o n f o r t h e g lobal meeting on the sub jec t , scheduled t o take place i n t h e USSR i n September.

END OF A SCOURGE

Freedom from smallpox was declared i n Asia on 1 4 December

1977 when a WHO International Commission off icial ly certi f ied the

ation of this ancient scourge from Bangladesh.

The Director-General of WHO. Or Halfdan Mahler, and the egional Director, Dr V. T. H. Inaratne. look on whi le the

wa i rman of the International Commission. Or A. D. Langmuir,

presents the f inal report of certi f ication t o the President of

Bangladesh. His Excellency Major- General Ziaur Rahman.

Af ter addressing the f ie ld staff a t the Smallpox-Zero headquarters i n

Dacca (right), Dr. Mahler personally congratulates them

(right, below).

Vehicles, which played such a v i ta l ro le , stand l i k e proud

soldiers, l ined up after the hard- won victory.

(Photos : WH0IA.S. Kochar)

Left: An auxiliary nurse-niidwife helps a community heal th worker examine a pregnant woman as part of prenatal care. They f ind her anaemic and (above) give her iron and vitamin tablets Lett, below: Immunizing against child- hood diseases is also oart of a health worker's functions. (Photos on thisand opposite page: WHO1 A.S. Kachar)

PHC IN ACTION - INDIA

To tackle the health problems in i ts half-a- mil l ion villages, the Indian Government, l ike - t h e n in the Region, has accepted that a

rogramme of primary heal th care is the ost feasible strategy. scheme using community health workers

,:HWs) was launched in October 1977. By February 1978. the f i rst batch of more than 15000 such workers had returned to their villages after three months' basic training in health care. Chosen by the i r own communities, they are helping to build self-reliance in matters of health in rural areas. The scheme aims to have one male and one female multipurpose health worker for every 5000 of the population.

Above : Community health workers collect health data and take blood Saltlpler tu

detect malaria (right). They are qualified .. .,.,,, ine and cope with minor ailments (below) and are equipped to give first-aid

(below, right).

PHC IN ACTION- THAILAND

In Thailand. as in other countrie! of the Region, community involvement plays an important role in primary health care. Village leaders. traditional healer and monks have al l been involve1 in the PHC programme to make it more broadbased and effective. (Photos on thlz and oppaslte page : WHOIA S Kochar)

A village health volunteer checks vaccination marks in children a t a day-care school.

i e also visits l ive guidance nygiene.

homes re on healt l

gularly to 1 and

t h e w l~o le village is involved in the construction of a storage tank for drinking water. While the villagers provide the land and labour. materials are supplied by the Government.

,..., . Tradit ional practi t ioners work closely w i t h the health services in providing primary hea l th care; they may even prescribe simple al lopathic medicines. Right : A v i l lage monk guides young children in dental care a t a day-care school. Below : The v i l lage heal th volunteer makes regular visits to homes and attends t o sickness. He also runs a f irst-aid post a t his house, attending to

. . ".,"a. juries (below, r ight).

WOMEN IN WHITE

Nursing personnel form t h e backbone of heal th servlces, especially for family health. Their impact on rura l health and primary heal th care is no t only through

direct nursing care bu t also as trainers of various types of vi l lage health workers and t radi t ional b i r th attendants.

Above : Nursing students being instructed in chi ld care i n Mongolia.

Below : Auxiliary nurse.midwives run t h e ru ra l heal th centres in Thailand. (Photo : WHO/A.S. Kochar)

Right : Burmese nurses explain to a mother how t o prepare a bo t t le feed for her twins.

Right. below : A public heal th nurse on her daily rounds in Sr i Lanka.

SEAlRC3112 Page 15

Two out of t h e Region's t en countr ies a r e a t present considered t o have achieved almost f u l l coverage with a reasonable l e v e l of s e rv ice , four have launched na t iona l programmes and another four a re i n the preparatory s t age of planning na t iona l schemes. It i s t o be noted tha t t h e promotive e f f o r t , when followed by a systematic na t iona l heal th planning process such as country hea l th programming, has resu l ted i n t h e development of r a t i o n a l programmes. These systematic planning e f f o r t s have thus strengthened and accelerated the implementation of PHC i n t h e countr ies concerned.

In some countr ies primary hea l th care has developed as an expansion of t h e government's bas ic hea l th se rv ices , i n some as a pa r t of community-initiated ac t ion , and i n y e t o thers as a combination of both. Within each of these broad types t h e r e a re shades of va r i a t ion which a r e s p e c i f i c t o each country. Wherever primary hea l th care has been i n i t i a t e d by community leadership as an i n t e g r a l p a r t of the community's a c t i v i t i e s , t h e government's bas ic hea l th serv ices a re being expanded t o provide t h e necessary support i n t r a i n i n g , r e f e r r a l , l o g i s t i c s , t echnica l guidance and supervision.

PHC is a l s o recognized as an evolving, dynamic approach, and as a s t age i n the process of continuing evolut ion which can thus be adapted t o t h e changing needs and varying s i t u a t i o n s of t h e community. I n the i n i t i a l s t ages of developing PHC, p r i o r i t y i s given t o achievingbet te r quan t i t a t ive coverage through t h e provision of a package of simple, e s s e n t i a l requirements within ava i l ab le resources. With the passage of time, increase of resources and the accumulation of p r a c t i c a l experience, q u a l i t a t i v e improvements could follow.

One important f ea tu re i n t h e development of PHC i n some countr ies i s t h e involvement of o ther s ec to r s i n the promotive and preparatory phase and the planning and implementation of the programmes a t a l l l eve l s .

In Bar.gZadesh, in tens ive promotional e f f o r t s i n 1977 culminated i n the formulation of the primary hea l th care programme (including the expanded programme on immunization) i n June 1978. This programme, which followed t h e second cycle of t h e country hea l th programming exerc ise conducted i n 1977, includes a l l se rv ices del ivered a t the v i l l a g e and domiciliary l e v e l pr imari ly by the loca l workers supplemented by v i l l a g e volunteers (v i l l age hea l th squads) and more c e n t r a l l eve l workers. The a c t i v i t i e s w i l l cover appropriate medical ca re , maternal and chi ld hea l th and family planning, n u t r i t i o n , cont ro l and surve i l - lance of communicable d iseases , hea l th education and environmental s a n i t a t i o n . The programme, t o be supported by the i n s t i t u t i o n a l hea l th se rv ices , envisages the ac t ive involvement of the familywelfare worker (one f o r every 4000 population) and the family welfare a s s i s t a n t ( th ree per union) fo r monthly house-to-house v i s i t s . In addi t ion t o the v i l l a g e hea l th squads i n each v i l l a g e , the requirements f o r manpower a r e estimated a t 15 358 family welfare workers and 16 224 family welfare a s s i s t a n t s .

SEAlRC3112 Page 16

In Buna, t h e implementation of the PHC programme, which had been formulated during t h e country h e a l t h programming exerc ise i n 1976, s t a r t e d i n Apr i l 1978 i n 15 townships. The programme aims t o cover 147 townships- about 50% of those i n r u r a l a r e a s - and w i l l involve t h e t r a i n i n g of 5240 community hea l th workers by 1982. Fur ther , 670 community h e a l t h workers were s e l e c t e d and given th ree weeks' t r a i n i n g i n t h e r u r a l h e a l t h cent res i n t h e i r townships. WHO and UNICEF have, i n coordinat ion, helped t o meet t h e cos t of t h e necessary suppl ies and, equipment including kits, t h e production of manuals, and t h e t r a in ing . This i n i t i a l phase of implementation w i l l be monitored and evaluated i n order t o apply t h e f indings i n improving t h e programme f u r t h e r .

I n India, t h e primary h e a l t h c a r e programme was launched i n October 1977 as t h e "community hea l th worker scheme". It was preceded by promotional a c t i v i t i e s , including a n a t i o n a l conference on primary h e a l t h care. I n t h e f i r s t phase, t h e scheme has been implemented i n 28 d i s t r i c t s . The t r a i n i n g of multi-purpose workers has been completed i n these d i s t r i c t s and i n one primary hea l th cen t r e i n each of the remaining 364 d i s t r i c t s i n t h e country. There a r e 777 primary hea l th cent res involved i n t h i s phase. During t h e cur rent five-year p lan i t i s envisaged t h a t t h e scheme w i l l be extended t o 4584 primary hea l th cent res i n a phased manner over a period of t h ree years . Future extension w i l l , however, be sub jec t t o an eva lua t ion , scheduled t o be ca r r i ed out i n June 1978. By t h e end of 1978, i t is planned t o t r a i n 90 000 community h e a l t h workers, who w i l l s e rve a population of 80-90 mi l l i on i n about 80 000 v i l l a g e s . The r u r a l h e a l t h scheme a l s o involves t h e t r a i n i n g of one dai per v i l l a g e who w i l l be provided with a s u i t a b l e k i t . The necessary t r a i n i n g manuals were prepared, t e s t ed and d i s t r i b u t e d . WHO, i n co l labora t ion with UNICEF, providedtechnica l cooperation i n these e f f o r t s .

