SEA/RC56/2 - The work of WHO in the South-East Asia Region: Report of the Regional Director 1 July 2002 - 30 June 2003

Report of the Regional Director 1 July 2002 – 30 June 2003

SEA/RC56/2

The Work of WHO in the South-East Asia Region

Report of the Regional Director 1 July 2002 – 30 June 2003

World Health Organization Regional Office for South-East Asia New Delhi June 2003

© World Health Organization 2003 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Printed in India

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Contents Page PREFACE .............................................................................................. ix EXECUTIVE SUMMARY ....................................................................... xiii 1. COMMUNICABLE DISEASES .......................................................... 1 Communicable Disease Surveillance ................................................. 1 Communicable Disease Prevention,Eradication and Control .............................................................................. 4 Leprosy .................................................................................. 4 Rabies .................................................................................... 6 Japanese encephalitis ................................................................ 7 Plague .................................................................................... 7 Leptospirosis ........................................................................... 8 Soil-transmitted helminthiasis ................................................... 8 Dengue fever/Dengue haemorrhagic fever (DF/DHF) .................... 9 Lymphatic filariasis ................................................................. 10 Vector control ........................................................................ 11 Research and Product Development for Communicable Diseases ........ 12 Malaria ........................................................................................ 13 Tuberculosis ................................................................................. 14 The Global Fund to Fight AIDS,Tuberculosis and Malaria ............. 18 NONCOMMMUNICABLE DISEASES AND MENTAL HEALTH ........................................................................ Surveillance, Prevention and Management of Noncommunicable Diseases ............................................................................... Tobacco ....................................................................................... Health Promotion .......................................................................... Disability/Injury Prevention and Rehabilitation .................................. Injury and violence prevention ................................................. Prevention of blindness and deafness ........................................ Ageing and health .................................................................. Rehabilitation ........................................................................ Mental Health and Substance Abuse ................................................ Prevention of harm from alcohol and substance use .....................

2.

19 19 23 25 28 28 29 30 31 31 33

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3.

FAMILY AND COMMUNITY HEALTH ............................................. Child and Adolescent Health .......................................................... Integrated Management of Childhood Illness .............................. Neonatal health ..................................................................... Infant and young child feeding .................................................. Child rights and protection ...................................................... Adolescent health and development ......................................... Research and Programme Development in Reproductive Health .......... Making Pregnancy Safer ................................................................. Women’s Health ............................................................................ HIV/AIDS ..................................................................................... SUSTAINABLE DEVELOPMENT AND HEALTHY ENVIRONMENTS ... Sustainable Development .............................................................. Nutrition ..................................................................................... Health and Environment ................................................................. Health Impact Assessment ...................................................... Occupational health ................................................................ Water for sanitation and health ................................................. Arsenic contamination of groundwater ...................................... Healthy Cities ....................................................................... Promotion of chemical safety ................................................... Children’s environmental health ............................................... Preparedness for chemical incidents ......................................... Health care waste management ................................................ Food Safety .................................................................................. Emergency Preparedness and Response ........................................... HEALTH TECHNOLOGY AND PHARMACEUTICALS ....................... Essential Medicines: Access, Quality and Rational Use ....................... Immunization and Vaccine Development .......................................... Poliomyelitis eradication ......................................................... Control of other major vaccine preventable diseases ................... Blood Safety and Clinical Technology ............................................... EVIDENCE AND INFORMATION FOR POLICY................................ Evidence for Health Policy .............................................................. Health Information Management and Dissemination .......................... Research Policy and Promotion ....................................................... Organization of Health Services ...................................................... Development of human resources for health .............................. Education and training support ................................................. GOVERNING BODIES AND EXTERNAL RELATIONS ...................... Governing Bodies ......................................................................... World Health Assembly .......................................................... Executive Board ..................................................................... Regional Committee ..............................................................

35 35 35 38 38 38 38 40 42 43 44 47 47 50 52 53 53 54 55 56 56 57 59 60 61 62 67 67 69 72 75 77 81 81 84 86 90 90 92 95 95 95 96 97

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5.

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Consultative Committee for Programme Development and Management ............................................... 98 Health Ministers’ Meeting .................................................... 100 Health Secretaries’ Meeting .................................................. 101 Regional Conference of Parliamentarians ................................. 101 Resource Mobilization and External Cooperation and Partnerships ..... 102 8. GENERAL MANAGEMENT ......................................................... 107 Budget and Management Reform .................................................. 107 Human Resources Development ................................................... 109 Financial management ................................................................. 111 Informatics and Infrastructure Services ........................................... 113 Procurement Services ........................................................... 115 General Support Services ..................................................... 115 REGIONAL DIRECTOR’S DEVELOPMENT PROGRAMME .............. 117 Public Relations and Media ........................................................... 117 Regional Office and Country Offices .............................................. 118 Regional Director’s Development Programme ................................ 119

9.

ANNEXES 1. Organizational Structure ........................................................ 2. Budgetary Implementation of Activities, by Country, 2002-2003 ........................................................ 3. Budgetary Implementation of Activities, by Area of Work, 2002-2003, ................................................ 4. Regular Budget Reserves 2000-2001 ....................................

121 122 124 126

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PREFACE It has been another year of fruitful collaboration with Member Countries in the Region during which gains in health development were further consolidated. On the other hand, new challenges have emerged. The outbreak of SARS particularly underscored WHO’s vital role in networking and pooling global expertise and resources to address national or local problems. Timely information and updates on the outbreak were shared with Member Countries to avoid any panic among the public. Efforts have continued to control various communicable diseases including HIV/AIDS. A special focus has been placed on the control of tuberculosis and malaria which continue to pose serious health challenges in most countries of the Region. With significant progress being made with regard to DOTS coverage, it is hoped that the Region will reach the global target set for TB control by 2005. Unfortunately, the goal of polio eradication suffered a setback with India witnessing an outbreak of wild polio virus. In the area of noncommunicable diseases, reducing lifestylerelated risk factors was the key approach. The unanimous adoption of the Framework Convention on Tobacco Control by the Fifty-sixth World Health Assembly is expected to provide the desired momentum to Member Countries to further accelerate efforts towards achieving a tobacco-free society. The first World Report on Violence and health was released in the Region as well as in some countries. Programmes related to injury, prevention of blindness and deafness as well as care of the elderly, and strengthening of rehabilitation and mental health services received continued attention.

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To address the issue of high mortality rates among children in the Region, the regional capacity for implementing the integrated management of childhood illness has been further strengthened. Considering that 20 per cent of the population in the Region is in the adolescent age group, this area has received special attention, with the focus on life skills education. Reduction of maternal and newborn deaths, promotion of skilled birth attendance and strengthening of reproductive health programmes received continued attention. Reproductive health, women’s health and gender mainstreaming were the other areas of focus. Efforts continued to put health at the top of the poverty alleviation agenda. The recommendations of the Commission on Macroeconomics and Health were given serious consideration by Member Countries, with some establishing their own national commissions to help implement the suggested action points. Environmental health issues, including safe water and sanitation as well as health care waste management, received attention. Essential drugs, with the focus on quality, accessibility and rational use, blood safety, strengthening of health information systems and health research, were the other areas of collaboration. Development of human resources for health through strengthening public health-related training institutions and establishing regional networks was pursued vigorously. In its overall pursuit of responding effectively to the needs of Member Countries, WHO laid more emphasis on the Country Focus Initiative to improve the quality of its collaborative programmes. Streamlining of budgetary mechanisms resulted in timely implementation of the programme budget with the lowest ever percentage of surrenders. Most countries had achieved the target of 85 per cent implementation for the first year of the biennium, set by the Regional Committee. The period under review saw a welcome addition to the SEAR family with Timor-Leste joining the South-East Asia Region as a member.

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A lot of ground has been covered and the Region is marching steadily towards its goal of health for all. What is needed is renewed commitment to fulfil the aspirations of our people for a healthier and better life. With the hope that we will achieve our cherished goals soon, I have great pleasure in presenting my report on the Work of WHO in the South-East Asia Region during the period 1 July 2002 – 30 June 2003.

Dr Uton Muchtar Rafei Regional Director

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EXECUTIVE SUMMARY Communicable Diseases There were several outbreaks of communicable diseases in the Member Countries for which technical, material and human resources support was extended by WHO to effectively respond to the situation. The outbreak of severe acute respiratory syndrome (SARS) once again highlighted WHO’s vital role in surveillance, networking and information sharing. Stockpiling of essential reagents, diagnostic test kits and other supplies as part of epidemic preparedness and response helped in effectively controlling the outbreaks. Efforts were made to strengthen national and regional surveillance of communicable diseases through an integrated multi-disease surveillance approach. Strengthening of capacity building in epidemiology and training in the management of priority communicable diseases continued. Sharing of information on outbreaks through web sites and the Outbreak Verification List (OVL) resulted in speedy retrieval of relevant information for use by the countries. The Region is yet to achieve the goal of elimination of leprosy. However, there have been creditable achievements. There has been a 92 per cent reduction in prevalence over a 15-year period (1987-2002) and over 10 million persons have been cured. Bangladesh, Bhutan, DPR Korea, Indonesia, Sri Lanka and Thailand had achieved the elimination goal at the national level by the target date of December 2000. Myanmar achieved the goal in January 2003. India, Nepal and TimorLeste are targeted to achieve the goal by 2005. WHO continues to provide technical support to all countries to integrate leprosy services into the general health services and in implementing critical and focused activities. India, which

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accounts for 90 per cent of the regional caseload, has been provided a “special package” to support advocacy, integration, decentralization, capacity building and monitoring. WHO supported critical activities in Myanmar and Nepal. Countries that have achieved elimination at the national level are being supported in their efforts towards sub-national elimination. Rabies and Japanese encephalitis (JE) are major public health problems in the Region. Of the estimated 50 000 human rabies deaths occurring globally annually, 70 per cent are accounted for by the Region. Outbreaks of JE are reported annually in India, Nepal, Sri Lanka and Thailand with high mortality rates. WHO assisted Member Countries in developing and implementing plans of action for controlling these diseases. The Region was free of plague during the reporting period. As a follow-up of the outbreak of plague in India in early 2002, WHO prepared regional guidelines for plague surveillance and control. Eight of the nine endemic countries in the Region conducted mass drug administration (MDA) using a combination of DEC and albendazole to eliminate lymphatic filariasis by 2020. A total of 37 million people were treated during the year. Mapping of the distribution of LF was completed in Sri Lanka and Thailand and is in progress in the other endemic countries. Attention was focused on prevention and alleviation of disability from LF. Eight of the eleven Member Countries are endemic to DF/ DHF. There is a declining trend in reported cases and casefatality rates. The revised regional strategies for prevention and control of DF/DHF are being implemented with the emphasis on social mobilization and Communication for Behavioural Impact (COMBI). “DengueNet”, an Internet-based global surveillance system for central data management, is being implemented. An in-depth external review of the DF/ DHF programme in Myanmar was conducted in June 2003. Indoor residual spraying (IRS) is the main vector control strategy. Insecticide-treated nets (ITNs) are being promoted as a complementary strategy. A regional strategy to scale up ITNs has been developed. xiv THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The TDR Special Programme continued to support Member Countries in undertaking research and development in tropical

diseases and in strengthening research capabilities. TDR/SEARO Small Grants Programme, a collaborative effort between the Regional Office and TDR, has been initiated to assist some Member Countries in strengthening research and development. Malaria remains a problem in poor, underserved and hardto-reach areas. However, the rising trend of malaria has been halted and stabilized below 3 million cases in the Region. Malaria control interventions have been scaled up using a stratified approach based on the prevailing local eco epidemiological situation. The Region carries the highest burden of TB among all the WHO regions with 3 million new cases and nearly 750 000 deaths due to the disease every year. The rising trends in HIV infection in some parts of the Region, together with the emergence of multidrug-resistant strains of tuberculosis, pose additional threats. Considerable progress has been made with the Directly Observed Treatment Short course (DOTS) coverage during the period under review by all the Member Countries. Given the current impetus and additional resources, the Region is expected to reach the global targets set for TB control by 2005, already achieved by Maldives and Nepal. In order that all countries do so, WHO is working closely with national TB programmes, not only in expanding and intensifying DOTS coverage, but also in maintaining the quality of implementation.

Noncommunicable Diseases and Mental Health The implementation of the Noncommunicable Diseases Control (NCD) programme is based on the Global Strategy for Prevention and Control of NCDs to modify lifestyle-related risk factors. There are three key components of implementation: (a) surveillance of risk factors; (b) preventive activities, and (c) strengthening health care management. Based on the recommendations of the regional consultation, held in 2000, and the World Health Report 2002 on “Reducing risks, Promoting healthy life”, the Region initiated NCD risk factor surveillance in eight Member Countries using the WHO step approach. A regional NCD network consisting of Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand was established. The recommendations of the regional

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consultations, held in August and October 2002, in this regard, included a plan on data management integration and utilization. While results of the community-based NCD prevention project in developed countries clearly demonstrated a reduction in NCD morbidity and mortality through adoption of healthy life styles, this is yet to be seen in developing countries. In order to improve the management of noncommunicable diseases at the PHC level, aimed at modifying intermediate risk factors (e.g. hypertension), the Regional Office is developing integrated “best practice” guidelines. WHO continued to support the participation of Member Countries in the Framework Convention on Tobacco Control (FCTC) negotiation process. The FCTC text was approved by the Fifty-sixth World Health Assembly in May 2003. Other important activities included: (a) training and conducting a Global Youth Tobacco Survey (GYTS) in Bangladesh, Bhutan, India and Maldives; (b) implementing the project “Channeling the Outrage”, using the UN Foundation (UNF) budget in Bangladesh, India, Nepal and Sri Lanka; (c) community-based interventions in tobacco use cessation in India, Indonesia, Myanmar, Sri Lanka and Thailand; (d) reviewing existing multisectoral mechanisms for comprehensive national tobacco control in eight countries; (e) finalizing the report on the study of Economics of Tobacco Control, conducted in seven countries of the Region; and (f) observing World No Tobacco Day on 31 May 2003 with the theme, “Tobacco free film and Tobacco free fashion - Action”. The health promotion strategy in the Region has laid emphasis on a healthy settings approach. Guidelines on Health Promoting Hospitals, Towards a Safe and Healthy Workplace, Health Promoting Schools and Healthy Districts were finalized. With a view to providing support to WHO headquarters in developing a “Global Strategy for Diet, Physical Activity and Health”, the Regional Office collected information on the subject from six Member Countries for use during the Regional Consultation in March 2003. Region-specific issues were well incorporated in the recommendations of the Consultation. xvi THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

In response to the increasing problem of injuries, India, Nepal and Sri Lanka were assisted in developing their respective national policies on injury prevention. Training courses on

injury surveillance and road safety were also organized at the WHO collaborating centres in Thailand. As a follow-up of the global release of the World Report on Violence and Health by the Director-General in November 2002, advocacy material on violence and health was prepared for use by Member Countries. The focus of WHO support in regard to prevention of blindness was on the study on the management of corneal ulcers and on capacity building in programme management. In regard to prevention of deafness, an assessment of the infrastructure and the human resources needed were conducted in seven Member Countries. Guidelines for the development of national programmes are being developed. With a view to strengthening information on the ageing population in the Region, a “Regional Profile on Care of the Elderly” is being finalized. An Intercountry Consultation on Strengthening Rehabilitation Services, held in August 2002, identified measures for strengthening local involvement through a multisectoral approach for community-based rehabilitation (CBR). Following the success in creating awareness on mental health issues in the Member Countries, several important activities were initiated. These included development of a communitybased programme on identification, management and stigma removal in epilepsy and psychosis; promotion of mental health amongst adolescents; study on suicide prevention in India and Sri Lanka and assisting countries in updating/developing modern mental health policies and services.

Family and Community Health To address the high mortality rates among children in the countries of the Region and strengthen preventive and promotive interventions for child health, WHO advocates the Integrated Management of Childhood Illness (IMCI) strategy. During the period under review, the regional capacity for implementing IMCI was further enhanced. IMCI is currently under implementation in Bangladesh, Bhutan, India, Indonesia, Myanmar, Nepal and Timor-Leste. DPR Korea has adapted generic materials and is likely to launch IMCI next year. Several activities were initiated to expand the access of

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disadvantaged population groups to IMCI. Notable among these is the development of an IMCI package for training basic health workers and private medical practitioners. The Indira Gandhi Open University in India introduced IMCI in its distance learning programme for doctors and paramedics. India and Nepal have initiated action to introduce IMCI in their preservice training curriculum for doctors. This will ensure longterm sustainability of IMCI. To learn from the experience gained so far and to help refine the strategy, review processes have been initiated. Bangladesh is one of the locations for the multi-country evaluation of IMCI. In addition, the analytical review of IMCI, conducted in Indonesia, will provide guidance about factors that contributed to success and identify constraints with a view to scaling up implementation of the IMCI strategy. To help countries in making realistic situational analyses for effective programming, WHO has initiated a process of documenting child health status in selected Member Countries. During the year under review, child health profiles of Bangladesh, Indonesia and Nepal were drafted and are being finalized in consultation with the respective governments. To achieve the Millennium Development Goals (MDG) in respect of child health, it is imperative that focused attention be accorded to the relatively neglected issue of neonatal survival and development. The Regional Office has initiated a consultative process to evolve a Regional Strategic Framework for Newborn Health. A draft regional situation analysis on neonatal health has been prepared in collaboration with BASICS II/USAID and shared with Member Countries for their inputs. Over 20 per cent of the population in the countries of the Region is in the adolescent age group. During the year, progress was achieved in advocacy and policy and strategy development for adolescent health programming. A situation analysis covering six countries was completed and policy and strategy development was initiated in Bangladesh, India, Indonesia, Maldives and Myanmar. To introduce the concept of adolescent–friendly health services, training workshops were facilitated in Bangladesh, India and Sri Lanka. The InterAgency Working Group (IAWG) India on Population and Development entrusted the Regional Office with the task of developing tools

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for health promotion of out-of-school adolescents, especially in regard to life skills education and training. Modules for this purpose were finalized and are under print. The Regional Office provided technical assistance and facilitated various workshops/meetings in an effort towards advocacy and capacity building for adolescent health. With regard to achieving MDG goal for reducing maternal and newborn deaths, WHO assisted Member Countries in strengthening the processes and mechanisms for monitoring and evaluation of access, utilization and quality of maternal and newborn health services. It also promoted skilled birth attendance, introduced evidence-based norms and standards for maternal and newborn care, and facilitated the use of methods for reviewing cases of maternal deaths. Member Countries have been actively strengthening their maternal and newborn health programmes in the context of reproductive health. Strengthening emergency obstetric care has become a priority in some countries, such as Bangladesh, India, Nepal and Sri Lanka. India, Indonesia, Myanmar and Nepal have initiated safe abortion or post-abortion care activities to further reduce maternal mortality. In Indonesia, field-testing of a decisionmaking tool for assisting clients to decide on selecting appropriate contraceptive methods has been conducted. Promotion of evidencebased practices in the broad area of reproductive health has been strengthened through the introduction of the WHO Reproductive Health Library CD-ROM at national and international congresses and at the Workshop on Implementing Best Practices in India. Updating of the reproductive health profile is progressing in most Member Countries in order to provide recent data for better programme planning. With regard to women’s health and gender mainstreaming, although progress has been achieved, the implications of gender difference on public health are not yet well understood. While attention is being paid to reproduction, other aspects of women’s health, particularly, the social, economic and cultural factors which impact women’s health and access to care, are still neglected. What is needed is a broadening of the global agenda for women’s health. The AIDS epidemic continues to spread in the Region. As a co-sponsor of UNAIDS, WHO continued to provide technical support in the health sector aspects of HIV/AIDS. Continued xix THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

advocacy and mobilization of resources as well as prioritization of effective interventions, strengthening of health systems and allocation of sufficient trained human resources for scaling up such inter ventions remain the major tasks for all stakeholders at regional and country levels.

Sustainable Development and Healthy Environments To support political processes in order to put health at the top of the poverty alleviation agenda, WHO assisted in the development of national strategies on health and poverty reduction in Sri Lanka and Nepal. The report of the Commission on Macroeconomics and Health (CMH) has been widely disseminated. While India, Myanmar and Sri Lanka have established national commissions, Nepal has established a subcommission under its National Commission on Sustainable Development to carry forward the work on CMH. A Working Group on Investing in Health has been constituted in Thailand for this purpose. In the area of nutrition, all countries of the Region have developed national plans of action. Most countries have also adopted national food policies. An analysis, however, showed that although food in most countries of the Region is generally available, poverty and maldistribution hinder access. Undernutrition is still a major problem with unacceptably high levels of moderate to severe stunting. Almost 40 per cent of the 10.5 million deaths annually among children under five years of age in the countries of the Region are associated with undernutrition. Iron and folate deficiencies, and resulting anaemia, affect more than 60 per cent of women of child-bearing age and millions of young children in the Region. However, with the epidemiological transition taking place in the countries, there is an urgent need to develop multi-faceted nutrition programmes that address not only undernutrition and infectious diseases, but also diet-related chronic diseases, such as diabetes, obesity, cardiovascular diseases and certain cancers. The underlying causes that contribute to under- and overnutrition need to be addressed and regional and national strategies for improving nutrition throughout the life cycle developed. xx THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

WHO assisted the countries in identifying and assessing health hazards and issues in such sectors as agriculture, industry

and the environment. Nine countries have initiated or developed Health and Environment programmes and adopted or drafted plans of action involving intersectoral partnerships. The countries were also assessed on the policy framework and procedures for Health Impact Assessment. The publication of this assessment will be critical in providing policy and advocacy support to policy-makers and catalyzing intersectoral collaboration in mitigating the health impact of environmental hazards. A situation analysis of occupational hazards in the Region has been prepared. This has led to the development of draft surveillance guidelines and a regional strategic plan addressing occupational health comprehensively, from risk management to infrastructure support and capacity building. A regional protocol on risk management related to arsenic contamination in water is being field-tested before it is adopted as a guideline for the affected countries. Results of the research conducted by ICDDRB on skin lesions in relation to malnutrition provide further guidance for implementation of the arsenic mitigation programme. WHO also provided technical support to Bangladesh in securing a UNF grant worth $1.2m to address the health aspects of arsenic contamination at the upazila level. Seven countries completed national assessments of water supply and sanitation. The reports show that most countries will require increased levels of investments if they are to meet the Millennium Development Goals for water supply and sanitation coverage. The regional analysis of drinking water quality indicated wide variations in the depth and coverage of national drinking water quality surveillance programmes. It was also revealed that none of the countries had an adequate water quality surveillance programme. The success of the WHO-supported project in West Delhi slums on householdlevel disinfection and safe storage of drinking water is being replicated in Bangladesh, Myanmar, Nepal and Sri Lanka. The Regional Office commissioned a study on Healthy Cities initiatives in five countries. Important factors contributing to the successful implementation included exposure of decisionmakers, particularly local politicians; clarity of vision and mission with a strong planning and management team; sense of ownership of policies; high degree of stakeholders’ involvement and institutionalization of healthy city programme policies.

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The Regional Office pursued the Healthy Environments for Children Alliance (HECA) visibility by developing educational materials for use at the national level. Nine countries have already developed national health and environment plans (NHEPs). The World Health Report 2002 identified six groups of environmental risks to children that must be tackled as a priority: unsafe water, lack of hygiene and poor sanitation, indoor air pollution, vector-borne diseases; chemical risks and unintentional injuries. These risk factors cause the bulk of environmentally-related deaths and diseases among children and undermine development. The World Health Day theme for 2003 focused on children’s environmental health and provided a unique opportunity to mobilize public support for HECA and set it high on the political agenda. In the area of management of health care waste, efforts to strengthen national legislation, with particular attention to the management of infected sharps at primary health facilities were pursued. Apart from direct interventions in a number of countries affected by humanitarian crises, the Regional Office supported preparedness activities in various countries, including Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand. WHO was involved in the Consolidated Appeal Process for DPR Korea and Indonesia for 2003. As part of institutional strengthening and inter-regional cooperation, the WHO Regional Offices for South-East Asia and the Western Pacific and the Asian Disaster Preparedness Centre (ADPC), Bangkok, signed a Memorandum of Understanding to continue organizing the training programme on Public Health and Emergency Management in Asia and the Pacific (PHEMAP). Within this framework, courses will be offered at the international level for senior MoH staff, previously supported by the Japan International Cooperation of Welfare Services (JICWELS), and at the national level for local MoH staff, with extrabudgetary resources.

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Activities during the period under review covered virtually all the areas in the WHO Medicines Strategy. The resolution on essential drugs at the 55th session of the Regional Committee reaffirmed the commitment: the bulk purchase scheme is a

promising initiative that needs to be developed further. The activities with the drug regulatory authorities focused on quality though affordability is now gaining increasing prominence. Counterfeit drugs are emerging as a problem which needs to be tackled effectively. Evaluations by teams from the Regional Office and WHO headquarters have helped countries to identify areas that need improvement and also revealed successful innovative approaches. The period under review was particularly intense for IVDrelated programmes. An outbreak of wild polio virus in India meant a renewed focus on implementing high quality and regular polio supplementary immunization activities in large areas of the country. Countries and states bordering India still infected with polio virus need to be especially vigilant. India, and therefore the South-East Asia Region, are now the number one global priority for polio eradication efforts. In order to learn from past efforts, WHO has been examining how the polio immunization infrastructure could be utilized to strengthen the quality of immunization services for other vaccine preventable diseases. Since polio surveillance and laboratory services in the Region are world class, during 2003 most countries will begin integrating AFP surveillance and laboratory activities with other diseases. The strategic policy for regional measles mortality reduction, developed in 2002, should help strengthen knowledge and capacity to control measles and neonatal tetanus and to reduce mortality across the Region. With Global Alliance for Vaccines and Immunization (GAVI) funding, early 2003 saw a series of new initiatives, including the phased introduction of hepatitis B vaccine and auto-disable syringes across the Region. Work in the past year also addressed the needs of national ser vices that support the Expanded Programme on Immunization. In particular, WHO invested considerable efforts to support the National Regulatory Authorities in their role as guardians of the quality of vaccine supply, and preparing and piloting strategies to improve the standards of injection safety and waste management. Safe blood is one of the priority areas of WHO, both at the global and regional levels. The WHO global strategy aims at improving access, quality and safety of blood. Various group xxiii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

educational activities were organized to strengthen the capacity of Member Countries in the management of blood transfusion services, donor recruitment, screening for transfusion transmissible infections (TTIs) and clinical use of blood. Technical support was provided to DPR Korea, Nepal and Sri Lanka where ambitious programmes to reorganize blood transfusion services have been initiated. Bhutan, Indonesia, Maldives, Myanmar, Nepal and Sri Lanka were assisted in strengthening screening for TTIs. An independent assessment of quality in selected blood centres was carried out through two regional centres. Timor-Leste was provided technical support to establish a functional public health laboratory system. The regional status on the bacteriological component of antimicrobial resistance monitoring was ascertained and major areas that need to be addressed identified.

Evidence and Information for Policy The WHO collaborative programme on Evidence and Information for Policy focused on collecting, compiling, validating, analysing, synthesizing, reporting and disseminating evidence-based health information. National capacity on management of health information systems was strengthened in the areas of quality improvement in morbidity and mortality statistics; knowledge on methods and issues related to health systems performance assessment; training in increasing use of ICD-10 coding; and improvement of vital registration systems and health surveys. Member Countries evaluated their health management information systems and their reports were consolidated and compiled to form a regional strategy on HMIS development. The regional strategy aims at making HMIS more dynamic and responsive to the requirements of decision-makers. Indonesia initiated sub-national health systems performance assessment, along with 10 other countries around the world in order to compare the progress of the district health systems over a period of time. A series of methodology development activities were undertaken in this respect to identify and measure appropriate intermediate health indicators and health outcomes. Staff were trained in the use of web-based technology for data collection and communication on HIS in the countries.

