REGIONAL COMMITTEE Fifty-ninth Session Dhaka, Bangladesh 22-25 August 2006
Provisional Agenda item 8 SEA/RC59/10 (Rev.1) 20 July 2006
PROPOSED REGIONAL PROGRAMME BUDGET 2008-2009 The planning and formulation of proposed regional Programme Budget (PB) for 2008-2009 will follow a significantly different approach compared to previous bienniums. It will be based on the six-year Medium–term Strategic Plan (MTSP) covering the period 2008 -2013. The MTSP and the PB 2008-2009 have been combined into one document at the global level. As such, this approach would guide the review of the proposed regional PB 2008-2009. The proposed regional Programme Budget for 2008-2009 reflects the Region -specific priorities for the biennium. Part I of this document describes the s cope of the strategic objectives, regional indicators and targets, regional issues and challenges, and strategic approaches of the region to be used in achieving respective strategic objectives for 2008-2009 biennium. Part II presents the proposed regional Programme Budget for 2008-2009 which also coincides with the first biennium of the MTSP. The resources required to implement the work in the Region have been estimated through consultations between and among the country offices and the Regional Office. It encompasses funds from both the Regular Budget and Voluntary Contributions envisaged for the 2008-2009 biennium. Appropriate comparisons have been made with the regional budgets pertaining to previous bienniums in order to indicate key changes represented in the proposed regional PB 2008-2009. The preliminary draft of the proposed regional Programme Budget for 2008-2009 was discussed at the 43rd meeting of the Consultative Committee
for Programme Development and Management (CCPDM) held in June 2006 in the Regional Office, New Delhi. In addition, discussions were held with Ministry of Health counterparts in Member States for reviewing it. The proposed regional Programme Budget 2008-2009 is now submitted for review and comments by the 59th session of the Regional Committee. Based on these comments, appropriate revisions will be made and further discussions will be held with Member States of the Region to develop the detailed operational plans for the 2008-2009 biennium.
Contents Page Introduction............................................................................................................................. 1 Part I – REGIONAL STRATEGIC OBJECTIVE STATEMENTS .................................................. 5 Strategic Objective 1 – To reduce the health, social and economic burden of communicable diseases ........................................................................................................ 7 Strategic Objective 2 – To combat HIV/AIDS, malaria and tuberculosis .....................11 Strategic Objective 3 – Prevent and reduce disease, disability and premature death from chronic noncommunicable conditions, mental disorders, violence and injuries. ..........................................................................................................................17 Strategic Objective 4 – To reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence, while improving sexual and reproductive health and promo ting active and healthy ageing for all individuals, using a life-course approach and addressing equity gaps.............................................................................19 Strategic Objective 5 – Reduce the health consequences of emergencies, disasters, crises and conflicts, and minimize their social and economic impact........................23 Strategic Objective 6 – Promote health development, prevent and reduce risk factors for health conditions associated with tobacco, alcohol, drugs and other psychoactive substance use, unhealthy diets, physical inactivity and unsafe sex....26 Strategic Objective 7 – Address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro -poor, gender-responsive, and human rights-based approaches. .....................................................................................28 Strategic Objective 8 – Pro mote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health .......................................................31 Strategic Objective 9 – To improve nutrition, food safety and food security throughout the life-course and in support of public health and sustainable development..........................................................................................................................34
Strategic Objective 10 – To improve the organization, management and delivery of health services .................................................................................................................38 Strategic Objective 11 – To strengthen leadership, governance and the evidence base of health systems........................................................................................................41 Strategic Objective 12 – Ensure improved access, quality and use of medical products and technologies .................................................................................................45 Strategic Objective 13 – To ensure an available, competent, responsive and productive health workforce in order to improve health outcomes............................50 Strategic Objective 14 – To extend social protection through fair, adequate and sustainable financing...........................................................................................................52 Strategic Objective 15 – Provide leadership, strengthen governance and foster partnership and collaboration in engagement with countries, to fulfill the mandate of WHO in advancing the global health agenda as articulated in the 11th General Programme of Work ......................................................54 Strategic Objective 16 – Develop and sustain WHO as a flexible, learning Organization, enabling it to carry out its mandate more efficiently and effectively 57 PART II – PROPOSED REGIONAL PROGRAMME BUDGET FOR 2008-2009 ....................63
Introduction 1. The World Health Organization’s Medium-term Strategic Plan (MTSP) sets out strategic directions for the Organization over a six-year period. The first global MTSP has recently been drafted to cover the period 2008-2013. It is based on the 11th General Programme of Work (GPW), various Country Cooperation Strategies and resolutions of WHO Governing Bodies. The MTSP identifies 16 Strategic Objectives (SOs) to guide the work of the Organization. It describes the scope of each SO along with the targets and indicators as a means of monitorin g and evaluating the performance of the Organization in implementing the MTSP. Targets for the SO are meant to be achieved by both WHO Member States and the Secretariat. The work of the Secretariat itself is shown in the Organization-wide Expected Results (OWER) describing how the Secretariat expects to contribute to the achievement of each Strategic Objective. Each SO has five to eight OWERs, with its own set of indicators and targets to assess the overall performance of the Secretariat. WHO follows the biennial budgeting system. As such, the MTSP covers three bienniums. However, as of now the detailed budget is being provided only for the first biennium (2008-2009) of the MTSP. Budgets for the subsequent two bienniums will be developed along the normal schedule of budget formulation and approval. 2. All WHO Offices are expected to contribute to the achievement of Strategic Objectives. However, since the health situation and priorities of each Region and country vary, each WHO office will contribute in different ways. The South -East Asia Region’s priorities and approaches to the MTSP are spelled out in this document. Using the MTSP structure, the specific priorities and strategies for the Region are described in detail in Part I of this document, covering the following: 3. Scope of the strategic objective – This is derived from the MTSP and describes
the scope of work to be covered by the Strategic Objective throughout the Organization. 4. Regional indicators and targets – These are the regional indicators and targets for the respective Strategic Objectives to be accomplished by the WHO Member States and the Secretariat within the 2008-2009 biennium. These are high-level indicators reflecting progress in key areas of health for Member States and should drive the work of the Organization in the South -East Asia Region. It should be
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noted that these indicators and targets are related to the global indicators and targets, listed in each Strategic Objective of the MTSP document (SEA/RC59/9 and Corr.1). 5. Regional issues and challenges –The South-East Asia Region faces specific issues and challenges in achieving these Organization-wide targets. This section describes such issues and challenges which have to be taken into account while formulating the work of the Organization in the Region covering the first biennium of the MTSP. 6. Strategic approaches of the Region – In order to achieve the overall global Strategic Objectives, and in light of the region-specific issues and challenges, the Regional Office for South -East Asia (SEARO) will follow region-specific strategic approaches. The approaches described here therefore focus on the region -specific work of the Organization. 7. Part II of this document, wherein the proposed regional budget for the first biennium (2008-2009) is presented, links the regional priorities, strategies and funding for the work of the Secretariat pertaining to the Region. These estimates include the total resource requirements from both the Regular Budget and Voluntary Contributions for the two-year period. They were derived from baselines of the 2006 -2007 Programme Budget, country estimates based on the latest Country Cooperation Strategies and the work requirements expected at the Regional Office. An analysis has also been performed to compare the trends in regional funding and to reflect new priorities represented in the regional Strategic Objective statements in Part I. 8. Necessary revisions will be made to the document following discussions at the 59th session of the Regional Committee. The process to furthe r develop and finetune the Regional Programme Budget for 2008-2009 will continue. The regional budget for each Strategic Objective will be divided into the Organization-wide Expected Results within each SO, since the final PB 2008-2009 will include regional allocations for each OWER. Following this, one or more Regional Expected Results (RERs) will be developed for each OWER relevant to the Region. RERs will have specific indicators, baselines and targets to reflect the work of the Secretariat relevant to the Region. During this process there will be close consultation with the country offices to ensure that these RERs and allocations are in line with the WHO
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priorities for its work in and with countries. In early 2007, work will begin on the operation plans for 2008-2009.
PART – I REGIONAL STRATEGIC OBJECTIVE STATEMENTS
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Strategic Objective 1 – To reduce the health, social and economic burden of communicable diseases Scope of the strategic objective 9. The work under this strategic objective focuses on prevention, early detection, diagnosis, treatment, control, elimination and eradication measures to combat communicable diseases that disproportionately affect poor and marginalized populations. The diseases to be addressed include, but are not limited to: vaccinepreventable, tropical, zoonotic and epidemic-prone diseases, excluding HIV/AIDS, tuberculosis, and malaria.
Regional indicators and targets • • By the end of 2009, all Member States would have achieved and maintained certification of polio eradication. By the end of 2009, all Member States would have achieved a 50% reduction of vaccine-preventable disease mortality in children under-five years of age (Baseline mortality: 757,000 in 2002). (2013 target: two third reduction) • By the end of 2009, all Member St ates would have achieved 20% reduction of annual new leprosy case detection. (Baseline: end 2007).(2013 target: 50% reduction) • By the end of 2009, all Member States would have achieved at least 25% coverage of the population at risk for lymphatic filariasis by mass drug administration. (Baseline:10% in 2006). (2013 target: 80% coverage) • By the end of 2009, all Member States in the Region would have complied with the core requirements of the International Health Regulations (2005) for surveillance, reporting, notification, verification and response.
Regional issues and challenges 10. This strategic objective aims at a sustainable reduction in the health, social and economic burden of communicable diseases in the South-East Asia Region (SEAR) of WHO. The work includes investing in health to reduce poverty, building individual and regional health security, harnessing knowledge, science and technology, strengthening health systems and improving universal access.
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11. Communicable diseases, excluding HIV/AIDS, tuberculosis, and malaria, globally account for 20% of deaths in all age groups, 50% of child deaths and 33% of deaths in the least developed countries. A major proportion of these deaths occur in countries of SEAR and can be prevented by the use of available or soon to be available vaccines. In fact, close to 10 million children in the Region fail to receive the basic set of EPI vaccines each year. This Region is actively engaged in the elimination of polio and accelerated measles mortality reduction, which still account for substantial morbidity. The Region also accounts for a disproportionate burden of some tropical diseases such as leprosy, lymphatic filariasis, kala-azar and yaws. These diseases are amenable to elimination/eradication within a definite timeframe since safe, simple and cost-effective interventions are available. 12. The Region is also vulnerable to epidemics of emerging infections, many of which are zoonotic. These include SARS, Avian influenza, Nipah, Japanese encephalitis, leptospirosis and 60% of the global burden of rabies. Another area that significantly contributes to the communicable disease burden in the Region is the potentially unsafe and irrational use of blood and blood products. For example, this Region annually requires an estimated 15 million units of blood, of which only 9.3 million are being collected at present and only 61% from voluntary donors, which leaves open the issue of quality of screening and safety. 13. Without a reduction in the disease burden, the achievement of other healthrela ted goals in the Region, as well as those in education, gender equality, poverty reduction and economic growth, will be jeopardized. Combating the burden of communicable disease requires strategies that are country-specific and that use cost-effective approaches to address diseases and conditions that account for the greatest share of the burden. In particular, the Region faces the big challenge of introducing effective integrated surveillance and monitoring systems to control communicable diseases and improve the quality of health data. 14. This Region is prone to epidemics, and natural disasters with the attendant risk of more epidemics, which place sudden and intense demands on health systems. The epidemics expose existing weaknesses in health systems. They cause heavy morbidity and mortality and can disrupt economic activity and development. The need for rapid response drains resources, staff, and supplies away from previously defined public health priorities and routine disease control activities, such as ch ildhood immunization. The Regional Office and country offices of WHO have a primary role in preparedness, detection, risk assessment and communications and response to public health emergencies such as epidemics and pandemics.
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15. Infrastructure and capacity to diagnose emerging infectious diseases is limited in most countries. There is no national laboratory policy and focal point on health laboratories in the ministries of health in most countries. Quality systems are inadequate and continuous availability of reagents is difficult to assure. Virological and molecular biological services need to be strengthened. Though national networks of laboratories exist, these need to be activated and laboratories from other sectors included. 16. Under the revised International Health Regulations (2005), which will come into effect in 2007, the Regional Office and country offices of WHO will have a legal obligation to strengthen their internal epidemic/public health alert and response capacity and to support Member States in t he development and maintenance of minimum core capacities for the detection and assessment of, and response to, public health risks and emergencies of which the majority are attributable to communicable diseases. 17. WHO's role in the response to the avian influenza outbreak in Indonesia, and the threat of an avian influenza outbreak in the Region, its role in the response to the polio outbreak in that country in 1995, and its role in the tsunami of December 2004 demonstrated the importance of coordination, leadership and transparency in dealing with natural disasters and epidemics and pandemics. The polio eradication and measles mortality reduction initiatives in the Region have also highlighted the need to couple targeted disease control measures, such as campaigns, with overall strengthening of health systems. 18. The challenge is to ensure political commitment, policy support and priority for these diseases in Member States and assist them in resource mobilization and promote partnerships for effective implementation of the strategies/activities.