In Indonesia, prepara t ions f o r t h e launching of t h e primary hea l th ca re programme included considerable promotion, planning and research. The WHO p ro jec t IN0 HSD 001 was involved i n t h e above e f f o r t s , which were marked by a pragmatic and mult i -sectoral approach. Following the organizat ion of a t a sk fo rce on PHC, a na t iona l conference and a workshop on t h e implementation of PHC were held. The t r a i n e r s of primary h e a l t h ca re (kabupaten) workers were t r a ined i n t h e s i x provinces i n which in t e r - sec to ra l p i l o t p ro jec t s on PHC were launched. PHC workshops a r e planned f o r September 1978 i n four o ther provinces.

Maldives, where t h e b a s i c hea l th se rv ices a r e developing, w i l l benef i t f romtheplanned community-based PHC programme f o r each of t h e inhabited i s lands . WHO and UNICEF p a r t i c i p a t e d i n a na t iona l meeting on PHC.

Mongolia, which has now achieved almost 100% hea l th coverage of t h e population, has v a s t experience i n developing primary h e a l t h care. The "bag-nurse", o r t h e primary h e a l t h worker, with th ree months' t r a i n i n g , was t h e backbone of r u r a l hea l th se rv ices during 1921-1940. Over the next 20 years t h i s category of worker was replaced by t h e f e ldshe r , whose t r a i n i n g l a s t e d four years . The f e ldshe r programme

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was expanded t o every brigade, and i n t h e 1960s was f u r t h e r supported, a t t h e somon, aimak and na t iona l l e v e l s , by a s t rong s t r u c t u r e of i n s t i t u t i o n s and mobile teams cons is t ing of physicians, s p e c i a l i s t s and a u x i l i a r i e s and providing both preventive and cura t ive care. A na t iona l symposium on PHC was held i n August 1977 with 50 pa r t i c ipan t s drawn from a l l categories of hea l th profess ionals , as well as Red Cross o f f i c i a l s .

In Nepal, desp i t e a s i g n i f i c a n t expansion i n t h e bas ic hea l th se rv ices , i t i s r ea l i zed t h a t funct ional coverage through house-to-housevisiting has not been achieved, espec ia l ly i n the h i l l y and mountainous regions where 61% of t h e population l i v e s . Accordingly, a primary hea l th care approach through village-based volunteers has been conceived. A scheme t o t r a i n t r a i n e r s who i n turn would t r a i n 3600 community leaders and motivate them i n community pa r t i c ipa t ion i n hea l th development, was i n i t i a t e d by t h e in tegra ted community hea l th pro jec t . Another approach which i s being considered f o r implementation i n th ree d i s t r i c t s envisages t h e t r a i n i n g of v i l l a g e volunteers t o de l ive r simple medical ca re , f i r s t - a i d , bas ic preventive and promotive measures and lay report ing. The basic hea l th serv ices w i l l provide the necessary support and the voluntary organizat ions w i l l be involved i n these e f f o r t s . I n i t i a l l y , t h e p i l o t pro jec ts i n Jumla, Nuwakot and Bhanke w i l l provide the necessary experience f o r developing a na t iona l scheme. A mult i -sectoral na t iona l conference on PHC was held i n 1977.

In Sri Lanka, too , i n s p i t e of a r e l a t i v e l y good i n f r a s t r u c t u r e of bas ic hea l th serv ices coupled with a f a i r l y high l i t e r a c y r a t e and good communications, t he re i s much scope f o r improvement i n the funct ional coverage. There i s s i g n i f i c a n t under-ut i l izat ion of l o c a l s e rv ices and over-use of more cen t r a l i n s t i t u t i o n s , r e f l e c t i n g on the q u a l i t y of serv ice . The problem i s aggravated by the shortage of manpower caused by t h e "brain drain" among hea l th profess ionals , and t h e paucity of f i n a n c i a l resources. To remedy t h i s s i t u a t i o n , the Government plans t o r e c r u i t 1500 non-transferable community hea l th a ides , who w i l l be t ra ined f o r multi-purpose hea l th work cons is ten t with community-based primary hea l th care and with emphasis on preventive and promotive measures. The t r a i n i n g curriculum w i l l include communicable-disease cont ro l , hea l th education, family hea l th , school hea l th , environmental s a n i t a t i o n , n u t r i t i o n , elementary medical care , accident prevention, f i r s t - a i d and r e h a b i l i t a t i o n . The Sarvodaya Movement, which i s a self-help mult i -sectoral socio-economic develop- mental e f f o r t and which has a PHC approach, now covers more than 900 v i l l a g e s .

In ThaiZand, as r e fe r r ed t o e a r l i e r under sub-section 1.1.3, "Operational Studies", s eve ra l innovative models of PHC have been evolved. Following the country hea l th programming exerc ise , the provinc ia l h e a l t h care pro jec t (THA PHC 001), which was formulated i n 1976, includes a country-wide primary hea l th care component. The p ro jec t ' s t a r g e t s f o r 1977-1981 include the s e l e c t i o n , t r a in ing and deployment of 22 400 v i l l a g e hea l th volunteers , about 200 000

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v i l l a g e h e a l t h communicators, 2800 "tambon doctors" and 8400 "granny midwives". To provide t h e necessary support and supervision t o these personnel, about 6130 b a s i c hea l th workers, 7450 midwives and 2100 nurse p r a c t i t i o n e r s w i l l r ece ive in-service r eo r i en ta t ion t r a in ing . Implementation of t h e PHC component s t a r t e d i n 1977 following the f i n a l i z a t i o n of t h e bas i c document. The achievements of the p ro jec t include: t r a i n i n g of t r a i n e r s a t p rov inc ia l and d i s t r i c t l e v e l s , p repara t ion of guidel ines on the community approach t o v i l l a g e l e v e l planning and p ro jec t management, t r a i n i n g of 500 v i l l a g e hea l th volunteers and 2500 v i l l a g e hea l th communicators and the preparat ion of a PHC monitoring system. WHO and UNICEF a r e providing thenecessary t echn ica l cooperation i n t h e form of subs id ies f o r t r a i n i n g and the provision of k i t s and suppl ies . US A I D is supporting the t r a i n i n g of "granny midwives". The American Pub l i c Health Association i s support ing t h e Lampang p ro jec t . UNICEF and UNDP a r e supporting the Songkhla model. The population p r o j e c t , which has been f i n a l i z e d , is supported by IBRDIIDA, Aus t r a l i a , Canada, Noway and US A I D .

Two inter-country p r o j e c t s were launched i n 1978, t h a t i s , "Organiza t ion and Administration of PHC" (ICP PHC 002), and "Development of Appropriate Technology i n r e l a t i o n t o Primary Health Care" (ICP PHC 003). These two p r o j e c t s , which have replaced the e a r l i e r pro jec t 9 , Organization and Administration of Primay Health Care" (ICP PHC 001), w i l l support t h e country p ro jec t s .

1.3 Family Health

I n t h e South-East Asia Region, family hea l th is i d e n t i f i e d a s an i n t e g r a l p a r t of primary hea l th care . Greater s t r e s s is l a i d on the maternal and ch i ld care component, including family planning, a l s o known a s family welfare. I n co l labora t ing with governments i n carrying out these programmes, WHO has been giving technica l support t o the United Nations Fund f o r Population Activities(UNF'PA) andUNICEF.

In BmzgZadesh, i n l i n e with t h e importance at tached t o ch i ld hea l th care i n t h e country's family hea l th programme, WHO supports UNICEF i n running c l i n i c s f o r t h e under-fives. Cooperation with t h e World Food Programme has continued. A T r i p a r t i t e Review of UNFPA-funded p ro jec t s was held i n Apr i l .

I n B u n a , f i e l d work on t h e co l l abora t ive study of pregnancy and its outcome, including low birth-weight, was completed i n February. A proposal f o r an ad hoc survey on i n f a n t and ea r ly childhood mor ta l i ty , which was scheduled t o s t a r t a f t e r the completion of the WHO-assisted p e r i n a t a l study (see below), has been under the Govern- ment's considerat ion. Support i s being given t o the development of hea l th manpower f o r maternal and ch i ld hea l th and school hea l th .

In India , t h e f i r s t d r a f t of a handbook on maternal and ch i ld hea l th was completed. A seminar f o r s t a t e - l eve l maternal and ch i ld hea l th o f f i c e r s was organized ea r ly i n November t o h ighl ight t h e Government's

SEA/RC31/2 Page 19

new programme f o r t h e d e l i v e r y of r u r a l h e a l t h s e r v i c e s through community-level workers and t h e problems and needs of ma te rna l and c h i l d h e a l t h . WHO p a r t i c i p a t e d i n a t r i p a r t i t e review of t h e UNFPA- funded programme f o r t h e supply of c o n t r a c e p t i v e s . Promotion of t h e fami ly h e a l t h programme was t h e s u b j e c t of r e g u l a r and p e r i o d i c d i s c u s s i o n s w i t h t h e n a t i o n a l a u t h o r i t i e s .

The p e r i n a t a l s t u d y was s t a r t e d i n August 1977 i n c o l l a b o r a t i o n w i t h B . J . Medical Co l lege , Poona, and i s making p r o g r e s s .

C o l l a b o r a t i o n was extended t o Indonesia i n des ign ing t h e p e r i n a t a l m o r t a l i t y s t u d y , which s t a r t e d i n March. It i s proposed t o p rov ide t h e s e r v i c e s of a shor t - term c o n s u l t a n t t o a s s i s t w i t h t h e schoo l h e a l t h programme.