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An update on the review of the progress made by Member Countries in implementing the “Declaration on Health Development in the South-East Asia Region in the 21st Century”, adopted by the Health Ministers of the Region in August 1997, was submitted to the Eighth meeting of Health Secretaries in Kathmandu in April 2003. The update highlighted the progress and achievements in health development and recommended priority policy actions that the countries might need to take in order to accelerate health development processes. The Health Information Management and Dissemination programme continued to promote the storage, production and dissemination of valid information as widely as possible. The Regional Office library continued to function as a portal for disseminating WHO information and also providing technical support for proper documents storage, retrieval and dissemination of health and health-related information. Development of national health accounts was actively followed up in countries of the Region. Based on the regional strategies for health research systems development, profiles on national health research systems of Member Countries were updated which brought a paradigm shift in systematic analysis and development of health research within the new framework of health research systems. National ethical guidelines were developed in many countries. In February 2003, the national ethical guidelines were endorsed by the Minister of Health, Indonesia, and, at the same time, the National Ethics Review Board was officially constituted within the National Institute for Health Research and Development. Most countries have refined their respective national ethical guidelines through a series of scientific debates and workshops. Training is being conducted to disseminate the guidelines as well as to strengthen the ethics review boards of institutions. In order to promote national centres/institutions being designated as WHO collaborating centres, a series of national workshops were held in India and Thailand. These helped to improve understanding of the managerial and administrative steps and procedures for designation, redesignation and termination and on ways to strengthen collaboration with WHO technical programmes.

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Development of the human resources for health component remains an important concern at all levels in countries of the Region. Several activities to strengthen the quality of human resources for health training were carried out. WHO supported Member Countries through strengthening public health-related training institutions and establishment of regional networks among such institutions and specialists. Development of family medicine as a core curriculum is also being emphasized. The multidisciplinary South-East Asia Regional Advisory Group on Management of Nursing and Midwifery, constituted in 2001, concluded its work and developed guidelines for countries to effectively manage their nursing and midwifery work force. A new regional advisory group has been established to guide countries and the Regional Office to address priority issues in this area.

Governing Bodies and External Relations Key matters discussed at the Fifty-sixth World Health Assembly in May 2003 included: appointment of the Director-General; assignment of the Democratic Republic of Timor-Leste to the South-East Asia Region; representation of developing countries in the Secretariat; Framework Convention on Tobacco Control; health promotion; World Summit on Sustainable Development; smallpox eradication: destruction of variola virus stocks; WHO medicines strategy; strengthening nursing and midwifery; eradication of poliomyelitis; revision of the International Health Regulations and severe acute respiratory syndrome (SARS). Important matters discussed at the 111th and 112th sessions of the WHO Executive Board, held in January and May 2003, respectively included: WHO’s contributions to achievement of the development goals of the UN Millennium Declaration; follow-up of the UN General Assembly special session on HIV/AIDS; country focus initiative; strategy for child and adolescent health and development; traditional medicine; influenza; revision of the International Health Regulations; international non-proprietary names; genomics and world health; human organ and tissue transplantation; and the proposal for a “health” Internet domain. xxvi THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The 55th session of the Regional Committee for South-East Asia, held in September 2002, noted the threat posed by

indiscriminate advertisement campaigns carried out by multinational companies promoting tobacco use and unhealthy foods and life styles; technical support provided by WHO in obtaining resources from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM); problems being faced by many countries in the areas of health sector reforms and health care financing; and health problems arising from global warming. The 39 th meeting of the Consultative Committee for Programme Development and Management was held in September 2002. It observed that some of the common denominators for delayed programme implementation often were: (a) late approval of work plans, (b) low quality APWs and fellowships as well as lack of facilities for in-country fellowships, and (c) frequent turnover/reorganizations in ministries of health. While no real increase was planned in the global regular budget allocation, there was a considerable increase in the projected extrabudgetary resources for 20042005. Though the Region accounted for a quarter of the world’s population and more than 40 per cent of the global disease burden, this fact had so far not been reflected in the share of extrabudgetary funds allocated to it. The 52nd Meeting of the Regional Director with the WHO Representatives, held in April 2003, discussed key issues relating to: implementing, monitoring and reporting of PB 2002-2003; work plans for the 2004-2005 biennium; technical updates on lessons learnt in the preparation of proposals and implementation issues for GFATM; emergency preparedness and response; Commission on Macroeconomics and Health; country focus initiative, and how to improve the quality of WHO collaborative programmes with Member Countries. The Twentieth Meeting of Health Ministers of the countries of the Region, held in September 2002, reviewed the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the regional mechanism for bulk purchase of selected quality essential drugs. It recommended that the Regional Office convene a regional consultation of drug regulatory authorities to refine prequalification criteria and to finalize the Bulk Purchase Scheme of quality essential drugs. The Ministers recommended that the report of the Commission on Macroeconomics and Health should continue to be used for advocacy for health

xxvii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

and as an instrument to mobilize additional resources, both domestic and external. They also recommended that National Commissions on Macroeconomics and Health or equivalent mechanisms at the country level be established. The Eighth meeting of Health Secretaries was held in Kathmandu in April 2003. It reviewed implementation of the Programme Budget 2002-2003, Programme Budget 20042005, and ICP-II Work Plans for PB 2004-2005 (report of the High- Level Task Force on ICP-II: Focus on Expected Results and Products). A Regional Conference of Parliamentarians on the Report of the Commission on Macroeconomics and Health, held in December 2002, recommended that: wide dissemination and advocacy of the key findings and recommendations of the CMH report be undertaken; suitable national mechanisms to carry forward and develop the CMH strategic framework at the country level be established; health systems be strengthened; and development partners be encouraged. To meet the ever-increasing requirement of external resources for WHO’s programmes and for national health development, WHO continued to play an active role in resource mobilization. At the end of 2002, US$ 95m of extrabudgetary funds had been mobilized in the Region. This was 95 per cent of the projected amount of US$ 100.5m for the whole biennium and represented an increase of 31 per cent compared to the last biennium. WHO facilitated Member Countries in receiving external funding from international financial institutions such as the World Bank. WHO also continued to generate resources for the immunization programmes in Member Countries. The Global Alliance for Vaccines and Immunization (GAVI) is expected to provide more than US$ 200m to eligible countries in the Region over the next five years. The Global Fund to fight HIV/AIDS, Tuberculosis and Malaria also approved a total of US$ 283m for several countries of the Region in the first round in March 2002 and US$ 275m in the second round in February 2003. WHO continued to sustain and strengthen its partnerships with UN system agencies, other intergovernmental organizations, including regional agencies and nongovernmental organizations, to bring health in the centre of development. WHO had high-level meetings with UN ESCAP

xxviii THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

to expand collaboration and be actively involved in its governing body sessions and ministerial conferences focusing on various health and health-related issues. The Regional Office also strengthened its collaboration with UNICEF, UNAIDS and other UN system agencies at the regional level for polio eradication, immunization programmes and control of HIV/ AIDS through various regional coordinating mechanisms. WHO’s collaboration with ASEAN was consolidated further with the renewal of its Memorandum of Understanding in April 2002, for another five years. WHO and ASEAN made joint efforts to place health high on the political agenda in ASEAN Member States. WHO and SAARC also held high-level and other consultations to actively follow up on their MoU. WHO country offices in the Region were closely involved in the UN system’s joint initiatives, notably development and follow up of UNDAF and preparation of country reports on Millennium Development Goals. Country offices also actively participated in the various inter-agency coordinating mechanisms established under the UN Resident Coordinator System.

General Management As part of global human resources reforms, a new system of staff contracts came into force on 1 July 2002, which aimed at improving the conditions of service of temporary staff. Appropriate mechanisms were also established to review “long-term short-term” staff and their transition to fixed-term staff. A Regional Service Appointment Review Committee has been established to determine the mechanism for awarding open-ended service contracts which have no specific time-limit but may be terminated by either party subject to certain specified conditions. Selection procedures have been streamlined to help attract well-qualified staff and to enable fair selections. In order to infuse competition and merit in recruitment, written tests and interviews are now being required as part of the selection process for both GS and professional posts. Compared with 1998-1999, the Region’s Regular Budget reserves were 20 per cent lower and surrenders to miscellaneous income were reduced by more than 60 per cent at the end of the 2000-2001 biennium. Eight countries and the RO/ICP

xxix THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

programmes met the 85 per cent implementation target for the first year of the 2002-2003 biennium, with all funds scheduled to be committed by the end of June 2003. Nine country offices have now dedicated Internet connectivity. In order to automate the preparation, clearing, approval and distribution process of Travel Authorizations, a computer-based Travel and Meeting Administration System was implemented. As part of the overall UN security preparedness, stringent requirements have been put in place regarding state-of-the-art telecommunications and radio equipment, and the institution of a warden system in all WHO locations, in order to meet the Minimum Operating Security Standards laid down by UNSECOORD.

Regional Director’s Development Programme With the global SARS outbreak, much of the media effort was focused on communicable diseases. In this regard, the Information Unit played a proactive role in trying to stem the sense of panic by ensuring that the media were given the facts about the disease, how it is transmitted and the case definitions. During the visit of the Director-General to the Regional Office and India, the Unit supported media coverage, including the special World Health Day events. Technical Units were supported in their public/media outreach activities. The Regional Director’s Development Fund continued to support country as well as intercountry initiatives in different areas. In terms of health and emergency relief measures, prompt support was extended following the floods in Jakarta as well as for humanitarian activities in the northeast of Sri Lanka. Member Countries were also supported in SARS - related activities.

xxx THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

1 COMMUNICABLE DISEASES Communicable Disease Surveillance During the period under review, several outbreaks of diseases were reported in the countries of the Region (Figure 1.1). WHO extended support in terms of technical, material and human resources to enable the countries to respond effectively to these outbreaks. The capacity of the health services in the Member Countries to prepare for and respond to any public health emergency, be it from natural or man-made causes, is generally inadequate. Therefore, efforts were made to strengthen the preparedness of the health sector towards public health emergencies through a proactive role in the preparation and dissemination of information on possible public health emergencies (disease outbreaks/biological/chemical agents) and related training. During the outbreak of plague in India and scrub typhus in Maldives in 2002, timely technical support was provided to the Governments of India and Maldives in controlling these outbreaks. Similarly, WHO coordinated a global response to the reported outbreak of severe acute respiratory syndrome (SARS) in some countries of the Region, taking a proactive role in the dissemination of information on SARS through WHO web sites, which included daily updates and other relevant information. Services of international experts were provided to Member Countries for enhancing their state of preparedness to combat SARS. Personal protection equipment comprising masks, goggles, coveralls etc. were provided to various Member Countries. ELISA and IFA tests are under development and are likely to be available soon.

WHO coordinated a global response to the reported outbreak of severe acute respiratory syndrome (SARS) in some countries of the Region

1 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Figure 1.1: Major outbreaks of diseases in the SEA Region DPR Korea Japanese encephalitis

Bhutan Nepa l

Bangladesh

Meningitis Dengue/DHF Malaria Anthrax Leptospirosis SARS

India

Myanmar Dengue Acute diarrhoeal disease Nepah virus

Cholera Acute diarrhoeal disease Measles atypical Dengue/DHF Leptospirosis; Plague Nepah virus; SARS

Thailand

Sri Lanka Maldives

Anthrax Rabies Dengue/DHF Leptospirosis SARS

Hand, foot and mouth disease Scrub typhus

Dengue/DHF Japanese encephalitis Hand, foot and mouth disease

n

I

d

o

n e s i a N

Timor-Leste Source: WHO/SEARO

W S

E

The Regional Office is planning to organize a regional consultation to strengthen national response mechanisms as well as a training workshop on good infection control practices to create a core of national trainers in Member Countries. In addition, provision of essential supplies and reagents is being continued as per the requirements and requests of the Member Countries. Regional training institutes in Thailand, Indonesia and India continued to be used for capacity building in epidemiology and training in the management of priority communicable diseases. WHO supported the training of medical officers and paramedical staff from Bangladesh, Bhutan, DPR Korea, Maldives, Myanmar and Nepal at these institutes. The 10-day Course on Epidemic Preparedness and Response, developed by WHO, has been adapted by several Member Countries. A number of national courses were held. At the request of Member Countries, WHO developed training modules for a five-day course for the first contact doctor at the primary health care level. Technical support was also provided for training courses in DPR Korea in November 2002 and in

2 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Sri Lanka in April 2003. Two intercountry training courses were conducted at the National Institute of Epidemiology (NIE), Chennai, India, in June 2003. Training manuals for managing priority communicable diseases, one for health workers and the other for doctors at the PHC level, were developed. These manuals use a systems approach to promote integrated management. Following a peer review and field-testing in India, Nepal and Myanmar, both manuals have been printed. A Regional Strategic Plan for Integrated Disease Surveillance (IDS) was developed by the Regional Office. An intercountry consultation, held in Yangon in August 2002, discussed the strategic plan and agreed on the broad framework, concept and content of the document for integrated disease surveillance. The strategy envisions that by 2010 all Member Countries in the Region will have established a functional, effective and coordinated integrated disease surveillance system that would satisfy all disease surveillance partners and ensure continuous, accurate, timely and complete information for disease prevention, control, elimination and eradication. Technical guidelines, standardized protocols, training manuals and advocacy documents for assisting Member Countries in the implementation of IDS are being developed. Technical and financial support was provided to Sri Lanka to conduct a comprehensive assessment of the surveillance system in March 2003. It was noted that Sri Lanka had a good surveillance system. This, coupled with the existence of a competent and well-staffed epidemiology unit, is a major strength and a sound base from which to progress to a strong, effective and integrated surveillance system. Support to the Government of India continued on the implementation of the national Integrated Disease Surveillance Programme (IDSP). Technical support was also provided for the development of an operational manual and a training strategy. Sharing information on outbreaks through the web sites and the Outbreak Verification List (OVL) has resulted in speedy retrieval of relevant information for use by the countries for timely action.

3 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Communicable Disease Prevention, Eradication and Control Leprosy The Region accounts for 74 per cent of the globally registered and 80 per cent of the new cases of leprosy detected in 2002. India alone accounts for 90 per cent of the regional and 66 per cent of the global caseload. Bangladesh, Bhutan, DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand achieved the elimination goal (prevalence rate <1 per 10 000 population) at the national level before the target date of December 2000. Myanmar achieved the goal in January 2003. India, Nepal and Timor-Leste are targeted to achieve the goal by 2005 (Table 1.1). Table 1.1: Leprosy situation in the SEA Region, as of April 2003 Population (000) 129 248 659 1 067 482 207 840 270 52 827 24 154 19 086 61 879 849 1 564 294 Registered leprosy cases 8 143 33 334 377 16 837 19 4 965 7 291 1 639 1 905 249 385 458 Prevalence rate/ 10 000 population 0.63 0.50 3.23 0.81 0.70 0.94 3.02 0.86 0.31 2.93 2.46 Newlydetected cases in 2002 9 844 13 473 658 12 377 29 7 386 13 830 2 214 1 000 281 520 632 New case detection rate/ 100 000 population 7.62 1.97 44.37 5.96 10.74 13.98 57.26 11.60 1.62 33.10 33.28 Cumulative cured with MDT since 1982 140 440 940 10 383 038 257 690 1 163 226 698 94 448 34 534 56 561 N.A. 11 195 512 Year of reaching elimination target 1998 1997 2005 2000 1996 2003 2005 1995 1994 2005 2005

Country

Bangladesh Bhutan India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste SEA Region Source: WHO/SEARO

4 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

In India, the prevalence rate for leprosy is 3.23 per 10 000 population. The prevalence in four states is above 5 per 10 000 population, between 2 and 5 in six states and <2 per 10 000 in the remaining states. Technical support continued to be provided for the integration of leprosy control into the general health services and for all critical activities related to elimination. WHO recruited state/zonal coordinators in the most endemic states and provided anti-leprosy drugs to the entire country and monitored its supply. Capacity building and

management as well as monitoring and supervision of the implementation of leprosy elimination was supported. A largescale leprosy elimination monitoring (LEM) exercise was carried out in the 12 most endemic states. WHO provided technical inputs and supported the simplification of a new leprosy information system, which is being implemented since November 2002. In order to give a further boost to the programme, a joint WHO/NLEP-India meeting was organized in February 2003 in Yangon in conjunction with the third meeting of the Global Alliance for Elimination of Leprosy (GAEL). This meeting, which was also attended by all the partners, was useful in determining priorities and the steps that need to be taken for achieving leprosy elimination by 2005. In Nepal, there were 7 291 registered cases, giving a prevalence rate of 3.02 per 10 000 population. The prevalence is high in central, eastern and far-western regions. Support was provided for intensified leprosy elimination activities covering several areas. In Timor-Leste, a total of 249 cases have been registered, giving a prevalence rate of 2.93 per 10 000 population. The high prevalence has to be considered in the background of the pre-independence conflict which resulted in severe dislocation of the health services. Therefore, most of the leprosy cases registered in 2002 are likely to be backlog cases. Support was provided for the preparation of a strategic plan for the elimination of leprosy and for capacity building as the first step in strengthening the national leprosy programme. Myanmar achieved the goal of leprosy elimination at the national level in January 2003. Ten of the fourteen states/ divisions have achieved elimination. WHO supported leprosy elimination campaigns (LECs) in 120 townships in 2002. Support was also provided to strengthen monitoring and supervision at the township level and in “cleaning” of registers. To advocate and enhance political commitment towards leprosy elimination in the Region, an Intercountry Meeting of National Programme Managers for Leprosy Elimination was held in Colombo in November 2002. The meeting evaluated the progress towards the goal of leprosy elimination and made important recommendations. These included further strengthening of efforts for integration of leprosy, phasing out vertical structures in a definite time-frame and undertaking

5 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The third meeting of the Global Alliance for Leprosy Elimination was held in Yangon.

measures to prevent operational factors like “over-diagnosis” and “re-registration” of cases leading to a high level of new case detection in some countries. Since 1982, over 11 million persons have been cured with multidrug therapy (MDT) (Table1.1). During the period 19852002, the prevalence has reduced by 92 per cent. All countries of the Region are integrating leprosy services into the general health services. Countries that have achieved elimination at the national level are concentrating on efforts to achieve subnational elimination. India, Nepal and Timor-Leste are intensifying and accelerating their activities to achieve elimination by 2005. All countries are committed to implementing the Final Push Strategies, recommended by WHO, and have forged partnerships to further reduce the burden of leprosy. Through improved and easier access to early detection, treatment and intensive education and awareness programmes, there is a positive change in the public perception of leprosy in all countries. WHO will continue to provide technical support and supply free MDT drugs to Member Countries. Close, intensive collaboration is continuing with partners, including The Nippon Foundation, Sasakawa Memorial Health Foundation, Novartis, the World Bank, DANIDA as well as NGOs and others to attain the goal of leprosy elimination in the Region.

6 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Rabies The Region continues to account for approximately 70 per cent of the estimated 50 000 annual human deaths due to

rabies globally. The disease is endemic in eight of the 11 countries, with India accounting for about 85 per cent of the deaths. The disease is invariably fatal but is preventable through an effective vaccine. Member Countries are being encouraged to give priority to rabies control. A Steering Committee for Rabies Control in Asia has been established to provide advice and guidelines. One of the priorities is to obtain realistic estimates of the burden of rabies, especially in Bangladesh, India and Myanmar. WHO is supporting a study to collect baseline data in India. The study commenced in March 2003 and involves 22 medical colleges and 32 veterinary colleges as sentinels. A similar study is ongoing in Myanmar. Four countries - Bangladesh, India, Myanmar and Nepal continue to produce and use the outmoded nerve tissue vaccine. A policy decision, however, has been taken in all countries to phase out these vaccines and shift to the modern tissue-culture vaccine (TCV). WHO is promoting the use of intra-dermal administration of TCV which is as potent and more costeffective compared to intra-muscular administration.

The SEA Region accounts for 70 per cent of the estimated annual human deaths due to rabies globally

Japanese encephalitis Outbreaks of Japanese encephalitis (JE) are reported annually in India, Nepal, Sri Lanka and Thailand. Sporadic cases have also occurred in Bali (Indonesia), Myanmar and Timor-Leste. The affected countries are being supported in developing JE surveillance and appropriate outbreak response. The strategies for prevention and control of JE include health education, capacity building of concerned health staff, vector control and vaccination. Though effective vaccines are available, none is pre-certified by WHO. However, in view of the need, WHO recommends the use of vaccines produced in Japan and Korea.

Plague The Region was free of plague during the reporting period. Three countries - India, Indonesia and Myanmar – have rodent plague foci. The last outbreak occurred in Himachal Pradesh, India, in February 2002, which was successfully contained 7 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Plague surveillance activities are being strengthened in the Region.

rapidly. In order to assist Member Countries in establishing and strengthening plague surveillance and prepare them for appropriately tackling outbreaks, an intercountry consultation was organized in Bangalore, India, in July 2002. During the consultation, draft regional guidelines for plague surveillance and control were prepared. These have now been finalized.

Leptospirosis Leptospirosis is an infectious disease caused by “leptospire”, a group of bacteria and is mainly transmitted through human contact with the urine of rats. This is an emerging public health problem in some countries of the Region. In 2002, outbreaks occurred in Jakarta and in some states of India. WHO assisted Indonesia in the development of a fact file on leptospirosis.

Soil-transmitted helminthiasis Around two billion people, mostly in developing countries, harbour these infections, while 300 million are severely ill with worms. Of these, at least 50 per cent are school-age children. This group of infections, caused mainly by roundworms, whipworms and hookworms, is a major public health problem in all countries of the Region. 8 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Member Countries have identified national focal points to coordinate activities related to the control and prevention of these diseases. WHO played a catalytic role in mobilizing donor

assistance for deworming activities. Myanmar scaled up the implementation of its school deworming programme in two of the four ecological zones. WHO provided technical assistance for all aspects of implementation, including development of proposals and obtaining funds from the donor agency, German Pharma Health Fund (GPHF). Similar activities have been launched in Bhutan. Technical assistance was also provided to other countries to implement deworming activities which include school feeding and deworming programmes in Nepal, supported by WFP and UNICEF, and the UNICEF-funded school deworming programme in Maldives. Over the last decade, Maldives, Sri Lanka and Thailand have shown a decline in the prevalence of helminth infections. A WHO-sponsored study, conducted in Sri Lanka to assess the impact of mass drug administration for elimination of lymphatic filariasis on soil-transmitted helminthiasis, showed an overall reduction in the transmission of infection. School teachers are being encouraged to give deworming treatment.

Dengue fever/Dengue haemorrhagic fever (DF/DHF) Globally, 2.5 billion people live in areas where dengue viruses can be transmitted. It is estimated that 50 million dengue infections occur each year with 500 000 cases of DHF and at least 22 000 deaths, mainly among children. Dengue/DHF is endemic in eight of the 11 countries in the Region. As of August 2002, there were 85 197 reported cases and 252 deaths. The case-fatality rate is on the decline. In response to the resolution of the Fifty-fifth World Health Assembly on the prevention and control of DF/DHF, WHO headquarters created an Internet-based global surveillance system called “DengueNet” to collect and analyse standardized information in a timely manner and to present epidemiological trends as soon as new data are entered. The notable achievements on dengue prevention and control in the Region were: (1) As a follow-up of the revised regional strategies, a Workshop on Communication for Behavioural Impact (COMBI) was organized in collaboration with WHO headquarters and the Western Pacific Regional Office, in Lao PDR in January 2003. Indonesia and Thailand participated in the workshop where COMBI work plans were developed for implementation in 2003; (2) Guidelines for physicians for diagnosis and management of DF/DHF are being developed in

9 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

order to improve case management; (3) The Queen Sirikit National Institute of Child Health, Bangkok, has been redesignated as a WHO Collaborating Centre for Clinical Management of DF/DHF for another four years from 2003; (4) WHO assisted countries to develop five-year (2003-2007) national strategic plans for prevention and control of DF/DHF.

Lymphatic filariasis Eight Member Countries of the Region account for 60 per cent of the global burden of lymphatic filariasis (LF). These countries have developed national plans to reach the elimination goal by 2020 by adopting two main strategies, i.e., mass drug administration (MDA) of diethylcarbamazine and albendazole, and disability alleviation. The second meeting of the Regional Programme Review Groups (RPRGs) of the Indian Subcontinent and Mekong-Plus was held in Bali, Indonesia, in July 2002. The meeting reviewed the progress on the elimination of lymphatic filariasis, and recommended the supply of albendazole to Bangladesh, India, Indonesia, Myanmar, Sri Lanka and Thailand for the second round of MDA and an additional supply to Nepal for its first round of MDA which was postponed last year. As part of technical support, in conjunction with the above RPRGs’ meeting, WHO organized a bi-regional meeting which was attended by programme managers from the South-East Asia and the Western Pacific Regions, among other significant partners of the Global Alliance for the Elimination of LF. With technical and financial support from WHO, national task forces for the elimination of lymphatic filariasis are functional in each endemic country. Mapping of the distribution of LF cases was completed in Sri Lanka and Thailand and is expected to be completed by 2005 in all endemic countries. The Region placed a high priority for social mobilization as the cornerstone for achieving a high coverage of MDA. The COMBI plan to increase peoples’ compliance for taking medication and involving the private sector advertising firms was implemented in Sri Lanka and in Tamil Nadu, India. There was evidence that this approach helped significantly in increasing the coverage of MDA.

10 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Nepal also implemented MDA in May 2003 where the principles of COMBI were applied to obtain a high coverage. During the year under review, Bangladesh scaled up MDA, by six-fold, compared to the previous year, and covered a population of 4.86 million. India covered 24 million people with a combination of DEC and albendazole. Sri Lanka targeted the entire population at risk and covered 8.63 million people achieving a coverage of 86 per cent. Nepal too has planned to commence MDA in 2003 covering a population of 500 000. Indonesia conducted one round of MDA with combination drugs covering 255 000 people. Thailand also targeted the high risk areas comprising a population of about 138 000 of which 118 000 people were covered with combination drugs.

Vector control Vector-borne diseases are a major cause of morbidity and mortality in the Region. In the absence of vaccines and specific drugs, vector control assumes greater importance in the prevention and control of these diseases. The countries in the Region still rely on indoor residual spray (IRS) as their main vector control strategy. Most countries have already phased out DDT while many have introduced synthetic pyrethroids. However, only India, Myanmar and Thailand are still using DDT. Member Countries have been urged to revive and strengthen the insecticide policy for public health use. Guidelines in this respect are being developed in collaboration with WHO headquarters and other regions. WHO is supporting the use of insecticide-treated nets (ITNs) as a personal protective measure against malaria and vectorborne diseases. A regional strategic plan to scale up the ITN programme has been developed and operational guidelines on the use of ITN are being prepared. To strengthen national capacity on disease vector control, the fourth WHO Regional Training Course on Comprehensive Vector Control (CVC) was held at the Vector Control Research Centre (VCRC - WHO Collaborating Centre for Integrated Method for Vector Control) in Pondicherry, India, during August-September 2002. The CVC training course is now an annual feature of the Centre with participating countries

Countries in the Region still rely on indoor residual spray as their main strategy for vector control

11 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

providing their own funding and WHO providing technical support. In addition, other Member Countries are being assisted to extend the CVC training course to their nationals. Preparations are under way to strengthen national capacity in Indonesia by organizing a six-week international CVC course in Salatiga on the lines of the course being held in Pondicherry. For strengthening the RBM technical support network on transmission risk reduction, funding support was provided for three projects in Myanmar and two in India on biological control of malaria vector and ITNs. In addition, multi-country collaborative studies to evaluate the operational programme of ITNs have been developed for implementation in 2003 in India, Indonesia, Myanmar and Thailand.

Research and Product Development for Communicable Diseases TDR is a UNDP/World Bank/WHO special programme for research and training in tropical diseases. WHO is the executing agency of the programme which is financed by voluntary contributions from governments, intergovernmental and nongovernmental agencies, foundations and other external sources. The TDR programme continued to support research and product development focusing on priority diseases of the Region, such as malaria, lymphatic filariasis, leishmaniasis and leprosy. Studies on drug resistance in malaria, vaccine development, vector control, monitoring of drug efficacy and new drug regimen were also supported. Studies on lymphatic filariasis emphasized the impact of mass chemotherapy with DEC or albendazole (India, Myanmar and Sri Lanka), filariasis endemicity (Myanmar, Sri Lanka) and use of insecticide impregnated curtains (Sri Lanka). Through a joint initiative by the Regional Office and TDR, Member Countries are being provided small grants. Under this, one fellowship of 12-24 months would be awarded by WHO headquarters while 10 small grant proposals up to a maximum of US$ 7 500 each from four countries in the Region (Bhutan, DPR Korea, Maldives and Timor-Leste) would be invited and supported.