Lessons learnt • The prevention, control and surveillance of communicable diseases are essential components in human security, including health security, economic development and trade. • Public health emergencies due to communicable diseases can cost billions of dollars, not only in direct health-related costs, but also in the impact epidemics can have on trade and finance. • Not only is the prevention of communicable diseases one of the most costeffective public health interventions, it can also yield positive economic
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returns, particularly among the most marginalized and economically disadvantaged population groups in the Region. • The control of vaccine-preventable, epidemic-prone and tropical diseases has proved remarkably successful in narrowing gaps in equity by reaching marginalized, poor, young populations and women, particularly mothers. • These interventions are among the most effective components of health systems in many countries; they also provide a platform for disse minating other essential public health services. • To achieve the strategic objective, it will be essential to move beyond vertical programmes and, on the basis of a thorough assessment of past successes and failures in the creation of strategies for integrated health systems development, to build on past strengths and address weaknesses.
Strategic approaches of the Region 19. Achieving this objective calls for Member States to invest human, political and financial resources to ensure and expand equitable access to high quality and safe interventions for the prevention, early detection, diagnosis, treatment and control of communicable diseases among all populations. A key component in the financial and operational sustainability of communicable disease prevention and control will be the establishment and maintenance by Member States of effective coordination mechanisms with all partners and across all relevant sectors at the country level, and a willingness to work with WHO in extending these coordination mechanisms to the regional and international spheres. 20. The International Health Regulations (2005) will require Member States to adopt the necessary legal, administrative, financial, technical and political provisions for the development, strengthening and maintenance of integrated surveillance systems at primary, intermediate and national levels and related activities, to enable them to detect, report on, and respond to public health risks and potential public health emergencies, and to generate information for evidencebased policy decisions on public health interventions. 21. In supporting Member States' efforts , WHO will focus on: • strengthening its leadership role, as well as its collaboration with health stakeholders, partnerships and civil society, while working with Member States to articulate ethical and evidence -based policies. It will facilitate the expansion of community access to existing and new tools and strategies, including new vaccines, medicines and technologies, that meet acceptable
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standards of quality , safety, efficacy and cost-effectiveness, while reducing disparities in access. In particular, it will take advantage of global alliances and the substantial resources available to protect more people; • strengthening its capacity to fulfil its obligations to provide technical assistance, build capacity and respond to Member States, in particular, in respect of commitments entered into through Health Assembly resolutions related to communicable diseases and the International Health Regulations. This includes facilitating national and international resource mobilization and advocacy efforts; • maintaining and strengthening an effective regional system for alert and response to epidemics and other public health emergencies with immediate technical support to affected state(s) and collective international action for containment and control; • facilitating public health preparedness in collaboration with other United Nations agencies and partners, including private and civil society organizations as appropriate; • • • providing Member States with tools, strategies and technical assistance to evaluate and strengthen monitoring and surveillance systems; coordinating integrated surveillance activities at regional level to inform policy decisions and public health responses; shaping the research agenda on communicable diseases and stimulating and supporting the generation, translation and dissemination of valuable knowledge for use in the formulation of ethical and evidence-based policy options; • strengthening the capacity of Member States to undertake health research, especially on the development of tools and strategies for the prevention, early detection, diagnosis, treatment and control of communicable diseases; and • encourage voluntary donation through community and NGO involvement and promoting production and rational use of blood components.
Strategic Objective 2 – To combat HIV/AIDS, malaria and tuberculosis
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Scope of the strategic objective 22. Work under this Strategic Objective will focus on scaling-up and improving HIV/AIDS, TB and malaria prevention, treatment, care and support interventions so as to achieve universal access, including high-burden populations, women, infants, children, adolescents, poor and vulnerable groups; advancing related research; addressing key bottle necks that are impeding intervention access, use and quality; and contributing to the broader strengthening of health systems.
Regional indicators and targets • By the end of 2009, coverage of antiretroviral treatment would have increased to 45% of people needing antiretroviral treatment in all Member States (Baseline: 17% in 2005). (2013 target: 80%) • By the end of 2009, coverage of preventive interventions targeting vulnerable populations (injecting drug users, sex workers and men who have sex with men) would have increased to 50% in all Member States (Baseline: 5% for IDU, 19% for SWs and 1% for MSM in 2005). (2013 target: 80% increase) • By the end of 2009, TB mortality in the Region would have reduced to less than 350,000 annually (Current estimated baseline: 600,000 annually). (2013 target: 150,000) • By the end of 2009, TB prevalence rate in the Region would have reduced by 25% of 2007 level (Current estimated baseline: 350/100,000 population). (2013 target: 50% reduction) • • • By the end of 2009, malaria morbidity and mortality would have reduced by 45% from the 2002 levels (2013 target: 50% reduction) By the end of 2009, malaria would have eliminated from at least one Member State in the Region.(2013 target: two Member States) By the end of 2009 80% coverage of households would have achieved with insecticide-treated nets or indoor residual spraying in malaria-risk populations in the Region. • By the end of 2009, access to early diagnosis and prompt treatment of clinically suspected malaria cases would have increased to 80%.
Regional issues and challenges HIV/AIDS
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23. The HIV epidemic in this Region is very diverse and is largely confined to populations most at risk such as injecting drug users and their partners, sex workers and their clients, and men having sex with men and their partners. Explosive epidemics among injecting drugs users, commercial sex workers and men having sex with men occurred in Thailand, Myanmar, India and in more recent years in Indonesia and Nepal. The spread of infection to the low risk general population from the mentioned high risk groups through bridge populations like clients of sex workers, including truckers and migrants is a big concern. Out of the estimated 6.7 million (3.9 to 10.0 million) people living with HIV (PLHIV) by the end of 2005, 1.9 million are young people below 25 years of age and the proportion of women is consistently increasing representing 26% of all PLHIV. 24. Though political commitment, partnerships in facing the epidemic and access to care and ART has been accelerated through the ‘3 by 5’ initiative the number of PLWHA receiving ART has only reached an estimated 163,000 persons (35%) as of December 2005. 25. The main challenges include the following: • Low coverage of effective interventions to prevent HIV transmission including those targeting most-at-risk populations in most of the countries; Weak health systems including programme management in many countries placing constraints on the expansion of HIV/AIDS prevention, care and antiretroviral treatment (ART) services; Prevailing stigma and discrimination; Insufficient allocation of national resources for scaling up prevention, care and treatment programmes; and High costs of antiretroviral drugs (in particular second-line drugs), commodities, and diagnostics.
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• • •
Tuberculosis 26. To build on and further enhance the DOTS strategy to effectively deliver TB control services, attention needs to be focused on securing commitment and resources to build and sustain adequate human workforce and infrastructure to deliver effective services f or TB control, including laboratory services. In countries instituting health reforms, transitions to decentralized systems or sector-wide approaches has been difficult and prolonged as in Thailand and Indonesia, due to limited management and technical capacity at sub-national levels. Improving human resource capacity is therefore one of the persistent challenges.. In recent
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years, the emergence of both HIV-associated TB and anti-TB drug resistance threaten to reverse hard-won gains in TB control. This calls for urgent and decisive action. Planning and implementing interventions to address TB/HIV and multi-drug resistant TB (MDR-TB) particularly in countries with high HIV prevalence are a priority. Greater involvement of other sectors, particularly the private sector is necessary to enhance the reach and access to services. At the same time, expanding collaborative interventions will require close attention and monitoring to ensure adherence to internationally recommended standards for TB care in order to ensure quality. National TB programmes together with other related programmes will need to focus also on advocacy, communication, information and social mobilization approaches to improve community awareness and utilization of services. In order to report objectively on progress towards the Millennium Development Goals (MDGs), national programmes will also need to build capacity for better surveillance, monitoring and evaluation. Ensuring sustainable financing from both domestic and external sources will be critical for the countries in the Region in order to effectively carry out all planned interventions in these different areas. Malaria 27. Malaria remains one of the most serious problems in the countries of SEA Region. The disease is endemic in all the countrie s of the Region except Maldives. Although significant progress has been made in reducing trends in morbidity and mortality, the disease remains an important cause of continuing poverty because of ill health, decreased productivity, transportation costs and treatment expenses. It must be noted that the population most affected by malaria not only have low income, but also large inequities in education, work opportunities, access to health services, environment and housing quality. Indigenous or tribal minorities of the countries are most vulnerable, are less protected against the disease, and have the least access to health services, hampered by socio-economic and cultural barriers. Hence, they remain an important focus for national control programmes of the countries to achieve a significant reduction of malaria. 28. The coverage with indoor residual spray (IRS) is declining and limited to 23.7% of the high risk population. The poor capacity in implementing IRS, the high costs of insecticides, and resistance of vectors to insecticides are limiting the use of IRS as a vector control strategy. The coverage with insecticide-treated nets is also low varying from 2% to 20% and is not uniform in the Region. 29. Like all other health programmes, the national malaria control programmes face several health system-related challenges.
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30. Besides the above-mentioned challenges, there are many technical challenges like emergence of multi-drug resistant P falciparum, vector resistance to insecticides and uncontrolled population movement leading to frequent epidemics etc. hampering the malaria control efforts by the Member States.
Strategic approaches of the Region 31. The strategic focus for HIV, TB and malaria in the Region in the coming years is to achieve the Millennium Development Goals and promote universal access and delivery of essential interventions for prevention, treatment, care and support, taking into account the situation that exists in the countries. Strategies have been developed to facilitate this. The common strategies for the three diseases are as follows: • • • • • • • • • Develop supportive management. national and local policies, leadership and
Strengthen and support human resources and provider networks. Ensure availability and proper use of high quality medicines, diagnostics, and health commodities. Expand quality-assured laboratories. Strengthen monitoring, evaluation, and surveillance systems for decisionmaking and accountability towards HIV, TB and malaria targets. Empower affected persons and communities. Advance partnerships and develop networks. Secure and sustain financing. Enable and promote research to support prevention, treatment, and care.
32. Further, equitable services particularly to hard -to-reach populations and vulnerable groups should be a major focus. Overall, programmes will lay emphasis on addressing the health systems-related challenges of limited management capacities, inadequate infrastructure and logistic support, insufficient skilled human resources and weak surveillance, monitoring and reporting systems.
HIV/AIDS 33. The specific approaches for HIV/AIDS are:
(a) Scaling up prevention, treatment and care. Particular emphasis will be on targeted interventions for populations at high -risk including sex workers, reach populations, and access to quality care and treatment. intravenous drug users, men having sex with men, and other hard -to-
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(b) Contributing to health systems strengthening including strategic information and research; planning, monitoring and evaluation; financial resources and integration into other health related programmes including TB, blood safety, maternal and child health, reproductive health, adolescent health, nutrition, and mental health.
Tuberculosis 34. The focus for TB control in the coming years is to achieve the TB targets under the MDGs in all Member States by 2015. Towards this end, a Regional Strategic Plan for TB Control 2006-2015 incorporating the new expanded global stop TB strategy, but focusing on priorities in this Region has been developed. The interventions proposed towards achieving the set targ ets and the overall goal for TB control are grouped under the following four key strategies:
(a) Sustaining and enhancing DOTS to reach all TB patients, improve case detection and treatment success; resistant TB;
(b) Establishing interventions to address HIV-associated TB and drug(c) Forging partnerships to ensure equitable access to an essential standard of care to all TB patients, and
(d) Contributing to health systems strengthening . Malaria 35. IRS should remain the mainstay of disease prevention on a selective basis in areas of high risk of malaria in the Region. The widespread use of insecticidetreated mosquito nets (ITNs) is another important intervention that needs to be continued. Efforts should be made to scale up early diagnosis and prompt treatment (EDPT) in order to prevent deaths. 36. In order to obtain high treatment success rate and delay the spread of the drug-resistant strains, Artemisinin -based combination therapy (ACT) needs to be adopted by all countries. 37. The following are the proposed medium-term strategies:
(a) Reform approaches to programme planning and management. (b) Revamp surveillance and strengthen monitoring and evaluation. (c) Target interventions to risk groups.
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(d) Scale up control of vivax malaria. (e) Increase coverage and proper use of insecticide-treated mosquito nets.
Strategic Objective 3 – Prevent and reduce disease, disability and premature death from chronic noncommunicable conditions, mental disorders, violence and injuries Scope of the strategic objective 38. The work under this strategic objective focuses on policy development, programme implementation, monitoring and evaluation, strengthening of health and rehabilitation systems and services, implementation of prevention programmes and capacity building in the area of chronic noncommunicable conditions, including cardiovascular diseases, cancer, chronic respiratory diseases, diabetes, hearing and visual impairment and genetic disorders, as well as mental, behavioural, neurological and psychoactive substance use disorders, and injuries due to road traffic accidents, drowning, burns, poisoning, falls, violence in the family, community or between organized groups, and disabilities from all causes.