With WHO c o l l a b o r a t i o n , t h e Government of Maldives h a s drawn up a programme f o r improving fami ly h e a l t h . A shor t - t e rm c o n s u l t a n t has been ass igned t o a s s i s t w i t h mate rna l and c h i l d h e a l t h c a r e a c t i v i t i e s . The MCH programme i n t h e i s l a n d s was reviewed and a s s e s s e d . The s e r v i c e s of a c o n s u l t a n t were provided from t ime t o t ime t o conduct a c h i l d h e a l t h c l i n i c .

A WHO medical o f f i c e r was ass igned t o Mongolia i n June 1977 t o h e l p i n promoting, improving and expanding t h e mate rna l and c h i l d h e a l t h s e r v i c e s a s an i n t e g r a l p a r t of t h e g e n e r a l h e a l t h s e r v i c e s . WHO has been c o l l a b o r a t i n g w i t h UNICEF i n t h e expansion of t h e mate rna l and c h i l d w e l f a r e programme. Short- term c o n s u l t a n t s were provided i n t h e f i e l d s of c h i l d haematology, nephrology and pe r ina to logy . The develop- ment of h e a l t h manpower i n mate rna l and c h i l d h e a l t h con t inues t o r e c e i v e a s s i s t a n c e . F u r t h e r t e c h n i c a l suppor t was provided t o t h e n a t i o n a l a u t h o r i t i e s i n t h e p lann ing , moni to r ing and e v a l u a t i o n of t h e f i r s t phase of t h e programme of ep idemio log ica l s t u d i e s of popu la t ion growth.

I n Nepal, t h e UNFPA-assisted p r o j e c t f o r t h e development of t h e family h e a l t h a s p e c t s of i n t e g r a t e d h e a l t h s e r v i c e s was r e v i s e d i n o r d e r t o re-phase t h e a c t i v i t i e s . A c o n s u l t a n t was provided t o a s s i s t i n t r a i n i n g d i s t r i c t medical o f f i c e r s i n t h e "minilap" t echn ique of s t e r i l i z a t i o n . Fel lowships were awarded t o s t r e n g t h e n t h e fami ly p lann ing programme f u r t h e r .

A new WHO-supported p r o j e c t was s t a r t e d dur ing t h e y e a r w i t h t h e aim of s t r e n g t h e n i n g t h e mate rna l and c h i l d h e a l t h a s p e c t s of t h e family h e a l t h programme w i t h i n t h e i n t e g r a t e d h e a l t h s e r v i c e s . Support was provided i n t r a i n i n g manpower f o r ma te rna l and c h i l d h e a l t h through t h e award of r e g i o n a l f e l l o w s h i p s .

I n S r i Lanka, where t h e family h e a l t h programme was extended by a f u r t h e r y e a r , two new p r o j e c t s were s t a r t e d . One of them aims a t s t r e n g t h e n i n g t h e hospi ta l -based s e r v i c e s funded by UNFPA a s w e l l a s

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increas ing t h e s t e r i l i z a t i o n se rv ices and mobile s t e r i l i z a t i o n teams. The o the r p r o j e c t , which i s under t h e WHO Headquarters Special Programme of Research, Development and Research Training i n Human Reproduction, w i l l t e s t t h e f i e l d research study on t h e familyplanning serv ices . The Government has appointed a na t iona l coordinator f o r t h i s p ro jec t . During t h e year S r i Lanka a l s o s t a r t e d t h e c o l l a b o r a t i v e study on p e r i n a t a l mor ta l i ty .

In ThaiZand, t h e t h r e e new UNFF'A-funded family hea l th p ro jec t s s t a r t e d last year were continuing s a t i s f a c t o r i l y . The p ro jec t "Accelerated Development of MCH and Family Planning Services" (THA MCH 002) i s due t o be completed t h i s year .

The co l l ec t ion of da t a f o r t h e community phase of the co l labora t ive study on p e r i n a t a l mor ta l i ty was completed i n t h e f i r s t qua r t e r of 1978. Action i s i n hand t o process and analyse t h e data . The h o s p i t a l phase of t h e s tudy i s making progress.

The Regional Team on Family Health continued t o a s s i s t governments i n the implementation, monitoring and evaluat ion of t h e i r family hea l th programmes. The team l eade r of t h e pro jec t took up her dut ies i n June 1977.

As a l ready mentioned, t h e year saw progress i n regard t o the WHO co l l abora t ive study on p e r i n a t a l mor ta l i ty . Indonesia and S r i Lanka i n i t i a t e d t h e s tudy during t h e period under review. It was making progress i n India and Thailand, and i n Burma, the study was completed and t h e da ta were being analysed.

A c t i v i t i e s under t h e WHO Headquarters' Special Programme of Research, Development and Research Training i n Human Reproduction a r e being undertaken i n Bangladesh, Ind ia , Indonesia, S r i Lanka and Thailand. Two s c i e n t i s t s from t h e Region, one from Ind ia and the o ther from S r i Lanka, a r e on t h e 12-member Headquarters Advisory Committee f o r t h i s programme. The Regional Office and t h e WHO Representat ives a t country l e v e l a r e increas ingly involved i n iden t i fy ing p r i o r i t y research problems, s c i e n t i s t s and i n s t i t u t i o n s . The All-India I n s t i t u t e of Medical Sciences, New Delhi , i s t h e Research Training Centre f o r t h i s region. I n October 1977, Regional Office s t a f f pa r t i c ipa t ed i n a meeting of t h e Advisory Committee which reviewed t h e Programme and discussed t h e formulation of i t s s t r a t egy . I n order t o s t rengthen coordinat ion, i t i s planned t o e s t a b l i s h a post of s p e c i a l o f f i c e r f o r t h i s programme i n t h e Regional Office.

1 .4 Nursing

The resources i n nursing and midwifery manpower have inc reaseds t ead i ly i n a l l count r ies of t h e Region. This increase includes profess ional l e v e l nurses and midwives and various ca tegor ies of a u x i l i a r y l e v e l personnel. There i s , however, t h e problem of uneven d i s t r i b u t i o n of s t a f f , with a tendency towards concentrat ion i n urban areas . I n some

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count r ies , emigration continues t o deple te t h e ranks of professional l e v e l s t a f f . Although new approaches a r e needed t o solve the problem of mald is t r ibut ion of nurses and o ther hea l th workers, i t must be noted t h a t nursing personnel form the bulwark of family hea l th serv ices i n r u r a l a r eas , with t h e numbers increasing along with the expansion of t h e i n f r a s t r u c t u r e of r u r a l hea l th serv ices . The major impact of nurses and midwives i n r u r a l areas is on t h e hea l th of mothers and chi ldren , and they must be given a good share of the c r e d i t f o r t h e reduction i n maternal and chi ld mor ta l i ty andmorbidity. Their contr ibut ions a re through d i r e c t nursing care and hea l th education, r e f e r r a l s t o hea l th centres and hosp i t a l s , and through the t r a i n i n g and supervision of aux i l i a ry workers, v i l l a g e hea l th workers and t r a d i t i o n a l b i r t h a t tendants .

A fu r the r impact nurses have made on r u r a l hea l th and primary hea l th care i s through t h e i r r o l e as t r a i n e r s of various types of v i l l a g e hea l th workers and t r a d i t i o n a l b i r t h a t tendants . The World Health Assembly i n a r e so lu t ion (WHA30.48) ca l l ed f o r a comprehensive review of t h e ro l e s and funct ions of hea l th personnel within the context of na t iona l hea l th programmes, emphasizing t h e u t i l i z a t i o n of nursing/ midwifery personnel i n t h e planning and management of primary hea l th care and vaccinat ion programmes and a s teachers and supervisors of primary hea l th care workers. The reso lu t ion was reaffirmed by the Regional Committee a t i t s t h i r t i e t h sess ion .

In Bangladesh, t h e College of Nursing reached i t s goal of t r a in ing 75 t r a i n e r s f o r t h e family welfare v i s i t o r s (FWV) programme. More than 400 FWVs were t ra ined and the enrolment of new intakes is under way. The t r a i n i n g programme f o r family welfare a s s i s t a n t s and family planning a s s i s t a n t s reached 90% of i t s goal, with 15 297 workers t r a ined by t h e end of Ju ly 1977.

The midwifery t r a i n i n g programme i n B m a i s being revised t o s t rengthen t h e community h e a l t h aspec ts , and a new curriculum has been designed f o r t r a i n i n g t r a d i t i o n a l b i r t h a t tendants .

Two s t a t e s i n India , Maharashtra and West Bengal, continued with surveys and assessments of community hea l th nursing serv ices . An advisory committee was formed i n West Bengal f o r the purpose of d i r e c t i n g surveys on community hea l th needs as a bas i s f o r planning s t a f f i n g p a t t e r n s , f o r improving the organizat ion and management of serv ices i n hea l th cen t r e s , and fo r developing in-service programmes. I n Maharashtra, progress was made i n s t rengthening supervisory and l o g i s t i c support f o r aux i l i a ry nurse-midwives who a r e posted i n r u r a l areas. Courses i n community hea l th were conducted f o r t u t o r s of ANMs i n severa l s t a t e s i n t h e country i n order t h a t they may i n tu rn place g rea t e r emphasis on community hea l th nursing i n the ANM t r a i n i n g programme.