12 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Malaria Countries of the Region have seen a resurgence of malaria, which continues to be a leading public health concern. Over the past two decades, countries have switched over to the control concept by decentralizing malaria control through the primary health care system. The global malaria control strategy (GMCS) was evolved in 1992 as a model approach and has achieved good results; the rising trend of malaria has been halted and has now stabilized at 3 million cases annually. Malaria, however, is still a problem in underserved and hard-to-reach areas largely associated with poverty. To tackle the problem in the Region, selected countries are vigorously pursuing the Roll Back Malaria (RBM) initiative which aims at halving the malaria burden by 2010. The initiative emphasizes community-based action through country-level partnerships, health sector development, integration and intersectoral collaboration, as well as a high level of advocacy for bringing about a change. Three technical resource network groups, established through intercountry cooperation, undertook 21 priority operational projects in the field of drug resistance and policy, transmission risk reduction, surveillance, information system and epidemic response. National centres of excellence, WHO collaborating centres as well as research and academic institutions collaborated in the operational projects. In view of the spread of multidrug resistance malaria in the Region, WHO, in collaboration with Member Countries and partners, established drug resistance surveillance networks in the Mekong region (Mekong network of six countries) and in Bangladesh, Bhutan, India, Myanmar and Nepal (South Asia network of five countries). Technical support was provided to Member Countries in collecting data on the therapeutic efficacy of first and second-line antimalarial drugs. Networks among countries in the Mekong region on drug and rapid diagnostic test and quality assurance are being developed by WHO and RBM-Mekong partners. Malaria control interventions have been implemented by using a stratified approach based on the local ecoepidemiological situation. The operational tools were already available for rolling back malaria in seven countries. To reduce case fatality, “Guidelines on Management of Severe Malaria

Member Countries are vigorously pursuing the Roll Back Malaria initiative which aims at halving the malaria burden by 2010

13 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

for Small Hospitals” have been developed. Similarly, efforts are under way to establish a monitoring and evaluation system at the country level, in line with the agreed framework developed by the Regional Office to monitor the progress of RBM and evaluate outcomes. To facilitate information exchange, a user-friendly RBM web site and RBM Newsletter are in the offing, while an updated database is on the Intranet. Increasing access to diagnosis and treatment of malaria in children, including vector control measures, is a priority to reduce mortality in children under five years. This can be achieved through collaboration between IMCI (Integrated Management of Childhood Illness) and RBM. Community mobilization is important to achieve success since poor and unreached people suffer the most from the ill-effects of malaria. Plans were prepared jointly by staff from WHO headquarters and the Regional Office and RBM-IMCI collaboration was initiated in the countries of the Region in 2002. An intercountry meeting was organized in November 2002 with the participation of programme managers of IMCI and RBM from five most-affected countries, and WHO staff from the countries, the Regional Office and WHO headquarters. It was agreed that collaboration will be initiated in at least one district in each country where the experience will be carefully documented and then scaled up to cover larger areas. WHO collaborating centres and national centres of excellence and WHO supported ACTMalaria (Asian Collaborative Training Network for Malaria) are being increasingly involved in capacity building on priority areas in the control of malaria and other vector-borne diseases. In addition, ACTMalaria focuses on training of national staff on the management of malaria field operations, drug policy formulation, malaria case management, health education and community mobilization. ACTMalaria has also established a web site.

Tuberculosis The Region carries 37 per cent of the global burden of TB. Three million new cases and nearly three-quarters of a million deaths due to the disease occur in the Region every year. The incidence of disease is highest in the most productive age groups (15-54 years). Rising trends in HIV infection in some

14 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

countries, together with the emergence of multidrug resistant strains of tuberculosis, pose additional threats. Considerable progress has been made in the expansion of Directly Observed Treatment Shortcourse (DOTS) by Member Countries (Figure 1.2), especially those carrying a high burden

Figure 1.2: DOTS coverage in high burden countries 100 90 80 90 95 95 85 86

Percentage coverage

70 60 50 40 30 20 10 0 Bangladesh India Indonesia 13 46

67

45

40

Myanmar

Thailand

Source: WHO/SEARO

1999

2002

of the disease, e.g. Bangladesh, India, Indonesia, Myanmar and Thailand. Bangladesh has covered virtually the entire country; case detection is being intensified. India has expanded the programme rapidly, covering 560 million people by April 2003. Currently, it has the second largest DOTS programme in the world, after China. Indonesia is expanding DOTS and has demonstrated a strong political commitment during the process of health sector reform. Myanmar has covered 85 per cent of the country with DOTS. With support from WHO and the Global Drug Facility (GDF), it is expected to cover the entire country by end-2003. Thailand has achieved 86 per cent coverage. DOTS implementation in the urban areas, TB-HIV collaborative activities and strengthening of the key components of DOTS during the ongoing health sector reform are areas of focus for the TB control programme. Among the low burden countries, Bhutan has achieved complete population coverage; improving the delivery of ambulatory DOTS in remote areas and ensuring accurate reporting are under way. DPR Korea is rapidly expanding DOTS; current population coverage stands at 66 per cent.

15 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Maldives achieved and has maintained global targets since 1995. Nepal achieved these targets in July 2002. Sri Lanka has achieved 95 per cent population coverage with DOTS; fully ambulatory DOTS has been introduced in 13 districts. With improved cure rates, global targets are expected to be achieved during 2003 and 2004. DOTS coverage now extends to over 60 per cent of the Region’s population; under the DOTS strategy, over 700 000 patients are being put on treatment every year with a success rate of around 80 per cent in areas where the strategy has been applied. The quality of diagnosis has been good; however, the number of cases detected is still low at fewer than 30 per cent of estimated cases.

Member Countries have made considerable progress in the expansion of DOTS

Though the quality of DOTS implementation in all Member Countries is good, it is necessary to further expand and intensify activities in order to increase case detection (see Figure 1.3) and ensure that increasing numbers of those suffering from TB are successfully treated and cured. Epidemiological issues relating to this are being analysed. Continuing constraints for national TB programmes are: a lack of adequate technical and managerial expertise to sustain and improve the core functions of DOTS; transitional difficulties in the implementation of DOTS programmes during the process of health sector reform, including insufficient commitment to TB control, particularly at the level of local governments in countries where health care has been decentralized; and the need to meet emerging challenges such as HIV-associated TB and MDR-TB. Partnerships with other key sectors have to be further developed and operational research to increase the reach and utilization of DOTS undertaken. The required key interventions have been identified and considerable resources committed by bilateral donors and partners as well as the Global Fund. Given the current impetus and additional resources, it is expected that the Region will reach the global targets set for TB control by 2005. The Regional Office has developed guidelines and assisted countries in developing plans for the implementation of TB control activities in the next five years. A Regional Strategic Plan for TB Control has been prepared. Member Countries were assisted in developing proposals for the first two rounds of GFATM; five out of the six countries in the Region who

16 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Figure 1.3: TB case detection in the SEA Region, 1994 - 2001 100 90 Cases notified under DOTS (%) 80 70 60 50 40 30 20 10 0 1 1 1995 4 1996 5 1997 8 13 17 26 Target: 70 % by 2006

1994 Source: WHO/SEARO

1998

1999

2000

2001

applied for support for TB control qualified. Several Member Countries, namely Bangladesh, DPR Korea, India, Indonesia, Myanmar and Sri Lanka, have received, or will receive, assistance through the Global Drug Facility (GDF) to ensure regular supplies of quality anti-TB drugs. Joint plans of action for initiating disease control in adjoining border districts between Bangladesh, Bhutan, India, and Nepal have been drawn up and will be implemented in 2003. Assistance was provided to develop a network of quality assured laboratory services for smear microscopy in several countries and for establishing drug resistance surveillance. Initiatives to promote effective collaboration with other sectors providing care for TB patients in order to increase access to standardized care has led to the documentation and development of successful models of public-private partnerships in India, Indonesia, Myanmar and Nepal. Draft regional guidelines for the introduction of DOTS in the workplace have been developed. Joint meetings of national TB and HIV programme managers have been held since 2000 to discuss joint and collaborative activities. A regional framework for a comprehensive approach to TB-HIV has been developed and countries are being assisted in developing collaborative TB-HIV projects. Operational research in priority areas such as gender equity in access to health, DOTS services in urban areas and in hard-to-access areas, for the marginalized and those co-infected with TB and HIV , are also being supported.

17 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Several regional training courses on various aspects of TB control were also held during 2002-2003. In addition, technical and training materials were developed and widely disseminated.

The Global Fund to Fight AIDS, Tuberculosis and Malaria AIDS, TB and Malaria, which are closely linked with poverty, have had a devastating global impact. To address these problems, a Global Fund to fight AIDS, TB and Malaria (GFATM) was established at the initiative of the UN SecretaryGeneral, to mobilize and rapidly disburse additional financial resources through a new public-private partnership. The aim of the Fund is to make a significant contribution to the reduction of illness and death, and thereby contribute to poverty reduction. For the South–East Asia Region, which bears an extremely high burden of communicable diseases, the availability of additional resources could make a considerable difference. The Fund, therefore, presents a good opportunity for the countries to substantially enhance effective interventions to combat these priority health problems. Over the past year, the Regional Office supported Member Countries in preparing proposals and in mobilizing resources from the Global Fund. This resulted in an amount of US$1.4b being allocated over five years during the first round of proposals, of which US$ 282m was allocated to countries in the South-East Asia Region. In addition, the GFATM Board, in January 2003, approved the second round of proposals, including 9 components from 6 countries in the Region (Bangladesh, India, Myanmar, Nepal, Thailand and Timor-Leste) with an allocation of US$ 275m over five years.

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2 NONCOMMMUNICABLE DISEASES AND MENTAL HEALTH Surveillance, Prevention and Management of Noncommunicable Diseases Noncommunicable diseases (NCDs), including cardiovascular diseases (CVDs), cancers, chronic pulmonary diseases, diabetes mellitus, and other chronic diseases, are assuming alarming proportions and becoming the leading causes of mortality, morbidity and disability in the Region. This situation is due to the demographic and socioeconomic transformation taking place in the Region which, in turn, has resulted in profound lifestyle changes. The observed increase in NCDs has however not resulted in the adoption of appropriate measures to contain these diseases. This is reflected in the meagre resources allocated and the limited interest of most governments in identifying and addressing public health priorities related to NCD prevention and control. The NCD control programme in the Region is based on the Global Strategy for Prevention and Control of NCDs. The strategy targets important modifiable lifestyle-related risk factors like tobacco and alcohol consumption, physical inactivity, poor diet and nutrition, obesity and high blood pressure. The key components of the strategy include: (a) surveillance as an essential tool to quantify and track epidemics of NCDs and their determinants; (b) preventive activities to reduce the burden of premature mortality and disability; and (c) strengthening health care and supporting health sector management.

The NCD control programme in the Region targets important modifiable lifestyle-related risk factors like tobacco and alcohol consumption

19 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

There is a lack of reliable NCD morbidity and mortality data. Information that is available is mostly institution-based. There are also substantial deficiencies in the availability, accessibility and validity of data on risk factors for major NCDs. The publication, “Noncommunicable Diseases in South-East Asia – A Profile”, developed by the Regional Office, has been useful to Member Countries in developing sustainable databases for NCDs. Efforts are being made to develop a regional NCD risk factor profile and establish a regional NCD risk factor information base. Scientifically sound databases on NCDs will be an easily accessible source of information that will contribute to the planning, monitoring and evaluation of interventions. The World Health Report 2002 on “Reducing risks – promoting healthy life” highlighted the fundamental role of risk factors as a cause of ill-health. Five of the top ten risk factors identified are: tobacco, alcohol, high blood pressure, high cholesterol and obesity - all major risk factors for NCDs. These risk factors are now becoming increasingly prevalent in developing countries leading to a double burden of disease. Hence, the regional NCD surveillance programme focuses on NCD risk factors. This approach is regarded as the most feasible and appropriate way to strengthen regional health information systems and assist countries in health planning, advocacy and evaluation of NCD programmes. Eight countries, viz. Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand, are being supported in planning and conducting standardized NCD risk factor surveys using the WHO STEP-wise approach. This approach provides standard materials and offers a simple and flexible tool for the collection of risk-specific health data which can help predict major chronic diseases. The approach is being adapted as a methodological and conceptual framework for NCD risk factor surveillance activities implemented in the Region. The current focus is on strengthening the capacity of Member Countries to plan and conduct standardized surveys and to analyse and utilize their results. In order to provide comprehensive technical support in implementing STEPs surveys, a Regional Statistical Support Group and a Regional Pool of Equipment were established. Intercountry training on applying the STEPs methodology and on data management, analysis and reporting was conducted by WHO in 2002 and 2003.

20 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Recognizing the importance of setting up a simple, reliable and sustainable system of NCD surveillance, the Regional Office supported the development of national NCD surveillance networks in six Member Countries, viz. Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand. The workshops held in these countries facilitated the development of a national consensus on the objectives, scope and methods of surveillance of major NCDs and their risk factors. Based on these experiences, the Regional Office initiated a Regional Network for NCD Surveillance in 2002. A regional strategy for NCD surveillance was formulated in October 2002 which provides a framework and sets targets till 2010. While in the initial stages the focus is on NCD risk factor data collection, data management and utilization are also given due emphasis. The subsequent focus is on setting up databases, integrating NCD data into national health information systems and on NCD morbidity and mortality surveillance. Following the recommendations of the Intercountry Consultation on Regional Strategy for Integrated Disease Surveillance, held in Yangon in August 2002, Member Countries are being encouraged to set up mechanisms for the integration of NCD risk factor surveillance into national health information systems. NCDs are the leading cause of death and disability. Though disease rates from these conditions are increasing in the Region and affect all socioeconomic strata of society, NCDs are not yet regarded as a high public health priority. Also, the present capacity for planning, implementing and evaluating NCD prevention and control programmes in the Region is limited and needs to be enhanced. Reduction of morbidity and premature mortality due to NCDs requires vigorous action and involvement of multiple sectors at all levels – from primary prevention to treatment and rehabilitation. Interventions applied during the advanced stage of the diseases usually have a limited impact and are less cost-effective. Therefore, prevention is a more feasible option for low-resource countries. Although a majority of the Member Countries implement various NCD prevention and control programmes, they are most often vertical, disease-specific and tertiary-care focused rather than integrated, oriented on population-based

NCDs are not yet regarded as a high public health priority

21 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

prevention and directed at addressing common determinants of NCDs and their risk factors. NCD programmes in the Region require a more holistic approach utilizing health promotion strategies, ensuring community empowerment and involving multiple sectors. Some countries, such as Thailand, are relatively advanced in implementing an integrated NCD programme. The results of community-based NCD prevention projects implemented in developed countries have clearly demonstrated that even modest risk factor reduction through adoption of healthy life styles brings a huge public health benefit. However, the evidence on feasibility and effectiveness of applying such interventions in the developing world is still missing. Bangladesh, India and Indonesia recently initiated demonstration projects on integrated community-based NCD prevention with WHO support. The pilot phase of the projects has been completed. At an intercountry consultation, held in New Delhi in January 2003, the outcomes were reviewed. It was concluded that a community-based approach to prevention of NCDs is feasible and appropriate for implementation in the Region. The consultation recommended scaling up projects from the pilot phase to the demonstration phase, to improve documentation of the intervention process and to carry out a systematic evaluation of its impact. Accordingly, baseline surveys using a standard methodology have already been conducted at the demonstration sites. Health promotion and disease prevention are more effective in an overall environment of suitable public health policy, appropriate legislation, supported by cost-effective interventions for established diseases and for individuals at greater risk. For this reason, the Regional Office is using the experience of other regions that have initiated regional NCD prevention networks and integrated them within the Global Forum for NCD Prevention and Control. Four Member Countries, viz. Indonesia, Maldives, Sri Lanka and Thailand, are being supported in capacity building and developing national NCD prevention networks. These networks will facilitate coordinated planning, implementation and evaluation of NCD prevention programmes. They will also help in promoting implementation of an integrated approach to NCD prevention and control and establishing sustainable mechanisms for intersectoral collaboration.

NCD programmes in the Region require a holistic approach utilizing health promotion strategies and involving multiple sectors

22 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The epidemiological transition occurring in the Region is stretching the limited resources of Member Countries resulting in major developmental implications that need to be urgently addressed by appropriate action aimed at strengthening control of NCDs. WHO is emphasizing the need to shift the focus of policy-makers and medical practitioners from expensive tertiary care-based diagnostic and curative procedures to primary and secondary prevention through community and primary health care-based interventions. Management of NCDs at the PHC level needs strengthening. One of the important WHO priorities in this area is developing simple practice guidelines to help improve standards and quality of care, improve cost-effectiveness of applied interventions and reduce costs of treatment by avoiding unnecessary investigations, procedures and medication. This will also help to emphasize the importance of therapeutic education and thereby improve compliance. A regional review of the existing national guidelines for management of CVDs, conducted in 2002, revealed that although such guidelines exist in some Member Countries, they do not address the needs at the PHC level and do not have governmental endorsement. In 2003, the Regional Office initiated a process of developing integrated “best practice” guidelines for the management of major NCDs at the PHC level.

Tobacco As part of continuing efforts to assist Member Countries to participate effectively in the WHO Framework Convention on Tobacco Control (FCTC) and to facilitate their participation in its negotiations, the 4th and the 5th Regional Intersessional Meetings (ISMs) on FCTC were organized in Yangon in August 2002 and in Geneva in February 2003, prior to the fifth and sixth sessions of the Intergovernmental Negotiating Body (INB) in Geneva. These meetings helped Member Countries to clarify and strengthen their positions on various sections of FCTC. The culmination was the unanimous adoption by the Fiftysixth World Health Assembly, in May 2003, of the Convention which aims at curbing tobacco-related deaths and diseases. The Convention requires countries to impose restrictions on

23 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The Fifty-sixth World Health Assembly unanimously adopted the Framework Convention on Tobacco Control, in May 2003

tobacco advertising, sponsorship and promotion, establish new norms for labelling and clamp down on tobacco smuggling. Youth being the most vulnerable and easily reachable target of the tobacco industry, WHO and the Center for Disease Control (CDC), Atlanta, USA, developed the Global Youth Tobacco Survey (GYTS) to track tobacco use among youth across countries. The intention is to enhance the capacity of countries to design, conduct surveys, write the report and evaluate tobacco control and prevention programmes focused on youth. GYTS activities were undertaken in six states of India (Delhi, Maharashtra, Andhra Pradesh, Bihar, West Bengal and Tamil Nadu) and in Indonesia, Myanmar, Nepal and Sri Lanka. In order to expand the study, principal investigators from Bangladesh, Bhutan and Maldives and eight states of India (Gujarat, Karnataka, Andaman and Nicobar Islands, Punjab, Haryana Himachal Pradesh, Madhya Pradesh, and Kerala) were trained in Mumbai in December 2002. Following this, a GYTS Analytical Workshop was also organized at the same venue. It was attended by investigators from eight states of India and one each from Indonesia, Myanmar, Nepal and Sri Lanka. The results of the Global School Personnel Survey (GSPS), which were combined with GYTS, were also analysed. In addition, the draft of the Global Medical Doctor Survey questionnaire was discussed. There is also a plan to repeat GYTS in some countries. Following an invitation from WHO headquarters for proposals from NGOs for funds under the UN Foundation’s (UNF) project entitled, “Channelling the Outrage”, five proposals from Bangladesh, India, Nepal and Sri Lanka were selected. Agreements (APWs) were concluded with the identified contractual partners to implement the project. Similarly, under another UNF project entitled, “Protecting the Youth from Tobacco in 5 countries”, four proposals from India were selected and APWs were concluded with the identified experts/institutions. The activities are expected to be completed by the end of 2003. A workshop on Community-based Tobacco Use Cessation Interventions was held in Colombo in September 2002 with the participation of principal investigators from India, Indonesia, Myanmar, Sri Lanka and Thailand. After the

24 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

workshop, studies on the implementation of pilot projects on community-based tobacco cessation interventions have been initiated in these countries. In view of the greater impact and the need to adopt a multisectoral approach to tobacco control, a review of existing and potential multisectoral mechanisms for comprehensive national tobacco control in eight countries, viz. Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand, was initiated. As a follow-up of the joint WHO-World Bank economic analysis of tobacco control, conducted in seven countries of the Region in 2001, a workshop on Economics of Tobacco Control was organized in Bangkok in March 2003. The workshop reviewed and finalized the reports of the country studies. As usual, World No-Tobacco Day was observed on 31 May 2003. This year’s theme was “Tobacco free films, Tobacco free fashion - Action”. The Regional Office developed an information kit and supported Member Countries in observing the day in a befitting way. Given the impact of Bollywood films on tobacco consumption among the youth, the Regional Office disseminated the findings of the WHO study on the portrayal of tobacco in Indian cinema entitled, “Bollywood – a victim or ally”? In order to assess the situation on the overall impact of tobacco on women, a regional situation analysis on the subject is being carried out. Similarly, given the widespread production and use of chewing tobacco and its serious health impact, another regional situation analysis has been undertaken in this area.

A regional situation analysis is being carried out on the impact of tobacco use on women.

Health Promotion During the period under review, there was increased emphasis on advocacy for health promotion. To give a greater thrust to the concept of healthy settings, three documents, Health Promoting Hospitals, Towards a Safe and Healthy Workplace and Health Promoting Schools, were finalized. Following the Regional Committee resolution in 2000 and the Intercountry Consultation on Integrated Management of 25 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Prominent leaders in Member Countries participated actively in promoting healthy life styles.

Healthy Settings at the District Level in May 2001, “Healthy District” projects have been initiated during the second half of 2002 and early 2003 in Mirzapur District, India; Gaaf Alif Atoll, Maldives, and Amparae District, Sri Lanka. The Healthy District approach will help in coordinating the development of a range of healthy settings within the district. The regional concept and strategies paper and Operational Guidelines on Healthy Districts, developed in 2002, are being finalized. The training module on the management of integrated healthy settings at the district level will also be field-tested.

26 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

A facilitators’ guide for imparting training on life skills education and dealing with adolescent health is being finalized. It will help countries to expand health promotion in schools through health jamborees, etc. A study was undertaken in seven countries to document healthy life styles with the emphasis on physical activity and diet. On the basis of the study reports, a draft Regional Profile on Diets and Physical Activities for Health in the SEA Region was prepared. It was discussed at the Regional Consultation on Global Strategy for Diet, Physical Activity and Health, held at New Delhi in March 2003 with support from WHO headquarters. In the light of the expressed concerns of Member Countries, an Inter-Regional Consultation on Capacity Building for Health Promotion was organized in Bangkok in February 2003 with technical collaboration and financial support from WHO headquarters. The Fifty-fifth World Health Assembly adopted a resolution on Diet, Physical Activity and Health in 2002. WHO was requested to develop a Global Strategy for Diet, Physical Activity and Health within the renewed WHO strategy for the prevention and control of NCDs, in consultation with Member States and other UN agencies. WHO headquarters developed a draft Global Strategy which will be finalized after regional consultations are held. Inspired by the World Health Day theme for 2002 “Move for health”, political leaders in Bhutan and Thailand, supported by WHO, made a very strong public demonstration of their commitment to healthy life styles. In September 2002, Lyonpo Sangay Ngedup, Minister of Health and Education, Bhutan, with a small team, trekked 560 km over a period of 16 days, across tough mountain ranges in the Himalayas. In November, led by Thailand’s Prime Minister, Dr Thaskin Shinawatra, the country organized a historic gathering of nearly 50 000 people who performed aerobics for over an hour. This year, the World Health Day (WHD) theme was “Healthy Environments for Children”, with the slogan, “Shape the Future of Life”. The Regional Office supported various activities in the Member Countries. At the invitation of the

27 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The WHO Director-General celebrated World Health Day in New Delhi with the Health Minister of India and the Chief Minister of Delhi.

Government of India, Dr Gro Harlem Brundtland, DirectorGeneral, WHO, visited the country from 5 to 8 April 2003 to participate in the WHD activities.

Disability/Injury Prevention and Rehabilitation Injury and violence prevention Recognizing the huge burden of injuries and violence in the Region (1.3 million deaths in 2000), WHO initiated several activities to reduce the burden and impact of injuries in Member Countries. A regional strategy was prepared with the participation of all countries. The strategy identifies three areas of work for injury prevention: (a) policy development, advocacy and programme development, (b) human resource and infrastructure development, and (c) reducing injury burden through programme implementation. Two Member Countries, Nepal and Sri Lanka, were assisted in preparing a national policy framework for preventing injuries. Discussions on the subject are under way with the Ministry of Health in India. An advocacy brochure on “Injuries in SEA Region – Priorities for Policy and Action” was prepared and disseminated to all Member Countries and other WHO regions.

28 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

To strengthen human resources, a regional training programme for trauma epidemiology and injury surveillance was organized at the WHO Collaborating Centre for Injury Prevention and Safety Promotion in Khon Kaen, Thailand, in December 2002. Twenty professionals from eight countries participated in the training. Further support for establishing injury surveillance systems in these Member Countries is being provided. An international course on road safety was held in New Delhi in December 2002 where 30 participants from Member Countries learnt about road safety management. This helped in creating a critical mass of change agents in the area of injury prevention and safety promotion. Similarly, a regional survey on infrastructure and human resources for injury prevention is under way in seven countries of the Region. The survey protocol was finalized at a meeting of principal investigators in Bangalore, India, in November 2002. At the national level, a study on the epidemiology of injuries was completed in India with support from the Regional Office while Maldives developed an injury information system, with WHO support. Following the global release of the World Report on Violence and Health by the Director-General, the Regional Director released the report on 15 November 2002. A regional seminar to discuss the recommendations of the report followed the release. Three countries, Nepal, Sri Lanka and Thailand, held a national seminar to discuss the report and its importance and have since released the report. To provide further advocacy support, an information booklet on violence and health was prepared and distributed.

Prevention of blindness and deafness An intervention pilot project has been launched in three countries (Bhutan, Myanmar and India) for prevention of corneal ulcer following ocular injuries. The results of this study, expected to be completed by December 2003, will go a long way in identifying appropriate models for prevention of injury-related blindness.

29 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

A regional consultation on corneal blindness was organized in November 2002 in Delhi. Key issues identified included the development of a protocol for the treatment of corneal ulcers for all levels of the health system and strengthening eye banking services in the Member Countries. To strengthen eye care programmes, 19 directors of eye hospitals, five programme managers and six administrators from Member Countries were trained in eye care management at Aravind Eye Hospital and Lions Aravind Institute of Community Ophthalmology, Madurai, India. The hospital is a WHO collaborating centre for prevention of blindness. A team consisting of an ophthalmologist, an anaesthetist and an ophthalmic nurse is being trained to provide surgical eye care to children to address the problem of childhood blindness in eight countries of the Region. One batch each from Bangladesh, Indonesia, India and Nepal have completed the training. Support is being provided to these countries to set up paediatric eye care units. All the above activities have greatly helped in furthering the objectives of Vision 2020: The Right to Sight, in the Member Countries. A survey of available infrastructure and human resources for deafness and ear disease was completed during the period under review in Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. Mechanisms to reduce the impact and burden of deafness and hearing impairment were identified at an intercountry consultation in December 2002. A Regional Forum for Prevention of Deafness and Hearing Impairment, as suggested by the consultation, is being constituted. Support was also provided to the countries for training primary health care workers in primary ear care and for conducting mobile ear camps. Guidelines for formulating national programmes for prevention of deafness are being developed.

Ageing and health 30 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

To address the issues related to the rapidly ageing population, a “Regional Profile on Care of the Elderly” is under preparation. The profile examines the health status of the elderly in relation

to morbidity, mortality and disability, as well as the behavioural risk factors for illness. Economic security, living conditions and participation of the elderly in the community have been explored and national initiatives reviewed. The profile provides the necessary evidence base for formulating a regional response to the increasing problem of ageing population in Member Countries.