Regional indicators and targets • By the end of 2009, at least four Member States would have developed and implemented na tional policy and plan to deal with major noncommunicable diseases, mental disorders, violence and injuries (2013 target: six Member States) • By the end of 2009, at least four Member States would have improved their surveillance and related information systems for planning, monitoring and assessing impact of national programmes for prevention and control of noncommunicable diseases, mental disorders, violence and injuries (2013 target: six Member States) • By the end of 2009, at least four Member States would have established and/or strengthened their multisectoral networks for prevention and control of noncommunicable diseases, mental disorders, violence and injuries (2013 target: six Member States)
Regional issues and challenges 39. Chronic noncommunicable conditions, mental disorders, violence and injuries are currently the major causes of death and disability in all countries of the
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Region.. The total number of deaths from these conditions represents 54% of the regional mortality and 44% of the disease burden according to projected deaths by cause in the Region in 2005. Over the next decade, deaths from chronic noncommunicable conditions, mental disorders and injuries are expected to increase rapidly which threatens not only the lives and health of the people, but also affect overall socioeconomic development of the Region. During recent years, the World Health Assembly, the Regional Committee and the United Nations General Assembly and other high-level policy meetings have given an important set of mandates to WHO and Member States to address these issues. 40. A full range of health promotion and preventive interventions, especially those that could be implemented at community level, for chronic noncommunicable conditions, mental disorders, violence and injuries have been shown to be costeffective and affordable. For example, a per capita outlay of US$7 covers the cost of a basic mental health package at primary health care level, a dollar spent on a helmet produces a saving of US$30, a dollar spent on counselling linked to child abuse will save 10US$, combination drug therapy for individuals at high risk of a cardiovascular event is estimated to avert 63 million disability adjusted life years every year worldwide, at the cost of less than 500 US$ per life saved and cataract surgery generates increased economic productivity equivalent to 1500% of the cost of the intervention during the first year. 41. At present, WHO SEAR allocates approximately 6% of its total budget for technical work in areas covered by this strategic objective. It would be increased to 7% in 2008-2009 and more during 2009-2015 for programmes to be carried out in these areas. Appropriate technical staff and programme support will be made available. The existing large gap between needs and resources is expected to grow, unless there is a substantial shift in the allocation of resources. In this context, the major challenges are: • • • • to increase awareness of the magnitude of the problem and the potential that exists for prevention; to increase the political will to address the problem; to initiate appropriate multi-sectoral collaboration; and to generate the necessary resources in an environment of competing interests.
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Strategic approaches of the Region 42. To achieve this objective, priority will need to be given t o addressing the chronic noncommunicable conditions, mental disorders, violence and injuries, within national and international health and overall development agendas. A comprehensive public health approach that includes the strengthening of epidemiology, information system, fostering of multi-sectoral collaboration and innovation, and community-based integrated interventions is essential. Coordinated but distinct responses to chronic, noncommunicable diseases, mental disorders, and violence and injury that are based on comprehensive and integrated action are needed. Focusing on primary prevention, reorienting the emphasis towards prevention in health care and ensuring community participation are key factors for achieving successful outcomes in countries. 43. The strategic approaches to be taken will focus on: • • advocating increased political commitment and action; providing assistance for the collection, analysis and use of data on the epidemiology and consequences of chronic noncommunicable conditions, mental disorders, violence and injuries; • • • developing technical guidance and training materials; supporting the development, implementation and monitoring of policies and programmes for prevention, management and rehabilitation; assessing and strengthening health and other systems through capacity strengthening, resource mobilization and infrastructure development to prevent, manage and provide services, including rehabilitation; and • building and supporting multi-sectoral networks and partnerships with governmental and nongovernmental organizations, other United Nations and international agencies, professional and consumer/family groups and the private sector.
Strategic Objective 4 – To reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence, while improving sexual and reproductive health and promoting active and healthy ageing for all individuals, using a life-course approach and addressing equity gaps
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Scope of the strategic objective 44. The work undertaken according to this strategic objective will focus on action towards ensuring universal access to and coverage with effective public health interventions for maternal, newborn, child, adolescent, and sexual and reproductive health, with a major emphasis on addressing gender inequality and health equity gaps; development of evidence-based, gender-sensitive, coordinated and coherent approaches to addressing needs at key stages of life and improving sexual and reproductive health, using a life-course approach; fostering synergies between maternal, newborn, child, adolescent, sexual and reproductive health along with other public health programmes, and supporting action to strengthen health systems; and formulation and implementation of policies and programmes that promote healthy and active ageing for all individuals.
Regional indicators and targets • By the end of 2009, at least four Member States would have an integrated policy on universal access to effective interventions for improving maternal and newborn health. (2013 target: nine Member States) • By the end of 2009, at least three Member States would have an integrated policy on universal access to sexual and reproductive health. (2013 target: seven Member States) • By the end of 2009, capacity for promoting neonatal care at primary care level would have built in five Member States. (2013 target: All Member States) • • By the end of 2009, IMCI reviews would have conducted in at least 3 member States to guide IMCI expansion. (2013 target: six Member States) By the end of 2009, at least three Member States would have built in capacity for improving hospital care for children (2013 target: five Member States) • By the end of 2009, at least seven Member States would have national strategy on Adolescent Health and Development. (2013 target: All Member States) • By the end of 2009, at least three Member States would have adapted Strategic Framework on HIV/AIDS among young people within the HIV/AIDS national strategies. (2013 target: seven Member States)
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By the end of 2009, national capacities on provision of Adolescent Friendly Health Services would have strengthened in at least six Member States. (2013 target: All Member States)
Regional issues and challenges • High burden of maternal and neonatal and child morbidity and mortality in the Region, a large proportion of which is preventable. The maternal and neonatal and child mortality continues to be high in many Member States claiming lives of almost 174,000 mothers and over three million children including 1.4 million newborns every year. This unacceptable state of affairs is related to lack of access to affordable quality health care for women and neonates and children during pregnancy, childbirth and the postpartum period • • Skilled birth attendance in five countries is less than 50% Functional referral systems are not universally available and accessible resulting in poor health sector response for maternal and newborn emergencies • High prevalence of low birth weight babies (about 30%) and malnut rition in children contributes to the high burden of morbidity and mortality in children. • Access to community level, evidence based interventions for promoting child health and survival is limited through public health system. Quality of care provided to sick children in public health facilities needs improvement. • Despite increase in contraceptive prevalence rates, there continues to be an unmet need for contraception resulting in unwanted pregnancies especially for the poor and the marginalized, adolescents and unmarried couples. This results in almost 20 million induced abortions annually, some of which are terminated under unsafe conditions. Of these unsafe abortions, 40% are among 15-24-years olds which exact a heavy toll on maternal health contributing to 12% of all maternal deaths • • Escalating health care costs and implementation of user fees in some Member States pose financial barriers impairing access further Weak vital registration systems in most of these countries results in most of the deaths and disabilities going unrecorded, unaccounted and unnoticed. Moreover, this happens in the poorest marginalized sections
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that do not have a voice in their own family, let alone at the national and global levels. • • Reproductive ill health continues to be a challenge in the Member States resulting in poor reproductive health outcomes The increasing prevalence of STIs, including HIV/AIDS, posts a threat to the health and welfare of the society, especially women, newborns, children and young people. • Despite commitments through global resolutions like ICPD and Beijing Declaration and Conventions like CEDAW that direct countries to protect the reproductive rights of individuals, gender-based violence and trafficking in women continue to pose challenges.
Strategic approaches of the Region 45. The strategies to improve the health outcomes of family and community in the Region would be incorporating the principles of equity, focus on continuum of care and assure high quality services delivered according to evidence-based best practices. 46. It would be an integrated approach designed in the spirit of ownership, partnership and combined responsibilities that would ensure sustainability through technical and financial capacity building: • Provide evidence-based information to governments and stakeholders and assist Member States in implementing the package of interventions for improving family health using the public health approach with special emphasis on the unreached and marginalized population. Provide evidence-based tools and guidelines to improve access to quality, client oriented maternal, newborn and child care, family planning services, prevention and management of unsafe abortion, reproductive health services for adolescents and young people and prevention and management of reproductive health diseases • Respond to country needs to achieve universal coverage of essential interventions that will ensure skilled care for every birth including referral care for emergencies • Assist ministries of health and other partners within the M ember States to build national capacities through technical support, for improved health system response and quality of services
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• •
Assist Member States to increase utilization of services through support of individuals, families and communities Improve the r egional pool of knowledge and bridge programmatic gaps through programme reviews, sharing lessons learned and experiences gained, and gather evidence through operations research
•
Build effective partnerships across relevant programmes for coordinated action in countries to improve efficacy and reduce duplication e.g. integrated approach for addressing maternal and newborn health, Malaria in Pregnancy and HIV/AIDS including VCT, PMTCT and ART for mothers and newborns
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Strengthen assessment, monitoring and evaluation for better decisionmaking by policy-makers and planners.
Strategic Objective 5 – Reduce the health consequences of emergencies, disasters, crises and conflicts, and minimize their social and economic impact Scope of the strategic objective 47. The joint efforts of the Member States and the Secretariat regarding this strategic objective encompass the following aspects: health sector emergency preparedness, intersectoral action for risk and vulnerability reduction within the framework of the International Strategy on Disaster Reduction; response to the health needs (including nutrition as well as water and sanitation) of emergencies and crises; needs assessment of affected populations; transition and recovery health actions in post-conflict and post-disa ster situations; fulfilling the mandate of WHO within the framework of humanitarian reform; global alert and response system for public health emergencies, threat-specific risk reduction along with preparedness and response programmes for environmental and food safety public health emergencies.
Regional indicators and targets • By the end of 2009, at least five Member States would have achieved comprehensively all SEAR Benchmarks for Emergency Preparedness and Response. (2013 target: all Member States)
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By the end of 2009, in 60% of all declared emergencies in the Region would have kept crude mortality rate below the threshold level (1/10,000 population/day) at the initial emergency phase. (2013 target: 100% )
•
By the end of 2009, at least 40% of declared emergencies in the Region would have ensured health services are restored to pre-emergency states and accessibility to the affected population within one year of the event. (2013 target: 70%)
Regional issues and challenges 48. The main thrust of this objective is to contribute to human security by minimizing the health impact and addressing the health and nutrition needs of vulnerable populations affected by emergencies, disasters, conflicts and other humanitarian crises. Over the past decade,1 the Asia Pacific Region had the maximum number of natural (1339) and technological disasters (1282). This comprises 44% of all disasters reported from all over the world for the same time period. Around 700 000 people died in these events contributing to 78% of deaths due to disasters. This was largely due to the tsunami of 2004 where 224 495 people died, accounting for 90% of the death toll in 2004. Such a heavy toll due to emergencies makes it an important public health issue that needs to be addressed. • There are varying levels of capacities for emergency preparedness and response in SEAR countries. As these capacities differ, efforts towards strengthening them have to be customized to country needs. Such a situation though, allows for inter-country exchange and support and the se should be facilitated. • There are different systems of coordination of disaster management in countries. As such, the modalities of support to operations for various responses for health will vary. The way preparedness, prevention and mitigation is strengthened in the health sector should also be according to these systems. • The strength of health systems varies within and between countries. The strength and resilience of a health system has a large impact on the effectiveness and efficiency of disaster ri sk management in the health sector. In fact, the indicator and target on health services and crude mortality for this SO are reflective of this premise. Emergencies highlight gaps and weaknesses in systems and can disrupt delivery of health services 1
World Disasters Report 2005, International Federation of the Red Cross note: classification of
countries does not follow WHO Regional Distribution
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for prolonged periods and, in the medium and long term, economic activity and development. • Ensuring community engagement and empowerment is what facilitates effective and appropriate preparedness and response. This is a focus of many resolutions and the SEAR Benchmarks on EPR. Several efforts have been made in this regard and a number of countries have community empowerment initiatives for emergency preparedness and response in place institutionally. However, more efforts are needed towards a systemic and systematic inclusion and support for communities to be strengthened in emergency preparedness and response. This is an area which calls for the involvement of various sectors. • There is a need to increase investments in other phases of disaster management apart from response. Countries should be able to develop mechanisms and finance preparedness and mitigation efforts. Support for such activities result in better response and eventual prevention of avoidable ill-health and deaths.
Strategic approaches of the Region • Recent resolutions addressing needs for emergency preparedness and response have been adopted by the World Health Assembly (WHA 58.1 and 59.22) and the Regional Committee (RC57/R3 and RC58/R3) and action has been taken. These resolutions will continue to guide the strategic approaches for EPR in the Region, particularly in the areas of: benchmarks and • standards setting; community empowerment; coordination mechanisms and comprehensive disaster risk management among others. The achievement of the SEAR bench marks for emergency preparedness and response is a strategic approach which frames the essential elements for this strategic objective. As these were developed together with countries and considerable progress has been made on a number of these benchmarks framing activities for EPR is systematically set within this framework. • Development and achievement of other benchmarks for recovery and rehabilitation should also be done as the countries in the Region have enough experience and information to set benchma rks and standards in these areas.
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•
Improving research on and in emergencies provides the basis for best practices. Intensified efforts in developing and implementing a research agenda is key in taking the work in this area forward.
•
Linkages with other sectors and partners should be strengthened since the work in emergencies cannot be achieved by the health sector alone. The goals of protecting and promoting health should be pursued in coordination and collaboration with other sectors. Clear and specific agreements and pre-arrangements are needed to operationalize these linkages.
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As the experiences and levels of capacities in countries in the Region vary, intercountry exchange of information and knowledge through focused joint activities should be promoted. The Multi-Country Activities will provide a good platform for this exchange.
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Developing and implementing systematic mechanisms for training and capacity building are needed. These initiatives should not be one-off or based on theory alone. In the Region, the Public Health Emergency Management in Asia and the Pacific (PHEMAP) is a mechanism which is promoting this organized approach to training and, as such, is continuing with more focus on the National PHEMAP Courses.