The scheme f o r r e s t ruc tu r ing t h e t o t a l nursing system i n Indonesia made outstanding progress during t h e year . The main focus continues

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t o be on t h e primary h e a l t h nurse (PK) t r a i n i n g programme, which w i l l eventual ly rep lace a mult i tude of spec ia l ty t r a i n i n g programmes. The PK t r a i n i n g programme i s comprehensive i n na ture , inc luding bas i c h o s p i t a l nursing and a s t rong component i n community hea l th . I n the na t iona l development scheme, t h e primary hea l th nurse i s thedes ignated worker responsible f o r bas i c hea l th serv ices a t community l e v e l . During t h e yea r , 18 schools of nursing were converted t o PK t r a i n i n g , making a t o t a l of 28, and 23 more a r e i n t h e process of conversion. Retraining of nurses and midwives and teacher t r a i n i n g continued, with the emphasis i n a l l t h e programmes on ac t ive learn ing experiences i n t h e v i l l ages . A unique f e a t u r e of these new t r a i n i n g programmes is the focus on s tudent s e l f - r e l i ance i n iden t i fy ing and analysing the needs of v i l l a g e populations and developing appropr ia te nursing se rv ices i n response t o these needs. These a c t i v i t i e s a r e undertaken i n f u l l par tnersh ip and col labora t ion with t h e people, with t h e r e s u l t t h a t v i l l a g e r s themselves have assumed various r e s p o n s i b i l i t i e s f o r improving t h e i r environment, e s t ab l i sh ing f a c i l i t i e s f o r c l i n i c s and o the r measures f o r t h e promotion of hea l th .

Nurses i n t h e MaZdives have major r e spons ib i l i t y f o r t h e t r a i n i n g of t r a d i t i o n a l b i r t h a t t endan t s , t h e foolumas, and t h e community hea l th workers, who serve i n t h e a t o l l s . The t r a i n i n g i s a s s i s t e d by WHO.

I n Mongolia, b a s i c and post-basic nursing education was expanded and upgraded. F u l l secondary education is now required f o r admission t o b a s i c nursing, and 760 s tudents were admitted t o the four schools of nursing i n 1977. Physical f a c i l i t i e s were improved and add i t iona l teaching equipment procured through WHO and UNICEF ass i s t ance . Construction of a new bui ld ing f o r t h e school i n Ulan Bator is expected t o s t a r t i n 1978. The nursing programme i s one component of t h e t o t a l scheme f o r t r a i n i n g middle l e v e l hea l th workers. The WHO nurse educator and post-basic s tudents i n nursing adminis t ra t ion completed a survey of s t a f f funct ions , working condit ions, and opinions of p a t i e n t s , doctors and supervisors i n 14 h o s p i t a l s i n Ulan Bator. Annual surveys a r e conducted on t h e numbers and d i s t r i b u t i o n of middle-level hea l th workers. Continuing education received major a t t e n t i o n , including r e f r e s h e r courses f o r various ca tegor ies of middle-level workers,and seminars on educat ional sc ience f o r nursing and medical teachers . In-senrice education f o r nursing s t a f f i n hosp i t a l s was designed s p e c i f i c a l l y t o improve c l i n i c a l a reas used f o r s tudent p rac t i ce . Hospital serv ices were f u r t h e r benef i ted through t h e post-basic course on nursing se rv ices adminis t ra t ion , with 30 graduates cons i s t ing of matrons and head nurses. New job speci- f i c a t i o n s fo r these nursing pos ts were approved.

In Nepal, WHO a s s i s t e d wi th t h e r ev i s ion of t h e curriculum of t h e post-basic midwifery t r a i n i n g programme of the I n s t i t u t e of Medicine, Tribhuvan University. Nurses a l s o form p a r t of t h e hea l th team responsible f o r t r a i n i n g and supervising a u x i l i a r i e s f o r t h e i n t e g r a t e d h e a l t h se rv ice scheme.

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In S r i Lanka, t h e f acu l ty of t h e Post-Basic School of Nursing and WHO nurse consul tants developed proposals and the curriculum f o r a B.Sc. programme i n nursing which a r e under considerat ion by t h e Government and t h e Universi ty a u t h o r i t i e s . The development of in-service education f o r nurses i n hosp i t a l s was a s s i s t e d through the assignment of a nurse-educator from an inter-country pro jec t .

In ThaiZand, nurses continued t o play a major r o l e i n the preparation of educat ional mater ia l s and t h e t r a i n i n g of t r a i n e r s f o r primary hea l th workers. The e n t i r e scope of nursing education has been revised with t h e objec t ive of preparing nurses f o r broader functions i n p a t i e n t care and the del ivery of serv ices i n the community. This change appl ies t o bas i c nursing education and culminates a t a higher l e v e l i n t h e nurse p r a c t i t i o n e r programme and the M.Sc. i n Public Health Nursing a t Mahidol Universi ty. The nurse p r a c t i t i o n e r is prepared i n s k i l l s of physical assessment and bas i c medical care and i s t o se rve primari ly i n out-pat ient c l i n i c s and i n hea l th centres which do not have medical s t a f f .

Throughout t h e Region, t r a i n i n g programmes continue t o be hampered by t h e lack of educat ional mater ia l s . During t h e period under review, na t iona l nurses and WHO nurse-educators have made s i g n i f i c a n t progress i n t h e preparat ion of manuals, t e x t s and o ther teaching a ids . In Indonesia, i n s t r u c t i o n a l modules f o r the PK programme were revised. In Thailand, modules were prepared f o r the t r a in ing manual f o r v i l l a g e hea l th workers, and, i n India , nurses and medical personnel completed major tasks on t h e preparat ion of manuals f o r multi-purpose hea l th workers, community hea l th workers and t r a i n e r s . In Maldives, educat ional mater ia l s were prepared f o r the continuing education of community hea l th workers through a correspondence programme.

A WHO nurse consul tant who has taken up a number of assignments i n the Region completed t h e wr i t i ng of a book on "Orthopaedic Nursing i n Developing Countries". This was published by t h e Regional Office and has been wel l received not only i n t h i s region but a l s o i n o t h e r p a r t s of t h e world. Another very usefu l publicat ion wr i t t en by a WHO nurse- educator, "Guide t o Care of t h e Low Birth-weight Infant" , is being revised and expanded before repr in t ing .

Nurses i n Bangladesh have t r ans l a t ed manuals from English i n t o the l o c a l language; i n Thailand, t h e t r a n s l a t i o n of a second u n i t of Brunner's Textbook on Medical-Surgical Nursing has been completed. In Mongolia, work s t a r t e d on t h e t r a n s l a t i o n of some t e x t s i n t o the Mongolian language, and the WHO nurse-educator, na t iona l nurse-tutors and s tudents produced a s e t of s l i d e s on t h e fundamentals of nursing.

Continuing education f o r a l l l eve l s of nursing personnel received major impetus during t h e year. Short courses i n c l i n i c a l subjec ts included paed ia t r i c , neurological , psychia t r ic and orthopaedic nursing, and r ehab i l i t a t ion . Several sho r t courses and in-service programmes were conducted i n t h e f i e l d of commr-ntty heal th. A pro jec t i n India ,

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designed s p e c i f i c a l l y t o prepare nurses f o r planning continuing education i n t h e i r own i n s t i t u t i o n s and l o c a l i t i e s , sponsored seve ra l workshops i n Delhi and held two na t iona l workshops i n o ther p a r t s of t h e country. Some of t h e co l leges of nursing i n India have es tab l i shed departments of continuing education.

The inter-country p ro jec t on continuing education i n nursing conducted shor t courses and in-service programmes i n seve ra l count r ies .

An inter-country workshop on "Community Health-oriented Nursing Education" was he ld i n t h e Regional Office i n October, followed by a Consultat ive Meeting attended by p a r t i c i p a n t s responsible fo rdec i s ion - making i n nursing education i n t h e i r r e spec t ive countr ies . The p ro jec t came t o an end i n December, t o be superseded by a new p ro jec t on "Continuing Education f o r Health Workers". This p ro jec t i s designed t o prepare h e a l t h personnel f o r t h e planning and implementation of continuing education programmes, e spec ia l ly those r e l a t e d t o nursing and midwifery s p e c i a l t i e s . A major focus w i l l be on the i d e n t i f i c a t i o n and development of t r a i n i n g f a c i l i t i e s i n Member count r ies with p o t e n t i a l usefulness f o r continuing education i n various types of spec ia l ized t r a in ing . These f a c i l i t i e s could be used f o r fellows from o t h e r count r ies a s we l l a s f o r na t iona l hea l th workers.

In a l l count r ies , t h e r e a r e many long-standing problems which impede progress i n nursing education and t h e de l ivery of e f f e c t i v e nursing serv ices . These problems r e l a t e t o organizat ion and management, funct ions and u t i l i z a t i o n of personnel, development of c l i n i c a l teaching areas and f i e l d p rac t i ce i n community h e a l t h , establishment of information systems and cont ro ls , i n t h e form of l e g i s l a t i o n , r e g i s t r a t i o n and acc red i t a t ion , and o v e r a l l planning f o r the develop- ment of resources i n nursing manpower.

Aside from a few ope ra t iona l s t u d i e s , very l i t t l e has been done i n t h e f i e l d of nursing research, but a p ro jec t i n India has made a good beginning i n t h i s respec t . Several workshops were held f o r f acu l ty members, nurse adminis t ra tors and publ ic hea l th nurses, i n which p a r t i c i p a n t s received guidance i n preparing study designs, i n carrying out small research p ro jec t s and i n analysing and wr i t ing the r e s u l t s .