Rehabilitation The steady increase in the elderly population as well as the number of people who have survived serious injuries has resulted in a rapid increase in the number of disabled. To address this issue, measures for strengthening rehabilitation services in six countries (Bangladesh, Bhutan, India, Nepal, Sri Lanka and Thailand) were discussed at an intercountry consultation in August 2002. Measures for strengthening local involvement and multisectoral approaches in community-based rehabilitation (CBR), provision of rehabilitation services at the primary health care level and specialized services, building rehabilitation systems as well as monitoring and evaluation were identified. Specific roles for each of the key stakeholders (WHO, governments, NGOs, disabled persons’ organizations etc.) were recommended. During the period under review, the issue of “Employment Opportunities for Persons with Disabilities” was discussed at an intercountry meeting held in New Delhi in February 2003. Organized in collaboration with the Office of the Chief Commissioner for Persons with Disabilities, Ministry of Social Justice and Empowerment, Government of India, the meeting included participants from Member Countries comprising government representatives, health managers, industry representatives, NGOs, the International Labour Organisation and WHO. The next step will be to implement the key recommendations of the meeting which includes creating awareness among prospective employers and promoting a barrier-free working environment for disabled people who have been suitably trained. The increasing number of elderly people in the Region is a cause for concern.

Mental Health and Substance Abuse As a follow-up of the World Health Day theme devoted to Mental Health in 2001, activities in mental health and substance

31 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

abuse were strengthened in Member Countries. There is increased awareness about the importance of mental and neurological disorders and the need to shift from hospitalbased psychiatric care to community-based mental health services which include promotion of mental health and prevention of disorders. It is estimated that about 1 per cent of the total population of the Region (i.e. about 15m people) are affected by epilepsy. Unfortunately, less than 100 000 of those affected get appropriate treatment, leading to significant morbidity amongst persons affected by epilepsy. Also, the stigma associated with epilepsy prevents patients and families from seeking modern medical treatment. As a follow-up of the intercountry workshop, held in Bangkok in November 2001, a simple questionnaire containing only six questions has been developed. If four out of six questions are positive, it is likely that the person has generalized tonic-clonic type of epilepsy and needs to be treated. This questionnaire has been tested in eight Member Countries and will soon be ready for implementation in the community on a large scale. A simple manual describing the optimum method of treatment with phenobarbitone for such patients has been developed. This easy-to-use manual can be used by health care providers even in rural and remote areas. The cost of medication is extremely low and can either be provided by governments or purchased by patients. A similar programme on identification, management and stigma removal for psychosis is being developed and is in the second phase of testing. Mentally challenged individuals, both children and adults, need rehabilitation services in order to reintegrate into their families and the community. A manual has been developed for implementation in rural and remote areas for rehabilitation of children with mental retardation. This manual is now being printed in draft form and will be finalized at a workshop later in 2003. 32 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Adolescence is a critical period in a person’s life. In the rapidly changing social, cultural and economic environment, adolescents are coming under increasing mental and psychological pressure.

To promote positive mental well-being amongst adolescents, eight modules entitled: Coping with Stress, Conflict Resolution, Strengthening Bonds with Others, Handling Peer Pressure, Selfesteem Enhancement, Dealing with Emotions, Prevention of Harm from Alcohol, and a Trainers’ Guide for implementation of these modules have been developed. These modules have been tested in India, Indonesia and Thailand and found to be very useful. The modules are being finalized and Member Countries will be supported in “Training of Trainers” using these modules on a nationwide basis. Suicide, particularly amongst the young, is a major problem in some Member Countries. An intercountry study has been initiated by WHO headquarters in which three countries – India, Sri Lanka and Thailand – are participating. The results of this study are expected to help in the identification of unique local factors which predispose a person to commit suicide and thus help in saving precious lives. In collaboration with WHO headquarters, a programme on assisting Member Countries in the Region in updating/ developing modern mental health policies and services has been developed. Modules which serve as resource material for sensitizing senior policy-makers, bureaucrats and health professionals have been adapted for use. Sensitizing senior policy-makers and planners about mental health policies and services is important to ensure that appropriate priority is accorded to mental health and to help develop services in keeping with recent advances in medical science. With advances in public health and control of infectious diseases, life expectancy has increased in most parts of the world. Thus, the number of the elderly is rapidly increasing. There are significant socioeconomic and humanitarian implications of this phenomenon which require intensive study for planning and policy development. Also, there is increasing awareness of the mental health needs of the elderly, including development of the field of psychogeriatrics, which is virtually non-existent in the Member Countries of the Region.

In the rapidly changing social, cultural and economic environment, adolescents are coming under increasing mental and psychological pressure

Prevention of harm from alcohol and substance use The attitudes to and practices of alcohol use have been undergoing definitive changes in the countries of the Region,

33 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

more so in the last two decades. The WHO Global Status Report on Alcohol documents that alcohol consumption in the SouthEast Asia Region is rising. This trend also needs to be seen in the context of rapidly falling consumption patterns in the European region. It is believed that with the developed countries reaching stable, saturation or declining patterns of consumption, market forces are targeting developing countries. Alcohol abuse in the rural communities of Member Countries is a particularly serious problem. No reliable population-based data are, however, available. The pattern of drinking is usually binge drinking centred around pay day or on special occasions, such as marriages and festivals. Alcohol is frequently related to domestic violence, quarrels with neighbours and numerous accidents such as road accidents etc. Also, given the poor socioeconomic status of most rural communities, disproportionate amounts of family income are spent on alcohol, leaving very little for food, education, housing and health. Thus, a vicious cycle of poverty is perpetuated. Usually, locally-brewed or home-brewed alcohol is consumed. Sometimes this is contaminated with methanol or other toxic agents, leading to frequent cases of poisoning in rural areas. An intercountry workshop, held in Bali in June 2002, in which six Member Countries participated, developed outlines of innovative projects which can be tested for their impact on prevention of harm from alcohol use in the community. These projects will be tested in these countries with WHO support. Since time immemorial, in most countries of the Region, drugs have traditionally been used, in addition to alcohol, for ritual, religious and recreational purposes. These drugs were mainly cannabis products and opium. The apparent social acceptance of such substances stemmed largely from the fact that there was no abuse. Where there was, it was severely ostracized. Unfortunately, what is seen today, on a global scale, is a virtual epidemic of drug dependence. A disturbing trend is that more and more younger people are being drawn into this devastating habit. Moreover, problems such as petrol and solvents sniffing are increasing amongst adolescents, particularly street children and slum children. This often acts as a “gateway drug” for the use of more dangerous substances later.

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3 FAMILY AND COMMUNITY HEALTH Child and Adolescent Health Integrated Management of Childhood Illness The Integrated Management of Childhood Illness (IMCI) strategy is an important initiative for improving the status of child health in the Region. The strategy aims to improve health worker skills in managing common childhood illnesses (acute respiratory infection, diarrhoea, measles, malaria and malnutrition) and to promote child health and development. A cornerstone of the strategy is effecting health system improvements and promoting appropriate family and community practices. During the period under review, regional and national-level capacity for implementing IMCI was further enhanced. Intercountry IMCI training courses were organized and the Kanti Childrens’ Hospital, Kathmandu, was designated as a WHO collaborating centre for training in child health. The Regional Office provided technical support for the adaptation of the generic IMCI guidelines and facilitated two national-level training courses in India. Technical support was provided to nationallevel training courses in Bangladesh and Timor-Leste. A substantial proportion of the population in many countries approach community-based health workers for curative and preventive health services. WHO has developed an IMCI package for basic health workers (BHW) to increase the access of disadvantaged population groups to IMCI. The package has been adapted and is in use in India and Nepal.

The IMCI strategy aims to improve health worker skills in managing common childhood illnesses and to promote child health and development

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The Integrated Management of Childhood Illness strategy is an important initiative for improving child health.

A demonstration training course for BHWs was organized in Bangladesh. Responding to a demand from some Member Countries, the IMCI package for basic health workers was expanded to include management of malaria and newborns. The draft package was shared with Member Countries at a workshop held at Agra, India, in January 2003. Feedback received from the countries would be incorporated in the training materials before field-testing and finalization. Bangladesh has initiated adaptation of the package to meet its programme needs. A review of the early implementation phase of IMCI in Bangladesh was carried out in February 2003. It resulted in a set of recommendations which will guide the expansion of IMCI in the country. In September/October 2002 an analytical review of IMCI was undertaken in collaboration with the Government of Indonesia, partners and WHO headquarters. The review is part of a global initiative for an in-depth analysis of factors that contributed to success and identifying constraints to help enhance the effectiveness of the IMCI strategy. India will introduce the adapted version of IMCI called Integrated Management of Newborn and Childhood Illness (IMNCI) in six districts under the UNICEF-supported Border Districts Cluster Strategy project. Technical support was provided to facilitate the inclusion of IMNCI in the World Bank-supported Reproductive and Child Health Programme

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(Phase II), expected to commence later in 2003. DPR Korea was assisted in initiating IMCI. Adaptation of the generic IMCI materials was completed and support was provided for initiating the planning process. To bring private practitioners into the IMCI fold, guidelines for private practitioners were developed. These are currently being field-tested by the Indian Academy of Paediatrics involving a cohort of 1 000 private practitioners. IMCI has been included in distance learning courses for doctors and paramedics by the Indira Gandhi National Open University (IGNOU) in India. India has decided to introduce IMCI in five medical schools. Adaptation of materials and training of faculty has been completed. The selected medical schools will include IMCI training from the academic session commencing in 2003. Pre-service training has been introduced in eight medical schools in Nepal. The faculty of the national apex institute Council for Technical Education and Vocational Training (CTEVT) - which is responsible for pre-service training of paramedical staff, has been trained. The National Institute of Public Cooperation and Child Development (NIPCCD), New Delhi, has introduced the Basic Health Worker IMCI package in the pre-service curriculum of ICDS workers following a pilot study in Haryana state in which 300 workers and 25 supervisors received training. Collaborative efforts with other programmes in the Regional Office continued. A Strategic Framework for RBMIMCI collaboration has been developed. An intercountry meeting on RBM-IMCI collaboration was organized in November 2002 in New Delhi. Collaboration with EHA (Emergency and Humanitarian Action) Unit resulted in the production of an orientation package on IMCI for health workers who provide health care to children in disaster situations. To assist countries in making available information relating to child health, compilation of country-specific child health profiles has been initiated. During the reporting period, child health profiles in respect of Bangladesh, Indonesia and Nepal were drafted and are in the process of finalization in consultation with the respective governments.

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Neonatal health It is well recognized that neonatal mortality contributes to over two-thirds of the deaths during infancy. It is thus imperative that attention be accorded to this relatively neglected area in child health programmes if the Millennium Development Goals are to be achieved. A regional consultation on the subject was organized in April 2002 which, inter alia, recommended the development of a regional strategic framework for improving neonatal health. As a follow-up of the recommendations of the consultation, a draft Regional Strategic Framework, a regional situation analysis and advocacy documents were developed and circulated to Member Countries and partners for their review.

Infant and young child feeding Malnutrition rates among children in the Region are unacceptably high. WHO has developed a Global Strategy for Infant and Young Child Feeding which is being adapted for the Region with support from the Regional Office.

Child rights and protection The Regional Office has taken a lead in promoting child rights through, among other activities, advocacy materials. As a follow-up of the Regional Orientation Workshop on the Convention on the Rights of the Child, held in 2002, an orientation workshop was organized for the southern states of India at Ooty, Tamil Nadu, in September 2002. Participants representing health, social welfare, education, juvenile justice, water and sanitation sectors participated.

Adolescent health and development Adolescence is recognized as a period of great opportunities and risks. Over 20 per cent of the population in the countries of the Region is in the adolescent age group. The health needs of this sub-group had been relatively neglected in the past. During the year, the following aspects of the programme were addressed: 38 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Advocacy for policy and strategy formulation was carried out in Bangladesh, India, Indonesia, Maldives, Myanmar and

Healthy children - a nation’s future.

Sri Lanka. To assist policy formulation, a situation analysis in six countries has been completed. The need to develop adolescent-friendly health services (AFHS) has now been recognized. Six new AFHS centres were opened in India and one in Nepal. Training workshops on AFHS were supported in India and Nepal. During workshops on adolescent health, orientation sessions on AFHS were conducted in Bangladesh, Maldives and Sri Lanka. The Inter-Agency Working Group (IAWG) India on Population and Development entrusted the Regional Office with developing tools for health promotion of out-of-school adolescents, especially in regard to life skills education and training. Modules for this purpose were finalized and are under print. Peer counselling is a well-tested method for providing adolescents with health messages to bring about a positive change in the level of their information and attitude, risktaking behaviour and health care-seeking behaviour. A package comprising a Trainers’ Guide, Learner’s Guide, Illustrated Booklet and Learner’s Facilitation Guide was developed and field-tested. Regional meetings and workshops, in collaboration with concerned departments in the Regional Office and WHO headquarters, were organized in the areas of adolescent nutrition, health promotion and capacity building for NGOs working with street children.

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Research and Programme Development in Reproductive Health Reproductive ill-health accounts for approximately 36 per cent of the overall burden of disease and disability among women of reproductive age in developing countries, compared with only 12 per cent for men. Problems related to pregnancy and childbirth represent 14 per cent of healthy years of life lost in women of reproductive age, in addition to 14 per cent lost because of sexually-transmitted infections, including HIV/AIDS. A number of activities in the broad area of reproductive health were organized in the Region. In India, training of doctors in emergency obstetric care was conducted to provide them with necessary skills and competencies to manage cases requiring life-saving emergency obstetric care at the first referral level. A strategy paper on community midwifery has been prepared and will be piloted in selected states. Safe abortion services have been piloted in eight states; guidelines and standardized training materials were developed and a review of the progress of maternal and newborn health programmes was conducted in early 2003. Plans for strengthening or implementing some methods of maternal death review methodology have been submitted by India, Nepal and Myanmar for technical support.

40 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION Member Countries are being supported in promoting skilled birth attendance.

In Indonesia, WHO support is concentrated on pre-service training of midwives. As a Making Pregnancy Safer spotlight country, Indonesia is strengthening its supervision system for maternal and newborn health service providers as well as improving methods of maternal death reviews. Coordination among donors has been strengthened to avoid duplication of activities. A review of maternal and newborn health data collection and its quality in the context of decentralization was initiated. In Myanmar, WHO is collaborating with UNFPA in executing the UNFPA Project: Strengthening Reproductive Health Services 2002-2005, aimed at supporting the Ministry of Health in implementing its policy for reproductive health in more sustainable programme development. Further, development of a national reproductive health strategy has been initiated. This is in accordance with the recommendations of a bi-regional consultation, held in mid-2003, in the light of accelerating the achievement of the Millennium Development Goals. In Bangladesh, piloting of a skilled birth attendant policy, developed with WHO and UNFPA support, is under way with the involvement of the Obstetrical and Gynaecological Society of Bangladesh. The Society has played an important role in improving the training and management of skilled attendants. In Indonesia, field-testing on the use of a decision-making tool, developed by WHO in collaboration with partners for assisting clients to decide on appropriate contraceptive methods, has been initiated. Evidence-based practices, their reviews and corresponding new commentaries with some practical recommendations have been communicated to Member Countries through the introduction and distribution of the WHO Reproductive Health Library (RHL) CD-ROM. This activity has been widely implemented in Thailand and India, and initiated in Indonesia. Development of a training module that can be used widely in the Region is progressing. Member Countries were assisted to critically look at their reproductive health situation and problems, and to develop or update their reproductive health profiles. These profiles are expected to allow more focused programme planning in addressing the compelling country-specific issues.

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Making Pregnancy Safer More than 30 per cent of the global maternal deaths occur in countries of the Region. The estimated maternal mortality ratio (MMR) varies from 23 in Sri Lanka to 539 in Nepal. The coverage of antenatal care at least once during pregnancy ranged from 23 per cent in Nepal to 99 per cent in Sri Lanka, Thailand and DPR Korea. Skilled birth attendance ranged from less than 20 per cent in Bangladesh and Nepal to 98 per cent in DPR Korea. Most of the deliveries in Member Countries, except in DPR Korea, Sri Lanka and Thailand, were conducted at home. Access to essential obstetric care in most countries, except in DPR Korea, Sri Lanka and Thailand, was very limited, because of lack of transport, high cost of services and lack of knowledge on danger signs during pregnancy, childbirth and the postpartum period. Moreover, a large number of women, particularly the poor and the marginalized, do not always have effective access to such life-saving technologies. Support was provided to countries to achieve the Millennium Development Goals in regard to reduction of maternal and newborn deaths. Monitoring and evaluation of the maternal and newborn health programme, including aspects of access and utilization, was conducted. In July 2002, a regional consultation on this issue was organized to encourage and facilitate representatives from Member Countries to strengthen processes and mechanisms for monitoring and evaluation of maternal and newborn health. To assure the quality of maternal and newborn health services, evidence-based norms and standards for maternal and newborn care are being promoted. While the WHO publication, Managing Complications in Pregnancy and Childbirth has been distributed, another publication, Pregnancy, Childbirth and Newborn Care: A Guide for Essential Practice, is being printed. These publications include technical standards for maternal and newborn care at first referral care and primary health care levels. Their wide distribution and adaptation is under way in India, Indonesia, Nepal and Thailand. 42 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Access to essential obstetric care in most countries of the Region is very limited due to various constraints

Collaboration with development partners has been productive in creating awareness and putting Safe Motherhood on the national development agenda of Member Countries. The

Regional Office participated in an international conference organized by the White Ribbon Alliance for Safe Motherhood, India, where representatives of countries shared their experience on safe motherhood practices. Along with UNICEF, the Regional Office has been very active in promoting best practices and implementing standards for managing complications during pregnancy and childbirth. Work on strengthening emergency obstetric care is progressing in five countries of the Region.

Women’s Health The primary focus in Bangladesh, India and Myanmar has been on gender mainstreaming. In Bangladesh, following support for the development of a Gender Equity Strategy in the Fifth Health and Population Sector Programme (19982002), WHO and partners in the Ministry of Health focused attention on promoting greater awareness of the Gender Equity Strategy among health care managers and service providers at district and sub-district levels, and on improving the capacity of the Gender Issues Cell in the Directorate General of Family Planning and the Directorate General of Health Services. India has focused on integrating a gender perspective in the Reproductive and Child Health Programme, including strengthening national capacity to collect and use sexdisaggregated data for gender analysis of health issues. Myanmar has undertaken a broad strategy to raise awareness on the links between socio-cultural factors and women’s health within the Ministry of Health through training and advocacy for women in positions of leadership and influence. In addition to the work done in country offices, training manuals were developed by the Regional Office to provide community members and health professionals a better understanding of the socio-cultural factors that influence women’s health. These manuals, together with the related tools for analysing societal determinants of health, are currently being pilot-tested. In respect of neglected or priority areas of women’s health, Indonesia developed and field-tested guidelines for hospitals to respond to victims of domestic violence. Nepal developed a strategic plan to address high priority women’s health issues. As part of this effort, a study to better understand the health needs of elderly women was designed. Sri Lanka continued its

Member Countries are actively engaged in promoting mother and child health.

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work on improving general health care services for women and reaching vulnerable groups such as female migrant workers and women employed in the free trade zone.

HIV/AIDS The AIDS epidemic continues to spread in South-East Asia, which is the second most affected region in the world, after sub-Saharan Africa. Of the estimated 42 million persons living with HIV/AIDS, more than 5 million are in the SEA Region. The HIV prevalence and the predominant modes of transmission of HIV are given in Table 3.1.

Table 3.1: HIV prevalence and predominant modes of HIV transmission in the SEA Region Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand 1 2

Reported AIDS cases1 172 13 0 48933 3

HIV prevalence (estimated number of cases)2 13 000 <100 0 3970000 120 000 <100 420 000 58 000 4 800 670 000

Mode of transmission Heterosexual + + -+++ + + +++ + + +++ Injecting drugs + --+ ++ -++ ++ -++

3568 9 5 623 624 139 2

208456

As of December 2002 As of 2001 3 As of March 2003 (--) Unknown or minimal HIV transmission; (+) Limited HIV transmission; (++) Moderate HIV transmission; (+++) Major HIV Source: WHO/SEARO

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The epidemiological patterns of HIV/AIDS are diverse in the Region, ranging from HIV epidemics with HIV prevalence in pregnant women attending ANC (>1% in Myanmar, Thailand and six states of India) to concentrated epidemics in Nepal and Indonesia (>5% HIV prevalence among high-risk behaviour groups), and low-level epidemics in Bangladesh, Bhutan, DPR Korea, Maldives and Sri Lanka. However, there is a potential for rapid spread of HIV in all countries as risk

behaviours and vulnerabilities, which fuel the spread of the infection, exist in all countries. Many countries, such as Indonesia and Nepal, recently experienced a rapid increase in HIV prevalence among injecting drug users and subsequently among commercial sex workers after a prolonged period of low prevalence. Thus, the epidemic in the Region can be considered as highly dynamic. Member Countries of the Region have made considerable progress in fighting the epidemic. They are implementing national strategic plans with the involvement of a number of government sectors, the private sector and nongovernmental organizations. Priority is being given to scaling up effective targeted interventions such as 100 per cent condom use at situation of risk coupled with management of sexually transmitted infections and harm reduction among injecting drug users. Interventions to decrease HIV transmission in the general population are being implemented in a number of countries, including the prevention of mother-to-child transmission (PMTCT), and voluntary counselling and testing (VCT). India and Thailand are expanding PMTCT programmes on a nationwide scale. VCT is being implemented nationwide in Thailand and eight additional countries of the Region are in the process of scaling up VCT services. Bangladesh, India, Myanmar, Nepal and Thailand have undertaken behavioural sentinel surveillance in order to monitor risk behaviours among selected population groups. Increasing attention is also being given to cross-border spread of the infection with preparation of joint plans of action for cross-border interventions between India, Nepal and Bhutan as well as between Thailand and Myanmar. Although there is a high level of commitment to the AIDS problem, only scaling up interventions will have an effect on HIV incidence. The coverage of interventions to prevent HIV and provide care for people living with HIV/AIDS, including second generation surveillance and programme monitoring, is still low in most countries. A prioritization of interventions in countries where resources are limited is needed. Forty per cent of the global TB burden is in the countries of the Region and there is epidemiological evidence that HIV fuels the TB epidemic. The major challenge is to contain the HIV epidemic urgently in most affected countries.

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The Regional Office continued to play a leading role in providing technical support in the health sector aspects of HIV/ AIDS, such as surveillance, STI prevention and care and blood safety. It also increased its efforts to support countries in scaling up harm reduction among IDUs, VCT, PMTCT and care, including antiretroviral treatment for people living with HIV/AIDS. The South-East Asia and the Western Pacific Regional Offices are fostering bi-regional collaboration in the areas of harm reduction among injecting drug users, enhancing access to HIV/AIDS care, including antiretroviral treatment, and coordinating the UN Task Force on HIV/AIDS Care in Asia. The Regional Office has been working with the UNICEF Regional Offices in Bangkok and Kathmandu on the prevention of mother-to-child transmission. It also continued its participation in the UN Task Force on PMTCT. WHO organized a joint meeting of national AIDS and TB programme managers in Sri Lanka in November 2002. It provided an opportunity for the programme managers to exchange experiences and opinions on TB/HIV infection and to discuss common issues related to the two infections. The meeting endorsed the draft Regional TB/HIV Strategy. Technical support was provided to Member Countries through country visits and preparation of guidelines and various other publications, such as antiretroviral treatment guidelines, HIV fact sheets for nurses, World AIDS Day materials and the regular newsletter, AIDSWatch. As a follow-up of the United Nations General Assembly Special Session on HIV/AIDS, the Regional Office will develop a regional health sector strategy in order to define and strengthen the role of the health sector within a multisectoral response. The involvement of people with HIV/AIDS in this response will especially require further strengthening. Continued advocacy and mobilization of resources as well as prioritization of effective interventions, preparation of health systems and allocation of sufficient trained human resources for scaling up such interventions remain major tasks for all stakeholders at regional and country levels. 46 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

4 SUSTAINABLE DEVELOPMENT AND HEALTHY ENVIRONMENTS Sustainable Development The concept of sustainable development encompasses economic, ecological and social parameters. The economic approach focuses on generating maximum income/economic growth while maintaining the stock of assets or capital. The ecological view stresses the stability of biological and physical systems and their protection and management for posterity. The social concept is people-oriented and seeks to maintain the stability of social and cultural systems leading to human capital formation. Correspondingly, sustainable development has economic growth, human development and resource management as its central goals. Countries in the South-East Asia Region are either developing or least developed. They face growing threats to health from exposure to urban, industrial and agro-chemical pollution in addition to the traditional environmental risks such as inaccessibility to clean water and air and basic sanitation. They are beset with a variety of communicable and vectorborne diseases hindering sustainable development, many having an environmental etiology or being linked to pollution. The problem is aggravated by rising noncommunicable diseases due to changing life styles and patterns of consumption and production. Widespread poverty, illiteracy, population explosion and its consequences further compound the situation. The focus on placing health in a broad development context and on making it a force for poverty reduction and economic growth is a crucial area of work for WHO. An important part of the Organization’s role is to engage in

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political processes that would put health at the top of the poverty reduction agenda. In this context, WHO supported the seminars for development of national strategies on health and poverty reduction, held in Sri Lanka and Nepal during the period under review. Countries in the Region have been strengthening the infrastructure and improving energy services to cope with traditional environmental threats. The rapid pace of urbanization and population pressure, however, continue to expose large numbers to health risks associated with lack of clean water and basic sanitation. Similarly, while environmental standards are being developed and their enforcement strengthened, the “conflict” between economic growth and environmental protection continues to expose human health to modern environmental risks. The paramount need for inter- and intra-sectoral planning and action for minimizing environmental risks to human health cannot be overemphasized. However, the mechanisms for intersectoral planning and action need to be appropriately strengthened in most countries. Food and nutrition are closely interlinked with sustainable development. Therefore, it is encouraging that all Member Countries have developed national plans of action for nutrition. Most countries have also adopted national food policies. Yet, food insecurity continues to haunt many. The problem now is not so much to do with adequacy of food production as with its distribution. Food is mostly available but it is not yet accessible to all due to poverty. In the South-East Asia Region, as elsewhere, it is the poor who suffer disproportionately from unsafe environmental conditions and food insecurity. Just as poverty is both a cause and a consequence of ill-health, poverty is also caused by growing environmental risks - both modern and traditional – and, in turn, it aggravates those risks. At the same time, most environmental interventions are costeffective in achieving positive health outcomes. Therefore, action on health and environment in the perspective of sustainable development leads not only to improved environment and better health, it also contributes to poverty alleviation, which is an over-arching goal of countries in the Region and their development partners.

Member Countries have developed national plans of action for nutrition and also adopted national food policies

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The report of the Commission on Macroeconomics and Health (CMH) has been widely disseminated. The report highlighted that a few health conditions are responsible for a high proportion of avoidable deaths in poor countries. Member Countries are being encouraged to establish national commissions or its equivalent on macroeconomics and health. While India, Myanmar and Sri Lanka have established national commissions, Nepal has established a sub-commission under its National Commission on Sustainable Development to carry forward the work relating to CMH. A Working Group on Investing in Health has been constituted in Thailand for this purpose. It is visualized that the Planning Commission of Bhutan will do the needful in this regard. Other countries are considering various alternatives to take forward the CMH vision of health transformation by scaling up essential health interventions and thus stimulate economic growth and alleviate poverty. The World Summit on Sustainable Development, held in Johannesburg in 2002, reaffirmed the importance of investment in people as the key to sustainable development and highlighted the central place of health within that agenda. At this summit, improving people’s health was accepted not just as an outcome of sustainable development but as a powerful means through which it can be achieved. The major outcomes of the World Summit were a plan of implementation and a political declaration. The plan of implementation includes new agreements as well as a reaffirmation of past commitments, many of which have still to be acted on by governments. To provide a focus for the World Summit, the United Nations Secretary-General proposed that delegates should concentrate on five sectoral issues: water, energy, health, agriculture and biodiversity. The health agenda, as it emerged from the negotiations, addresses a variety of issues that intersect health, environment and development. These can be categorized into two key areas: health care and disease control, and environmental health and lifestyle issues. In addition to general advocacy for health in sustainable development through meetings of Health Ministers, Parliamentarians Conferences have been held on various subjects. During the period under review the Parliamentarians

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Conference deliberated on the Report of the Commission on Macroeconomics and Health. These have served to enhance the advocacy for intersectoral policies, programmes and actions that are required for health development, particularly that of the poor and the vulnerable groups.