Strategic Objective 6 – Promote health development, prevent and reduce risk factors for health conditions associated with tobacco, alcohol, drugs and other psychoactive substance use, unhealthy diets, physical inactivity and unsafe sex Scope of the strategic objective 49. The work under this strategic objective focuses on integrated, comprehensive, multisectoral and multidisciplinary health promotion processes and approaches across all relevant WHO and country programmes, and the prevention and reduction of six major risk factors: use of tobacco, alcohol, drugs and other psychoactive substances, unhealthy diet and physical inactivity and unsafe sex. 50. The main activities involve capacity building for health promotion across all relevant programmes, risk factor surveillance, the development of ethical and evidence-based policies, strategies, interventions, recommendations, standards and guidelines for health promotion, and the prevention and reduction of the major risk factors.
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Regional indicators and targets • By the end of 2009, at least four Member States would have reduced tobacco use prevalence rate by 2% from 2005 level. (2013 target: six Member States) • By the end of 2009, at least four Member States would have adopted and implemented comprehensive alcohol control policies; (2013 target: six Member States) • By the end of 2009, at least four Member States would have adopted and implemented comprehensive integrated NCD prevention and control, general and mental health promotion programmes (2013 target: six Member States)
Regional issues and challenges 51. Chronic noncommunicable diseases, mental disorders and injuries are a major and growing public health problem in the Region. The major risk factors for these diseases and conditions which include tobacco and alcohol use, unhealthy diets, physical inactivity, and unsafe sex are easily amenable to modification. Together with them, the intermediate risk factors like high blood pressure, high blood levels of glucose and lipids, and overweight, explain the epidemiological situation. They also point to future increases in the prevalence and deaths from these conditions. Beyond risk factors, there are major socioeconomic determinants, like socioeconomic conditions, education, culture, globalization and communication, etc., that could increase the prevalence. These factors actually lie outside the domain of the health sector. Available knowledge on simple health promotion and disease prevention measures could be used effectively and efficiently to address these conditions. Member States need to apply a holistic, multise ctoral and multidisciplinary perspective, to be promoted and facilitated by WHO.
Strategic approaches of the Region 52. Appropriate steps will be initiated based upon the Regional Framework for NCD Prevention and Control, the Regional Strategy for Tobacco Cont rol, the Regional Strategy for Health Promotion, the Regional Alcohol Policy Framework, and the Regional Strategy for Mental Health Promotion, to support Member States to formulate, update and strengthen national policies, strategies and programmes for integrated prevention and control of NCDs.
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53. Risk factor surveillance for NCD, mental disorders and injury need to be strengthened within national health information systems. 54. Mechanisms to promote multisectoral, multidisciplinary and multilevel collaboration for integrated prevention of chronic noncommunicable diseases, mental disorders and injuries will be promoted and strengthened. 55. Technical assistance needs to be provided to Member States for capacity building for planning, management and implementation of national prevention and control programmes.
Strategic Objective 7 – Address the underlying social and economic determinants of health through policies and programmes that enhance health equity and integrate pro-poor, gender-responsive, and human rights-based approaches Scope of the strategic objective 56. The work under this strategic objective focuses on: leadership in intersectoral action on the broad social and economic determinants of health; improvement of population health and health equity by better meeting the health needs of poor, vulnerable and excluded social groups; connections between health and various social and economic factors (labour, housing and educational circumstances; trade and macroeconomic factors; and the social status of various groups such as women, children, the elderly, and ethnic minorities); development of policies and programmes that are ethically sound, responsive to gender inequalities, effective in meeting the needs of the poor and other vulnerable groups, and consistent with human rights norms.
Regional indicators and targets • By the end of 2009, gender disaggregated data available in four Member States for mortality and morbidity of vulnerable groups including women, elderly, disabled, poor and displaced people. (2013 target: all Member States) • By the end of 2009, health policies and programmes specifically aimed at vulnerable groups based on rights based and gender responsive principles available in four Member States. (2013 target: all Member States)
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By the end of 2009, at least two Member States would have enhanced inter-sectoral collaboration to implement and monitor health policies and strategies for vulnerable groups reflecting the rights based and gender responsive principles. (2013 target: six Member States)
Regional issues and challenges 57. Equity in health requires an examination of the role of social and economic determinants of health in relation to improving or worsening the health outcomes of individuals, families and communities. In the Region, inequity still exists to most vulnerable groups includes women, children, elderly people and displaced population groups. There is a need to establish effective mechanisms for considering the social and economic needs of vulnerable groups namely, women, children, the elderly and the displaced populations. 58. The Millennium Development Goals underscore the deeply interwoven nature of health and economic development processes, the need for coordination among multiple sectors to reach health goals and the importance of addressing poverty and gender inequality. 59. There is a dearth of expertise in WHO to address the fundamentals associated with determinants that contribute to inequity. The lack of availability of gender disaggregated data hampers research needed to reveal such inequities, and other community and culture related actions that are non -conducive to health. We thus need improved databases and modern management and IT systems and enabling policies to take such action. It would therefore be essential for WHO to work with other organizations including UN agencies and civil society groups to address the social and economic determinants associated with inequity. There is a need for commitment and cooperation from Member States in order to create an environment conducive to addressing pr oximal and distal factors that contribute to inequity. Member States will engage all relevant line ministries especially related to those who act as coordinators of vulnerable groups such as those related to women’s empowerment, social affairs, etc and not only the Ministry of Health in order to effectively address key factors leading to negative health outcomes associated with inequity. Effective means to promote health gains for vulnerable groups include the integration into health sector policies and programmes of equity-enhancing, pro-poor, gender-responsive, ethically sound approaches. Human rights offer a unifying conceptual framework for these strategies and standards by which to evaluate success of assuring equal access, equal opportunity and ultimat ely, equal results for such vulnerable groups.
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Strategic approaches of the Region 60. The structural determinants of health encompass the political, economic and technological context; patterns of social stratification by differentiating factors such as employment status, income, education, age, gender and ethnicity; the legal system; and public policies in areas other than health. Fostering collaboration across sectors is therefore essential. Achieving this strategic objective will require policy coherence amo ng all ministries based on a whole-government approach that positions health as a common goal across sectors and social constituencies in light of a shared responsibility to ensure the right of everyone to enjoy the highest attainable standard of health. There is need for Member States to build capacity for addressing the various social and economic determinants of health. The capacity required should include but not be limited to the development of (a) infrastructure; (b) policy (c) strategies; and (d) guidelines. WHO should provide technical support for developing mechanisms for assessing causes-of-the-causes of social determinants of health as well as establishing norms, standards and guidelines for implementing possible interventions. 61. National strategies and plans should take into account all forms of social disadvantage and vulnerability that impact on health and should involve civil society and relevant stakeholders through, for example, community-based initiatives. Principles of human rights and ethics should guide the policy-making process to ensure the fairness, responsiveness, accountability and coherence of health -related policies and programmes while overcoming social exclusion. 62. The WHO Secretariat will focus on: • Providing technical and policy support to Member States to develop and maintain national systems for the collection and analysis of health-related data on a disaggregated basis especially in gender data and to develop, implement and monitor health policies based on the whole-government approach to health. • Ensuring that gender equality, pro -poor focus, ethics, and human rights are incorporated in the work of technical programmes and regional offices through developing common terminology, tools and advocacy materials; gender mainstreaming stra tegy; enlarging the knowledge base and implementation capacity; and ensuring coherent strategies, and to establish a data bank on social and economic determinants of health at local, national and regional levels that could be used during programme planning and implementation of interventions.
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•
Using the recommendations of the Commission on Social Determinants of Health to support policy action on the underlying causes of health inequities such as social exclusion, gender bias perspectives, low educational status, lack of economic power, persistence of barrier and work opportunities as well as inequalities based on gender, age, disability, or ethnicity.
•
Partnering with other UN agencies and programmes, and when appropriate civil society and the private sector, to advance health as a human right and human rights as a tool for improving health and reducing inequities; to address macroeconomic factors relevant to health including international trade; and to support institutions that improve ethical decision-making on health-related policies, programmes, and regulations.
Strategic Objective 8 – Promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to healt h Scope of the strategic objective 63. This strategic objective is aimed at addressing and reducing a broad range of traditional, modern and emerging health and environmental risks. Its purpose is to encourage strong health sector leadership for primary prevention of disease through environmental management as well as to support strategic direction and guidance to mobilize non-health sector actors about how their policies and investments can lead to win-win development strategies that also benefit health. 64. The work undertaken in this strategic objective will focus on reducing the adverse health impacts of environmental factors, which currently contribute to 25% of the total regional burden of disease (WHO 2006). This will be achieved by assessing and managing environmental and occupational health risks, including such risks as: unsafe water and inadequate sanitation; exposure to toxic chemicals in agriculture, industry and public health; indoor air pollution and solid fuel use; as well as disease vector transmission. The scope of this strategic objective also includes: health risks related to change in the global environment (e.g. climate change and biodiversity loss); development of new products and technologies (e.g. nanotechnology); consumption and production of new energy sources and the increasing number and use of chemicals; and also health risks related to changes in lifestyles, urbanization, and working conditions (e.g. deregulation of labour, an
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expanding informal sector and export of hazardous working practices to poor countries).
Regional indicators and targets • By the end of 2009, policy and settings-based action would have enhanced to address the reduction of environmental hazards such as unsafe water, poor sanitation, indoor air pollution, hazardous exposure to toxic chemicals to health care waste, and work -related disease and injuries, focused on vulnerable segments of the population. • By the end of 2009, action by Ministries of Health would have enhanced to review, update and implement national plans of action for Health and Environment with a focus on alliance building with other sectors towards a stronger public health approach in reducing and controlling environmental and development-associated hazards. • By the end of 2009, budget shift would have been demonstrated towards an increase in the health sector and related ministries for addressing health-and environment-related threats. • By the end of 2009, it would have an effective interaction between the health sector and productive sectors to reduce occupational risks and realize health, income and production gains. • By the end of 2009, it would have an effective interaction between the health sector and local authorities, using participatory and local healthy settings approaches, to engage with farmers, urban planners, slum dwellers and the informal sector occupational health conditions. to improve environmental and
Regional issues and challenges 65. The rapid pace of urbanization and population pressure continues to expose large proportions of populations to health risks associated with lack of clean water and basic sanitation. Similarly, while environmental standards are being developed in Member States and their enforcement strengthened, the “conflict” between economic growth and environmental protection continues to expose human health to modern environmental risks. The need for developing action plans on health and environment has been highlighted during recent years. Nine countries have initiated/developed health and environment programmes and adopted or drafted plans of action involving intersectoral partnerships.
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66. The water supply coverage in the Region increased from 68% to 84% during the period 1990 to 2002. Services were extended to an additional 442 million persons during this period, but despite this enormous effort, more than 262 million persons, i.e. 16% of the population of the Region, currently lack access to this basic necessity of life. 67. The rapidly growing cities in the Region need timely and community-based solutions to degrading environment and health situations. Urban primary health care approaches and the study of health and environment linkages could help many low-income and unplanned areas to redirect their efforts towards more healthy settings. Healthy settings approaches that promote health can not only work in mega cities and towns, but can also be applied in institutional settings such as child-friendly schools, and less formal environments like healthy villages and healthy islands. 68. An estimated 40-50 million people may be at risk for arsenic-related diseases by virtue of consuming arsenic-contaminated ground water in Bangladesh, India, Myanmar and Nepal. Anthropogenic mining activities in one province in Thailand have also been responsible for arsenic contamination. 69. The total work force of SEAR countries is approximately 560 million and a variety of occupational hazards and unsafe work practices are prevalent in rural and urban farms and industrial workplace. Health impact assessments in the Region have shown that a variety of environmental hazards are associated with the effluents from the growing number of industrial development programmes in the Region. Furthermore, policymakers lack specific data on the burden of disease associated with a development project in order to institute control measures.
Strategic approaches of the Region 70. Strengthening individual, institutional and sectoral capacities, at the local, national and regional levels, through identification of human capacities in WHO offices and national counterpart institutions, by reviewing and updating the terms of reference of staff in order to reflect the emerging technical needs and exposing them to activities through focused field visits. 71. Enhancing knowledge management through development and implementation of a knowledge manage ment system by way of participatory training, establishment of efficient reporting system, documentation and dissemination of technological advancements, promoting use of existing networks, increased use of IT potential, etc.
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72. Mobilizing political commitment through policy advocacy for creating support for environmental action, forging alliances and building partnerships across all sectors towards health promotion and collective (joint) programming for action, and promoting most relevant approaches for susta inability. 73. Providing technical support to enhance the implementation of norms and standards through dissemination of “best public health practices” to government authorities and collaborating agencies and strengthening national infrastructure and capacity using international Conventions as important supporting tools. 74. Stimulating research and development by promoting operational research on behavioural pathways, piloting new approaches for community-led projects/programmes, cost-effectiveness prevention and management of environmentally linked diseases, and developing a monitoring system to assess the performance of WHO Collaborating Centres and other institutions in the Region.
Strategic Objective 9 – To improve nutrition, food safety and food security throughout the life-course and in support of public health and sustainable development Scope of the strategic objective 75. The work under this strategic objective focuses on: nutritional quality and safety of foods; promotion of healthy dietary practices throughout the life -course, starting with pregnant women, breastfeeding and adequate complementary feeding, and considering diet-related chronic diseases; prevention and control of nutritional disorders, including micronutrient deficiencies, especially among the biologically and socially vulnerable, with emphasis on emergencies, and in the context of HIV/AIDS epidemics; prevention and control of zoonotic and nonzoonotic foodborne diseases; stimulation of intersectoral actions promoting the production and consumption of, and access to, food of adequate quality and safety; and promotion of higher levels of investment in nutrition, food safety and food security at the global, regional and national level.