1 .5 Health Education

I n most of t h e count r ies i n t h i s region, increased e f f o r t s a re being made t o s t rengthen na t iona l h e a l t h education a c t i v i t i e s as an i n t e g r a l p a r t of t h e h e a l t h se rv ices . Consequently, t h e r e has been a corresponding strengthening of programmes t o t r a i n h e a l t h workers f o r h e a l t h education and h e a l t h education s p e c i a l i s t s t o provide profes- s i o n a l guidance t o them.

In BangZadesh, t h e WHO h e a l t h education s p e c i a l i s t continued t o work with groups concerned with primary hea l th care as wel l a s with hea l th education s p e c i a l i s t s a t t h e cent re and i n t h e d iv is ions . Training

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programes i n hea l th education f o r both hea l th personnel as wel l as hea l th educators were organized t o enable them t o perform t h e i r d i f f e r e n t h e a l t h education funct ions more e f f ec t ive ly . A second hea l th education s p e c i a l i s t was assigned t o t h i s country t o a s s i s t with the development of t h e hea l th education aspects of primary hea l th care serv ices and the t r a in ing of hea l th personnel i n hea l th education.

In Burma, t h e h e a l t h educators assigned t o the divis ions have been increas ingly deployed t o a s s i s t hea l th workers inplanning , implementing and evaluat ing hea l th education as an i n t e g r a l p a r t of primary h e a l t h care serv ices . The Ass is tan t Director of the Health Education Bureau has been awarded a WHO fellowship t o observe hea l th education serv ices i n o ther countr ies of t h e Region so t h a t he could bring t o bear these experiences i n t h e development of hea t lh education i n Burma.

In India , heal th educators a t t h e c e n t r a l , s t a t e and d i s t r i c t hea l th education bureaux a s s i s t e d i n t h e hea l th education a c t i v i t i e s of community hea l th workers and o thers . I n addi t ion , they helped t o give t r a i n i n g i n h e a l t h educat iontophys ic ians , nurses and community hea l th workers a t these bureaux and i n regional t r a i n i n g centres .

I n Indonesia, where hea l th education bureaux have been es tab l i shed i n a l l bu t two o f t h e provinces, hea l th educators work closely with primary hea l th workers helping t h e l a t t e r t o p lan , implement and evaluate hea l th education as a pa r t of t h e i r work. The Direc tora te of Health Education i n Jaka r t a , with t h e ass i s tance of the WHO hea l th education s p e c i a l i s t , i d e n t i f i e d t h e i r tasks i n r e l a t i o n t o hea l th education i n t h e provinces and regions, and developed working procedures and p rac t i ces t o encourage, guide and a s s i s t hea l th education i n the provinces.

The Government of Maldives, recognizing t h e importance of hea l th education, espec ia l ly i n the outer i s l ands , prepared plans f o r a country-wide hea l th education serv ice with the ass i s tance of a WHO short-term consul tant . Health education has been strengthened i n the t r a i n i n g of community hea l th workers, nurse-aides and t r a d i t i o n a l midwives, and i t has a l s o been i n t e n s i f i e d i n Male Hospital. Further , s t eps have been taken t o s t rengthen hea l th education i n the cu r r i cu la of primary and secondary schools and i n programmes f o r the t r a i n i n g of primary school teachers . The community educat ionprograme of Maldivian Broadcasting Services provides fo r weekly rad iobroadcas ts on hea l th education.

In MongoZia, t h e S t a t e House f o r Health Education has, i n col laborat ion with a WHO short-term consul tan t , increased i t s e f f o r t s a t a s s i s t i n g t h e h e a l t h education bureaux i n the aimaks and the somons. Proposals were drawn up fo r i n s t i t u t i n g pre-service t r a in ing i n hea l th education i n t h e country's hea l th t r a i n i n g schools and hea l th in s t ruc t ion i n primary and secondary schools and i n teachers ' col leges. These t r a i n i n g a c t i v i t i e s a re expected t o gather momentum l a t e r t h i s year .

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In NepaZ, t h e h e a l t h education a c t i v i t i e s i n i t i a t e d l a s t year recorded progress. The ac t ing Chief of Health Education and h i s a s s i s t a n t have both been s e n t abroad f o r f u r t h e r t r a i n i n g i n hea l th education and, on t h e i r r e tu rn , i t i s expected t h a t t h e hea l th education a c t i v i t i e s , including t r a i n i n g , w i l l be i n t e n s i f i e d .

In S r i Lanka, with cooperation from WHO, hea l th education se rv ices have been well-establ ished. Health educators a r e now assigned t o each of t h e Superintendent of Health Services (SHS) a reas , and more than 6000 hea l th volunteers have been t r a ined t o lend support t o l o c a l hea l th workers, e spec ia l ly i n secur ing community pa r t i c ipa t ion .

I n ThaiZand, where a plan of operat ion f o r a h e a l t h education p r o j e c t was prepared and signed by t h e Government and WHO, hea l th education u n i t s i n t h e d iv i s ions and t h e provinces a r e being es tab l i shed . Health educators assigned t o these u n i t s a r e providing increas ing a s s i s t ance t o h e a l t h workers i n t h e i r h e a l t h education work i n primary hea l th care. A WHO short-term consul tant i s expected t o be assigned t o the country l a t e r i n 1978.

I n addi t ion t o these a c t i v i t i e s i n community hea l th education going on i n various count r ies , increas ing a t t e n t i o n was paid t o hea l th education i n h o s p i t a l s and o the r c l i n i c a l i n s t i t u t i o n s . The year under review saw an expansion of such e f f o r t s i n Ind ia , whichorganized seve ra l na t iona l workshops on h o s p i t a l h e a l t h education with WHO support and is now increas ingly introducing hea l th education a s a p a r t of h o s p i t a l care.

Similar a c t i v i t i e s a l s o took p lace i n Thailand. A major p ro jec t t o introduce hea l th education as a p a r t of p a t i e n t care i n hosp i t a l s i n t h i r t y provinces is now under way i n t h a t country. Progress i n h o s p i t a l hea l th education i s a l s o reported from Bangladesh, Maldives, Mongolia and S r i Lanka. In these count r ies na t iona l workshops were held t o t r a i n h o s p i t a l personnel i n hea l th education and t o plan hea l th education a c t i v i t i e s i n out-door d ispensar ies , c l i n i c s and wards.

India , with a s s i s t ance from a WHO short-term consul tan t , made f u r t h e r progress i n t h e f i e l d of school h e a l t h education. Following a review of t h e textbook on school h e a l t h education f o r Grades I X and X which had been prepared l a s t yea r , a d r a f t teachers ' guide t o supplement the textbook was completed t h i s year i n co l labora t ion with t h e National Council fo r Educational Research and Training, t h e Central Board of Secondaxy Education, s e l ec t ed teachers ' co l leges and school teachers . Arrangements a r e being made t o prepare a source book on school hea l th and t o design audio-visual a i d s t o supplement the textbook, and f o r teacher t r a i n i n g i n school hea l th education. In Thailand, hea l th education i n schools is be ing i n t e n s i f i e d . A textbook on t h e sub jec t has been prepared and t h e Ministry of Education has taken a pol icy decis ion t o e s t a b l i s h a programme majoring i n hea l th education i n the teachers ' co l leges and physical education col leges throughout the country. A c t i v i t i e s i n t h e f i e l d of school h e a l t h education have made f u r t h e r progress.

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A t t h e regional l e v e l , t h e Regional Office ca r r i ed out a survey of t h e present s t a t e of h e a l t h and population education i n the primary and secondary schools and teachers ' col leges i n nine countr ies of the Region. On t h e bas i s of t h e f indings of t h e survey i t is proposed t o take f u r t h e r ac t ion t o extend school hea l th education i n col laborat ion with UNESCO.

During t h e year , four inter-country workshops supported by UNFPA funds were he ld , two i n t h e Regional Office and two i n S r i Lanka. Follow-up a c t i v i t i e s i n respect of each workshop, a s well as na t iona l workshops, a r e planned i n most of t h e countr ies .

In addi t ion t o co l labora t ing i n t h e in-service t r a i n i n g of hea l th workers i n hea l th education i n Bangladesh, Burma, India , Indonesia and Mongolia, t h e Organization s t imulated government i n t e r e s t i n pre- s e rv ice t r a i n i n g i n t h e subject . During t h e year , governments continued t o s t rengthen t h e hea l th education component i n the cur r icu la fo r t h e bas ic t r a i n i n g of hea l th workers and t o develop textbooks and o ther learn ing resource mater ia l s i n na t iona l languages. Following the two inter-country workshops held i n S r i Lanka, some o the rcoun t r i e s a re taking ac t ion t o draw up hea l th education cur r icu la f o r the bas ic t r a i n i n g of physicians, nurses and s a n i t a r i a n s , and t o t r a i n teachers and prepare textbooks f o r t h e teaching of hea l th education. WHO continued t o co l labora te i n these a c t i v i t i e s .

The Organization's technica l cooperation i n t h e post-graduate t r a in ing of hea l th education s p e c i a l i s t s continued during t h e year. In Thailand, t h e programme of Master of Science i n Public Health has s t a r t e d on t h e b a s i s of t h e curriculum prepared e a r l i e r with the ass i s tance of a WHO short-term consul tant . There was f u r t h e r progress with regard t o the programme i n the o ther count r ies , f o r example, t h e MPH Programme i n Health Education of t h e University of Indonesia, Jakar ta ; the diploma programmes of t h e All-India I n s t i t u t e of Hygiene and Public Health, Calcut ta; t h e I n s t i t u t e of Rural Health and Family Planning, Gandhigram, India , and t h e Central Health Education Bureau, New Delhi. Assistance was provided t o these i n s t i t u t i o n s t o s t rengthen t h e i r l i b r a r i e s .