Nutrition The major problem in most countries continues to be undernutrition. Reduction in mild and moderate degrees of malnutrition is very slow. At the same time, the prevalence of obesity and diet-related chronic noncommunicable diseases (NCDs), such as diabetes, cardiovascular diseases and certain cancers is increasing. Many countries have low rates of exclusive breast-feeding ranging from 3.6-8 per cent in Thailand and Maldives to 17.7-24 per cent in Myanmar and Sri Lanka. Bangladesh, India and Indonesia are reportedly progressing well, the exclusive breast-feeding rates being 53 per cent, 55 per cent and 52 per cent respectively. There is also considerable variation among and within the countries with respect to complementary feeding being untimely - either too late or too early. Feeding frequency, the amount and micronutrient content are also generally inadequate. WHO country offices, with their national counterparts, are monitoring the implementation of national plans of action in nutrition as per the goals of the International Conference on Nutrition (ICN). A draft document entitled “Guidelines for the in-patient treatment of severely malnourished children” is being processed by the Regional Office and WHO headquarters, in consultation with the London School of Hygiene and Tropical Medicine. Countries will use these guidelines to train staff and to monitor management protocols. Several research activities have been undertaken during the reporting period. A research grant to study the prevalence of iron deficiency anaemia in adolescent school girls in Myanmar and to explore the dietary intake of iron in this group was given. Technical assistance for research and training activities is being provided to the four WHO Collaborating Centres for Nutrition (2 in India and 1 each in Indonesia and Thailand). The titles and terms of reference of two of these centres have been revised in order to address new regional priority areas.

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Plans are under way to revitalize and strengthen the Nutrition Research-cum-Action Network. At the same time, technical assistance is being provided to individual countries according to their research needs. A web site link in the Internet has been prepared for this Network which will enable collaborating centres and Member Countries to access information. A draft review of research on the nutritional status of adolescents in countries of the Region to identify further areas of operations research and interventions has been prepared and is being reviewed externally. A regional meeting on Improvement of Nutritional Status of Adolescents was conducted in Chandigarh, India, in September 2002. The aim of the meeting was to obtain country inputs to the draft regional situation analysis, build a consensus around it, and to focus attention on adolescent nutrition. The first WHO Intercountry Workshop on Iodine Monitoring, Laboratory Procedures and Iodine Deficiency Disorders (IDD) Elimination was held in New Delhi in September 2002. The goal of this workshop was to identify key issues and specific interventions for strengthening the capacity of laboratories in Member Countries to accurately measure iodine content in salt and urine. A combined external and internal evaluation team undertook an assessment of Bhutan’s IDD programme at the government’s request in January 2003. WHO and UNICEF are in the process of certifying that according to the WHO indicators, Bhutan has virtually eliminated IDD – the first country in the Region to do so. The first country complementary feeding counselling course was conducted in Dhaka in March 2003 in collaboration with WHO headquarters. The aim of the course was to enable health workers to develop effective counselling skills to assist mothers and other care-givers of young children (6-24 months) in adopting appropriate complementary feeding practices. A regional meeting on Infant and Young Child Feeding in Emergencies was held in Bogor, Indonesia, in April 2003. The objectives of this meeting were to orient nutrition and disaster programme managers in the management of infant and young child feeding in emergencies and to plan for building up this area in national disaster management plans.

The prevalence of obesity and dietrelated chronic noncommunicable diseases is increasing in the Region

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A bi-regional consultation for the South-East Asia and Eastern Mediterranean Regional Offices was held in Chiang Mai, Thailand, in June 2003 in collaboration with the Institute of Nutrition, Mahidol University, Thailand. The consultation aimed at building a consensus on monitoring strategies for sustainable iodine deficiency disorders control programmes in these regions. Increased efforts are being made to collaborate with other agencies, especially UNICEF and the World Bank, by inviting them to WHO meetings, consultations and training workshops. International NGOs, such as the Micronutrient Initiative, have also contributed to, and participated actively in regional collaborative efforts.

Health and Environment Environmental changes are having an increasing impact on health, particularly that of poor and vulnerable populations According to the World Health Report 2002, environmental hazards cause or contribute to the premature death of millions of people and result in ill-health or disability of hundreds of millions more each year in Member Countries of the Region. Environmental changes – both global and local – are having an increasing impact on health, particularly that of poor and vulnerable populations. Some of the major environmental and occupational health problems in the Region are due to exposure to pathogens through unsafe water, poor sanitation and lack of hygiene, including food hygiene. Significant disease burden is also due to chemical hazards such as arsenic contamination of ground water and misuse of pesticides as well as to biological hazards such as disease vectors related to insanitary conditions. Physical hazards are especially crucial at the workplace. A healthy environment is one in which people are protected from risks associated with chemical pollution, environmental degradation and disasters, and where all have access to safe and sufficient food and water, adequate sanitation and safe working environments. In order to provide a unifying concept in such a diverse programme and activities, the Regional Office has taken the strategic approach of exposure assessment, risk assessment and risk mitigation in each of the areas of work.

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Health Impact Assessment Rapid urbanization and development projects in the countries of the Region invariably impact human health. The World Health Report 2002 estimated the environmental burden of disease to be approximately 1.6 million deaths and 44.8 million disability adjusted life years in 2000. Hence, to promote sustainable development, there is an urgent need to develop and apply a tool such as Health Impact Assessment (HIA) that can help policy and decision-makers to maximize the benefits of development and minimize the negative impact on health. A situation analysis was undertaken to assess impediments to HIA in the Region. The Member Countries were assessed on the policy framework and procedures for HIA, existing infrastructure required to support HIA, the capacity for undertaking HIA and the potential for intersectoral collaboration. The findings highlight that Environmental Impact Assessment (EIA) is being implicitly used as a substitute for HIA which is not explicitly or routinely conducted in virtually all countries of the Region. Therefore, policy, infrastructure, capacity and intersectoral collaboration need strengthening for routine implementation of HIA. The challenge faced during this situation analysis was the lack of environmental data. This was, however, overcome by the constitution of expert committees and through meta-analysis. The next step is translating these findings into evidence-based action for mitigating the environmental impact on health.

Occupational health Despite its large work force, the Region still lacks a strategic plan for occupational health and injury. This situation is being remedied in a step-wise manner to gather the necessary evidence for action. Available data show a high prevalence of occupational hazards in the absence of a strong policy, infrastructure and capacity for addressing occupational health issues. A regional strategic plan addressing occupational health comprehensively from risk management to infrastructure support and capacity building is being developed through consultation with experts in occupational health.

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Water for sanitation and health Country-level assessments of water supply and sanitation were initiated in nine Member Countries in the previous biennium as a follow-up of the joint WHO/UNICEF Global Water Supply and Sanitation Assessment 2000 Report. Seven countries completed the exercise during the period under review. Generally, the country reports confirmed the findings of the Global Assessment 2000, including the conclusion that 14 per cent of the total population of the Region lack access to improved drinking water supplies and 62 per cent lack access to improved sanitation facilities. The reports indicated that most countries of the Region will require increased levels

Demonstration projects for household-level disinfection and safe storage of drinking water in slums have been undertaken by some countries.

of investments if they are to meet the Millennium Development Goals for water supply and sanitation coverage. In most countries, it was recommended that the national health authorities strengthen their capacity to act as evidencebased advocates for increased investment in the water supply and sanitation sector and for increased sector efficiency. During the period under review, the Regional Office published a regional analysis of drinking water quality. The study found wide variations in the depth and coverage of national drinking water quality surveillance programmes in Member Countries. It is concluded therefore that although nearly 212 million people in the Region lack access to improved drinking water sources, many more lack access to safe drinking water.

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WHO was able to mobilize extrabudgetary funds for a pilot project in West Delhi slums on household-level disinfection and safe storage of drinking water. This project is demonstrating the effectiveness of point-of-use treatment of drinking water as a strategy for reducing childhood diarrhoea. The intervention is being complemented in the West Delhi slum project with safe food and hygiene initiatives, and similar demonstration projects are ongoing or under development with WHO’s technical support in Bangladesh, Myanmar, Nepal, and Sri Lanka. In collaboration with the Emergency and Humanitarian Assistance programme, a regional strategy for strengthening the capacity of the Regional Office to support water supply and sanitation needs of Member Countries in emergencies was developed. Funds are now being sought to implement the strategy.

Arsenic contamination of groundwater Groundwater contamination in excess of WHO’s guideline value of 0.01 mg/L has been observed in five Member Countries - Bangladesh, India, Nepal, Myanmar and Thailand. Over 10 million tubewells are in use with nearly 40 million50 million people estimated to be consuming unsafe water. The health consequences of chronic arsenic poisoning include both non-cancerous and cancer end-points. The burden of disease projected from this massive exposure is almost 12.5 million people, within the next 10 years. Technical and financial support was provided to the affected Member Countries in applying the principle of risk management to arsenic by hazard identification, dose response relationship, exposure assessment and risk characterization. Thus, multi-disciplinary expert groups were convened nationally and regionally to provide evidence-based norms, standards and guidelines for case definition, surveillance and management as well as for developing policy and procedures for arsenic removal technologies and arsenic testing. Regional protocols are being field-tested before they are adopted as guidelines for arsenic mitigation in the Region. Technical support was provided to Bangladesh in securing a UNF grant worth US$ 1.2m to address the health aspects of 55 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The health consequences of chronic arsenic poisoning include both non-cancerous and cancer endpoints

arsenic contamination at the upazila level. Active collaboration is continuing with other agencies, such as CDC, Atlanta, for the development of a risk assessment module for the Region, and with UNICEF for joint funding of WHO-supported projects.

Healthy Cities The Regional Office commissioned a study on Healthy City initiatives in five countries with the objective of: assessing progress in relation to political mobilization, community participation, increased awareness of health issues in urban development, creation of increased capacity of municipal governments to manage these, and creation of a network of cities for information exchange and technology transfer. Some of the important observations/conclusions of this study are: l

Exposure of decision-makers, particularly local politicians, contributes greatly to the successful implementation of the Healthy City project. For example, sensitized politicians and highly motivated residents of local communities have successfully implemented programmes, such as healthy schools, healthy eating houses and healthy working places in Matale Municipality in Sri Lanka. A high degree of stakeholders’ involvement greatly contributes to the implementation of the Healthy City project. Institutionalization of healthy city programme policies, i.e. establishment of separate Healthy City offices ensures continuous support to the programme, e.g. Yala in Thailand and Banepa in Nepal.

l

l

Promotion of chemical safety During the period under review, the focus of this technical programme was on promoting the protection of children’s environmental health, enhancing better preparedness for chemical incidents and response from poison centres, and on supporting the implementation of sounder systems for the management of medical waste.

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Children’s environmental health Children are particularly vulnerable to environmental hazards because they are constantly growing and consume more food, air and water than adults do in proportion to their weight. Their immune, reproductive, digestive and central nervous systems are still developing and they spend their time closer to the ground where dust and chemicals accumulate. Exposure to environmental risks at early stages of development can lead to irreversible long-term, often life-long mental and physical damage. The World Health Report 2002 identified six groups of environmental risks that must be tackled as a priority: unsafe water, lack of hygiene and poor sanitation, indoor air pollution, vector-borne diseases, chemical risks and unintentional injuries. These risk factors cause the bulk of environmentally-related deaths and disease among children and undermine development. A new initiative, the Healthy Environments for Children Alliance – HECA – was presented at the World Summit on Sustainable Development in Johannesburg in September 2002. Several governments, NGOs and international organizations evinced interest to work together - in an alliance - to galvanize worldwide action on some of the major environmentallyrelated risks to children’s health. HECA is a worldwide alliance to intensify global action on environmental risks to children’s health that arise from the settings where they live, learn, play and work. This is done by providing knowledge, increasing political will, mobilizing resources, and catalyzing action. During the period under review, the Regional Office pursued HECA visibility by developing educational materials at the national level such as a guide for teachers on health effects from environmental determinants and a game board for school children on the same issue. WHO’s advocacy work has focused on highlighting the key role Member Countries can play in crystallising political will and strengthening networks to coordinate action in favour of children’s environmental health. This can be done by identifying the major environmentallyrelated health risks, taking stock of ongoing actions in

57 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Dr Uton Muchtar Rafei, Regional Director, WHO South-East Asia Region, launched a set of board games on children’s environmental health, developed with WHO support.

that field, and defining the role of the health sector. Member Countries are encouraged to improve intersectoral collaboration to boost efficiency and to orient action using the “settings approach” for increased impact. Research pilot projects on children’s environmental health (CEH) were initiated after the Interregional Workshop on the “Promotion of CEH Collaborative Research”, organized by WHO and the Chulabhorn Research Institute, Bangkok, in February 2003. The following topics of CEH research, both exposure sources and health outcomes, were singled out and prioritized for intervention: air pollution (indoor and outdoor); water and sanitation; injuries and accidents (as a result of unsafe settings); vector-borne diseases; pesticides and persistent organic pollutants (POPs); metals (lead, mercury, arsenic, chromium) and fluorides; food contamination; and noise pollution. The main health outcomes addressed in relation to the above included asthma and allergies, respiratory diseases, immune and neurodevelopmental disorders (educational outcomes), birth defects, and the health effects due to both acute and lowlevel chronic exposure to specific contaminants. 58 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Together with USA and Australia-based partners, India and Thailand are implementing specific collaborative research projects on children’s health in the following areas: (a) arsenic

exposure in pregnant women and children (USA and Asian countries); asthma and allergies (Australia, Singapore and India); pesticides and POPs (UNEP , GEF and World Bank to be approached by WHO); and feasibility of national children’s studies (USEPA, WHO and Thailand). World Health Day 2003 celebrations in the Region focused on children’s environmental health and presented a unique opportunity to mobilize public support for HECA and set it high on the political agenda.

Preparedness for chemical incidents Keeping in mind the global scenario, Member Countries in the Region recognize the need to be better prepared for emergencies due to deliberate or accidental incidents involving biological, chemical and radiation (BCR) agents. While the 55th session of the WHO Regional Committee for South-East Asia highlighted the need to enhance capabilities to manage BCR threats at country and regional levels, the Fifty-fifth World Health Assembly, in May 2002, also drew attention to the need for a public health response to such threats. Consequently, the Regional Office organized an Intercountry Meeting on the Management of BCR Emergency Preparedness in Bangkok in March 2003. Representatives from the 10 participating Member Countries agreed to incorporate BCR elements into existing EHA coordination mechanisms and to allocate additional funds not only to BCR issues but notably to public health preparedness as such. Very relevant to the area of chemical safety was the agreement to undertake/update national inventories of existing chemicals and to augment national capacity in the management of poisoning. The meeting reiterated the need to continue promoting the establishment/updating of national profiles for the sound management of chemicals (to date seven countries of the Region are implementing it) and the need for much stronger support to poison information centres (to date 15 such centres are functioning in 6 countries of the Region).

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Health care waste management Poor management of health care waste exposes health care workers, waste handlers and the community to infections, toxic chemicals and injuries. Indeed, improper disposal creates opportunities for reuse of contaminated medical equipment while poor disposal practices damage the environment (release of toxics such as dioxins, furans and mercury). According to the World Health Report 2002, unsafe injection practices and needle reuse in the South-East Asia Region are estimated to be responsible for a significant amount of the disease burden. Between 22 and 53 per cent of hepatitis B cases, 31 and 59 per cent of hepatitis C cases and 7.0 and 24 per cent of HIV/AIDS cases are associated with these unsafe public health practices. The proportion of syringe reuse in the Region is very high. It is estimated to be 30-75 per cent of all injections given, mainly among those given for therapeutic purposes. Health care workers are among the most exposed. In the Region, prick injury from contaminated sharps are estimated to cause 192 000 cases of hepatitis B, 85 000 cases of hepatitis C, and 28 600 cases HIV/AIDS. In the informal sector too, this risk is high as up to 3 per cent of the total urban work force in some countries is involved in waste-picking, many of them being children. With the renewed thrust to expand the reach and coverage of immunization programmes in the Region through the efforts of the Global Alliance for Vaccines and Immunization (GAVI), all countries in the Region have introduced or are planning to introduce auto-disable syringes. A Regional Office - supported study on the technological pathways developed in India to manage infectious sharps was conducted in the second half of 2002, in close collaboration with Srishti, an Indian NGO. In this context, and responding to the needs of most countries in the Region, a cross-section of senior EPI officials at policy-making level and environmental regulators/policy-makers from 10 countries attended a threeday workshop in March 2003. They discussed the study results and possibilities to enhance a more sustainable system to manage and dispose infected sharps derived from immunization activities.

Unsafe injection practices and needle reuse in the SouthEast Asia Region are estimated to be responsible for a significant amount of the disease burden

60 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Considering the urgent need, development of national legislation for sound management of health care waste is being vigorously promoted. Nearly all countries in the Region have guidelines on health care waste management but only three have enacted legislation. Particular attention will be given to the management of infected sharps at primary health care facilities. Some countries agreed to initiate assessment reports on health care waste management (only three have done it so far), and to develop and hold regular training courses. A “wreath” of technical options for final disposal of sharps was discussed to provide guidance to Member Countries. Priority was given to non-burn technologies, central reprocessing units and economic waste collection systems.

Food Safety Food-borne illness represents a big threat to public health in many countries of the Region. While several countries have appropriate legislation, well-defined national food safety policies and strategies have yet to be developed in many. The resolution on food safety, adopted by the Fifty-third World Health Assembly in May 2000, urged Member Countries to strengthen their food safety programmes in close collaboration with applied nutrition and epidemiological surveillance programmes. The emphasis was on preventive approaches. The WHO Draft Global Strategy for Food Safety takes particular note of the need to amend national policies to take into account new technologies. Use of sentinel sites for foodborne disease surveillance and promotion of training in food safety through broader involvement of WHO collaborating centres is also stressed. Technical assistance for reviewing food safety strategies and programmes to update food safety legislation is being provided to Bangladesh, Bhutan, Myanmar, Nepal, Sri Lanka and Thailand. Regional and national capacities for establishing databases for food contamination monitoring and food-borne disease surveillance are also being strengthened. Meanwhile, a food hygiene training module targeting street vendors and their customers in four urban slums of Delhi is being

While several countries have legislation on food safety, well-defined national policies and strategies have yet to be developed in many of them

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developed. A comprehensive analysis of organochlorine pesticide residues in food commodities in the Region is also being undertaken.

Emergency Preparedness and Response The Region continues to be affected by natural disasters and complex emergencies resulting in a severe impact on the health of affected populations. Apart from direct interventions in a number of countries affected by humanitarian crisis, support on preparedness activities is being extended to various countries, including Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand. WHO was also involved in the Consolidated Appeal Process for DPR Korea and Indonesia for 2003. As part of institutional strengthening and inter-regional cooperation, the Regional Offices for South-East Asia and the Western Pacific and the Asian Disaster Preparedness Centre (ADPC), Bangkok, signed a Memorandum of Understanding to continue organizing the training programme on Public Health and Emergency Management in Asia and the Pacific (PHEMAP). Within this framework, courses will be offered at the international level for senior MoH staff, previously supported by Japan International Cooperation of Welfare Services (JICWELS), and at the national level for local MoH staff, with funds from extrabudgetary resources. The impact from major emergencies and disasters facing the Region is summarized below: l

Eighty-two per cent of disaster events in Asia and the Pacific are due to mass accidents (37 per cent), floods (18 per cent), storms (19 per cent) and earthquakes (8 per cent). Floods are significantly associated with extended periods of excess morbidity from communicable diseases and storms/earthquakes cause displacement of large populations into temporary shelters for long periods. Ninety-five per cent of morbidity and mortality in the first week after these events is due to trauma and only 5 per cent due to disease (including mental health).

l

l

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l

Seventy-two per cent of these events involve less than 50 trauma victims (deaths plus injuries). Sixty per cent of these trauma victims need only simple first aid or primary medical care; 95 per cent of deaths occur before the victim reaches a hospital.

l

The Second Inter-Regional Training Course on Public Health and Emergency Management in Asia and the Pacific (PHEMAP 2) was conducted in October 2002 at ADPC, Bangkok. As a follow-up of the inter-regional courses, India will be conducting the first national PHEMAP course in 2003. In India, capacity strengthening in four vulnerable states was initiated through institutional support, inter-state consultations, and effective partnerships with UN agencies under the United Nations Disaster Management Team (UNDMT) programme as well as with NGOs. Noting the effective WHO interventions and proactive initiatives, a number of donors showed increasing interest in supporting EHA activities. The European Union agreed to support the appeal made to cater to the nutritional aspects due to the drought in the state of Rajasthan, India. Geographically, Indonesia lies in a potential area for natural as well as man-made disasters. Emergency preparedness and response constitute a substantial part of WHO’s technical collaboration in the country. While continuing to ensure the health aspects of humanitarian coordination across the country, WHO assisted the Ministry of Health in establishing an information system for emergency preparedness and early warning. WHO and the Office of the Coordinator of Humanitarian Affairs undertook an independent nationwide assessment on the state of emergency preparedness in the country. Although the focus of the assessment is on the health sector, other sectors essential for emergency management are assessed to present an overall picture on emergency preparedness. In Nepal, not only socioeconomic factors but also geological, topographical and climatic conditions contribute to multiple hazards, most prominently earthquakes, floods, landslides, fires, thunderbolts, windstorms, hailstorm and avalanches. The UN and the health sector have agreed to prepare for a worst-case scenario in the shape of a major

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earthquake similar to the seismic event that occurred in 1934. The seismic record of the country seems to suggest that such an earthquake (up to MMI Scale X) occurs approximately every 75 years. WHO and UNDP are deeply involved in promoting emergency planning and preparedness at the national level. WHO was instrumental in drafting a health sector emergency plan in collaboration with the Disaster Health Working Group Secretariat, the Epidemiology and Disease Control Division of the Department of Health Services and the Ministry of Health, Nepal. More than 600 health sector staff were trained in mass casualty management through various modalities such as computer simulations, desk-top exercises and mock drills. Two thousand “triage” tags are in the process of being distributed to strategic health facilities in the country.

Member Countries have been assisted with emergency supplies to rebuild their health systems.

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In partnership with UN agencies, the government and NGOs, the health system in the north-east province of Sri Lanka was assisted to meet the short-term needs of conflictaffected communities, leading to mid- and long-term strategies for health systems recovery. WHO has been designated as the lead agency to coordinate and guide all other development partners to assist in recovering/reconstructing the health system in the north-east. With its field-level presence, WHO was able to effectively functions as a lead agency and implement EHA programme activities and to play a very strong coordinating role.

Since 1997, the Emergency and Humanitarian Action Programme has been instrumental in channelling WHO assistance to DPR Korea. In 2001, the WHO Representative’s Office was opened in Pyongyang, facilitating greater collaboration with the government and UN agencies and a more explicitly developmental approach to the country’s health needs. The project, “Health Coordination at Myanmar-Thailand Border”, implemented by WHO and funded by CHAD/DFID, started in January 2001 for a two-year period with the aim to improve the health of the migrant population in Thailand along the Myanmar border. A joint WHO/DFID review mission was fielded in November 2002 to assess the effectiveness of the project, to recommend a forward strategy and to explore possibilities for a similar approach on the Myanmar side of the border. The review confirmed that WHO is well placed to contribute to health development of irregular migrants. Implementation of the project has resulted in several useful achievements towards three defined project products: assessment of health status to identify needs, improved coordination of health initiatives and enhanced distribution of health information.

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66 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

5 HEALTH TECHNOLOGY AND PHARMACEUTICALS Essential Medicines: Access, Quality and Rational Use Activities under this programme in the Region ranged across the four areas, viz. policy, access, quality and rational use, and consisted of regional and country capacity building for achieving essential medicines that are safe, effective, affordable and of appropriate quality. While there were some highly visible short-term results, the ground work for long-term projects was also laid. The resolution adopted by the 55th session of the Regional Committee restated the importance of essential medicines and encouraged countries to strengthen their Drug Regulatory Authorities to ensure safe and effective quality medicines. It also urged the countries to use regional bulk purchase schemes as a practical means of delivering the necessary medicines to the people. This resolution was a follow-up of the Twentieth Meeting of Health Ministers, held in Maldives in August 2001, which first discussed bulk purchase schemes. Countries in the Region are now focusing on implementing the resolution. A single uniform scheme would not be successful given the diversity of the pharmaceutical capacities of the countries. India has a sophisticated, vertically integrated pharmaceutical industry capable of developing new drugs. Bhutan and Maldives have no pharmaceutical industry and are interested in cost-effective methods of procuring medicines. Hence, WHO’s thrust is on sharing experiences and technical expertise and building a consensus among countries that have similar interests.

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Unless suitable legislation is enacted by 2005, TRIPS may prevent countries of the Region from obtaining new drugs essential for their public health needs

With the expansion of the private sector in health care, access to essential medicines has become an important issue. While most countries provide essential medicines in their public health sector, either free of charge or for a nominal fee, patients in the private sector have to pay the full cost. Countries in the Region have long-standing price control mechanisms for essential drugs. India regulates drug prices through the National Pharmaceutical Pricing Authority (NPPA). Sri Lanka and Bangladesh too have price control mechanisms. However, the low margin on essential medicines may drive manufacturers to drugs with a bigger margin. To maintain a balance between keeping essential medicines affordable and providing a sufficient return to the manufacturer is difficult. In this context, the Regional Office has been encouraging information exchange between countries and evaluation of drug pricing systems. Drug prices were not the only issue in Access. Trade Related Intellectual Property Rights (TRIPS) may prevent countries of the Region from obtaining new drugs essential for their public health needs in the future unless suitable legislation is enacted by 2005. Bangladesh, with its well-developed pharmaceutical industry but “least developed country” status, has to amend its legislation only in 2016. This has stimulated the country to evaluate its position carefully. WHO also supported a consultation on “The WTO/TRIPS Agreement and Access to Medicine: Appropriate Policy Changes” for Asian countries, held in April 2003 in Sri Lanka. Officials from the Drug Regulatory Authorities (DRAs) of the Region met in Hong Kong immediately after the International Conference of the Drug Regulatory Authorities in June 2002. The Regional Office supported this regional regulators’ forum which was utilized for updating the officials on regulatory matters. The officials identified Good Clinical Practices (GCP) and counterfeit drugs as the two areas in which WHO assistance was required. GCP , used in clinical trials of new drugs, is rapidly becoming important to the Region as such trials are increasing and DRAs also have to evaluate GCP in the global registration dossier. The Regional Office, in association with the United States Pharmacopoeia, organized a meeting for DRAs on quality of drugs in September 2002 in Hyderabad, India. The HIV/AIDS Drugs Pre-qualification

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Scheme (coordinated by WHO) served as a case study and also provided relevant material for the Region. As part of the continuing process of evaluating DRAs in the Region, the DRA of Sri Lanka was reviewed in July 2002 and that of Nepal in February 2003. This was done by joint teams from the Regional Office and WHO headquarters. The Delhi Society for Promotion of Rational Use of Drugs (DSPRUD), an NGO, has played a significant role in improving the medicines situation in the government sector in Delhi state. DSPRUD has now formed partnerships with institutions in other states and has promoted drug policies, Essential Drug Lists (EDLs) and Standard Treatment Guidelines (STGs) in these states. Its activities have been supported by WHO headquarters with some coordination and technical support by the Regional Office. A joint evaluation team from WHO headquarters and the Regional Office reviewed DSPRUD activities for the past five years and noted significant progress, innovative approaches and useful tools. The team recommended continuing support for DSPRUD and also its better integration into the Government of India programmes to provide synergy and sustainability. This experience has shown the potential of a pluralistic approach to essential medicines activities. Timor-Leste had developed a Master Plan for its medicines sector as part of the reconstruction of its health system. An evaluation of the Central Medical Stores by a joint team from the Regional Office and WHO headquarters noted the progress and also the need for more pharmaceutical expertise and refining the supply system to suit peripheral health care institutions. The Master Plan has been modified in the light of these recommendations. Timor-Leste has also requested further WHO assistance in developing human resources as well as drafting legislation for the pharmaceutical sector.