Regional indicators and targets • By the end of 2009, proportion of underweight children under five years of age would have reduced by 10% as compared to the level in 1990. (2013 target: 40%)
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•
By the end of 2009, at least three Member States would have documented the proportion of overweight and obese children and having interventions to address them. (2013 target six Member States)
•
By the end of 2009, at least two Member States would have had legislation in place confirming an overarching food safety body at the national level, consisting of representatives of all key stakeholders to assure proper coordination of all food safety activities from production to consumption.
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By the end of 2009, at least three Member States would have implemented food safety risk analysis in vulnerable groups. (2013 target: five Member States)
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By the end of 2009, at least three Member States would have implemented the Hazard Analysis Critical Control Point (HACCP) methodology to improve food safety in Healthy Food Market. (2013 target: seven Member States)
Regional issues and challenges • Nutrition, food safety and food security are cross-cutting issues throughout the life-course, from conception to old age, and have to be addressed both in stable and crisis situations – including epidemics like HIV/AIDS and Avian influenza. • In SEAR countries, about 5-35% of the population is undernourished. The figure goes up to about 50% undernourished infants and young children, and contributes to over half of the under-five child deaths. Inappropriate infant and young child feeding practices are one of the major causes for this high pre -valence of under-nutrition. Despite substantial progress, micronutrient deficiencies especially of iron, vitamin A and zinc, are also prevalent, and iodine deficiency disorders have only been eliminated in one country in the Reg ion. • • At the same time, the proportion of overweight and obese children, adolescents and adults is increasing, even in the low income groups. Adolescents constitute one-third to one-half of the population in many countries, but have not as yet been sufficiently targeted for improving their dietary habits, nutritional status and lifestyle. These efforts can impact positively on family and community health, and also decrease the incidence of adult onset noncommunicable diseases. • The capacities of relevant health staff to provide nutrition counselling, and for prevention and management of malnutrition, is far from optimal in most countries.
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Limited funds are allocated for nutrition activities despite evidence which shows that improved nutritional status and sub sequent decreased morbidity and mortality can have a significant impact on national economies.
•
Despite the extent of food borne diseases, many Member States have no clearly articulated written policy on food safety, and in most countries, the Food Safety m andate is often scattered among several sectors. The reluctance to establish documented policies and plans of action relevant to all stakeholders in food safety and food security is an indication of the lack in awareness and adequate involvement of consumer organizations, politicians, food industry associations, academic and research institutions to recognize the true extent of the health and economic consequences of food-borne diseases.
•
•
Ineffective communication, lack of adequate data on the incidence and real costs of food borne diseases, cultural habits, differing social values, traditions and taboos, contribute to this situation.
• •
Lack of effective food and nutrition surveillance systems, including weak food testing laboratories. Variations in the degree of law enforcement in different countries are not only due to technical and human impairments, but also due to recurring food adulteration practices.
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Shortcomings in existing capacity to cope with statutory responsibilities in terms of regulatory testing a nd enforcement of foods consumed in the country, including imported foods, and to meet new challenges in this regard. With the growth of the food processing industries, the responsibility of the Governments for monitoring products has dramatically increased, well beyond their available human, technical and financial capacities.
•
Difficulties in acceptance of concepts like good manufacturing practice (GMP) and hazard analysis at critical control points (HACCP) at the level of the unorganized sector: food handlers/ retailers, small restaurants, grocery stores, street vendors.
Strategic approaches of the Region 76. The strategies to improve nutrition, food safety and food security in the SEA Region would be incorporating the principles of the lifecycle approach and in
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support of public health and sustainable development. It would be an integrated approach in strengthening national capacity and in the spirit of partnership. • Building partnerships, alliances and effective interactions with agencies within the UN system and between the UN agencies to promote the integration of nutrition, food safety and food security programmes at country level and mainstream them into national development policies; strengthening WHO´s country office participation in the joint planning processes and joint programming at national level. An overarching national food and nutrition body at the national level, consisting of representatives of all stakeholders should be established to assure proper co -ordination of food and nutrition activities from production to consumption. • Strengthening its normative functions, and collaborating with relevant partners to assure the dissemination and use of norms, standards and training materials; • Communicating effectively the need for integrated policies and strategies that improves nutrition and food safety and promotes healthy dietary practices to cover the whole spectrum of nutritional disorders, from under to over-nutrition and diet-related chronic diseases, while assuring a human rights' perspective in access to safe and nutritious food. • Increasing the technical support provided to Member States to strengthen their national capabilities in identifying problems and best policy options; developing leadership in implementing the required nutrition, food safety and food security interventions, in involving relevant intersectoral partners and in monitoring progress and assessing impact. • Assisting Member States in establishing databases to strengthen food contaminant monitoring and foodborne disease surveillance. Collection of economic cost of food-borne disease outbreaks and other food safety issues such as export rejects would assist policy makers to realize the enormity of the problem. • Assisting Member States to update and revise the national food legislation effectively taking into account Codex recommendations and the FAO/WHO model food law. • Assisting Member States to reemphasize on educational/ training/communication from general hygiene/microbiology to chemical contaminants and the newer technologies such as GMO food products, to review the qualifications and training of inspectors within the context of national needs and modern approaches, including HACCP. To assist
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Member States to develop a broad-based participative risk communication strategy to promote better knowledge, attitudes and practices related to food safety issues. • To underscore the importance of research and development by promoting operational research on priority food borne hazards, particularly chemical containments, and devising means for th eir prevention and control, but by also developing, piloting and evaluating new approaches for communityled projects/programmes such as Healthy Food Markets.
Strategic Objective 10 – To improve the organization, management and delivery of health services Scope of the strategic objective 77. The work to be undertaken as part of this strategic objective will enhance the way health systems perform in response to population's needs and demands. It is underpinned by the principles of Primary Health Care and Health for All, and a concern to reduce inequity in access and exclusion from the benefits of health care. 78. It seeks to equitably expand access across the range of services needed to improve health outcomes and respond to legitimate demand for care, by matching service response to needs and demand, by increasing organizational and managerial capacities of institutions and provider networks, and by strengthening informed demand; and covers the organization and management of all populationbased and personal health s ervices - individual providers, facilities and provider networks; public, private and voluntary; at all levels, from those within the community to tertiary hospitals and specialized services. 79. It is concerned with the promotion of all aspects of quality in relation to service delivery: patient- and community-centeredness, responsiveness, continuity of care, as well as safety, effectiveness and efficiency; by overcoming the fragmentation that results from the multiplication of disease -specific programmes and initiatives, in ways that are tailored to local and national circumstances and priorities; and anticipating how technological innovation, changing needs and evolving demand will influence service delivery.
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Regional indicators and targets • By the end of 2009, at least four Member States would have demonstrated progress in improving performance of health services in the following key areas: (expanded coverage and access; reduced exclusion; increased productivity and efficiency; improved responsiveness; and increased conformity with service, quality and safety standards. (2013 target: seven Member States); • By the end of 2009, at least five Member States would have demonstrated progress in identifying and meeting the organizational and managerial capacity shortfalls in their institutions and networks (2013 target: nine Member States) • • By the end of 2009, at least five Member States would have shown evidence of improved regulatory capacities. (2013 target: eight Member States) By the end of 2009, at least four Member States would have reduced inefficiency due to programme fragmentation . (2013 target: 10 Member States)
Regional issues and challenges 80. Failing or inadequate health organization, management and delivery of health services are currently the main obstacles to scaling-up interventions to a level that will make achievement of the MDGs and other national health targets, such as reducing incidence of noncommunicable diseases, a realistic prospect. The Region faces several major issues and challenges. These are: • Limited and inadequate capacity of health service delivery to reach all segments of the population, particularly the low-income households, people who live in rural and remote areas and other vulnerable groups. • Limited capacity to plan and allocate a budget for health which is often spent on providing services with limited public health significance and which is urban non-poor-biased. • • • Weak leadership and strategic management of the health services organization. Low coverage and quality of services, including lack of patient safety. Low productivity, efficiency and conformity with safety standards.
81. Social unrest in several areas of countries in the Region has prevented the health organization and service delivery to perform optimally. In countries with
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some form of decentralization, such as Indonesia, Nepal, etc, the roles and relations between the centre and other levels are shifting. Central ministries of health may be moving to commissioning of services and facilities from both the public and private sector. 82. Most countries in the Region have strong vertical programmes, in which funds are often directed to the achievement of disease -specific health outcomes, many interventions are delivered by the same - often limited - group of health workers and facilities. The way services are organized and managed affects access; determines the extent to which service coverage is genuinely pro-poor or equitable; and influences the achievement of improved health outcomes. 83. Although there is no single universal model for organizing service delivery, there are some well-established principles. First, attention needs to be paid to demand as well as to the supply of services: individuals and communities need sufficient knowledge to use services when needed, and not to be deterred by cultural, social or financial barriers. Second, it is important to take into account the full range of providers, and not merely those working in the public sector. Public sector managers have to understand and engage with different non-state providers to address concerns about quality, effectiveness and cost, and to make the most of any potential contribution to meeting public health goals. Third, there is a growing need to ensure that services are 'close-to-client', and avoid unnecessary duplication and fragmentation. 84. Training – for clinical, managerial or support tasks – is necessary but usually not sufficient to improve quality. Whether they work in the public sector or not, all managers have to deal with volume and coverage of services, allocation and efficient use of resources (staff, budgets, medicines, equipment), and a variety of partners and stakeholders. To do this well they need good quality information, functioning support systems, and enough managerial autonomy to encourage local decision making and innovation; at the same time the mechanisms need to be in place to ensure proper accountability.
Strategic approaches of the Region 85. Capacity of the Member States needs to be built and strengthened, particularly through setting up mechanisms, procedures and incentives that encourage all stakeholders – including public and non-public providers and provider organizations - to work together to improve service delivery and eliminate exclusion from access to care. Organizational and managerial practices of health
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organizations and service deliveries will be developed to ensure synergies between public and non-public providers, in embedding disease-specific programmes within general health services, and in focusing on obtaining observable improvements in their performance in terms of coverage, effectiveness, efficiency, quality and acceptability of service delivery. 86. In supporting the efforts of Member States, the WHO Secretariat will focus on: • Building the capacity health organization, management and service delivery based on the primary health care approach, and empowering the community in health development. WHO secretariat will provide technical leaderships to enhance capacities of Member States in managing health organizations and service delivery. • Strengthening knowledge management, particularly on knowledge acquisition through learning from the experience of others, as well as disseminating best practice; in the absence of a single universal model for service delivery, WHO has a key role to facilitate such learning and exchange, particularly in relation to innovative models to expand access and improve quality of health services. • Facilitating partnerships between non-state and public providers, to promote greater mutual understanding and better-informed policies and approaches in the pursuit of public health goals. WHO will collate and assess evidence on alternative models of service delivery so as to ensure evidence-based guidance and support to Member States. • Strengthening decentralization and “close-to-client” management of health service organizations, facilitating innovation , particularly to the extent that they can improve the effectiveness or reach of services in resource-poor settings, and assisting the Member States for preparing for the future. • Applying its normative function to work on service delivery; this will include defining service standards, measurement strategies and other approaches to ensuring quality.
Strategic Objective 11 – To strengthen leadership, governance and the evidence base of health systems Scope of the strategic objective 87. The work to be undertaken as part of this strategic objective covers the responsibilities and processes of governing health systems, i.e. the leadership,
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governance and steering of these systems (or “stewardship”, as it is referred to otherwise). It also covers the generation of system intelligence through research, production of information and evidence, and management of knowledge: these are critical to support policy-making and implementation processes. 88. The responsibilities and processes for governing of health systems relate to: leading and guiding policy formation and implementation, bridging the gaps between knowledge and practice; optimizing the allocation and use of resources, including financial and other cooperation with external agencies; building collaboration across government and with other actors and stakeholders; ensuring harmonization, alignment and a fit between policies and organizational structure and culture; setting fair rules of game; regulating the behaviour of actors and stakeholders; and putting in place effective mechanisms to ensure accountability and transparency. 89. Generation of system intelligence to underpin the governing of health systems at country and at global levels implies monitoring the health situation, assessing health trends and monitoring health system performance; shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; setting norms and standards for the generation of information, and promoting and monitoring their implementation; and articulating ethical and evidence-based policy options.
Regional indicators and targets • By the end of 2009, at least six Member States would have completed national Burden of Disease studies and using results in national policies and programmes formulation (2006 Baseline - one Member State). (2013 target: All Member States) • By the end of 2009, at least eight Member States would have aligned their Health Information Systems to meet the internationally accepted standards for health information required for policy making. (2006 Baseline- three countries). (2013 target: All Member States) • By the end of 2009, improved mechanism would have been in place to promote generation of relevant hea lth research outcomes through strategic alliance within health system and other sectors in priority Member States. • By the end of 2009, research investment, number of trained researchers and research managers, research networking, research information syste m and better use of research evidences in decision making would have been increased significantly.
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•
By the end of 2009, equity in access to core international health literature and key national health knowledge base in Member States would have been improved.
•
By the end of 2009, at least four Community of Practice (CoP) for Knowledge sharing would have been established in Member States covering major WHO Strategic Objectives. (2006 baseline: one regional CoP). (2013 target: 10 CoP).