With t h e expansion of hea l th education as an i n t e g r a l p a r t of hea l th programmes, t h e need f o r research i n seve ra l aspects of hea l th education t o secure community pa r t i c ipa t ion was increasingly f e l t . Health education bureaux i n India , Indonesia, S r i Lanka and Thailand have undertaken seve ra l s tud ie s i n t h i s regard. I n addi t ion , WHO Headquarters-assisted research pro jec ts a r e cur rent ly i n operat ion i n these four countr ies . It i s expected t h a t these research pro jec ts w i l l be completed during t h i s year and t h e r e s u l t s used f o r the t r a i n i n g of h e a l t h manpower as wel l as t o modify cur rent hea l th education p rac t i ces and procedures.

1.6 Nutr i t ion

Following the recommendations made a t the twenty-ninth session of the Regional Committee and during t h e t h i r t i e t h World Health Assembly,

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t h e Organizat ion 's e f f o r t s i n t h e f i e l d of n u t r i t i o n have centred round a s s i s t ance t o t h e count r ies of t h e Region i n s t rengthening the adminis t ra t ive and t echn ica l c a p a b i l i t i e s of t h e i r hea l th serv ices i n t h i s area. Whenever poss ib l e , these a c t i v i t i e s have been s p e c i f i c a l l y l inked t o those of o the r organizat ions such as FAOIWFP, UNICEF and the World Bank.

A Regional Seminar on t h e Organization and Delivery of Nutr i t ion A c t i v i t i e s i n t h e Health Sector was he ld i n New Delhi i n November1 December 1977 wi th p a r t i c i p a n t s from a l l countr ies of t h e Region. The conclusions of t h i s seminar were p a r t i c u l a r l y valuable i n c l a r i f y i n g t h e scope of n u t r i t i o n through hea l th , s p e c i f i c a l l y i n r e l a t i o n t o the con t ro l of protein-energy malnut r i t ion (PEM) i n ch i ldren under f i v e years of age and i n def in ing t h e type of a s s i s t ance required from WHO.

In Bangladesh, a publ ic hea l th n u t r i t i o n i s t was assigned t o the I n s t i t u t e of Publ ic Health Nutr i t ion ,Dacca , t o a s s i s t i n s t rengthening t h e various t r a i n i n g programmes f o r hea l th personnel, i n iden t i fy ing n u t r i t i o n a l problems as r e l a t e d t o pub l i c h e a l t h , i n determining p r i o r i t i e s f o r ac t ion , and i n undertaking applied research i n n u t r i t i o n .

A WHO guest l e c t u r e r de l ivered l e c t u r e s a t the two n u t r i t i o n courses organized by t h e National I n s t i t u t e of Nu t r i t i on , Hyderabad, India, annually - the three-month c e r t i f i c a t e course and t h e one-year degree course.

The Regional Adviser on Nutr i t ion took p a r t i n two World Bankappraisal missions t o Indonesia t o eva lua te the progress made i n the imple- mentation of t h e Indonesian Nu t r i t i on Development P r o j e c t , a na t iona l a c t i v i t y supported by t h e World Bank.

Technical a s s i s t ance was provided i n designing t h e n u t r i t i o n a l components of UNICEF p ro jec t s i n MzZdives and i n Mongolia.

I n ThaiZand, two-week t r a i n i n g courses f o r doctors , nurses , midwives and day-care a t tendants i n n u t r i t i o n and i n problems r e l a t e d t o the marketing, d i s t r i b u t i o n and s a f e t y of foods, e spec ia l ly of high- pro te in foods, were conducted during November/December 1977 with WHO'S f i n a n c i a l a s s i s t ance .

WHO s t a f f pa r t i c ipa t ed i n missions t o eva lua te WFPjFAO pro jec t s i n Bangladesh and India . A t t h e request of t h e Government of Bhutan, t h e Regional Adviser on Nu t r i t i on a s s i s t e d with a na t iona l seminar on feeding programmes sponsored by WFPIFAO and held i n Thimpu from 3 t o 6 May 1978.

The Organization took an a c t i v e p a r t i n an In t e rna t iona l Working Conference on Community-action Family Nu t r i t i on Programmes, held i n Hyderabad, India , and i n e labora t ing the pol icy and procedural

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g u i d e l i n e s t h a t emanated from t h e meeting. These g u i d e l i n e s were p r e s e n t e d t o t h e p a r t i c i p a n t s i n t h e I n t e r n a t i o n a l Congress of P a e d i a t r i c s , he ld a t New De lh i i n October 1977.

1 . 7 Medical Care

While t h e r e has been a g r a d u a l s h i f t i n emphasis from c u r a t i v e t o p r e v e n t i v e s e r v i c e s i n a lmost a l l c o u n t r i e s of t h e Region, governments have been concerned about and a r e making e f f o r t s f o r , t h e p r o v i s i o n of p roper medical c a r e , whether through h o s p i t a l s , o r through b a s i c h e a l t h s e r v i c e s i n c l u d i n g h e a l t h c e n t r e s .

I n BangZadesh, t h e Government has been promoting community p a r t i c i p a - t i o n i n t h e d e l i v e r y of medical c a r e and a number of seminars have been h e l d a t d i f f e r e n t l e v e l s . The Government of Burma, i n an a t tempt t o expand medical c a r e s e r v i c e s , e s t a b l i s h e d 20 new s t a t i o n h o s p i t a l s , 1 0 indigenous medicine d i s p e n s a r i e s and f o u r s o c i a l s e c u r i t y board d i s p e n s a r i e s . I n o r d e r t o improve t h e management of h o s p i t a l s s o a s t o p rov ide b e t t e r medical c a r e , a manual on h o s p i t a l admin i s t ra t ionwas p repared . I n Bhutan, medical c a r e i s provided through f i v e zona l h o s p i t a l s and a network of 46 d i s p e n s a r i e s cover ing remote a r e a s . I n o r d e r t o g i v e b e t t e r c a r e t o c h i l d r e n , t h e Government of MongoZia, d u r i n g t h e y e a r under review, s t a r t e d t h e c o n s t r u c t i o n of a new 120-bed c h i l d r e n ' s h o s p i t a l ; e i g h t new c reches have a l s o been opened. The p r o v i n c i a l h e a l t h c a r e p r o j e c t i n Thailand, which i s suppor ted by WHO, i s paying a s much a t t e n t i o n t o medical c a r e a s t o o t h e r p r e v e n t i v e , promotive and r e h a b i l i t a t i v e work.

The Organ iza t ion has been a c t i v e d u r i n g t h e y e a r i n p rov id ing advisory and m a t e r i a l a s s i s t a n c e t o governments. A workshop on h e a l t h and h o s p i t a l a d m i n i s t r a t i o n and management was organized i n Burma w i t h t h e h e l p of a WHO c o n s u l t a n t . Medical pe r sonne l from t h e DPRK were awarded WHO f e l l o w s h i p s f o r advanced t r a i n i n g abroad i n h o s p i t a l a d m i n i s t r a t i o n and o t h e r s p e c i a l t i e s r e l a t e d t o medical c a r e i n o r d e r t o s t r e n g t h e n t h e s e a c t i v i t i e s i n t h e country . I n MaZdives, a number of p a t i e n t s were opera ted upon w i t h t h e he lp of a s u r g i c a l team ass igned by t h e Organ iza t ion . S i m i l a r l y a team a l s o provided d i a g n o s t i c s u r g i c a l s e r v i c e s i n oto-rhino-laryngology. A WHO s k i n s p e c i a l i s t h e l d c l i n i c s and t e a c h i n g s e s s i o n s f o r d o c t o r s , nurses and community h e a l t h workers.

I n Mongolia, adv ice was given on p lann ing f o r t h e es tab l i shment of in ter -a imak and inter-somon emergency c a r e s t a t i o n s . The developments i n e d u c a t i o n , t r a i n i n g , s e r v i c e s and r e s e a r c h i n r egard t o medical c a r e i n c h i l d stomatology were assessed by a hWO c o n s u l t a n t ( s e e a l s o S e c t i o n 1 .10 , "Oral Heal th") .

An impor tan t element of t h e medical c a r e programmes i n t h e v a r i o u s c o u n t r i e s h a s been case-f inding and t h e t r ea tment of p a t i e n t s s u f f e r i n g from m a l a r i a , l e p r o s y and t u b e r c u l o s i s . These a c t i v i t i e s were c a r r i e d o u t on a con t inu ing b a s i s .

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1 .8 Rehab i l i t a t ion

Rehabi l i ta t ion of t h e d isabled is a f i e l d t h a t deserves t o be given p r i o r i t y a t t e n t i o n by governments. During the year attempts were made i n s e v e r a l count r ies t o i n i t i a t e r e h a b i l i t a t i o n programmes. The Organization has been a s s i s t i n g governments i n focusing a t t e n t i o n on the problem and i n undertaking co l l abora t ive a c t i v i t i e s .