Immunization and Vaccine Development During the last two years, WHO assisted eight eligible countries of the Region to successfully apply for funding for hepatitis B vaccine from the Vaccine Fund through the Global Alliance for Vaccines and Immunization (GAVI). Over the next five years, 69 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

approximately US$ 200m will be provided from the Vaccine Fund to the countries of the SEA Region for immunization services, injection safety and introduction of new vaccines (Table 5.1).

Table 5.1: Proposals for GAVI funding from countries of the SEA Region (as of June 2003) Country Bangladesh Bhutan DPR Korea India Indonesia Myanmar Nepal Sri Lanka Timor-Leste Source: WHO/SEARO

Strengthening of immunization services Approved Not eligible, DPT3 >80% Approved Application not submitted To apply in 2003 Approved Approved Not eligible, DPT3 >80% To apply in 2003

Injection safety Application pending Approved Approved Application not submitted Approved Approved Approved Approved To be decided

Introduction of new vaccines Approved Approved Approved Approved Approved Approved Approved Approved To be decided

One of GAVI’s main goals is to achieve DTP3 coverage of 80 per cent in all districts in at least 80 per cent of GAVI eligible countries by 2005. GAVI will also provide support for strengthening routine immunization, including the introduction of auto-disable (AD) syringes. WHO has committed itself to assisting countries as they strive towards the achievement of the “80/80” goal. Within the framework of the Expanded Programme on Immunization (EPI), four countries in the Region (Bhutan, Indonesia, Maldives and Thailand) had introduced hepatitis B vaccine into their routine immunization programme prior to 2001. With funding from the Vaccine Fund, six countries in the Region will introduce hepatitis B vaccine in 2003. TimorLeste will apply for funds to strengthen immunization services, also in 2003. Through the Regional Working Group on Immunization for South-East Asia, WHO has provided technical support to these countries in training, advocacy and monitoring necessitated by this innovation. The longer-term

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challenge will be to develop plans for financial sustainability to ensure that this necessary vaccine programme is continued. National Regulatory Authority (NRA) capacity building is a priority area for WHO to ensure continuous use of high quality vaccines in all immunization programmes in the Region. In 2002, NRA assessments were carried out in Bhutan and Bangladesh. Since the beginning of the NRA capacity building programme in 2000, this assessment has been carried out in 9 countries. It is also critical for countries to have a surveillance system for Adverse Events Following Immunization (AEFI). Support for developing AEFI reporting systems in several countries in the Region, including the production of guidelines and reporting forms, was provided. With the introduction of single-use syringes for immunization injections in all countries of the Region, sharp waste management has become a major concern among programme managers. In India, WHO supported a review of successful non-incineration methods by a national environmental NGO in collaboration with the Ministry of Health and the Indian Pollution Control Board. Lessons learned on methods of final disposal will be compiled and shared with all countries in the Region. A pilot project to install locallybuilt small-scale, double chamber incinerators in Myanmar was also continued in 2002. Supported by WHO, a waste management committee was established with participants from the Ministry of Health, Ministry of Environment and representatives from various training institutes who devised an activity plan for a field trial of 15 incinerators. Technical assistance was provided to design the incinerator, to identify the location and the availability of construction material, to build prototypes and to train local engineers. Cold chain reviews in Bhutan and DPR Korea showed how breakdowns in the system could potentially damage the potency and quality of vaccines. The review in DPR Korea led to a joint initiative between WHO and UNICEF to develop a project to procure and install 50 solar refrigerators. With guidance from the regional task force, WHO formulated a regional vaccine policy to provide the framework for vaccine research and development. The policy will also provide guidance on vaccine security and sustaining immunization programmes in the Member Countries.

National Regulatory Authority capacity building is a priority area for WHO to ensure continuous use of high quality vaccines in all immunization programmes in the Region

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Poliomyelitis eradication In 2002, the South-East Asia Region accounted for 84 per cent of the global burden of virus-positive polio, with India as the only country that had polio virus circulation. India reported 1 599 confirmed polio cases in 2002 representing an over fivefold increase compared with 268 cases reported in 2001 (Figure 5.1). The number of districts affected grew from 63 in 2001 to 159 in 2002. As of mid-June 2003, India had 83 confirmed wild polio virus cases.

Figure 5.1: Wild polio cases in India (as of 16 June 2003)

1 P1 Wild case (73 Cases) 1 P3 Wild case (10 Cases)

Source: WHO/SEARO

The epidemic occurred largely because: l

there was an accumulation of susceptible children in Uttar Pradesh and other states, due to the insufficient scale and quality of supplementary immunization activities. endemic polio transmission, as indicated by genetic sequencing data, continued in 2002 in western Uttar

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l

Dr Gro Harlem Brundtland, Director-General, WHO, launching the National Immunization Day in the state of Uttar Pradesh, India.

Pradesh and spread to central and eastern Uttar Pradesh as well as to other states from there. Bangladesh, Myanmar and Nepal have been polio-free since 2000 despite good acute flaccid paralysis (AFP) surveillance. Bhutan, DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand have all been polio-free for more than four years. During the past year, all countries in the Region conducted supplementary polio immunization rounds, with Bangladesh, DPR Korea, India, Indonesia, Myanmar and Nepal conducting National Immunization Days (NIDs) which were synchronized as far as possible. In addition, Bangladesh, Bhutan, India, Maldives, Sri Lanka and Thailand conducted Sub-National Immunization Days (SNIDs) in high-risk areas and provinces. It is particularly reassuring to note that more children were reached during SNIDs and NIDs in India, compared with earlier rounds in all states. This was attributed to better microplanning for supplementary immunization activities, improved information education and communication (IEC), greater government ownership and better monitoring of activities. IEC efforts will be continued to reach the unreached, particularly children of underserved communities in Uttar Pradesh and West Bengal.

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At the end of 2002, Bangladesh, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, and Thailand had sustained their non-polio AFP rate of at least 1 per 100 000 children aged less than 15 years. In response to Indonesia’s decline in AFP surveillance in the previous two years, WHO assisted the government to recruit and train an additional 34 surveillance medical officers and 10 supervisory surveillance officers. As a result, AFP surveillance in Indonesia increased to 1.26 in 2002 (Figure 5.2).

Figure 5.2: Non-polio AFP rate of <15 children in the SEA Region, 2002 3.5 AFP rate (per 100 000 population) 3 2.5 2 1.5 1 0.5 0 0 0 1.26 1.41 1.88 1.90 1.94 1.97 3.28

2.63

1.11

BHU Source: WHO/SEARO

TL DPRK INO

SRL

NEP MMR THA IND BAN MAV

WHO organized an independent, joint national and international AFP surveillance review in Myanmar in 2002. In India, during January and February 2003, rapid AFP surveillance assessments were conducted in the states where resurgence of polio virus cases occurred in 2002. An additional AFP surveillance review was conducted in Indonesia in June 2003. These reviews verify the quality of the surveillance data and emphasize opportunities for further strengthening of surveillance as necessary. All 17 laboratories in the polio laboratory network of the Region are fully accredited, including the Global Reference Laboratory in Mumbai, India. The laboratories provide timely and accurate information to allow targeted and appropriate planning and virus response. WHO has developed regional guidelines for the implementation of laboratory containment

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of wild polio viruses. To date, nine countries have finalized plans of action for containment. The estimated resource requirement for polio eradication activities during 2002 in the Region was approximately US$ 152m. Contributions came from a wide variety of bilateral and multilateral sources, including AusAID, the Bill and Melinda Gates Foundation, CDC, DFID, DANIDA, EC, Italy, Japan, KfW Germany, NORAD, Rotary International, UN Foundation, the World Bank, UNICEF and WHO among others. Funding the additional cost of implementing extra polio eradication activities, particularly in India in 2003 following the epidemic outbreak, until the Region is certified polio free, will be a major challenge for polio eradication. The estimated resource requirement for the Region in 2003 is US$ 184m. Table 5.2 shows the estimated resource requirement for selected countries.

Table 5.2: Estimated resource requirement for selected countries in the SEA Region US $ in million

Country Bangladesh DPR Korea* India Indonesia Myanmar Nepal Total *Based upon UN Appeal Source: WHO/SEARO

OPV 5.69 0 79.01 0 0.65 1.48 86.83

Operational 2.63 0 76.72 0 0.16 1.58 81.09

AFP and laboratory 1.05 0.62 11.05 1.53 0.49 1.00 15.74

Total required 9.37 0.62 166.78 1.53 1.30 4.10 183.70

Committed 9.37 0.62 136.88 1.21 0.60 3.30 151.98

Shortfall 0 0 29.90 0.32 0.70 0.80 31.72

Control of other major vaccine preventable diseases Measles accounts for an estimated 202 000 deaths/year in the Region. Five countries (Bangladesh, DPR Korea, India, Myanmar and Nepal) have not yet eliminated measles and neonatal tetanus (MNT). The infrastructure available to the programme is impressive drawing as it does on a large investment in the context of polio eradication activities. A revision of the Regional Strategic Measles Mortality Reduction plan was undertaken in February

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2003. The plan envisages measles and NT control campaigns across the Region based on improvements in national surveillance and laboratory capacity. Regional training workshops were held with the goal of establishing a measles laboratory network by the end of 2003. A sub-national measles campaign began in Myanmar and WHO investigated a major measles outbreak in Maldives. These activities should enable an expansion of measles control activities in other countries of the Region. EPI managers committed themselves to eliminate NT and reduce measles mortality by 50 per cent by the end of 2005. While polio supplementary immunization activities will continue until global certification is achieved, WHO is renewing its emphasis on strengthening routine EPI across the Region.

Issues and challenges What needs to be done to interrupt polio virus transmission in India? When will the South-East Asia Region be polio-free? Will polio eradication efforts help routine immunization? India needs to carry out at least six rounds of large-scale supplementary immunization during 2003 and 2004. If these rounds are implemented well and more children receive vaccine each time, polio virus transmission can be interrupted in the next 18 months. It will take about three years, after the last case of polio is discovered, for the Region to be polio-free. Until then, all countries in the Region need to remain vigilant. By 2005 the Region should be in the process of certification. High routine immunization coverage is an important strategy for controlling polio and many other diseases. The Regional Office is trying to help governments expand and improve their surveillance systems and routine immunization services – building on the infrastructure put in place by polio eradication activities. Can other vaccines be introduced into routine immunization services? Underused and new vaccines are being introduced into routine immunization services in many countries of the Region. Seven countries are in different phases of introducing hepatitis B vaccination into routine immunization services during 2002-2003. Disease burden studies are under way for other vaccine preventable diseases, such as Japanese

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encephalitis and meningitis/pneumonia due to haemophilus influenza, to ascertain whether new and underused vaccines to protect against these diseases should be introduced into the routine schedule. How can immunization systems be made sustainable? The major challenge is to ensure that the Region maintains the momentum of investments in immunization to make systems sustainable in the long term. To achieve this, Member Countries need an appropriate framework for the provision of affordable and quality vaccines from the Region. This requires political commitment and an allocation of national resources, including appropriate human resources, to immunization services. A policy framework is required whereby safe injections, the disposal of sharps waste in an environmentally sound way, internationally competitive vaccine manufacturing, and management and quality control systems are the norm. The regional vaccine policy aims at achieving these goals. It offers a possible road map for technology transfer and long-term sustainability and independence for regional immunization systems.

Blood Safety and Clinical Technology Safe blood is one of the priority areas of WHO, both at the global and regional levels. The WHO Global Strategy aims at strengthening nationally coordinated blood transfusion services, promotion of voluntary non-remunerative blood donation, reliable laboratory services for blood group serology and screening for transfusion transmissible infections (TTI), appropriate use of blood and its components, and implementation of a quality system in blood transfusion services. A regional workshop on organization and management of blood transfusion services was held in Colombo in November 2002 to strengthen management of blood transfusion safety. To promote voluntary non-remunerative blood donation, a regional workshop was organized in Aurangabad, India, in February 2003 to train the trainers from countries with low rates of voluntary blood donations, namely, Bangladesh, Bhutan, India, Indonesia, Myanmar and Nepal. The participants were also provided with training materials to facilitate similar workshops in their respective countries.

The WHO Global Strategy on Blood Safety aims at strengthening blood transfusion services, promoting voluntary blood donation and reliable laboratory services

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Realizing the need to ensure quality in screening for TTI in most Member Countries, support was provided to Bhutan, Indonesia, Maldives, Myanmar, Nepal and Sri Lanka. A handson workshop on blood group serology was conducted in Mumbai, India, in September 2002 to strengthen immunohaematology in blood centres in India and Maldives. This is expected to reduce the incidence of adverse reactions arising out of transfusion of mismatched blood. The incidence of adverse reactions as well as TTI can be reduced by optimal use of blood. Currently, less than onefourth of the collected blood is converted into components. A workshop was organized in Myanmar in April 2003 wherein trainers from Bhutan, Bangladesh, Indonesia, Maldives, Myanmar, Nepal and Sri Lanka representing various clinical specialties were oriented in appropriate use of blood. To create an infrastructure for production of quality components, hands-on training was imparted at a course held in Bangkok in December 2002 to professionals from Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, and Sri Lanka. Sub-regional quality management training courses for capacity building in quality management were organized in Bangladesh, Bhutan and Maldives wherein 15 participants were trained. Under the Quality Management Project of WHO, the Regional Office has, till date, trained 119 quality managers in all Member Countries. To provide technical support to the trained quality managers and to monitor their progress, the National Blood Centre, Thai Red Cross Society, provided technical support to Member Countries at a regional quality centre. Two centres under the Ministry of Public Health, Thailand, are conducting an external quality assessment scheme for blood group serology as well as screening for HIV and hepatitis B for the Region. Sri Lanka is revamping its blood transfusion services with aid from the Japanese Bank of International Cooperation and technical support from WHO. Timor-Leste was also provided extensive technical support to establish a functional blood transfusion service and to develop its public health laboratory system. 78 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Increasing attention is being given to promoting quality in health laboratories.

WHO continued to support Member Countries in promoting quality in health laboratories. A comprehensive

review of quality assurance activities in public health laboratories was carried out in which critical lacunae were identified and suggestions made to improve the quality of laboratory results. WHO has been actively involved in training trainers in uniform methodology for antimicrobial susceptibility testing and utilization of WHO developed software (WHONET 4 and 5) in rapid analysis of data. The regional status on the bacteriological component of antimicrobial resistance monitoring was reviewed. The major findings indicate the need for advocacy, capacity building and development of policies for rational use of antimicrobial agents in almost all Member Countries. Bioterrorism continued to be a topical issue during 2002. A Manual on Laboratory Diagnosis of Anthrax, published with inputs from various regional and global experts, was distributed to all Member Countries. A rapid, user-friendly and economical screening kit for anthrax, developed in the Region, was evaluated by a regional panel of experts and made available to all Member Countries. To strengthen quality assurance in radiotherapy, IAEA/ WHO Postal Dose Quality Audit for Co60 and Megavoltage X-ray beams (TLD) were sent to DPR Korea, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. Newsletters on quality assurance in health laboratory services and blood transfusion services (QA News) and on the Gonococcal Antimicrobial Susceptibility Programme (GASP Newsletter) were regularly published and disseminated to all Member Countries. A model Standard Operating Procedure (SOP) for blood transfusion services was published and widely distributed.

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80 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

6 EVIDENCE AND INFORMATION FOR POLICY Evidence for Health Policy The programme focused on collecting, compiling, validating, analysing, synthesizing, reporting and disseminating evidencebased health information, including analysing and reporting regional health situation and trends. National capacities on management of health information systems were strengthened in the area of (a) quality improvement in morbidity and mortality statistics; (b) knowledge on methods and issues related to health systems performance assessment at national and sub-national levels; (c) training in increasing use of ICD10 coding; and (d) improvement of vital registration systems and health surveys. This was achieved through a series of national and international workshops, seminars and fellowships programmes. Health management information systems (HMIS) of all Member Countries are at different stages of development. Each national focal point on health information system (HIS) evaluated its own national HMIS and the reports were consolidated and compiled into a regional strategy on HMIS development. The regional strategy is aimed at making HMIS more dynamic and responsive to the requirements of policy and decision-makers, especially in improving the performance of the vital registration system in each country and promoting efficient use of the available information. National focal points for vital registration systems were contracted to review the latest situation of vital registration systems in the respective countries. Based on national reports, a regional strategy for

The regional strategy on health management information systems aims at improving the performance of the vital registration system

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development and improvement of the vital registration systems would be formalized soon. The annual global “WHO Evidence for Health Policy Orientation Workshop” was held in Greece in October 2002. The workshop was aimed to expand knowledge and skills of public health experts and data management specialists from the countries of the SEA Region who were given a thorough briefing on the concepts, methods and uses of health systems performance assessment developed by WHO. Considering the need to systematically foster the development and strengthening of national multi-disciplinary teams in health system performance assessment, the participation of three to four nationals per country from Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand, including the WHO country office staff, at workshops covering different modules was supported. In collaboration with WHO headquarters, Indonesia has initiated sub-national health systems performance assessment along with 10 other countries around the world, in order to compare the progress in the development of district health systems over a period of time. A series of methodology development activities were undertaken to identify and measure appropriate intermediate health indicators and health outcomes. National and sub-national-level seminars, workshops and meetings were organized. An update on the progress made by Member Countries in implementing the “Declaration on Health Development in the South-East Asia Region in the 21st Century”, adopted by the Health Ministers of the Region in August 1997, was submitted to the Eighth Meeting of Health Secretaries in Kathmandu in April 2003. The update will also be submitted to the Twentyfirst meeting of Health Ministers, to be held in New Delhi in September 2003. It highlights the progress and achievements in health development, identifies challenges and recommends priority policy actions that the countries may need to adopt in order to accelerate health development processes. These discussions are expected to result in policy directions on health development. 82 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The Central Bureau of Health Intelligence (CBHI), New Delhi, also held national workshops for improving and strengthening data collection at the state level. In addition, staff have been trained in the use of web-based technology for data collection

and communication on HIS. Bangladesh and Bhutan conducted training on ICD-10 morbidity and mortality statistics for personnel at the district level. Maldives also trained its health workers on vital registration systems. Bangladesh, India, Myanmar, Nepal and Sri Lanka are involved in the WHO global initiative - World Health Surveys (WHS). WHS will compile comprehensive baseline assessment data on the health status of the sample population and the way health systems are currently functioning. At the same time, it would support national capability to monitor health systems inputs, functions, and outcomes. WHS will be complementary to national efforts in ensuring periodic data input in a cost-effective way by covering important gaps in health information. It will also establish a baseline for scaling up health activities. In order to ensure the quality of WHS, carried out in Asia-Pacific countries, WHO organized a Quality Assurance and Training Workshop in Guangzhou, China, in September 2002. In Bangladesh, a team from WHO headquarters trained the principal investigators and surveyors on the new methodology to be applied and reviewed the questionnaire. In Myanmar, the survey questionnaire was translated into the local language. It is proposed to train surveyors while an external expert in quality control is expected to assist in strengthening quality assurance. WHS in India and Nepal progressed well and the quality assurance programme has been implemented. The survey in Sri Lanka was completed by June 2003. Representatives from India, Nepal and Sri Lanka attended an intercountry workshop organized by WHO headquarters in mid-June 2003, where the first sets of national WHS reports were made available. All surveys are expected to be completed by end-2003. Since mid-2002, the Regional Offices for the Americas and South-East Asia have collaborated in developing a web-based health information system for managing regional and national core health data sets and country profiles. The software developed by the Regional Office for the Americas on the core health database, GIS and Intercod (interactive coding for ICD10 for data coders) was found suitable for application in the SEA Regional Office. The adaptation of the software was carried out jointly by a team consisting of staff from both the regional

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offices. By January 2003, the progress on development was reviewed by the joint team and further activities were initiated to develop a catalogue of basic health and health-related indicators and components for the Regional Office. A prototype has already been developed. It is now envisaged to implement the system in the WHO country offices.

Health Information Management and Dissemination The WHO Health Information Management and Dissemination (IMD) programme continued to promote the storage, production and wide dissemination of valid information. The Regional Office issued a document “Policy and Procedures for Development, Production and Dissemination of Health Information Materials” in order to have a broad-based and simplified process for issuing publications and to ensure the quality of WHO information materials. With a view to promoting transparency in contracting, the Regional Office also empanelled selected printing, designing and advertising agencies. Volume 6, Nos. 1 and 2 (2002) and Volume 7, No. 1 (2003) of the Regional Health Forum, covering World Health Day themes, health research, health care, communicable and noncommunicable diseases, reproductive health, health legislation, globalization etc. were issued. A wider section of health professionals contributed to the Forum that provides a useful platform for exchange of views and sharing of experiences on policies and technical programmes. A series of new and reprinted technical publications on child health, nutrition, regional health situation, traditional medicine, HIV/AIDS and tuberculosis and a few other subjects were brought out. The Regional Office continued to print documents for free distribution, including reports on various meetings and country missions, monographs, guidelines, training modules and advocacy materials in different technical areas. Documentation related to the 55th session of the WHO Regional Committee for South-East Asia, including the report of the Technical Discussions, were printed and distributed. Volume 3 of the Handbook of Resolutions and Decisions of the Regional Committee for South-East Asia was updated. Documents pertaining to the meetings of the WHO governing bodies, such as the World Health Assembly and the Executive

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Board, held during 2002 and 2003, were also disseminated to the Regional Office staff as well as the concerned national health authorities. The Regional Office participated in major book fairs organized in countries of the Region as well as in the Frankfurt Book Fair, giving visibility to WHO publications. At these fairs, WHO disseminated a large volume of books, documents, publications, reports, newsletters, posters and pamphlets. During the period under review, the sales turnover was approximately US$ 280 000. A new software, developed in-house, has been installed to manage sales of WHO publications. The web page has been updated with data pertaining to 1150 documents published by the Regional Office, from January 1991 till March 2003. The latest issue of the Regional Health Forum and the cover pages of the 67 most recent WHO publications, along with comprehensive bibliographical descriptions and abstracts, were published in the web site. With a view to reducing production costs and enabling wider distribution, WHO granted reprint rights in respect of 20 local editions of WHO publications to selected commercial publishers. WHO also offered translation rights in respect of 26 WHO documents, which were translated in various regional and local languages, including Bahasa, Bangla, Korean, Thai, Hindi, Tamil, Telugu and Gujarati. The library in the Regional Office continues to function as a portal for disseminating WHO information and providing technical support for proper documents storage, retrieval and dissemination of health and health-related information. An auto-installed web-based information management package – “WEBLIB-WR” was developed in mid-2002 to be installed and used in the libraries of the WHO country offices. One component of WEBLIB-WR, a facility called “Global Information Full-Text – GIFT”, provides direct access to over 1 000 biomedical journals and selected databases. WHO country offices having this package serve as major information centres for health and healthrelated institutions. Another service provided by the library is the daily electronic information dissemination on “Current affairs” sent 85 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The WHO Health Information Management and Dissemination programme continued to promote the storage, production and wide dissemination of valid information

to e-mail subscribers. It consists of health-related information, repackaged from a variety of sources, such as information circulars and press releases from WHO and other UN agencies, regional and international newspapers and online news services. Twenty-five registered institutions from Bhutan, Myanmar and Nepal had access to online full text information in respect of over 2 000 journal titles, as part of the global initiative called the “Health Inter-Network Access to Research Initiative (HINARI)”, launched by WHO in collaboration with major publishers in July 2001. This access has now grown to 59 registered institutions from six countries, namely, Bangladesh, Bhutan, Maldives, Myanmar, Nepal and Timor-Leste. The library functions as the HINARI coordinator in the Region by providing necessary technical and managerial support to HINARI-enabled libraries and institutions. The library continued to provide technical support to WHO country offices, libraries and other health information storage and dissemination institutions in Member Countries. With the inclusion of over 400 libraries in the Health Literature, Library and Information Services (HELLIS) Network, national information resources have expanded. Electronic exchanges through appropriate web-interfaces were facilitated for transferring research articles and reports from Indonesia, Nepal and Thailand, the national index medicus of Indonesia and Thailand, and the directory of health manpower of Indonesia and Myanmar.

Research Policy and Promotion The twenty-seventh session of the South-East Asia Advisory Committee on Health Research (SEA-ACHR), held at Dhaka in April 2002, discussed the profiles and development of national health research systems, and provided guidance on ethics in health research, health impact assessment and health research in cardiovascular diseases. A scientific debate on “health research in arsenic poisoning and its mitigation” was held during the session. The recommendations were followed up with collaborative work under different technical areas. 86 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Based on the regional strategies for health research systems development, which brought a paradigm shift in systematic

analysis and in developing health research within a new framework of health research systems, national health research system profiles of each country were updated. The SEA-ACHR reviewed the regional compilation of the national profiles and made further recommendations. In collaboration with WHO headquarters, a global project – “Health Research Systems Analysis Initiative (HRSAI)” was launched in 16 countries, including Indonesia and Thailand, as a pilot phase. This global project provides a framework to evaluate and strengthen national health research systems. The model will be refined by the end of 2003 and the project extended to 40 more countries, including India, Myanmar and Bangladesh. The data collected from this global initiative would be useful in analysing national health research systems and will also be used as major inputs for preparing the World Health Report 2004 with the theme, “Knowledge for Better Health”. In January 2003, Myanmar conducted a two-day workshop for academicians, medical experts, programme managers and technocrats for developing a national health research agenda. The workshop provided comprehensive information for identifying the research agenda for the national health plan 2001-2006. There is an increasing need for health research managers to mobilize resources and manage research in a cost-effective way. The Regional Office established an expert group consisting of eminent researchers from Bangladesh, Indonesia, Sri Lanka and Thailand to develop a set of health research management training modules aimed at promoting the application of the general principles of good management and good leadership, managerial competencies, knowledge and skills in health research. The content of these training modules is broad enough to provide flexibility for the course directors to choose and select specific modules/topics suitable for the target participants. Work on ethics and health research made substantial progress during the reporting period. The development of national ethical guidelines continues to evolve in many countries. In February 2003, the national ethical guidelines were endorsed by the Minister of Health, Indonesia, and, at the same time, the National Ethics Review Board was officially constituted within the National Institute for Health Research and Development. Most

The development of national ethical guidelines continues to evolve in many countries

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countries have improved national ethical guidelines through a series of scientific debates and by conducting workshops and training to disseminate the guidelines as well as to strengthen institutional ethical review boards.

Teaching guidelines on medical ethics are being fieldtested in medical institutions

The National Ethics Review Board of Indonesia organized orientation on health research and ethics to members of all institutional ethics review boards. In October 2002, the Indian Council of Medical Research (ICMR), in collaboration with WHO, organized an intercountry seminar to develop the regional compendium of case studies for orientation in health research and ethics. The workshop reviewed and approved the case studies relevant to the principles of research ethics. The workshop also developed action plans for expanding the use of the regional case studies as training materials for health ethics. Field-testing of teaching guidelines on medical ethics and health, developed by WHO, is being carried out in seven medical institutions in Bangladesh, India, Indonesia, Myanmar and Thailand. Some medical schools adopted the teaching guidelines as an integral part of the core curriculum while others included medical ethics as the main topic in the first year of medical education. For those institutions where medical ethics is already included in the curriculum, WHO teaching guidelines are complementing the existing ones. In mid-2002, the Forum for Ethics Review Committee of Asia and Pacific (FERCAP) conducted a workshop on good practices in health research which focused on monitoring the conduct of research on human beings once the ethical aspect of the research has been cleared by the Ethics Review Board. The workshop highlighted the need to use the guidelines issued by WHO headquarters (TDR) for monitoring resources involving human participants. In early 2002, the WHO Global ACHR submitted its report on “Genomics and World Heath” to the Director-General. The official launch of the report took place in India in October 2002. At the one-day report launching seminar, experts in genomics, senior health administrators and senior medical specialists responsible for genetic diseases, together with NGOs and the media, shared the Indian experience on health research and its applications on human and other human-diseaserelated genetics.