Regional issues and challe nges 90. Strengthening leadership, governance and the evidence base of health systems is both a technical and political endeavour. It involves a combination of vision, technical knowledge and ability to manage changes. It requires a complex set of institutional capacities that is only partially available in many countries in the Region. 91. Many countries in the Region have inadequate capacities to formulate clear policy objectives and strategies that correspond to health system needs, are based on scientific evidence, and are compatible with the cultural and social values of concerned societies. Health leaders and policy makers in the Region have been experiencing difficulties in reconciling competing demands for limited resources across services and programmes, an d in deciding about ways to organize them to maximize use of resources and to ensure that core public health functions are provided, despite limited evidence about 'what works' and sometimes in the face of earmarked external funds. 92. Limited capacity of ministries of health to manage the increasing number of financing and implementation partners and networks that they have to deal with: public bodies (ministries of finance and planning, national legislatures, etc); international agencies; multilateral, bilateral and nongovernmental agencies; and various types of private enterprises and civil society organizations. Most countries also do not have adequate regulatory and legislative mechanisms to ensure socially responsible behaviour of all stakeholders, fair r ules of game for all players, and implementation of strategies leading to the attainment of policy objectives. 93. Health information systems are also inadequate to support scientific and evidence-based policy development. In many countries in the Region, research is not a high priority. The budgets for research and development are usually minimal. Furthermore, capacity is limited for conducting research relevant to health systems.
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Strategic approaches of the Region 94. Achieving this objective will require building capacity of the Member States through setting up structures and processes which involve a range of actors in defining how the health sector should operate and be managed. The capacity of the ministries of health in reviewing and developing enforceable regulations, standards and incentives that promote a 'level playing field' for all health system actors need to be strengthened. Governments in the Region should also create mechanisms for better managing interactions with multiple partners. As governments decentralize so as to get closer to community concerns, efforts will be made to establish and promote effective accountability mechanisms to protect nationally agreed priorities. 95. Strengthening accountability would require the development of a culture of investing in and acting upon information and evidence as well as establishing functional (timely, reliable, relevant) health information systems. Building and sustaining the capacity for delivering nationally-relevant research for health, including health systems research, for establishing and maintaining sound health information systems and translating research findings into policy and practice, will be major conditions as well as e-Health platforms, to ensure that the right knowledge gets to the right people (policy-makers, managers, practitioners, development partners and the general public) for effective decision-making and performance monitoring across the health system. In supporting the efforts of Member States, the WHO Secretariat will focus on: • • Mainta ining an approach to country support that is tailored to the political, cultural and social context in which governance strengthening takes place; Contributing to strengthening the capacity of ministries of health to develop health sector policies that also fit with broader national development policies, and to allocate resources in line with policy objectives; • Assisting in building national information systems that can generate, analyse and use reliable information from population-based sources (surveys, vital registration), as well as clinical and administrative data sources, through collaboration with partners (e.g. UN, other agencies and the Health Metrics Network partnership). • Contributing to building national capacity to produce policy-relevant research, and synthesizing country experience so as to provide evidence-
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based guidance, in collaboration with partners and the International Alliance for Health Policy and Systems Research. • Providing technical guidance for resource allocation for health based on synthesis, analysis of country, and regional data, including comprehensive databases; a key role will be played by regional expert groups; • Facilitating exchange and dissemination of knowledge and experience within and between countries, and enhancing access to information and knowledge; and • Bridging the “know-do gap” by synthesizing experience and disseminating best practice, fostering an environment that encourages the creation, sharing/ translating, and effective application of knowledge to improve health; and helping to close the information divide between rich and poor communities.
Strategic Objective 12 – Ensure improved access, quality and use of medical products and technologies Scope of the strategic objective 96. Medical products include medicines; va ccines; blood and blood products; cells and tissues of mostly human origin; biotechnology products; traditional medicines and medical devices. Technologies include diagnostic tests, imaging, laboratory tests and e-Health. The work undertaken under this str ategic objective will focus on improving equitable access (as measured by availability, price and affordability) to essential medical products and technologies of assured quality (including safety, efficacy and cost-effectiveness), as well as their sound and cost-effective use. The sound use of products and technologies focuses on evidence -based selection; prescriber and patient information; appropriate diagnostic, clinical and surgical procedures; vaccination policies; supply systems, dispensing and injection safety; and blood transfusions. Information includes clinical guidelines, independent product information and ethical promotion.
Regional indicators and targets • By the end of 2009, at least 65% of the population would have got increased access to regular supply of essential medicines of adequate quality (Baseline: <60% in Member States). (2013 target: 75%) • By the end of 2009, at least four Member States would have established efficient Drug Regulatory Authorities.(2013 target: nine Member States)
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By the end of 2009, rational use of medicines in the Region would have improved by at least 30% of the prescriptions in public sector health care institutions are by generic name (current baseline: <30%). (2013 target: 50%)
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By the end of 2009, at least seven Member States with a functional national regulatory authority would have performed the relevant WHO recommended States) functions in accordance with the national vaccine procurement policy (Current baseline: four) (2013 target: All Member
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By the end of 2009, at least eight Member States with efficient and transparent procurement systems would have used global or recognized benchmarks in order to maintain uninterrupted supply of EPI vaccines of assured quality (Current baseline: three). (2013 target: All Member States)
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By the end of 2009, at least 70% of total blood units collected are from voluntary blood donors (baseline in 2006: 61%). (2013 target: 90%)
Regional issues and challenges Essential medicines 97. The region has the capability to produce quality medical products not only for the Region but for other regions as well. However, recent developments in globalization, Trade Related Intellectual Property Rights (TRIPS) may cause roadblocks even if adequate quality is achieved. On the other hand, there is insufficient emphasis on essential medicines that meet health care needs when focusing on industrial development. 98. The poor quality seen at times is due to poor regulation, which is common to many developing countries. However, the required quality can be achieved when the market demands it, as can be seen in exports to developed countries. The fundamental failures in regulation are due to weak of political commitment and insufficient resources. Ironically, resources can be generated through income from proper regulation. Further adjustments in governance are required to improve regulation. 99. The Region has sufficient resources for medicines if used rationally. Governments spend enough for citizens to have essential medicines through the health care system. However, distortions in use (irrational, irrelevant and wasteful medicines use) means that essential medicines are not available to a majority of the population in the Region. This distortion is brought about by lack of guidance
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(Standard Treatment Guidelines, Formularies) and, as importantly, a lack of mechanisms to implement them. In addition, due to lack of regulation and effort, uncontrolled drug promotion by industry creates further distortions. 100.The lack of overall financing of health care systems (which include medicines financing) means that imperfect markets prevail with “value for money” being the exception rather than the rule.
Vaccine supply and quality 101.Some Member States in the Region have difficulty in establishing appropriate levels of expertise for (i) regulating the manufacture and importation of vaccines; and (ii) monitoring vaccine safety quality and efficacy. National Regulatory Authorities (NRAs) in most industrialized countries employ “mutual recognition” in their evaluation of marketing authoriza tion to simplify and expedite the regulatory approval process for foreign-produced vaccines and drugs. Such a mutual recognition mechanism has not yet been developed for the Region even though several countries are major vaccine producers. 102.Recently, WHO initiated the Developing Countries Vaccine Regulatory Network (DCVRN) including nine developing countries with the mission to promote and support the strengthening of the regulatory capacity of NRAs for evaluation of clinical trial proposals and clinical trial data through expertise and exchange of relevant information. It is an important step towards global harmonization. However, there is a need to establish similar networking at the regional level with all NRAs to harmonize the marketing authorization proc edure, to rationalize lab access for vaccine quality control and to share post-marketing surveillance data. 103.Most countries in the Region have established a system for monitoring of adverse events following immunization (AEFI). However, case investigation and causality assessment need to be further strengthened to fully analyze, understand and address AEFI. When clusters of AEFI cases are reported, senior managers, and policy makers need to be well prepared to answer questions with scientific data. In this Region, where several new vaccines (JE vaccines, Conjugate DTP-Hep B, Flu pandemic vaccines, etc.) are likely to be introduced in the next five years, it is critical that countries collect appropriate data in different age groups to constitute baseline info rmation on the relevant diseases. 104.The Region includes the major producers of traditional EPI vaccines and will probably keep this leadership role in the global production of conjugate vaccines (DTP-HepB). It is a new trend compared to 15 years ago when vaccine
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manufacturers were located mainly in industrialized countries. The Region, which accounts for nearly one quarter of the world’s children, should benefit from this context because of its large demand and large vaccine producing capacity. However, the countries are still working in a very isolated manner to effectively address vaccine availability, procurement and regulatory issues and to foster better cooperation with manufacturers to address mid- and long-term vaccine needs.
Blood safety 105.Against an estimated annual requirement of 15 million units of blood in the SEA Region only 9.3 million are being collected. Only 61% of blood is from voluntary donors. The quality of screening for infectious markers viz HIV and hepatitis B and C needs to be improved. Only one fourth of blood is converted into components. Clinicians are not fully aware of the rational use of blood and its components. 106.Health laboratories in clinical settings are beset with problems of inadequate resources and weak quality systems. The importance of laboratories in supporting clinical decisions making, providing vital parameters for genetic and environmental studies as well as in assuring match between donor and recipient of organs for transplantation in addition to providing assistance in public health functions is not fully felt. Quality systems are weak and few external quality assessment schemes are in operation. These inadequacies prevent generation of reliable reports by the laboratories. At national level, laboratory policy and focal points need to be established to ensure strengthening and proper utilization of the laboratories.
Strategic approaches of the Region Essential medicines 107.The strategic approach is to advocate for an overall National Drug Policy which will bring some balance to the currently unbalanced (against health) situation in medicines. 108.However, the progress towards a comprehensive approach has been difficult to achieve. In the few cases where it has taken root, advancement will be sustained. 109.Therefore, a comprehensive approach through a National Drug Policy is required. Until this objective is actually reached, efforts are needed to develop the key components of a comprehensive approach and to advocate the importance of a National Drug Policy.
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Vaccine supply and qualit y 110.EPI vaccine procurement is driven by the global agenda led by GAVI that has generated demand and secured funds for the introduction of new/under-utilized vaccines. UNICEF has been instrumental over the past 20 years in providing vaccines to the developing world and to centralize demand and procurement of vaccines. A centralized procurement system has several advantages the most obvious being that it allows to negotiate a better vaccine price. 111.The decision-making, however, can be perceived by countries to be too centralized to take into account regional vaccine needs. Although, the introduction of vaccines is based on epidemiologic data and the capacity of countries to introduce the vaccine, the global introduction of a vaccine like Hib remains controversial vis-à-vis other regional and country priorities like JE (South-East Asia and Western Pacific Regions), malaria vaccines, meningitis or yellow fever (African Region). 112.The strategy to address vaccine supply and quality issues is built on the work and achievement of WHO to implement functioning NRA and build national capacity to undertake procurement of vaccines. In this connection, the Regional Office will continue to support country specific reviews of the National Regulatory Authority and national procurement procedures targeting the priority vaccine producing countries and countries that procure their vaccines directly from pre-qualified sources. Capacity building of NRA remains a high priority and will continue with the training of NRA specialists through the Global Training Network. Stronger links and participation of the NRA in the procurement process will be emphasized especially through enforcement of quality standards to select vaccine suppliers. 113.There is a real need to establish a regional forum to foster dialogue and cooperation among the NRA, EPI managers and procurement agencies responsible for addressing short-and-long term vaccine forecast, identifying and maintaining updated regional and global production capacity and addressing vaccine regulat ory challenges.
Blood safety 114.Encourage voluntary donation through community and NGO involvement and by promoting production and rational use of blood components. 115.Create appropriate infrastructure and capacity for virological and molecular biological techniques and forge functional networks that harness expertise available within the country.
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116.Promote efficient formal and continuous collaboration between health and animal health sectors; joint planning and implementation of prevention and control activities a nd strengthening of epidemiological and laboratory services.
Strategic Objective 13 – To ensure an available, competent, responsive and productive health workforce in order to improve health outcomes Scope of the strategic objective 117.The work under this strategic objective will address the stages of workforce development entry, working life and exit, focusing on developing national workforce plans and strategies; enabling effective regulation o f the educational system and job market towards an equitable distribution of health workers; achieving an appropriate mix of health workers responsive to population needs; and improving the management of the health workforce and the environment in which it works, including by providing financial and non -financial incentives, particularly for remote and underserved areas.
Regional indicators and targets • By the end of 2009, at least six Member States would have implemented the South-East Asia regional strategy on Human Resources for Health. (Baseline: no Member State) (2013 target: All Member States) • By the end of 2009, adequate number of staff would have been in position in key health workforce areas, with appropriate regulatory systems, in the context of overall activities of the health system. • • • By the end of 2009, adequate number of community-based health workers would have been in position with appropriate skills and competencies. By the end of 2009, incentive systems would have been implemented to ensure adequate health staff available in remote and under -served areas. By the end of 2009, accreditation systems would have been implemented in schools and universities to support the quality of newly trained health workers.