In India, with WHO a s s i s t ance , d i s a b i l i t y surveys t o i d e n t i f y the problems r e l a t e d t o r e h a b i l i t a t i o n were ca r r i ed out i n t h e s t a t e s of Maharashtra and Or issa . These were epidemiological s tud ie s of d i s a b i l i t i e s r e s u l t i n g from chronic physical and mental impairments. A WHO s p e c i a l i s t i n bio-engineering i s t o be provided t o the All-India I n s t i t u t e of Phys ica l Medicine and Rehab i l i t a t ion i n Bombay t o a s s i s t the I n s t i t u t e i n so lv ing problems r e l a t e d t o p r o s t h e t i c and o r t h o t i c appliances fo r pa t i en t s .

Assistance i n t h e f i e l d of medical r e h a b i l i t a t i o n has been given t o Indonesia from time t o time through an inter-country p ro jec t . A consul tant from WHO Headquarters advised on the development of a research p ro jec t i n r e h a b i l i t a t i o n .

Consultant serv ices were provided t o t h e Government of Mongolia t o help eva lua te t h e r e h a b i l i t a t i o n se rv ices i n t h a t country and t o recommend measures f o r t h e s t rengthening of these programmes. An orthopaedic surgeon was assigned f o r seven weeks f o r t h i s purpose. The Orthopaedic and Traumatological Hospital i n Ulan Bator has becomea r e h a b i l i t a t i o n cent re f o r d isorders of the locomotor system, and the construct ion of a new orthopaedic workshop is making progress.

In August 1977, a Regional Seminar on Medical Rehabi l i ta t ion was organized i n t h e Regional Office. Another inter-country a c t i v i t y on t h i s sub jec t i s being planned f o r November 1978 t o review the s t a t e of na t iona l p o l i c i e s , plans and l e g i s l a t i o n f o r the prevention of d i s a b i l i t y and the promotion of t h e welfare of the disabled.

1.9 Trad i t iona l Medicine

Trad i t iona l systems of medicine, which play a s i g n i f i c a n t r o l e i n the Region, have stood t h e t e s t of time, a r e widely accepted by the people and have simple and s a f e remedies which a r e use fu l i n day-to-day i l l n e s s e s . Their usefu lness was recognized by t h e 29th World Health Assembly and a l s o by t h e Regional Committee a t i t s twenty-ninthsession.

Immediately following t h i s recognit ion, i n November 1976, the Regional Office and t h e Government of India agreed on mutual co l labora t ion i n researchon the e f f i c a c y o f ayurvedic treatment of rheumatoid a r t h r i t i s . A four-year study is being ca r r i ed out a t t h e Ayurvedic Trust and Research I n s t i t u t e i n Coimbatore, through t h e Indian Council of MedicaL Research. An in ter im evalua t ion has yielded encouraging da ta based on which t h e c l i n i c a l t r i a l w i l l be pursued fu r the r . In Apr i l 1977, a Regional Seminar on Trad i t iona l Medicine was organized i n Colombo t o exchange information on and experience i n the t r a d i t i o n a l systems of medicine prevalent i n t h e Region.

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In March 1978, a research study group met i n t h e Regional Office t o evolve a work plan f o r research and draw up a l i s t of t r a d i t i o n a l remedies which could be used i n primary hea l th care. Most of i t s recommendations were accepted by t h e Regional ACMR. This programme w i l l be f u r t h e r strengthened by t h e compilation of data on the many aspects of these systems.

The programme of promoting t r a d i t i o n a l systems of medicine has three broad objec t ives : t h e use of t h e i r simple and s a f e remedies i n primary hea l th care ; u t i l i z a t i o n i n primary hea l th care of t h e considerable manpower represented by the various ca tegor ies of t r a d i t i o n a l p r a c t i t i o n e r s , and research i n various aspects of t r a d i t i o n a l medicine.

Tradi t ional systems of medicine a re being encouragedinMembercountries. In India , separa te councils f o r t h e organizat ionof t r a d i t i o n a l systems have been formed,andPHC programmes include the use of these systems. Nepal! encourages t h e manufacture of ayurvedic preparat ions a t the Baidya Khana, and l ays emphasis on t h e production of o ther t r a d i t i o n a l drugs and on appropriate research. I n Indonesia, c l i n i c a l evaluation of c e r t a i n herbal remedies is i n progress. In S r i Lanka, research on t h e s tandardiza t ion of ayurvedic drugs i s being undertaken.

1.10 Oral Health

Although o r a l hea l th problems have been on t h e increase i n a l l the countr ies of t h e Region, they have not received p r i o r i t y i n the ove ra l l context of t h e hea l th programmes of the governments. WHO ass i s tance has been d i rec ted t o the development of dental hea l th manpower and the s trengthening of stomatological serv ices .

A WHO den ta l o f f i c e r has been assigned t o BangZadesh t o help promote the development of comprehensive den ta l h e a l t h ca re serv ices . Assistance i s a l s o being provided i n a review of t h e cur r icu la of den ta l courses and i n t h e organizat ion of t ra in ing . Epidemiological s tud ie s a r e proposed t o be ca r r i ed out t o assess the prevalence of o r a l and denta l conditions i n order t o develop a programme of preventive den ta l hea l th .

The WHO den ta l t u t o r provided t o Burma a s s i s t e d i n the conduct of an o r a l h e a l t h survey and i n teaching. A consul tant from WHO Headquarters prepared a plan f o r a na t iona l o r a l hea l th survey f o r mapping t h e f luo r ide content of drinking water supplies and o ther water reservoi rs i n t h e country. A t present there a r e about 96 denta l centres i n Burma which provide den ta l serv ices t o t h e people.

I n MongoZia, a consul tant i n stomatology reviewed the s i t u a t i o n i n t h e f i e l d , a s s i s t e d i n running a course and made recommendations f o r s t rengthening t h e o r a l h e a l t h serv ices f o r chi ldren. The Government a l s o received a s s i s t ance i n t h e preparat ion of documents on the development of stomatology serv ices i n t h e country.

With a s s i s t ance from WHO, t h e Government of Sri Lanka undertook the reorganizat ionof den ta l hea l th care serv ices f o r chi ldren. A curriculum

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i n pedodontics was prepared and advice provided on the teaching of p a e d i a t r i c stomatology t o undergraduate and post-graduate s tudents . A WHO consul tant assigned t o S r i Lanka i n 1977 a l s o a s s i s t e d i n the prepara t ion of a f i e l d demonst ra t ion/c l in ica l t r i a l p ro jec t on mouth-rinsing with f luo r ide so lu t ions . The recommendations of t h e consul tant included enactment of a law on d e n t i s t r y , the establishment of a S r i Lanka Dental Council, and reorganizat ion of the ch i ld ren ' s o r a l h e a l t h se rv ices .

In Thailand, t h e na t iona l o r a l h e a l t h survey supported by WHO was completed. The r e s u l t s of t h e survey a r e expected t o c o n s t i t u t e a sound bas i s f o r t h e fu tu re planning and evaluat ion of den ta l publ ic h e a l t h serv ices . The Government received a s s i s t ance i n implementing t h e f i e l d t r i a l of various c a r i e s preventive agents as p a r t of the WHO Oral Disease Prevention Programme, and a l s o i n planning f o r the establ ishment of an inter-country t r a i n i n g and demonstration cent re f o r o r a l h e a l t h i n t h e country. A number of water samples were co l l ec t ed during t h e na t iona l survey and analysed f o r t h e i r f l u o r i d e content. The r e s u l t s showed t h a t t h e f l u o r i d e content i n most a reas of Thailand is very low. The teaching of den ta l publ ic hea l th i n t h e country's t h r e e den ta l schools has been strengthened. Thailand i s a l s o involved i n a WHO in ter - reg ional p ro jec t f o r the prevention of den ta l c a r i e s by f l u o r i d e r in s ings and f luo r ide chewing gums.

1.11 Mental Health

Important and p rac t i cab le recommendations concerning the development and implementation of n a t i o n a l and regional programmes of mental hea l th r e su l t ed from t h e f i r s t inter-country group meeting on the sub jec t , which was he ld i n t h e Regional Office i n December 1977. P a r t i c i p a n t s from s i x count r ies met together wi th WHO s t a f f from Headquarters and t h e Regional Off ice t o draw up a programme of a c t i v i t i e s t o promote t h e mental h e a l t h programme i n t h e Region. The recommendations, which cover t h e a reas of s e rv ices , t r a i n i n g and research, a r e being followed up.

I n BangZadesh, a consul tant assigned t o t h e Department of Psychiatry, Post-graduate Medical I n s t i t u t e , Dacca, a s s i s t e d with t h e f i r s t National Workshop on Mental Health, which was at tended b y p s y c h i a t r i s t s , medical consul tan ts and publ ic h e a l t h adminis t ra tors . This workshop made s p e c i f i c recommendations on t h e development of community mental h e a l t h and these have been forwarded t o t h e Government. Electro- medical equipment was supplied t o a number of medical i n s t i t u t i o n s i n t h e country.

