REGIONAL COMMITTEE
Provisional Agenda item 13
Fifty-sixth Session 10-13 September 2003
SEA/RC56/10 3 July 2003
DECLARATION ON HEALTH DEVELOPMENT IN THE SOUTH-EAST ASIA REGION IN THE 21ST CENTURY: REVIEW OF PROGRESS
CONTENTS Page
1.
INTRODUCTION................................................................................................................1
2.
DECLARATION ON HEALTH DEVELOPMENT IN THE SOUTH-EAST ASIA REGION ...........................................................................................1
3.
REVIEW OF PROGRESS.................................................................................................2
4.
PROGRESS REPORT ......................................................................................................3
5.
POINTS FOR CONSIDERATION......................................................................................6
1.
INTRODUCTION
The South-East Asia Region of WHO now consists of 11 Member States with the addition of Timor-Leste in May 2003. The Region bears a significant share of the global burden of diseases, partly due to the sheer size of its population (exceeding 1.5 billion) and also because it houses nearly half of the world’s poor. Nonetheless, the Region has made significant progress in health development with a considerable increase in life expectancy, and controlled most of the vaccine-preventable diseases through expanded immunization coverage and improved disease surveillance. Poliomyelitis and leprosy are on the verge of elimination. Health issues are being addressed more holistically through a life-span approach, particularly covering the health of children, adolescents, women and the elderly. Most countries have initiated reforms of their health systems in order to ensure universal access to quality health care. Such initiatives include the expansion of health infrastructure, introduction of alternative health care financing mechanisms, decentralized decision-making and improvement in governance, promoting private sector participation and increased involvement of the nongovernmental sector. The rapid liberalization of international trade has also affected health care development in the Region, especially in countries with weaker trade practices and legislation. While essential drugs and vaccines of reliable quality and efficacy are not accessible to a large proportion of the population, there is also the challenge of irrational and indiscriminate prescribing practices often leading to multi-drug resistance and adverse drug reactions. The increasing trend of tobacco and alcohol use, especially among the younger population, has led to adverse affects on overall morbidity and mortality. Mental disorders and substance abuse continue to be major problems accounting for nearly one-fourth of the burden from noncommunicable diseases.
2.
DECLARATION ON HEALTH DEVELOPMENT IN THE SOUTH-EAST ASIA REGION
The Ministers of Health of the countries of the Region, at their 15th annual meeting in Bangkok, Thailand, in August 1997, adopted a “Declaration on Health Development in the South-Asia Region in the 21st Century” (Regional Health Declaration). In this declaration, the Ministers noted the progress of health development in the Region since the adoption of the universal social goal of “Health for all” nearly two decades earlier. Envisaging the unfinished agenda and challenges that lay ahead and acknowledging the aspirations of the people, the Ministers affirmed their unstinted commitment and support to accelerating the progress in health development through enhancement of policy actions. The Ministers reaffirmed their faith in basic human rights and the ethical concepts of equity and social justice, particularly to ensure gender equity as fundamental to the sustainable pursuit of health for all. They recognized the close inter-relationship between poverty and ill-health and committed themselves to address the health needs of the poor as the highest priority. It was firmly believed that people have the right to health information and education in order to protect and promote their own health, and take control of the factors that determine their health. The Ministers identified the foremost challenges as follows: •
Closing the gaps and inequities in health in our societies;
SEA/RC56/10 Page 2 • • • •
Creating conditions that promote health and self-reliance; Ensuring basic health services to all, especially the poor, women and other vulnerable groups; Upholding and enforcing health ethics, and Placing health at the centre of development.
The Regional Health Declaration identified policy actions to meet the above challenges, especially in the areas relating to health sector reform and healthy public policy, with strategic directions to ensure universal access to quality health care, developing regional self-reliance and advocating intensively for health.
3.