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Regional issues and challenges 118.Notwithstanding the progress in human resources for health in general, most countries in the Region continue to face several key problems, such as: the absolute shortages or poor regional distribution of personnel, poor training and technical skills, inefficient skills-mix, inadequate staff supervision, lack of support and poor working environment, lack of opportunities for personal development, all leading to inefficient delivery of health care. 119.In the 1980-90s, community-based health workers contributed significantly to the achievement of health development goals. Unfortunately, in recent years, such development has been stalled or stopped in many developing countries, especially the least-developed ones. Various forms of health sector reforms and large-scale investment of selective health care programmes have either neglected or hindered further development of community-based health workers. 120.Another key issue is the limited capacity of health leaders in stewardship functions. In strengthening the health workforce, country health leaders should engage other prominent leaders and stakeholders to plan human investments, to manage for performance, to develop enabling policies, and to build capacity for public health research, training and practice while monitoring results. A strong action coalition has to be built across all stakeholders with interest in health workforce development. Only with a strong stewardship capacity of health leaders from various levels, can countries strengthen their health workforce to enable them to respond adequately to current and emerging health need s.
Strategic approaches of the Region 121.Achievement of the strategic objective will require an available workforce, in the right places, in the right numbers and with the right skills to respond to the health needs of the population, within the context of th e country’s own health systems. 122.To accomplish this, the Region needs strengthened advocacy for health workforce improvement at regional and national levels with partnerships created and promoted at all levels. Health workforce information systems are required to develop evidence -based, comprehensive national workforce policies and strategic health workforce plans that are systematically implemented, monitored and evaluated. Evidence-based best practices on development, education and management of health workers need to be collated and disseminated. Similarly adequate funding for the health workforce will require discussions and
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negotiations with finance ministries, labour and education ministries, and international development partners. 123.In addition, it will be necessary to expand capacity and improve quality of educational and training institutions; ensure appropriate skill mix and equitable geographical distribution of the health workforce through effective deployment and retention, by means of context-specific incentives. 124.In supporting the efforts of Member States, the Regional Office will provide technical leadership and develop and share the knowledge (data, information, and evidence) needed to change current practices, so that health workforce challenges are addressed and the overall performance of the health workforce continuously improves. Specifically, the Regional Office will focus on: • • Providing technical assistance to Member States in developing master plans of HRH in the context of overall activities of the health system; Providing technical assistance to strengthen HRH policies and management in Member States, and assist them in preparing for trade liberalization in health sector; • Supporting the development of national health workforce leadership at central and peripheral levels to mobilize resources for the health workforce and to formulate, implement, monitor and evaluate health workforce policies and plans responsive to health needs; • Strengthening national educational systems, including schools and universities, to support the production of all types of health workers, including community based health workers, with appropriate skills and competencies; • Strengthening the knowledge base through supporting national capacity to develop health workforce information systems and promote health workforce research; • Supporting mechanisms for regional networking of stakeholders, such as health workforce observatories, to generate information for evidencebased policy-making, monitoring and evaluation.
Strategic Objective 14 – To extend social protection through fair, adequate and sustainable financing
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Scope of the strategic objective 125.This strategic objective reflects the guiding principles described in World Health Assembly Resolution WHA 58.33, "Sustainable health financing, universal coverage and social health insurance". The work will focus on: increasing funding for health from domestic and external sources in poor countries; increasing the predictability of funding; ensuring new external resources contribute to the development of sustainable domestic financial institutions; developing financial risk pooling mechanisms to reduce the extent of financial catastrophe and impoverishment; reducing financial barriers to prevention, promotion, treatment, rehabilitation and intersectoral health actions; ensuring efficient and equitable use of available health resources, including the appropriate mix of public and nonstate providers and funding sources, and the appropriate mix of inputs including medicines; improving availability and use of key information on inputs, processes, outputs and outcomes of health financing systems; development of tools for monitoring and evaluating the performance of financing systems and ensuring transparency in revenue generation and use.
Regional indicators and targets • • • By the end of 2009, funding for health, particularly public spending on priority public health services for the poor would have been increased. By the end of 2009, direct out-of-pocket expenditure as a proportion of total health expenditures would have been reduced. By the end of 2009, fairness in financing, particularly a reduction in the number of households pushed below the poverty line, would have been in overall improved. • By the end of 2009, the use of appropriate tools for effective financial planning, management and monitoring in health would have been institutionalized. • By the end of 2009, innovative schemes for health care financing within broader and longer term social protection, particularly for the informal sector would have been designed, piloted, and institutionalized. • By the end of 2009, a multi-sectoral approach to health financing would have been institutionalized.
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Regional issues and challenges • • Low levels of public health expenditure (only five countries have total health spending at the WHO recommended level of 5% of GDP). Disproportionate share of direct, out -of-pocket expenditure (OOPs) in total health expenditure (and within this on drugs), especially among poor households. In fact, OOPs in the Region is among the highest in the world – e.g. in India 80+% of total health expenditure is OOPs. Evidence clearly suggests that OOPs is the most regressive health financing option. • • Improving the efficiency in use of resources, effectively targeting them as a priority to public health needs of the poor. Sustainable increases in the volume of (domestic) resources available for health, particularly public health, with financial protection for the poor – shifting out of OOPs to some form of co/pre -payment mechanism.
Strategic approaches of the Region 126.The focus of the Regional Strategic approach is country capacity development in the following key Health Care Financing areas: • Improving efficiency in use of resources for public health needs by e.g. costing for priorities (e.g. MDGs), National Health Accounts, resource tracking. • • • Social protection to ensure equity in health financing. Two particular approaches within this are important. Priority coverage of the large informal sector in the Region. Given the country contexts in the Region, the system be anchored at community level with the potential to be increased in scope/integrated into broader national systems in the future. • Effective linkages with other health systems functions and sectors that impact health financing e.g. drug procurement and distribution; (monetary) incentives for health workers to increase retention in poor areas. • Profiling health in development to increase and sustain both political and financial commitment to the sector e.g. by building on the considerable Commission on Macro -economics and Health effort in the Region.
Strategic Objective 15 – Provide leadership, strengthen governance and foster partnership and collaboration in
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engagement with countries, to fulfill the mandate of WHO in advancing the global health agenda as articulated in the 11th General Programme of Work Scope of the strategic objective 127.This strategic objective facilitates the work of WHO in all other Strategic Objectives. Responding to priorities in the 11 th General Programme of Work, it recognizes that the context for international health has changed significantly. The scope of this objective covers three broad, complementary areas: leadership and governance of the Organization; WHO’s support for, presence in, and engagement with individual Member States; and the Organization's role in bringing the collective energy and experience of Member States and other actors to bear on health issues of global and regional importance. 128.The main innovation implicit in this objective is that it seeks to harness the depth and breadth of WHO's country experience in order to influence global and regional debates - thereby to influence positively the environment in which national policy-makers work, and contribute to the attainment of the healthrelated Millennium Development Goals and other internationally agreed healthrelated goals.
Regional indicators and targets • By end of 2009, all World Health Assembly agenda items would have been discussed and where relevant, common positions would have been taken by Member States from SEAR. • By end of 2009, all Country Cooperation Strategies whose time or situation has lapsed would have been updated and endorsed by the respective Member State. • By end of 2009, at least three countries would have shown improvements in the allocation, harmonization and alignment of national and external resources with health priorities identified in the national health and development strategies compared with end 2007. • By end of 2009, qualitative improvements would have been demonstrated in the interaction with the UN System, intergovernmental bodies and regional groupings in the Region, NGOs and other partners at country and regional level on common health agendas, including financing for health.
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• •
By end of 2009, qualitative improvements would have been shown in the SEAR counties’ influence on global health architecture. By end of 2009, at least in six countries, qualitative improvement would have been demonstrated in accessing and sharing of relevant information, communication, knowledge bases and publications, including health researches.
Regional issues and challenges • Ensuring that Member States concerns and interests are discussed and addressed at global and regional governing body levels and Member States in the Region have a common position on major issues. • Mechanism to monitor and analyse the correlation between policy decision/resolutions and implementation at region and country level including resource allocation. • • Need for more coherent and real-time communication between the SEAR Member States and the Regional Office and Country Offices. Need to constantly improve the quality of WHO Country Cooperation Strategies with ever-changing global architecture and national priorities and financial commitment. • Coordination with other UN agencies, inter-governmental bodies and regional groupings difficult due to the difference in geographical coverage between SEARO and these organizations being widely varied. • UN reform and harmonization and alignment agenda complex and constantly evolving while inter-governmental Bodies and regional groupings in the Region are also rapidly developing and gaining strength. • With the ever increasing numbers of NGOs and Civil Society Organizations and the recent trend of formation of multiple and differing partnerships in health, ensuring appropriate and productive engagement of the Regional Office and national authorities will continue to be a challenge. • • Ensuring the level of increased delegation of authority with corresponding capacity, accountability and oversight. Balancing skill mix at the Regional Office and Country Offices.
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Strategic approaches of the Region • Ensuring that Member States are provided a forum to exchange experiences dialogue among themselves and take united positions on health issues of common concern and interest. • Strengthening governance through active engagement of Member States in the preparation and conduct of the Regional Committee and high-level meetings in the Region as well as the World Health Assembly and the Executive Board. • • Improving do cumentation and communication capacity with the help of increased capacity and advanced technology. Building consensus and capacity of the health sector of Member States and WHO country teams for implementing the UN reform, the harmonization and alignment agenda and other development initiatives. • • • Adopting a multi-regional approach to coordination with other UN agencies, inter-governmental bodies and regional groupings. Regular and systematic evaluation of the delegation of authority, capacity accountability and oversight. Addressing human resource (appropriate skill mix) needs of Country Offices through temporary deployments of Regional Office and Country office staff to needed locations/institutes.
Strategic Objective 16 – Develop and sustain WHO as a flexible, learning Organization, enabling it to carry out its mandate more efficiently and effectively Scope of the strategic objective 129.The scope of this objective covers the functions that support and enable the work of the Secretariat in countries, regional offices and headquarters. The work under this objective is organized according to the following mechanisms: entire results-based management framework and processes, from strategic and operational planning and budgeting to performance monitoring and evaluation; management of financial resources through monitoring, mobilization and coordination at an Organization-wide level, ensuring an efficient flow of available resources throughout the Organization; management of human resources, including human resource planning; recruitment; staff development and learning; performance management; and conditions of service and entitlements; provision of
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operational support, ranging from the management of infrastructure and logistics; language services; staff and premises se curity; staff medical services; to the management of information technology; ensuring that there are proper accountability and governance mechanisms in place across all areas. 130.In addition, the strategic objective covers a broad institutional reform agenda that will ensure that the above functions are continuously strengthened and provide better, more efficient and cost-effective support to the rest of the Organization. This agenda is closely linked to broader reforms within the United Nations system at both the country and global levels.
Regional indicators and targets • By the end of 2009, cost-effectiveness of operational support services (i.e., how much does it cost us today to deliver a certain function vs. the cost at the end of the period, everything else being equal, as a proxy measure of efficiency) would have been improved. • By the end of 2009, alignment of voluntary contributions with the Programme Budget (as a proxy measure of trust/effectiveness in the Organization) would have been improved. • By the end of 2009, effectiveness of managerial and administrative capacity at the country level (methodologies to measure this are being developed as part of the process of measuring WHO's overall effectiveness at country level) would have been improved. • By the end of 2009, application of result-based management framework including planning, monitoring and performance assessment would have been increased.
Regional issues and challenges 131.The work of WHO in the South-East Asia Region has increased steadily during the last three bienniums. In 2002-2003, total expenditure in the Region was less than $200 million. It is estimated that the budget for 2008 -2009 will be around $400 million. Furthermore, most of these increases have come from Voluntary Contributions (VC) while the Regular Budget (RB) has only increased slightly. This trend is expected to continue throughout the period of the MTSP. 132.There are two key implications of increased funding to SEARO. First, Member States and donors are demanding more accountability for the funds used by the Organization in terms of the results achieved. The Region has made progress in
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implementing the Results-based Management Framework (RBMF) stressing the development of plans that outline clear results and measuring the achievement of these results at the end of the biennium. The selection of results to be implemented is a key step in the RBMF. This requires close coordination and joint planning between WHO and country counterparts and health development partners to ensure that WHO selects results where its contribution is greatest. Furthermore, the country office and Regional Office plans should drive resource mobilization efforts of the Region, in order to ensure that there are adequate resources for the planned results. This is especially demanding in SEAR, which has no donor countries. 133.The second major implication is that the administration of these additional funds and activities must be more efficient. Doubling financial resources should not automatically mean that the number of staff will also double. Procedures must be streamlined to improve the efficiency of administrative operations. Since country offices spend over 75% of the WHO funds in the Region, this means that the operations of country offices must improve, as well as those of the Regional Office. 134.Beyond the increase in the funds managed by WHO in the Region, there are two other areas needing attention in the coming years. First, it is essential to improve information technology and communications between the different levels of the Organization: countries, the Regional Office and Headquarters. Countries should have the capacity to access resources at the Regional Office and Headquarters. Effective communication requires a significant investment in information technology (IT). Since the fixed costs of setting up this IT infrastructure are similar in all countries, small WHO offices find that the resource requirements are considerable. Nonetheless, without the investment, small offices will be cut off from the rest of the Organization and be at a disadvantage. 135.The last point is the issue of human resources in WHO. As a technical Organization, WHO must do more to ensure that its own staff are able to provide effective technical support to countries, not only for WHO work, but also to support non-WHO work of the Ministry of Health or health development partners. In addition, more efficient administrative and IT support require personnel who have the right skills and are motivated to improve their work efficiency.