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WHO collaborating centres (WHO CCs) and national centres of excellence (NCE) are the main institutions which help in building health research capacity in order to generate and manage expertise in the Region. New guidelines for designation and redesignation of WHO collaborating centres were adopted in late 2001 and are being used to further strengthen collaboration within and among Member Countries. As of May 2003, there were 84 WHO collaborating centres in the Region representing 7.4 per cent of the global figure of 1 137. Forty-five WHO collaborating centres were within the designation period, of which 14 centres were in the area of communicable diseases control, 12 in sustainable development, environment and health promotion, 14 in family and community health, and 5 in evidence and information for policy. There were 39 WHO collaborating centres that had completed their designation period, and were under consideration for redesignation. In order to promote the designation of national centres/institutions as WHO collaborating centres, a series of national workshops were held in India and Thailand. These meetings provided a better understanding of the managerial and administrative steps and procedures for designation, redesignation and termination and on ways of strengthening collaboration with WHO technical programmes and, at the same time, build networks among the centres. WHO Expert Advisory Panels (EAP) and Expert Advisory Committees (EAC) support technical programmes with appropriate advice and collaboration. Members of the expert panels are appointed by the Director-General on the recommendation of the Member Countries and the concerned WHO technical programmes. A resolution adopted by the Ffity-fifth World Health Assembly called on the DirectorGeneral to encourage nominations of experts from developing countries. WHO is working closely with the scientific communities of the Member Countries in identifying experts to be designated as members of EAP/EAC. As of May 2003, there were a total of 111 experts from the Region serving on 48 Expert Advisory Panels. There were 43 panel members from India, 25 from Thailand, 20 from Indonesia, 13 from Sri Lanka, 5 from Nepal, 4 from Myanmar, and one from Bangladesh. Bhutan, DPR Korea and Maldives are not yet represented in EAP/EAC.

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Organization of Health Services Development and updating of national health accounts (NHA) were actively and intensively followed up in countries of the Region. The Asia-Pacific National Health Accounts Network (APNHAN), in collaboration with WHO, organized an international seminar on NHA in Bangkok in June 2002. This seminar updated the methodology, the process and examination of NHA of 25 Asia-Pacific countries. In India, a national NHA workshop was organized in September 2002 in New Delhi with WHO support. The participants were exposed to the establishment and updating of NHA and developed a strategy for application at national and state levels. Similarly, the Department of Health Planning, Ministry of Health, Myanmar, initiated the updating of NHA, which is expected to be completed by mid-2003. WHO also organized a meeting of regional experts on Social Health Insurance (SHI) in March 2003. Experts from India, Indonesia and Thailand, where SHI schemes are being implemented on a large scale, contributed significantly at the meeting. Based on the discussions and recommendations of the experts, WHO prepared a working paper on SHI which addressed policy options for promoting and expanding SHI in the Region.

Development of human resources for health (including nursing and midwifery) A WHO intercountry meeting was held in Chandigarh, India, in November 2002 to discuss health-related sciences and specialities. The meeting identified areas for developing a sustainable mechanism for “Faculty and Information Exchange” between institutions and specialities in the Region. Regional accreditation guidelines in public health were printed and disseminated to national authorities and institutions in the Member Countries. As a follow-up, national accreditation workshops were held in Bangladesh, Nepal, Myanmar and Sri Lanka with WHO support. Decentralization, globalization and gender mainstreaming are new challenges to public health educators. Links between health and economic development have to be emphasized along with significant effects of multilateral trade agreements.

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Macro-economic policies and their implications for health development are new areas to be considered. Public health schools were assisted in addressing these concerns through a tailor-made course, held in Bandung, Indonesia, in September 2002. As a follow-up of the “Calcutta Declaration on Public Health”, an intercountry meeting, held in New Delhi in February 2003, reviewed recent developments in countries in public health education programmes and identified issues and challenges in emerging areas in public health training, education and research. It also formulated a framework for a regional network and identified areas of collaboration. Since primary care comprises provision of integrated, accessible health care services by clinicians to address health care needs of the people, family medicine is promoted as a speciality in the Region. Principles and framework for a core curriculum in family medicine were developed at an intercountry meeting held in Colombo in June 2003. WHO continues to collaborate with Member Countries in strengthening nursing and midwifery programmes. A multidisciplinary Regional Advisory Group on Management of Nursing and Midwifery Workforce concluded its work in December 2002. The Group developed guidelines on how best the countries could manage their nursing and midwifery

91 Collaboration continues with Member Countries in strengthening nursing and midwifery programmes. THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

workforce taking into account issues confronting nursing and midwifery identified through in-depth country assessments. Consequently, a new Regional Advisory Group on Nursing and Midwifery has been established to advise the Regional Office and Member Countries on addressing priority issues in nursing and midwifery. The group will also help in coordinating, facilitating, monitoring and evaluating the implementation of the newly-developed guidelines for strengthening nursing and midwifery at regional and country levels.

Increasing attention was given to strengthening allied health (paramedical) personnel in some countries of the Region

A regional consultation was convened in August 2002 to identify potential roles of nurses and midwives in priority areas, viz. HIV/AIDS, TB and malaria. In collaboration with the International Council of Nurses, training in nursing leadership and management was implemented in Bangladesh, Myanmar and Nepal. A core group of nurse managers in these countries is being developed to enable them to facilitate improvement in the quality of nursing and midwifery. A model for clinical performance development and management system was developed in Indonesia to enhance the productivity of nurses and midwives. Increasing attention was given to strengthening allied health (paramedical) personnel in some countries of the Region which constitutes a wide array of health personnel, such as health assistants, laboratory technicians, radiodiagnostic technicians, dental hygienists, dental technicians, pharmacy assistants, physiotherapists, dieticians, medical records technicians, etc. Indonesia took the initiative to make primary oral health services accessible, particularly to people in remote communities, through services of dental nurses. Action was also taken to strengthen physical therapist education in Indonesia and for enhancing the capacity of the trainers in all allied health (paramedical) schools in Sri Lanka.

Education and training support WHO has been pursuing a fellowships programme for its Member Countries, supporting the education and training of health professionals in various fields of medical and public health sciences. Currently, this consists of fellowships, study tours and intercountry training. A new system to train fellows through the APW mechanism has been introduced in a few

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countries of the Region. There has been an increasing trend of short-term training in specialized fields with greater use of regional resources. Presently, such training is in the areas of primary health care, field epidemiology, vector biology, community health care and research, malaria control and nursing. There is an upward trend in regional training as compared to extra-regional fellowships. Efforts are constantly being made to assess the training needs of the countries in terms of number, duration and field of study under the WHO collaborative programmes. During the period under review, 808 fellowship applications were received. Of these, letters of award in respect of 774 fellowships were issued. Of the 774 fellowships awarded last year, Fellowship Termination of Studies Reports in respect of 506 fellowships were received. Table 6.1 gives a broad picture of implementation of fellowships in the Region.

Table 6.1: Distribution of fellowships in the SEA Region 1 July 2002 to 30 June 2003 Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Total Source: WHO/SEARO

Number of applications received 235 32 40 137 30 24 178 56 66 7 3 808

Number of fellowships awarded 187 33 74 67 30 31 207 37 96 9 3 774

Number of fellowship termination of studies report submitted 84 31 112 20 3 11 154 15 70 3 3 506

Further, the Region offered services to the Western Pacific (WPR) and Eastern Mediterranean (EMR) Regions in the implementation of their fellowships programme. 106

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fellowships from the Western Pacific Region and 6 from the Eastern Mediterranean Region were implemented with support from the SEA Regional Office. Applications for 66 study tours were processed for implementation by the technical units. During the period under review, 80 meetings/group educational activities (GEAs) were held, of which 6 were policy meetings, 34 were advisory meetings and 40 were intercountry technical meetings. In order to streamline and strengthen fellowships operations in the Regional Office, a Documents Management System is being developed. Under the system, all fellowship application forms, fellowship placement requests, final fellowship estimates, letters of award and other communications generated in the ETS Unit would be scanned, indexed and stored in electronic form. This would facilitate easy retrieval and access of information in addition to providing indexing and CD back-up contributing to efficient management of fellowships. Information relating to the previous two biennia, viz. 19981999 and 2000-2001 has been archived while data relating to the biennium 2002-2003 are being scanned and indexed.

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7 GOVERNING BODIES AND EXTERNAL RELATIONS Governing Bodies World Health Assembly The Fifty-sixth World Health Assembly, held in Geneva from 19 to 28 May 2003, elected Dr Khandaker Mosharraf Hossain (Bangladesh) as President and Mr So Se Pong (DPR Korea) as one of the Vice-Presidents of Committee B. The Assembly adopted 35 resolutions as well as a treaty on the Framework Convention on Tobacco Control, which was a memorable landmark in the history of WHO. Nepal became a Member of the Executive Board for a threeyear term, to fill the vacancy caused by DPR Korea completing its term. The Assembly appointed Dr Jong-Wook Lee as the DirectorGeneral of the Organization for a five-year term beginning 21 July 2003. At its request, the Democratic Republic of Timor-Leste was assigned to the South-East Asia Region. The Assembly appointed the Comptroller and Auditor General of India as External Auditor for the accounts of the Organization for the financial periods 2004-2005 and 20062007. Discussions on technical and health matters included: International Conference on Primary Health Care, Alma-Ata: twenty-fifth anniversary; Prevention and control of influenza 95 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

pandemics and annual epidemics; Strategy for child and adolescent health and development; Joint FAO/WHO evaluation of the work of the Codex Alimentarius Commission; Implementing the recommendations of the World Report on Violence and Health; Elimination of avoidable blindness; Intellectual property rights, innovation and public health; Revision of International Health Regulations; Severe acute respiratory syndrome (SARS); Global health sector strategy for HIV/AIDS; and Traditional medicine. In addition to the regular discussion on management and financial matters, the Assembly decided to accept the latest available United Nations scale of assessment for assessed contributions of WHO Member States, suitably modified to account for WHO membership. The Assembly also passed an appropriation resolution for the financial period 2004-2005, approving a substantial Regular Budget increase, notably in non-substantive areas of work, like the Information Technology Fund. Recognizing that recruitment to WHO has been uneven in reaching the gender balance targets, the Assembly requested the Director-General to redouble efforts to achieve the target of gender parity and to raise the proportion of women at the senior level. Recognizing also the existing imbalance in the distribution of posts in the WHO Secretariat between developing and developed countries, the Assembly approved a revised formula for appointment of staff in WHO, with revised percentages of three factors, namely membership (45 per cent), contribution (45 per cent) and population (10 per cent).

Executive Board The 111th session of the WHO Executive Board was held in Geneva in January 2003. The important issues discussed included: Proposed programme budget for 2004-2005; Evaluation of WHO programmes 2000-2001; Meeting of Interested Parties 2002; Staffing matters including representation of developing countries in the Secretariat; and Policy for relations with NGOs. 96 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The technical and health matters discussed related to: WHO’s contributions towards achievement of the UN Millennium Development Goals; Follow-up of the UN General

Assembly special session on HIV/AIDS; Country focus initiative; Smallpox eradication: destruction of variola virus stocks; Assessment of health systems’ performance; Strategy for child and adolescent health and development; Traditional medicine; Influenza; and Revision of the International Health Regulations. The 112th session of the Executive Board was held in Geneva in May 2003. Among the technical matters discussed were: International non-proprietary names; Genomics and world health: Report of the advisory committee on health research; Human organ and tissue transplantation; and proposal for a “health” Internet domain. It also reviewed selected staffing and management matters.

Regional Committee The 55th session of the Regional Committee for South-East Asia was held in Jakarta, Indonesia, from 11 to 13 September 2002. It was attended by representatives of all the ten Member States of the Region, as well as the Democratic Republic of TimorLeste (as an Observer), the Director-General and representatives of other UN agencies, inter-governmental organizations and international and local nongovernmental organizations. The Committee discussed the report of the Regional Director on the work of WHO in the South-East Asia Region for the period 1 July 2001 to 30 June 2002. The Committee noted: l

the threat posed by indiscriminate advertising carried out by multinational companies promoting tobacco use, unhealthy foods and life styles; the technical support provided by WHO in obtaining resources from the Global Fund for AIDS, Tuberculosis and Malaria (GFATM); the problems being faced by many countries in the areas of health sector reforms and health care financing due to high cost of technology, the increase in the elderly population and inefficient systems;

l

l

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The fifty-fifth session of the Regional Commmittee for South-East Asia was held in Jakarta, Indonesia.

l

the health problems arising from global warming and rapid urbanization required urgent attention and baseline data; and the availability of a generic training module for quality assurance in primary health care and the assistance provided by WHO in this regard.

l

The Committee considered the recommendations arising out of the Technical Discussions on Management of Decentralization of Health Care, held during the 39th meeting of the Consultative Committee for Programme Development and Management. The Committee adopted four resolutions and three decisions.

Consultative Committee for Programme Development and Management The 39 th meeting of the Consultative Committee for Programme Development and Management (CCPDM) was held in Jakarta from 5 to 7 September 2002. The Committee, inter alia, critically reviewed the implementation of the WHO collaborative programmes at country and regional levels, including the intercountry programme for the biennium 2000-2001 and the first six months of the 2002-2003 biennium. The Committee, while taking note of the declining amount of surrendered reserves, requested the Member

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Countries and WHO to make further efforts to speed up implementation and to improve efficiency and thus reduce funds for final liquidation. The CCPDM also noted the reports by country representatives on their attendance at the meetings of the coordinating bodies of WHO global programmes (TDR/HRP). It reviewed and made recommendations on the regional implications of the decisions and resolutions of the World Health Assembly and the Executive Board. The CCPDM reviewed the findings of a joint evaluation on selected supplementary intercountry programmes carried out by country representatives and Regional Office staff. The evaluation was mainly conducted in Indonesia, Sri Lanka and Thailand. The recommendations of the CCPDM were forwarded to the 55th session of the Regional Committee for its guidance and noting. The Committee also selected one of the supplementary intercountry programmes, “Multi-disease surveillance and response, including health hazards, risk behaviour surveillance, through intercountry and interregional collaboration, and use of regional mechanisms like ASEAN, SAARC, Mekong Basin Project, and Intercountry Cooperation in Health Development” to be evaluated during 2003. It requested the Regional Director to report the findings to the 56th session of the Regional Committee. The CCPDM reviewed the Proposed Programme Budget for the period 2004-2005, including the Region-specific Part II of the budget document. The Committee made its recommendations to the 55th session of the Regional Committee for its guidance and noting. As part of the assigned duty by the Regional Committee, the Committee held Technical Discussions on “Management of Decentralization of Health Care” and prepared a summary report and recommendations including a draft resolution for the Regional Committee for its consideration. The Committee discussed the regional mechanism for bulk purchase of selected essential drugs and recommended that WHO continue to provide technical assistance to countries to enable them to further strengthen their Drug Regulatory Authorities. It also suggested that prequalification criteria should include companies whose products have been purchased by UN agencies using appropriate quality criteria.

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A technical update on the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) was also provided to the Committee. It noted WHO’s critical role in the provision of information and support to Member Countries in the preparation of proposals to the Fund.

Health Ministers’ Meeting The Twentieth Meeting of Health Ministers of the countries of the Region was held in September 2002 in Jakarta. The Ministers reviewed the Global Fund to Fight AIDS, Tuberculosis and Malaria as well as the regional mechanism for bulk purchase of selected quality essential drugs. They recommended that the Regional Office convene a regional consultation of Drug Regulatory Authorities to refine prequalification criteria and to finalize the Bulk Purchase Scheme of Quality Essential Drugs.

During the course of their twentieth meeting, the Health Ministers visited a unit producing traditional drugs.

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The Ministers also deliberated on the Report of the Commission on Macroeconomics and Health and recommended that the report should continue to be used for advocacy for health and as an instrument to mobilize additional resources, both domestic and external. The establishment of national commissions on macroeconomics and health or equivalent mechanisms at the country level was further recommended.

Health Secretaries’ Meeting The Eighth meeting of Health Secretaries was held in April 2003 in Kathmandu. The Health Secretaries reviewed: Implementation of the Programme Budget 2002-2003; Programme Budget 2004-2005 and ICP-II Work Plans for Programme Budget 2004-2005 (Report of the High-Level Task Force on ICP-II: Focus on Expected Results and Products). They also reviewed the progress on the Declaration on Health Development in South-East Asia in the 21st Century, adopted by the Health Ministers in 1997. Among the various items included in the provisional agenda of the Fifty-sixth World Health Assembly, the Health Secretaries were briefed on: Healthy environments for children (Round Tables); Framework Convention on Tobacco Control; Strengthening health systems in developing countries; WHO’s contribution to achievement of the development goals of the United Nations Millennium Declaration; Implementing the recommendations of the World Report on Violence and Health; Financial matters – Assessments for 2004-2005; and Staffing matters – Representation of developing countries in the Secretariat.

Regional Conference of Parliamentarians A Regional Conference of Parliamentarians on the Report of the Commission on Macroeconomics and Health was held in December 2002 in Bangkok, Thailand. The report was thoroughly discussed and the following recommendations were made: (1) Wide dissemination and advocacy of the key findings and recommendations of the CMH report should be undertaken. (2) Suitable national mechanisms to carry forward and develop the CMH strategic framework at the country level should be established. (3) Health systems should be strengthened to ensure that health resources are efficiently and equitably utilized in a transparent and accountable manner so that external assistance could be available on the basis of “accountability” rather than “conditionality”. WHO should provide technical assistance as required in this regard.

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(4) Development partners should be encouraged to provide the requisite technical and financial support for national efforts on a long-term basis: WHO should provide leadership in this endeavour.

Resource Mobilization and External Cooperation and Partnerships Mobilization of external resources has assumed added significance, both for WHO to meet increasing demands for technical collaboration, and for Member Countries to achieve their national health development goals. During the period under review, the Regional Office played an active role in mobilizing resources. Meanwhile, extrabudgetary resources (EB funds) increased significantly. By the end of 2002, the Region had mobilized US$ 95m as EB funds which was 95 per cent of the projected amount of US$ 100.5m for the whole biennium. This represents an increase of 31 per cent over the last biennium. With sustained and coordinated efforts at all levels of WHO, the major donors in the Region continued to be active in 2002. These included USAID (US$ 17m), DFID (US$ 16.8m), Rotary International (US$ 10.4m) and Sasakawa (US$ 4.2m). The major recipient programmes were Polio Eradication, including vaccines, TB Control, Emergency and Humanitarian Action and HIV/AIDS. The major recipient countries were Bangladesh (US$ 8.7m), India (US$ 38.4m), Indonesia (US$ 11.4m) and Nepal (US$ 9.5m). These countries accounted for approximately 70 per cent of the total EB funds for the Region. Several countries in the Region also receive significant assistance from the World Bank and the Asian Development Bank, which have emerged as major supporters in health development activities. To facilitate the efforts of Member Countries in mobilizing resources from these institutions, WHO country offices played an active role, especially in health sector review, project formulation, negotiations and agreement. The Regional Office continued to provide timely technical support and coordination.

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One of the examples in this respect is the North-East Emergency Reconstruction Programme in Sri Lanka, established with financial support from the World Bank/IDA. Here, WHO played a lead agency role in health sector review, formulation of the project proposal, negotiations and agreement, resulting in a project agreement of US$ 8m for two years. WHO also participated in the Eighth Round Table Meeting for Bhutan in Geneva in February 2003 and provided technical inputs to the discussion on health sector development in that country. The Regional Office and several Member Countries also participated in the Meeting of Interested Parties (MIP), held in Geneva in October 2002. This facilitated exchange of views on WHO’s priority health programmes and evaluation of the usefulness of WHO’s resource mobilization efforts. The Regional Office also assisted in the mobilization of resources for the immunization programmes in Member Countries. The Global Alliance for Vaccines and Immunization (GAVI) is expected to provide more than US$ 200m to several eligible countries in the Region over the next five years. The Global Fund to fight HIV/AIDS, Tuberculosis and Malaria approved a total amount of US$ 283m for several countries in the Region in the first round in March 2002. In the second round in February 2003, US$ 275m was approved. The improvement of national capacity for resource mobilization is one of the essential components of the regional strategy. In this context, the Regional Office is supporting Member Countries in organizing national training workshops on aid negotiation and project formulation skills development. To foster and strengthen public and private sector partnerships, the Regional Office participated in the India Economic Summit, held in New Delhi in November 2002. The Summit focused on tuberculosis control and stressed the need for each business establishment to adopt DOTS in the work place and for the Confederation of Indian Industry to play a key advocacy role in mobilizing the business sector in TB control activities. WHO continued to strengthen its cooperation and partnerships with UN system agencies and other intergovernmental and nongovernmental organizations. 103 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

One of the essential components of the regional strategy for resource mobilization is improvement of national capacity

In collaboration with ESCAP and UNFPA, WHO actively participated in the Fifth Asian and Pacific Population Conference, held in Bangkok in December 2002. The Conference adopted a comprehensive plan of action to further advance implementation of the Programme of Action of the International Conference on Population and Development. In view of the ESCAP reform in its Conference and Secretariat structure to focus, inter alia, on emerging social issues including health, the Regional Director held a meeting with the Executive Secretary of ESCAP in March 2002 to strengthen working relations between the two secretariats. This initiative was actively followed up by WHO with ESCAP , especially to explore and identify further areas of collaboration.

WHO continued to strengthen its cooperation and partnerships with UN system agencies and other intergovernmental and nongovernmental organizations

For the 59th session of ESCAP , held in April 2003, joint efforts were made by the two agencies to disseminate and support the implementation of the recommendations of the Commission on Macroeconomics and Health (CMH). This resulted in the inclusion of the CMH recommendations in many documents in the above session along with issues related to the control of HIV/AIDS. The Roll Back Malaria Mekong project, established to contribute to the Global Roll Back Malaria initiative, and also to follow up on the ECOSOC and ESCAP resolutions on the subject, made good progress. This included the development of IEC materials, training for malaria programme officers, and establishment of a network for drug quality control and quality assurance. WHO held a Joint Strategic Consultation in New Delhi in October 2002 with the UNICEF Regional Office for South Asia, (UNICEF/ROSA) and the Regional Office for East Asia and the Pacific, (UNICEF/EAPRO) on the Expanded Programme on Immunization. WHO and UNICEF also worked closely through the regional Inter-agency Coordinating Committee. This provided a good opportunity for the representatives of committed international donor agencies to discuss funding issues related to the achievement of the EPI disease control targets for poliomyelitis eradication, elimination of neonatal tetanus, and reduction of measles mortality and morbidity.

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WHO is actively working with UNICEF, UNFPA, UNAIDS and the World Bank in developing various policy guidelines,

norms and standards as well as programmes in the areas of Reproductive Health, Child and Adolescent Health, HIV/AIDS and Nutrition. It collaborated with UNAIDS in the development of an HIV/AIDS database for South Asia. The two agencies organized meetings of the South-Asia Theme Group on HIV/ AIDS and developed a unified budget work plan. They also supported Member Countries in the preparation of a “Regional Review Mechanism” for the Global Fund. WHO’s collaboration with ASEAN was further consolidated with the renewal of its Memorandum of Understanding (MoU) in April 2002, for another five years. WHO and ASEAN have together made efforts to place health high on the political agenda in ASEAN Member States. Considerable progress in technical collaboration between the two agencies has also been achieved, notably in the area of pharmaceuticals, including promotion of pharmaceutical standards, training of manpower, harmonization of technical requirements for drug registration, good clinical practices and control of counterfeit drugs. TB control is one of the major and ongoing collaborative programmes between WHO and SAARC. WHO continued to provide technical support to the SAARC TB Centre in Kathmandu, which is also a WHO Collaborating Centre for TB control. As a follow-up of the Regional Director’s meeting with the Secretary-General of SAARC on further strengthening collaboration between the two agencies under the Memorandum of Understanding (MoU) between WHO and SAARC, concluded in August 2000, consultations between the two agencies were held to review the MoU, identify priority areas and to develop collaborative plans. WHO country offices in the Region were actively involved in the joint initiatives of the UN system. These included the development and follow-up of UNDAF and preparation of the health component for the report on the Millennium Development Goals. Country offices also actively participated in the various inter-agency coordinating mechanisms established under the UN Resident Coordinator System such as the Inter-Agency Working Group, Theme Group, Support Committee and Task Forces and played a leading role on health in these coordinating mechanisms. The country offices also contributed substantially to the formulation of proposals for GAVI and GFATM.

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WHO collaborated at the country level with many UN agencies on various health and health-related subjects such as health sector reform, the health emergency preparedness and response plan of the UN system, health reconstruction programme, Expanded Programme on Immunization including GAVI, polio eradication, joint UN initiative on elimination of maternal and neonatal tetanus and reduction of measles mortality and morbidity, HIV/AIDS programmes, environmental health, water supply and sanitation, and Roll Back Malaria. The 111th session of the WHO Executive Board, in January 2003, recommended to the Fifty-sixth World Health Assembly to adopt a new policy for relations between WHO and nongovernmental organizations (NGOs). The new policy is split into two parts covering aspects of accreditation and collaboration. Under the new policy, the Regional Committee will be responsible for decisions regarding the accreditation of regional and national NGOs to the Regional Committee in accordance with the arrangement set out in the policy.

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8 GENERAL MANAGEMENT Budget and Management Reform The Regional Office continued its support to Member Countries on improving the managerial process for WHO programme development within the context of national health development. This was achieved through training and orientation of concerned national health officials and providing assistance in programme planning, implementation and evaluation. Regular and intensive programme planning, implementation and monitoring by WHO country offices and regional technical units, was carried out with the active participation of concerned nationals. This resulted in most Member Countries achieving the target of 85 per cent implementation by the end of the first year of the 2002-2003 biennium. Intensive consultations took place between the Regional Office and WHO headquarters, as part of the Organization-wide efforts to develop the Proposed Programme Budget for 2004-2005 (PB 2004-2005) and the Region-specific Part II of the Programme Budget. The Proposed Programme Budget 2004-2005 was reviewed by the 39th meeting of CCPDM. Its observations and recommendations were later reviewed and endorsed by the 55th session of the Regional Committee. The principles of resultbased budgeting were taken a step further in PB 2004-2005 with the definition of strategic approaches and indicators at the WHO operational level of all areas of work. As part of the Organization-wide training, a series of intercountry orientation workshops on “Results-based Management: Using a Logical Framework in WHO Programme 107 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Regular planning, implementation and monitoring resulted in most Member Countries achieving the implementation targets

Management” were organized. The first workshop was held in Yangon in July 2002, the second in Bangkok in November 2002, and the third in Colombo in December 2002. WHO staff from the country offices, field programme offices, the Regional Office, and national counterparts involved in planning, management, monitoring and evaluation of WHO collaborative programmes from all Member Countries, participated in these workshops. The last two were held in January and February 2003 in New Delhi and mainly included staff from the Regional Office and the WHO country office in India. Within the WHO global framework, the Regional Office provided guidelines for preparing detailed work plans for RO/ ICP and ICP-II for 2004-2005. Similar guidelines were also provided to WHO Representatives with regard to the preparation of country-level detailed work plans for the same biennium. The first phase, completed by March 2003, focused on the development of “country and regional expected contribution” with respective indicators, targets and baseline. In the second phase, completed by end-June 2003, the products, milestones, activities and proposed budget for each programme area will be incorporated. In order to ensure full involvement of Member Countries in the planning, implementation and evaluation of the supplementary intercountry programmes (ICP II), the Regional Director established a High-Level Task Force (HLTF). National officials from ministries of health at the decision-making level nominated by the Member Countries were members of this Task Force, and technical and operational officials familiar with the content areas to be addressed through the supplementary intercountry programme constituted the members of the Technical/Operational Group of HLTF. The terms of reference of HLTF included assisting the Regional Office in the joint planning of the draft detailed plans of action for the supplementary intercountry programme for the biennium, and to recommend a funding level for each of the content areas to be addressed by the supplementary intercountry programme for 2004-2005. 108 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

The HLTF reviewed the draft ICP-II work plans for PB 20042005 at its first meeting, held at Kathmandu in April 2003, and outlined a set of 14 content areas. The observations and

recommendations, including the proposed budget, were submitted to the Eighth meeting of Health Secretaries, held at the same place, in April 2003. These draft plans were discussed at the second meeting of HLTF in June 2003. As per the decisions of the 53rd and 54th sessions of the Regional Committee, the specific programmes under the supplementary intercountry programme (ICP II) had been evaluated by joint teams comprising country representatives and staff from the WHO country and Regional Offices. The teams visited Indonesia, Sri Lanka and Thailand and submitted their findings to the 55th session of the Regional Committee. The teams identified lessons learnt and made recommendations on: (a) the need for thorough briefing of national officials and WHO staff on the purpose and objectives of the intercountry programme, (b) the involvement of national officials at the technical and operational levels in the formal HLTF mechanism for the development of products and activities, and (c) the adequacy and complementarity of the intercountry programme. Technical support and guidance were provided to the WHO country teams from Bangladesh, Bhutan, DPR Korea, Sri Lanka and Thailand for revising their country cooperation strategies. Inputs were also provided to the global programme of Country Focus Initiative.