WHO continued t o co l l abora t e with India's premier na t iona l t r a i n i n g cen t r e f o r mental hea l th , t h e National I n s t i t u t e of Mental Health and Neurosciences a t Bangalore. With a s s i s t ance from a consul tant the I n s t i t u t e i s developing a diploma course i n psych ia t r i c s o c i a l work. Two consul tants were assigned t o a s s i s t with t h e administrat ion of the Mental Hospital a s an i n t e g r a l component of t h e I n s t i t u t e and t o help

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i n promoting mult i -discipl inary pa r t i c ipa t ion i n se rv ice and t r a in ing . Technical a s s i s t ance , including audio-visual equipment f o r teaching purposes, continued t o be given t o t h e Community Psychiatry Unit a t the I n s t i t u t e and t o i t s t r a i n i n g programme based on a model r u r a l community mental hea l th cent re a t Sakalavara v i l l a g e near Bangalore. A fu r the r consul tant was assigned t o a s s i s t the l e c t u r e r i n ch i ld and family psychiatry a t t h e I n s t i t u t e and t o develop appropriate progranrmes of s e rv ice and t r a i n i n g i n community-oriented chi ld and family psych ia t r i c p rac t i ce .

The WHO Collaborat ing Centre f o r Research and Training i n Mental Health based i n t h e Department of Psychiatry a t the Post-graduate I n s t i t u t e of Medical Education and Research, Chandigarh, made considerable progress i n its contr ibut ion t o the WHO Collaborat ive Study on S t r a t eg ie s f o r Extending Mental Health Care. The base l ine s tud ie s have es tab l i shed inter aZia t h a t a t l e a s t 10-15% of a l l p a t i e n t s cur rent ly seeking h e a l t h ca re s u f f e r from d e f i n i t e mental disorders .

I n Indonesia, a consul tant was assigned t o a s s i s t the Direc tora te of Mental Health i n organizing a na t iona l workshop on community mental hea l th . The Regional Adviser on Mental Health and t h e consultant v i s i t e d centres i n Java, Bal i and Sumatra where comprehensivecommunity mental h e a l t h se rv ices a r e being developed.

Planning continued f o r the t r a i n i n g of p sych ia t r i s t s i n epidemiological p r a c t i c e i n mental hea l th wi th t h e aim of introducing a community epidemiological survey of d i s a b i l i t y due t o mental i l l n e s s and mental re ta rda t ion .

Mongolia received a s s i s t ance f o r t h e development of out-patient serv ices f o r t h e mentally ill. The consultant assigned f o r t h i s purpose helped with t h e development of an epidemiological survey designed to a i d t h e appropriate development of such serv ices a s out-pat ient dispensar ies ,dayhospi ta l s and case-recording f o r mental hea l th as an i n t e g r a l pa r t of a general hea l th information system.

I n Sr i Lanka, a consul tant assigned t o the Department of Psychiatry, Peradeniya Campus, Faculty of Medicine, University of S r i Lanka, made a comprehensive repor t on developing t r a i n i n g i n c l i n i c a l psychology i n t h e country. H i s recommendations were forwarded t o t h e Government.

The Regional Adviser on Mental Health v i s i t e d the country t o discuss with t h e un ive r s i ty a u t h o r i t i e s and the Director of Health Services the development of the t r a i n i n g and se rv ice aspects of community- or iented mental hea l th .

In ThaiZand, t h e p r inc ipa l i nves t iga to r s i n a co l labora t ive study on monitoring mental hea l th needs have continued t o c o l l e c t da ta on the ex tent t o which the mental hea l th serv ices i n Khon Kaen Province a re u t i l i z e d by t h e community. Attempts were a l so made t o measure the needs f o r mental hea l th serv ices i n the same population.

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1.12 Drug Dependence

The hea l th a c t i v i t i e s of the United Nations/Burma Programme f o r Drug Abuse Control, fo r which WHO i s t h e executing agency, a r e multi- s e c t o r a l , involving a g r i c u l t u r a l , educationa1,law enforcement, hea l th and s o c i a l welfare components. Under t h i s programme, treatment centres f o r drug addic ts were i d e n t i f i e d i n Rangoon, Mandalay and Taunggyi and a re being in t eg ra t ed i n t o the e x i s t i n g mental hea l th ca re system. I n o the r towns, and i n v i l l a g e s , treatment f o r drugdependence w i l l be in tegra ted i n t o the e x i s t i n g b a s i c hea l th serv ices .

The National Health Laboratory i n Rangoon i s being developed f o r forens ic and research purposes and t o serve as a na t iona l reference laboratory. Intermediate l abora to r i e s capable of drug de tec t ion and recognit ion a re being developed a t t h e main treatment cent res and smaller l abora to r i e s a r e being es tab l i shed elsewhere.

Three in-service t r a i n i n g courses on t h e management of drug dependence were he ld f o r physicians and nurses a t the Rangoon Psychia t r ic Hospital . Fellowships and fore ign study tours a r e being arranged f o r various ca tegor ies of h e a l t h personnel concerned with the con t ro l of drug abuse.

Under t h e United NationslThailand Programme f o r Drug Abuse Control, surveys were ca r r i ed out on t h e na ture and extent of the use of opium i n t h e h i l l t r i b e population. The r a t e of opium addict ion w a s found t o vary from 6% t o 35% of t h e adu l t population i n the v i l l ages . A research programme on t h e evaluat ion of t h e outcome of treatment i n d i f f e r e n t treatment cent res i n Bangkok and Chiang Mai is being under- taken by t h e Health Research I n s t i t u t e of Chulalongkorn University, Bangkok.

In India, ass i s t ance t o t r a i n i n g i n t h e epidemiology of drug abuse and i n methods of prevention, treatment and r e h a b i l i t a t i o n of drug- dependent pa t i en t s , is now given under the mental hea l th programme.

1.13 Medical Stores Management

The importance of an e f f i c i e n t supply s e r v i c e as a supportingcomponent i n t h e de l ivery of h e a l t h se rv ices has been recognized i n countr ies of t h e Region. Assistance continued t o be provided t o Nepal i n t h e f i e l d of medical s t o r e s management. An appreciable improvement i n these serv ices has been not iced as a r e s u l t of good supervision and the s treamlining of t h e inventory con t ro l system. Model medical s t o r e s have been es tab l i shed i n th ree hosp i t a l s and a r e a l so expected t o be s e t up i n a number of hea l th posts i n due course. In some of the d i s t r i c t s , t h e organizat ion of s t o r e s has been completed. Assistance was provided i n preparing and d i s t r i b u t i n g t h e suppl ies and s t o r e s manual, e s t ab l i sh ing regional s t o r e s , t r a i n i n g store-keepers, s t rengthening t h e supervision of supply and s to rage services,organizing s t o r e s i n in t eg ra t ed d i s t r i c t s , improving s to rage f a c i l i t i e s i n

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d i s t r i c t s covered by t h e expanded programme on immunization and in h o s p i t a l s , formulating organizat ional and funct ional r e s p o n s i b i l i t i e s i n medical s t o r e s management, e s t ab l i sh ing permanent supply f i l e s , indenting suppl ies , evaluat ing t h e use of ayurvedic drugs i n i n t e g r a t e d hea l th pos ts , and i n reviewing supply l ists and the spec i f i ca t ions of t h e items ordered.

WHO a s s i s t e d t h e Government of Burma i n drawing up de ta i l ed work plans f o r t h e Cent ra l Medical S tores Depot i n order t o develop a proper l o g i s t i c s s y s t e m f o r t h e supply, c l ea rance , s to rage and d i s t r i b u t i o n of drugs.

Sri Lanka i s another country in t h e Region which received WHO support i n t h i s area. The se rv ices of a consultant, as we l l as fellowships and suppl ies and equipment, were provided t o he lp i n strengthening and expanding medical s t o r e s and supply serv ices i n t h e country.

2. DISEASE PREVENTION AND CONTROL - COMMUNICABLE DISEASES

Communicable d iseases continued t o c o n s t i t u t e the Region's majorpublic h e a l t h problems, and, accordingly, emphasiswas l a i d on s trengthening epidemiological su rve i l l ance and con t ro l measures, which a r e v i t a l f o r prevention and cont ro l .

For the second year , South-East Asia remained f r e e from smallpox. Nevertheless, malar ia posed ser ious problems, and human plague is s t i l l reported from one country-Burma. WHO continued t o co l labora te wi th t h e count r ies of t h e Region i n con t ro l l i ng tuberculosis . Leprosy con t ro l a c t i v i t i e s were f u r t h e r i n t e n s i f i e d , p a r t i c u l a r l y in view of t h e magnitude of t h e problem. Research on leprosy was among t h e sub jec t s considered a t a meeting of t h e Regional Advisory Committee on Medical Research (RACMX) held i n Apr i l (see Chapter 8) .

Cholera and d iar rhoeal d iseases have been another cause of concern. Maldives reported an epidemic of gastro-enteritis/cholera during January-May 1978, with a l a r g e number of cases and deaths. WHO, i n a c t i v e assoc ia t ion with UNICEF, cooperated with the Government i n undertaking con t ro l measures. I n September, a meeting of t h e Regional ACMR's Research Study Group on Diarrhoea1 Diseases of Children w a s he ld i n t h e Regional Office and reviewed t h e cur rent research on d iar rhoeal diseases. Its repor t was presented t o the four th session of t h e RACMR held i n Apr i l 1978, which approved the s p e c i f i c research topics i d e n t i f i e d .

Assistance was provided t o countr ies i n the Region i n expanding t h e i r progranrmes of immunization, w i th emphasis on progrannne planning and t h e t r a i n i n g of personnel.

Survei l lance of dengue haemorrhagic fever was f u r t h e r strengthened. Research on DHF was discussed a t a meeting of t h e Research Study Group