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Strategic approaches of the Region 136.There are several key strategic approaches that SEARO will take to meet the above challenges. The first is joint planning to support the RBMF for determining the plans for countries and the Regional Office, as well as to get support from Headquarters. The basis for joint planning is the Country Cooperation Strategies (CCS) that outlines those results where WHO can make the greatest contribution to the health development of the country. Efforts will continue to be made to strengthen the quality of the CCS to ensure that they provide a greater focus for WHO’s country work, determine appropriate WHO country presence for the CCS period and get support from the other levels of the Organization. Biennial development of workplans will also emphasize joint planning between WHO and national counterparts, as well as with various levels of WHO. Furthermore, biennium budgets and workplans must be developed in line with the CCS. Finally, more will be done to strengthen the planning and management capacity in country offices to help in scaling-up key country programmes. 137.The second major strategy for SEARO is the delegation of authority to country offices. Since March 2004, SEARO has stressed delegation of authority as the key policy to improve the operations of WHO in the Region. With most funds budgeted in country workplans, there must be local authority to manage implementation. Country offices now have additional authority to issue contracts, procure supplies and equipment and hire international consultants. This does not mean that countries have to solve technical problems on their own. The Regional Office staff has increased its role in supporting country operations and programmes. In some cases, Regional Office staff have been sent to supplement country work as needed. 138.Accountability is a necessary complement to delegation of authority. Programme and administrative performance is likely to vary among country offices. It is essential to review country performance and administration regularly to identify strengths and weaknesses in country operations. In future, SEARO will increase its efforts in accountability and take appropriate action to improve overall performance of country offices. 139.With over 70% of the Region’s budget from Voluntary Contributions, special efforts are needed in the area of resource mobilization. More will be done to ensure a good match between the programme budget, workplans and the resources mobilized for WHO work to ensure adequate resources for results. Funds need to be raised at the country, regional and headquarters levels of WHO. In addition, WHO technical staff will help support resource mobilization efforts for
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countries initiatives such as the Global Fund, GAVI or other multilateral and bilateral health development partners (see additional section on partnerships in SO 15). 140.One major initiative to improve administrative support in the Region is the Global Management System. This is a new Organization-wide effort to develop and implement integrated computer software to modernize programme management and administration. Financial transactions will be recorded instantaneous at all levels of the Organization and there will be expanded tools to monitor programme implementation, available to programme managers. This will also improv e the transparency of WHO’s work and administration throughout the Organization. SEARO will take steps to ensure the smooth transition to this new system and use it to improve its work efficiency. The new system should help to redirect current resources to the more value-added enabling function tasks such as analysis and monitoring as well as further redirection to support enabling work in country offices where the vast majority of SEAR resources are managed. 141.Finally, the work of WHO depends on staff members who are well-trained, highly motivated, ethical in their conduct and are able to communicate well. More will be done to improve staff recruitment and to support and develop existing staff in technical, management and administrative areas.
PROPOSED REGIONAL PROGRAMME BUDGET FOR 2008-2009
PART – II
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142.The currently proposed Programme Budget (PB) for 2008-2009 is $4.263 billion for the entire Organization, including both the Regular Budget (RB) and Voluntary Contributions (VC). This is an increase of 29% over the $3.313 billion for PB 2006-2007. While $ 1 billion is expected from the RB, the remainder ($3.263 billion) will be from Voluntary Contributions, of which $600 million will be financed from “Core Voluntary Contributions”. These are flexible funds provided by donors. The remainder of the budget will be financed by “project-type Voluntary Contributions”, the traditional form of donor funding to WHO. 143.The proposed PB 2008-2009 for the South -East Asia Region ($496 million) is 39% more compared to PB 2006-2007 ($357.2 million). This increase is greater than the overall Organizational increase of 29%. This is mainly due to the application of the validation mechanism used in WHO’s Strategic Resource Allocation process. 144.The RB 2008-2009 for the Region will increase to $108.4 million which is 9.5% more than RB 2006-2007. Table 1 shows the increasing trend of SEAR budgets, where the increases in RB have been very small. However, Voluntary Contributions to the Region’s budget have increased substantially over recent bienniums. In PB 2002-2003, Voluntary Contributions were 54% of total expenditures. In PB 20042005, this increased to 69% of all expenditures. In PB 2006-2007, Voluntary Contributions are 72% of the budget, and for PB 2008-2009 it is proposed to be 78% of the budget. This dramatic increase in Voluntary Contributions would have a substantial impact on WHO’s support to Member States. It means that donor funding will cover 78% of the Region’s budget in proposed PB 2008-2009. Table 1: South-East Asia Region Programme Budget from 2002 -2003 to 2008-2009 (US$ in millions) Regular Budget 93.0 (48%) 91.2 (46%) 93.5 (33%) 93.2 (31%) 99.3 (28%) Voluntary Contribution s 100.5 (52%) 106.4 (54%) 191.5 (67%) 205.7 (69%) 258.0 (72%) 193.5 (100%) 197.6 (100%) 284.9 (100%) 298.9 (100%) 357.2 (100%) % Increase in Total Budget ----44% --25%
Biennium
Total Budget
2002 -2003 (budgetted) 2002 -2003 (expenditures) 2004 -2005 (budgetted) 2004 -2005 (expenditures) 2006 -2007 (budgetted)
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2008 -2009 budget)
(proposed
108.4 (22%)
387.6 (78%)
496.0 (100%)
39%
145.Table 2 presents the budget for the 16 Strategic Objectives for the Proposed PB 2008 -2009 for the South -East Asia Region. In order to see how the work of the Region will change in the new biennium, it is necessary to compare the proposed budget to previous biennium budgets. However, the new Medium-term Strategic Plan (MTSP) makes it difficult to make direct comparisons with the previous budgets that used Areas of Work. Therefore, the budgets of the main programme areas of the Region were compared to note the changes implied in the newly proposed budget for 2008-2009. Table 3 shows the programme area breakdowns in recent and proposed programme budgets. Budget trends are also shown in Figure 1 below depicting total budgets by pr ogramme areas. Figure 1: SEAR Total Budget by programme areas – PB 2004-2005 through 2008-2009
160
140
120
100 Million US$
PB 04-05 Exp 04-05 PB 06-07 Wkpl 06-07 PB 08-09
80
60
40
20
0 CDS IVD NMH FCH HSD SDE EHA
146.Looking at the trends reflected in the proposed budget for 2008-2009, several programme areas have substantial budget increases. The budget for
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maternal, child and adolescent health, nutrition and gender and women’s health programme areas (FCH) increases by 129% over PB 2006-2007. This reflects the priority given to increasing efforts to reach the targets of the MDGs, i.e., to improve maternal, child, infant and neonatal health. Emergency and humanitarian assistance has also doubled to $24.5 million in the 2008-2009 biennium, reflecting the concern of countries to improve preparedness and response during emergencies. 147.Other large increases are proposed for three other programme areas: a 80% increase for health and environment including food safety (SDE); a 65% increase for health systems development including human resources (HSD); and a 52% increase for non -communicable diseases and mental health (NMH). The communicable disease and surveil-lance area (CDS) is propos ed to grow by 38%, in line with the overall increase in the Region’s budget. This area, however, still accounts for almost a third of the proposed budget. 148.The only programme area where there is a decrease is immunization and vaccine development (IVD), where the budget is proposed to be reduced by 22%. This assumes that funds for polio will decrease in the coming biennium, although work in routine immunization will continue.
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Figure 2: SEAR Budget from VC funds by programme areas – PB 2004-2005 through 2008-2009 160
140
120
100 Million US$
80
PB 04-05 Exp. 04-05 PB 06-07
60
Wkpl. 06-07 PB 08-09
40
20
0 CDS IVD NMH FCH HSD SDE EHA
149.With 78% of the proposed budget from Voluntary Contributions in PB 20082009, there will be more dependency on funds contributed by donors to WHO. Figure 2 shows the recent experience with Voluntary Contributions and its funding levels proposed for the PB 2008-2009 in the Region. From Table 3 it can also be seen that 92% of Voluntary Contributions were spent in only three programme areas during 2004-2005 i.e., IVD, CDS and EHA. Other programme areas received only a small proportion of Voluntary Contributions. Resource mobilization efforts will have to be expanded considerably to ensure that Voluntary Contributions are raised for those programme areas which donors have not traditionally supported. 150.Because of the uncertainty of obtaining Voluntary Contributions, the proposed RB was adjusted to ensure funding for p riority areas. Originally, RB funds were estimated in a bottom-up exercise by country offices and the Regional Office. In Table 3, the column of RB for the proposed PB 2008-2009 shows three departments where RB funds have been increased to reflect these changes: NMH from $10.554 million to $12 million; FCH from $9.305 million to $15 million; and HSD from $26.431 to $27.5 million. These increases were possible mainly through
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a reduction in the GMG/SCC RB funds, assuming that Project Support Costs would be used from Voluntary Contributions to cover administrative and management costs. Consequently, the country offices and Regional Office will shift RB funds to these priority areas. Table 2: Estimated SEAR budget by Strategic Objectives (Regular Budget plus Voluntary Contributions) SO No. 1 2 3 Proposed budget in US$ MTSP Strategic Objectives RB To reduce the health, social and economic burden of communicable diseases. To combat HIV/AIDS, malaria and tuberculosis. Prevent and reduce disease, disability and premature death from chronic noncommunicable conditions, mental disorders, violence and injuries. 4 To reduce morbidity and mortality and improve health during key stages of life, including pregnancy, childbirth, the neonatal period, childhood and adolescence, while improving sexual and reproductive health and promoting active and healthy ageing for all individuals, using a life -course approach and addressing equity gaps. 5 R educe the health consequences of emergencies, disasters, crises and conflicts, and minimize their social and economic impact. 6 Promote health development, prevent and reduce risk factors for health conditions associated with tobacco, alcohol, drugs and other psychoactive substance use, unhealthy diets, physical inactivity and unsafe sex. 7 Address the underlying social and economic determinants of health through policies and programmes that enhance health equity and inte-grate pro-poor, gender-responsive, and human rights -based approaches. 8 Promote a healthier environment, intensify primary prevention and influence public policies in all sectors so as to address the root causes of environmental threats to health. 9 To improve nutrition, food safety and food security throughout the life -course and in support of public health and sustainable development. 3.9 10.2 14.1 4.2 9.8 14.0 4.2 8.8 13.0 3.5 21.0 24.5 11.8 39.3 51.1 7.8 10.2 18.0 8.7 7.8 (millions) VC 126.4 73.5 Total 135.1 81.3
1.5
3.4
4.9
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SO No. 10 11 12 13 14 15
Proposed budget in US$ MTSP Strategic Objectives RB To improve the organization, management and delivery of health services. To strengthen leadership, governance and the evidence base of health systems Ensure improved access, quality and use of medical products and technologies. To ensure an available, competent, responsive and productive health workforce in order to improve health outcomes. To extend social protection through fair, adequate and sustainable financing. Provide leadership, strengthen governance and foster partnership and collaboration in engagement with countries, to fulfil the mandate of WHO in advancing the global health agenda as articulated in the 11th General Programme of Work. 9.0 9.2 18.2 6.8 4.6 4.2 8.7 1.7 (millions) VC 8.2 11.5 8.5 8.4 5.3 Total 15.0 16.1 12.7 17.1 7.0
16
Develop and sustain WHO as a flexible, learning Organization, enabling it to carry out its man date more efficiently and effectively. Total 108.4 387.6 496.0 20.0 33.9 53.9
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Table 3: South-East Asia Regional budget for PB 2008-2009 compared to previous biennial budgets (in thousands of US$) PB 2004 -2005 Department and programme areas Budget Expenditures PB 2006-2007 Budget Workplans PB 2008 -2009 Proposed budget Increase from 20062007 budget
RB
VC
RB
VC
RB
VC
RB
VC
RB
VC
Total
CDS Communicab le Diseases and surveillance IVD Immunizatio n and vaccine development NMH – Noncommuni -cable diseases and mental health FCH Maternal, child and adolescent health, nutrition and gender and women’s health HSD - Health systems development 25,690 13,500 25,107 including human resources SDE - Health and the environment, including food safety EHA Emergency 1,388 6,000 1,409 48,298 1,728 9,198 2,283 9,260 3,459 21,041 24,500 124% 6,298 3,000 5,116 809 4,784 4,589 5,639 4,322 4,767 12,053 16,820 80% 2,772 23,971 20,125 22,965 21,238 27,500 (26,431)* 45,300 72,800 65% 8,144 8,500 7,842 3,816 13,148 14,075 9,010 11,826 10,757 4,000 9,372 1,785 11,701 8,636 10,516 10,221 12,000 (10,554)* 19,000 31,000 52% 1,757 65,000 2,041 83,765 1,513 82,174 1,948 99,197 1,513 63,787 65,300 -22% 14,138 82,000 14,414 56,406 15,367 93,846 16,362 78,043 14,943 136,157 151,100 38%
15,000 (9,305)*
47,380
62,380
129%
Proposed Regional Programme Budget for 2008-2009 and Strategic Objective Statements Page 72 and Humanitaria n Assistance GMG/SCC Direction, governing bodies, planning, management and administrativ e support to the country and regional offices TOTAL 93,454191,500 93,152 205,749 99,251 257,962 104,088266,410 108,400 387,600 496,000 38.9%
25,282
9,500 27,851
8,098 27,039
25,319 35,365
32,303
29,218 (36,950)*
42,882
72,100
38%
* Reflects unadjusted amounts for proposed Regular Budget (see text)