Human Resources Development The current organizational structure of the Regional Office is at Annex 1. As part of the ongoing reforms in the Organization-wide management of human resources, a new system of contracts came into force on 1 July 2002. The new contractual arrangements aim at improving the conditions of service for temporary staff and enabling programme managers to better plan their staffing needs in relation to programme priorities. The contractual reform process included the introduction of term-limited contracts for temporary staff with an enhanced compensation package and full medical insurance coverage and coverage of dependent family members. Appropriate mechanisms were also established to review “long-term shortterm” (LTST) staff and their possible transition to fixed-term

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staff. There are 12 staff members in the Region who qualify for this conversion and establishment of fixed-term posts for them is under way. The reform process further benefited 88 fixed-term staff members in the Region by way of contract extensions of five years’ duration. In order to further harmonize action in the Regional Office with initiatives taken at WHO headquarters, a Regional Service Appointment Review Committee was established to determine the mechanism for awarding open-ended service appointments to eligible staff members. Service appointments have no specific time limit and may be brought to an end by either party subject to certain specified conditions. Consequent upon the global HR reform process, and in order to infuse competition and merit in recruitment, written tests and interviews are now part of the selection process for fixed-term GS and professional posts. Further streamlining of selection procedures is under way to help attract highly qualified staff and to enable fair selections. During the reporting period, special efforts were made to recruit new appointees from unrepresented and underrepresented countries, keeping in view the parallel objective of gender parity. A total of 18 appointments were made of which 6 were by way of reassignment from other regions. Six of these posts were filled by women (33 per cent) and 4 (33 per cent) by persons from unrepresented/under-represented countries.Table 8.1 shows the distribution of professional staff and the representation of women professional staff.

Table 8.1: Distribution of professional staff and representation of women professional staff in the SEA Region (as of June 2003) Location Regional Office Country Office Field Office Total Source: WHO/SEARO

Established posts 74 24 41 139

Staff in position Total 54 19 21 94 Male 36 16 13 65 Female 18 3 8 29

Percentage of female staff 34 16 43 33

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As a reflection of expanded activities at the country level, 24 posts of National Professional Officers (NPOs) have been established.

In the context of enhancing national capacity towards implementation of health programmes, 1083 special services agreement holders were hired of which 780 provided support for the National Polio Surveillance Programmes in India and Nepal. In accordance with the Director-General’s policy of mobility and rotation, and with a view to developing versatile careers, eight professional staff were reassigned throughout the Region. Likewise, job rotation was recently implemented among General Service staff across all departments in the Regional Office. This resulted in the reassignment of 27 staff members who fulfilled certain pre-established criteria. As part of the ongoing staff development programme, a number of workshops and training activities were organized. These included security awareness workshops, distance learning courses and in-house briefing/orientation programmes on different technical/managerial/administrative areas. The Organization has also established a modern and well-equipped fitness centre for the Regional Office staff and their dependents.

Financial Management The attention given to financial implementation in the 20002001 biennium yielded positive results. Compared with 19981999, the Region’s Regular Budget reserves were reduced by 20 per cent while the surrender of funds decreased from US$ 3.76m to US$ 1.5m (Figure 8.1 and Annex 4).

Figure 8.1: Regular Budget reserves surrendered, 1994-1995 to 2000-2001 5.00 4.40

Reserves surrendered (in US$ million)

4.27 3.76

4.00

3.00

2.00 1.50

1.00

0.00 1994-1995 Source: WHO/SEARO

111 1996-1997 1998-1999 2000-2001

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Financial implementation results: 2002-2003 Despite the ambitious targets, the financial implementation results have been encouraging. Eight countries and the RO/ ICP programmes met the 85 per cent implementation target for the first year of the biennium. All funds were committed by the end of June 2003 (Annexes 2 and 3). Key factors contributing to the positive financial implementation in 2000-2001 and 2002-2003 include: close collaboration between WHO and the government on planning and implementation; setting clear targets for implementation; and redirecting uncommitted funds quickly to priority programmes with better absorption capacity. A comparison of implementation between the bienniums 2000-2001 and 2002-2003 is given in Figure 8.2.

Figure 8.2: Implementation of activities, Regular Budget 2000-2001 and 2002-2003 100 88 82 Im ple me nta tio n

100

80 Allocation (percentage)

20 02

-03

60

56

59 00 20 1 -0

n atio ent m e pl Im

40 29 37

20 0

12 10

21

0

Mar

Jun Year 1

Sep

Dec

Mar Year 2

Jun

Source: WHO/SEARO

Extrabudgetary funds The provision of extrabudgetary funds to the South-East Asia Region in 2000-2001 was unfortunately not consistent with its large population and the high burden of diseases. Of a total of US$ 1355m extrabudgetary funds available to the Organization, only US$ 96.1m was spent on activities in the SEA Region, compared to US$ 497m and US$ 550m for the African Region and HQ respectively. Additional efforts will be

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required to sensitize donors to this persistent inequity. The issue also needs to remain high on the agenda of senior-level meetings in WHO.

Projections for the future As the current report relates to the period 1 July 2002 to 30 June 2003, it is premature to comment on the future budgetary trends for the SEA Region. Nevertheless, the Director-General’s proposals for the proposed Programme Budget for the 2004-2005 biennium contained positive elements for the Region, including, for the first time in four biennia, a cost increase in the budget allocation, US$1 million in relief for the prior costs resulting from the resolution WHA 51.31, and an allocation of US$1.5 million for TimorLeste. The approved budget maintained the latter two increases, but the proposed cost increase was aggregated at WHO headquarters for SARS and International Health Regulations, though some funds will ultimately be reallocated to regions.

Informatics and Infrastructure Services Sharing of knowledge and information among offices is a key step towards achieving the Organization’s mandate and strengthening the concept of “One WHO”. All country offices except DPR Korea have dedicated Internet connectivity. This facility will soon be extended to DPR Korea as well. The convergence of Information and Communication Technology (ICT) has been greatly enhanced by providing reliable, secure and cost-effective inter-office connectivity between the Regional Office and six country offices using GPN/VPN, online access to regional information sources and reliable e-mail facility throughout the Region. As a next step, secure inter-office connectivity will be extended to the remaining country offices. ICT infrastructures have been further upgraded and standardized in the WHO Representatives’ offices in DPR Korea, India, Maldives, Myanmar, Sri Lanka and Thailand. Support was also provided to the National Polio Surveillance Project (NPSP), India, for upgrading their information system Internet connectivity, LAN infrastructure and telephone system. Internet connectivity has also been enhanced in the Regional Office. In order to provide remote access to SEARO LAN,

All country offices will have dedicated Internet connectivity by the end of 2003

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initiatives have been undertaken to strengthen the infrastructure by upgrading it using the digital fibre optic technology. With this new technology, it will be possible for staff to have secure access to SEARO LAN resources from home or when on duty travel. Web site developments were supported for technical programmes in the Regional Office and country offices. A web builder tool was developed to ensure a distinct and coherent image of the Organization, and to strengthen the capacity of country offices for structured content management. Continuous efforts have been made to strengthen the Organization’s business processes by improving the information systems in the Region. Eleven technical and administrative information systems were developed and implemented in the Regional Office. In order to automate the preparation, clearing, approval and distribution process of travel authorizations, a computer-based Travel and Meeting Administration System (TMAS) was implemented. To manage information related to WHO research projects, collaborating centres and expert advisory panels in the Region, three web-based, user-friendly systems were also developed and implemented. Staff in six country offices and in the Regional Office were trained in the use of the remodelled Activity Management System (AMS), which will enable improved technical and financial monitoring of the bi-annual work plans. Member Countries in the Region are faced with the challenge of extending equitable, quality basic health services to all people, especially those in remote areas. Health telematics is one way to contribute towards achieving this goal. To effectively employ health telematics, it is necessary to develop pilot projects in the Region. Based on the lessons learnt from Bhutan, an implementation plan was developed for piloting health telematics in Sri Lanka in consultation with relevant government authorities. According to the plan, equipment was procured, start-up training provided, and the pilot system will be initiated soon. In December 2002, an implementation plan for a pilot project in Maldives was also developed, and the process for procuring the equipment initiated. In a parallel but independent action, a pilot health telematics project (E-Health) was initiated in Myanmar,

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primarily for information sharing. The next steps will be to explore the possibility of using the same system for other health telematics applications. The application of geographical information system (GIS) as a data analysis and presentation tool in the Regional Office was strengthened. Efforts are currently under way to ensure the availability of consistent standardized GIS spatial data. A prototype of a web-based GIS application is being developed for managing health-related data and indicators, producing various statistical reports, graphs and maps using standardized GIS spatial database, in close cooperation with WHO headquarters.

Procurement services Procurement by the Medical Supply Unit for the Member Countries and the Regional Office during the reporting period amounted to US$ 13 m of which US$ 5.89 m was provided from the Regular Budget and US$ 7.11 m from extrabudgetary sources. Items procured included drugs, vaccines and diagnostics, biological, laboratory and hospital equipment, office automation and informatics equipment, vehicles and medical literature. Procurement and logistical support, including laboratory equipment, reagents, office and informatics supplies and vehicles under the Global Polio Eradication programme also continued. These services were mainly for Bangladesh and India. Anti-TB drugs and supplies were procured for implementation of the DOTS strategy in India and DPR Korea. During the reporting period, various emergency supplies amounting to US$ 500 000 were also arranged for Bangladesh and DPR Korea. Assistance was provided for the procurement of supplies and logistic support to combat the emergency situation in Thailand and neighbouring countries following the outbreak of severe acute respiratory syndrome (SARS).

General support services Special emphasis has been placed on security of staff during the reporting period. This is linked to a UN-wide focus on security, with the new Department “UNSECOORD”, established in early 2002, reporting directly to the Secretary-General of 115 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

the United Nations. As a result of this new focus, steps have been taken to establish a post of Field Security Officer in the Region who will prepare security plans and provide training to all WHO staff at country and regional levels. It is expected that at least 50 per cent of the Field Security Officer’s time will be spent in supporting WHO country offices. As part of security preparedness, stringent requirements have been put in place regarding state-of-the-art telecommunications and radio equipment, and the institution of a warden system in all WHO locations in order to meet the Minimum Operating Security Standards (MOSS) laid down by UNSECOORD. Of all WHO regions, South-East Asia has, at present, the highest MOSS compliance level, but more will need to be done in the 20042005 biennium. The security of the Regional Office was also strengthened and tighter control of visitors introduced. As part of the general renovation of the Regional Office, action was also initiated to replace the water chilling plant of the central air-conditioning system as well as one of the two main generators in the office. Additional resources will be needed in future to renovate the 40-year-old building.

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9 REGIONAL DIRECTOR’S DEVELOPMENT PROGRAMME Public Relations and Media Overall, the Information Unit continued to work closely with the media and with the technical units, to promote the work of WHO. With the global SARS outbreak, inevitably much of the media effort focused on communicable diseases. The Unit was an intrinsic part of the SARS Task Force and played a proactive role in trying to stem the sense of panic by ensuring that the media were given the facts about the disease, how it is transmitted and the case definitions. Information sheets on: “Facts about SARS” and “Frequently asked questions by the press”, were circulated widely to the media and to the Member Countries. An important event during the period under review was the visit to the Regional Office and India by the WHO DirectorGeneral, Dr Gro Harlem Brundtland. As the focus of her visit was a major advocacy initiative for polio, she visited the state of Uttar Pradesh and launched SNID for polio. The Unit supported the media coverage, including the special World Health Day events arranged in New Delhi. The DirectorGeneral’s presence at the time of SARS elicited considerable media interest resulting in several media interactions with the top international and national media. Selected media representatives were invited to participate in a “lessons learnt” workshop in the aftermath of the cases of plague reported in the state of Himachal Pradesh, India, in 2002. Working closely with technical experts, they evolved a draft communications policy for use during epidemics.

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Technical units were supported in their public/media outreach activities - press conferences, press releases, special events (e.g. release of report on violence, leprosy GAEL meeting, special activities around the World Health Day theme, “Healthy environments for children” and the launch of the anti-tobacco report on Indian cinema entitled “Bollywood – a victim or ally?”. For the Twentieth Meeting of the Health Ministers, the 55th session of the Regional Committee and the GAEL meeting in Myanmar, the Unit undertook a new activity: special interviews were done with each of the Health Ministers, and copies of video tapes provided to each delegate, facilitating their telecast on national media in the Member Countries.

Regional Office and Country Offices During the period under review, the Regional Director’s office played an important role in monitoring and facilitating implementation through close collaboration with the WHO country offices. To facilitate coordination between and among country offices, the Regional Office and WHO headquarters in the smooth implementation of WHO’s collaborative programmes, a post of Coordinator was established in the Regional Director’s office. Support was provided to the Member Countries in revising/ updating the Country Cooperation Strategies to be implemented in a complementary manner with the WHO collaborative programmes. In an effort to strengthen the WHO country offices, consultation was also held on a new initiative called “Country Focus Initiative” to focus WHO’s support from all levels to country activities, including coordination of support from development partners and other agencies. The 51st Meeting of the Regional Director with the WHO Representatives was held from 12 to 14 June 2002 in Bangkok, Thailand. The venue of the meeting had to be shifted from New Delhi owing to the then prevailing security situation in India. The group reviewed the monitoring of the reserves pertaining to the 2000-2001 biennium and implementation of the first six months of the 2002-2003 programme budget, including quality management of the APW mechanism. The WHO Representatives also deliberated on issues pertaining to planning for programme budget 2004-2005 and its integration with CCS (Country Cooperation Strategy). The meeting recommended that

118 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

countries use CCS as the starting point for developing work plans for the 2004-2005 biennium, and that training be provided to the staff of WHO country offices and the Regional Office in the log-frame approach for the development of work plans. The WHO Representatives also took stock of the issues relating to improving WHO performance at the country level, including the Country Focus Initiative and Macroeconomics and Health. They were also provided a technical update on bulk purchase of essential medicines. The 52nd Meeting of the Regional Director with the WHO Representatives was held from 31 March to 4 April 2003 in the Regional Office. Among the important topics, the Representatives discussed country-specific issues concerning implementation, monitoring and reporting on programme budget 2000-2001 and 2002-2003, and the preparation for programme budget 2004-2005; Country Cooperation Strategy and improvement of the quality of WHO’s collaborative programme. Technical updates on the Global Fund for fighting HIV/AIDS, Tuberculosis and Malaria; preparedness and response for emergency and humanitarian action; the role of WHO in implementing the recommendations of the Commission on Macroeconomics and Health; the Country Focus Initiative; and strengthening of WHO country offices’ web sites were also provided. In addition, WHO Representatives had individual meetings with staff of various departments to discuss and follow up on programmatic and implementation issues.

Regional Director’s Development Programme The Regional Director ’s Development Fund continued to support country as well as intercountry programme initiatives. During the reporting period, support was provided in different areas including (1) organization of meetings on: preparation of proposals for GFATM; deafness and hearing impairment; and promoting good mental health etc. and (2) provision of technical support for control of hepatitis C, and for the Health Trust Fund in Bhutan. In terms of health and emergency relief measures, prompt support was extended for emergency relief measures following the floods in Jakarta, EHA activities in North-East of Sri Lanka and for SARS.

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120 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annexes

127 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annex 1

Organizational Structure

Regional Director Director Regional

Regional Cabinet (RCT)

Coordinator (RDO/Liaison with Country Offices)

Deputy Regional Director/ Director, Programme Management (DRD/DPM)

Director, Administration and Finance (DAF)

Communicable Diseases (CDS)

Sustainable Development and Healthy Environments (SDE)

Evidence and Information for Policy (EIP)

Family and Community Health (FCH)

WHO Representatives WHO Country Offices WHO Field Staff

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Annex 2

Budgetary Implementation of Activities by Country, 2002-2003 REGULAR BUDGET ( as of 30 June 2003) Expressed in US $

Country

Allotted 6 261 600 1 382 700 2 263 000 11 425 600 5 071 000 957 300 4 930 600 4 738 100 2 801 500 3 592 100 139 000 43 562 500 6 802 800 50 365 300

Disbursement 4 074 845 (65%) 1 149 642 (83%) 1 550 110 (68%) 7 041 203 (62%) 3 792 886 (75%) 725 997 (76%) 3 285 576 (67%) 2 420 389 (51%) 2 123 226 (76%) 1 685 442 (47%) 119 006 (86%) 27 968 322 (64%) 4 331 378 (64%) 32 299 700 (64%)

Unliquidated obligations 1 919 087 (31%) 232 007 (17%) 288 780 (13%) 3 945 127 (34%) 1 200 712 (24%) 196 026 (20%) 1 293 951 (26%) 2 064 507 (44%) 569 920 (20%) 1 899 041 (53%) 19 994 (14%) 13 629 152 (32%) 1 352 805 (20%) 14 981 957 (30%)

Total obligations 5 993 932 (96%) 1 381 649 (100%) 1 838 890 (81%) 10 986 330 (96%) 4 993 598 (99%) 922 023 (96%) 4 579 527 (93%) 4 484 896 (95%) 2 693 146 (96%) 3 584 483 (100%) 139 000 (100%) 41 597 474 (96%) 5 684 183 (84%) 47 281 657 (94%)

Earmarkings 211 859 (3%) 0 (0%) 422 705 (19%) 419 370 (4%) 54 058 (1%) 22 201 (2%) 350 256 (7%) 212 350 (4%) 107 500 (4%) 0 (0%) 0 (0%) 1 800 299 (4%) 748,399 (11%) 2 548 698 (5%)

Total committed 6 205 791 (99%) 1 381 649 (100%) 2 261 595 (100%) 11 405 700 (100%) 5 047 656 (100%) 944 224 (98%) 4 929 783 (100%) 4 697 246 (99%) 2 800 646 (100%) 3 584 483 (100%) 139 000 (100%) 43 397 773 (100%) 6 432 582 (95%) 49 830 355 (99%)

Uncommitted balance 55 809 (1%) 1 051 (0%) 1 405 (0%) 19 900 (0%) 23 344 (0%) 13 076 (2%) 817 (0%) 40 854 (1%) 854 (0%) 7 617 (0%) 0 (0%) 164 727 (0%) 370 218 (5%) 534 945 (1%)

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Country Total Intercountry SEAR Total

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EXTRABUDGETARY FUNDS (as of 30 June 2003) Expressed in US $

Country

Allotted 8 970 353 162 148 4 260 469 48 396 919 12 913 590 4 255 860 10 063 904 867 897 956 326 798 472 91 645 938 21 598 119 113 244 057

Disbursement 4 166 395 (46%) 140 458 (87%) 1 894 746 (44%) 23 479 231 (49%) 8 500 721 (66%) 1 838 196 (43%) 4 143 133 (41%) 266 310 (31%) 487 778 (51%) 675 142 (85%) 45 592 110 (50%) 9 609 430 (44%) 55 201 540 (49%)

Unliquidated obligations 1 518 193 (17%) 2 496 (1%) 1 225 570 (29%) 10 803 988 (22%) 1 486 622 (11%) 793 460 (19%) 1 800 067 (18%) 150 759 (17%) 153 622 (16%) 57 130 (7%) 17 991 907 (19%) 4 083 534 (19%) 22 075 441 (19%)

Total obligations 5 684 588 (63%) 142 954 (88%) 3 120 316 (73%) 34 283 219 (71%) 9 987 343 (77%) 2 631 656 (62%) 5 943 200 (59%) 417 069 (48%) 641 400 (67%) 732 272 (92%) 63 584 017 (69%) 13 692 964 (63%) 77 276 981 (68%)

Earmarkings 199 750 (2%) 0 (0%) 163 518 (4%) 1 388 336 (3%) 217 826 (2%) 12 618 (0%) 602 131 (6%) 32 000 (4%) 0 (0%) 0 (0%) 2 616 179 (3%) 1 001 897 (5%) 3 618 076 (3%)

Total committed 5 884 338 (65%) 142 954 (88%) 3 283 834 (77%) 35 671 555 (74%) 10 205 169 (79%) 2 644 274 (62%) 6 545 331 (65%) 449 069 (52%) 641 400 (67%) 732 272 (92%) 66 200 196 (72%) 14 694 861 (68%) 80 895 057 (71%)

Uncommitted balance 3 086 015 (35%) 19 194 (12%) 976 635 (23%) 12 725 364 (26%) 2 708 421 (21%) 1 611 586 (38%) 3 518 573 (35%) 418 828 (48%) 314 926 (33%) 66 200 (8%) 25 445 742 (28%) 6 903 258 (32%) 32 349 000 (29%)

Bangladesh Bhutan DPR Korea India Indonesia Myanmar Nepal Sri Lanka Thailand Timor-Leste Country Total Intercountry SEAR Total

123 THE WORK OF WHO IN THE SOUTH-EAST ASIA REGION

Annex 3

Budgetary Implementation of Activities by Area of Work, 2002-2003 REGULAR BUDGET (as of 30 June 2003) Expressed in US$

AOW number 01.1 01.2 01.3 01.4 01.5 02.1 02.2 02.3 02.4 02.5 03.1 03.2 03.3 03.4 03.5 04.1 04.2 04.3 0.4.4 04.5 05.1 05.2 05.3 06.1 06.2 06.3 06.4 07.2 08.1 09.2

AOW code CSR CPC CRD MAL TUB NCD TOB HPR DPR MNH CAH RHR MPS WMH HIV HSD NUT PHE FOS EHA EDM IVD BCT GPE IMD RPC OSD REC BMR DDP

Area of work Communicable Disease Surveillance Communicable Disease Prevention, Eradication and Control Research and Product Development for Communicable Diseases Malaria Tuberculosis Surveillance, Prevention and Management of Noncommunicable Diseases Tobacco Health Promotion Disability/Injury Prevention and Rehabilitation Mental Health and Substance Abuse Child and Adolescent Health Research and Programme Development in Reproductive Health Making Pregnancy Safer Women’s Health HIV/AIDS Sustainable Development Nutrition Health and Environment Food Safety Emergency Preparedness and Response Essential Medicines: Access, Quality and Rational Use Immunization and Vaccine Development Blood Safety and Clinical Technology Evidence for Health Policy Health Information Management and Dissemination Research Policy and Promotion Organization of Health Services Resource Mobilization and External Cooperation and Partnerships Budget and Management Reform Director-General’s and Regional Director’s Development Programme and Initiatives

Allotted 2 455 355 1 485 705 91 976 1 562 795 1 053 386 3 727 111 1 833 918 1 109 716 1 524 270 1 325 799 1 970 129 360 300 1 683 868 560 091 1 551 071 1 332 400 836 179 2 926 049 892 936 1 046 200 2 517 180 1 874 147 1 302 425 1 978 987 75 900 1 501 779 11 234 628 45 000 18 000 488 000

Committed Total 2 428 628 1 475 572 91 961 1 536 759 1 040 474 3 719 409 1 791 206 1 104 948 1 509 452 1 280 579 1 973 891 356 446 1 667 103 555 181 1 543 113 1 266 746 831 176 2 895 351 869 737 1 043 112 2 513 771 1 850 617 1 294 384 1 971 477 71 285 1 474 341 11 162 760 42 756 7 325 460 795 % 99 100 100 99 99 100 98 100 99 97 100 99 99 99 100 95 100 99 97 100 100 99 99 100 94 98 100 95 41 94

Total

50 365 300

49 830 355

99

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EXTRABUDGETARY FUNDS (as of 30 June 2003) Expressed in US$

AOW number 01.1 01.2 01.4 01.5 02.1 02.2 02.3 02.4 02.5 03.1 03.2 03.3 03.4 03.5 04.1 04.3 04.5 05.1 05.2 05.3 06.1 06.2 06.3 06.4 07.2 09.1

AOW Code CSR CPC MAL TUB NCD TOB HPR DPR MNH CAH RHR MPS WMH HIV HSD PHE EHA EDM IVD BCT GPE IMD RPC OSD REC DGO

Area of work Communicable Disease Surveillance Communicable Disease Prevention, Eradication and Control Malaria Tuberculosis Surveillance, Prevention and Management of Noncommunicable Diseases Tobacco Health Promotion Disability/Injury Prevention and Rehabilitation Mental Health and Substance Abuse Child and Adolescent Health Research and Program Development in Reproductive Health Making Pregnancy Safer Women’s Health HIV/AIDS Sustainable Development Health and Environment Emergency Preparedness and Response Essential Medicines : Access, Quality and Rational Use Immunization and Vaccine Development Blood Safety and Clinical Technology Evidence for Health Policy Health Information Management and Dissemination Research Policy and Promotion Organization of Health Services Resource Mobilization and External Cooperation and Partnerships Director General’s and Regional Director’s Offices Total

Allotted 1 892 029 6 405 249 3 474 187 20 827 629 224 784 538 441 181 354 151 541 95 102 1 165 326 875 455 101 700 11 300 4 421 903 348 722 505 864 7 118 290 658 012 62 419 324 389 175 467 299 132 855 420 000 32 759 303 267 82 490 113 244 057

Committed Total 904 192 4 428 162 2 453 048 12 947 662 173 982 419 224 159 991 115 615 62 431 1 119 427 246 248 13 438 1 300 1 953 932 112 742 323 811 5 610 307 432 820 48 163 557 263 569 270 762 132 309 300 662 13 100 208 966 63 800 80 895 057 % 48 69 71 62 77 78 88 76 66 96 28 13 12 44 32 64 79 66 77 68 58 100 72 40 69 77 71

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Annex 4

Regular Budget Reserves, 2000-2001 (as of 30 June 2003) Expressed in US$

Country

Opening balance 1 514 788 304 490 489 530 3 327 433 1 194 476 166 358

Disbursed 1 192 386 (79%) 292 515 (96%) 499 428 (102%) 2 760 265 (83%) 926 998 (78%) 155 532 (93%) 345 035 (89%) 977 371 (74%) 281 186 (83%) 893 287 (93%) 20 721 (66%) 8 344 724 (83%) 2 316 543 (87%) 10 661 267 (84%)

Unliquidated obligations 5 721 (0%) 0 (0%) 0 (0%) 212 894 (6%) 125 850 (11%) 11 239 (7%) 243 (0%) 14 320 (1%) 0 (0%) 22 838 (2%) 0 (0%) 393 105 (4%) 136 281 (5%) 529 386 (4%)

Total (Disb.+ULO) 1 198 107 (79%) 292 515 (96%) 499 428 (102%) 2 973 159 (89%) 1 052 848 (89%) 166 771 (100%) 345 278 (89%) 991 691 (75%) 281 186 (83%) 916 125 (95%) 20 721 (66%) 8 737 829 (87%) 2 452 824 (92%) 11 190 653 (88%)

Total surrendered* 316 681 (21%) 11 975 (4%) (9 898) (2%) 354 274 (11%) 141 628 (11%) (413) (0%) 40 988 (11%) 322 267 (25%) 57 386 (17%) 49 190 (5%) 10 711 (34%) 1 294 789 (13%) 203 850 (8%) 1 498 639 (12%)

Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste Country Total Intercountry SEARO Total

386 266 1 313 958 338 572 965 315 31 432 10 032 618 2 656 674 12 689 292

*Final figures will be known after 31 December 2003

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