REVIEW OF PROGRESS
The fiftieth session of the WHO Regional Committee for South-East Asia, in September 1997, noted the developments in the Region in implementing the strategies for health for all, and also endorsed the Regional Health Declaration (resolution SEA/RC50/R4). The Committee, inter alia, urged the Member Countries to take necessary steps to further adapt and integrate the policy guidance laid down in the Declaration. As a follow-up, WHO organized a regional consultative meeting in Colombo, Sri Lanka, in February 1998, to review and take necessary steps to implement the policy actions stipulated in the Regional Health Declaration. The meeting recommended that Member Countries ensure wide dissemination of the Declaration and strive to integrate principles and policy actions within national health development plans. Five years have passed since the adoption and integration of the principles and policy actions stipulated in the Regional Health Declaration into national health development plans and activities. During this time, Member Countries have taken concrete steps to implement the policy actions enunciated in the Declaration. Many countries have incorporated the policy guidance into medium- and long-term national health development plans and have achieved notable success in several areas. It is therefore appropriate to assess the progress and report back to the Ministers. The Regional Office published, in September 2002, the tenth volume in the series of Regional Health Bulletins, called “Health Situation in South-East Asia Region, 1998-2000”, which contains an analysis of the socioeconomic, political, demographic and epidemiological situation as well as the health systems development of countries of the Region between 1998 and 2000. It also provided an updated overview of health challenges for the near future. In addition, the Regional Office made use of the information already available in the Reports of the Regional Director on the Work of WHO, submitted to the annual sessions of the Regional Committee, the reports of the Regional Committee sessions, the reports of various consultative meetings, seminars, workshops and conferences, and other published documents on technical and policy matters, including World Health Reports, to prepare the review of the progress. Using these references, each technical unit in the Regional Office initially made an analysis of the progress under each area of the policy actions stipulated in the Declaration, taking into account the background, the progress made and the proposed action for future challenges and the unfinished agenda. New challenges in respective areas were identified and recommendations made for further action.
SEA/RC56/10 Page 3
The Health Secretaries, at their eighth meeting in Kathmandu, Nepal, in April 2003, reviewed the draft progress report and observed that much has been accomplished by Member Countries in meeting the challenges envisaged in the Regional Health Declaration. It was noted that more information needed to be reported on new challenges, such as emerging and re-emerging diseases, NCDs, drugs and food safety, health of the elderly, accidents and injuries. They also recognized the limitations of reporting using the existing multiple conflicting data, non-updated sources and the absence of disaggregated data necessary for proper planning and resource mobilization. The importance of disaggregated data to highlight inequities at the sub-national level was also recognized. It was suggested that the focus should be on the trends revealed by the data rather than on the individual data points. The issue of the need to strengthen the capacity of WHO to more effectively address the challenges highlighted in the Declaration was raised. It was clarified that WHO’s Country Focus Initiative, which will strengthen WHO’s presence in the countries and enhance the technical support provided through the WHO Country offices, is being implemented globally to address such concerns. The Health Secretaries endorsed the draft “Declaration on Health Development in the South-East Asia Region in the 21st century (Regional Health Declaration): Progress Review”, with a suggestion for further revision based on the above observations.
4.
PROGRESS REPORT
Incorporating the observations and comments of the Eighth Meeting of Health Secretaries, the Progress Report (SEA/RC56/Inf.3) is now submitted to the Regional Committee. The following is a summary of the Progress Report which provides a review of implementation of the policy actions stipulated in the Regional Health Declaration and what remains to be done. The Regional Health Declaration stipulated policy actions for initiating health sector reforms and development of healthy public policies, including, among others, the following: •
Ensure universal access to quality health care through health sector reforms by strengthening infrastructure and equitable financing, decentralizing decisionmaking and governance, promoting private sector participation and improving emergency preparedness and response. Develop regional self-reliance so as to increase the capacity of each country and of the Region to be more creative and innovative in developing health and medical sciences, medical technology and health care services, through regional solidarity and intercountry cooperation. Advocate intensively for health to underscore that health is central to development and that sustained development is important for health and to ensure that health placed high on the political agenda of governments and on the social agenda of people.
•
•
The Region has made significant progress in health development with a steady increase in life expectancy. This trend is also reflected in the percentage change of the average life expectancy over the same period – 72.4 per cent in Bhutan, 61.8 per cent in India, 73.6 per cent in Indonesia, 65.8 per cent in Maldives and 62.9 per cent in Myanmar.
SEA/RC56/10 Page 4
While old scourges like leprosy, kala-azar, malaria and tuberculosis are still rampant, vaccine-preventable diseases like poliomyelitis, measles, diphtheria, tetanus and hepatitis B continue to be major killers and cripplers. Emerging diseases like HIV/AIDS and dengue/DHF continue to affect the vast majority of people, especially the poor and underprivileged, thus tending to widen the health gaps. In order to ensure basic health services to all, especially the poor, women and other vulnerable groups, countries of the Region have strengthened community action for health. They have also implemented targeted programmes such as “making pregnancy safer”, and conducted special campaigns like NIDs in order to reach the difficult-to-reach groups. The lack of financial and human resources have hampered these efforts. With improved and sustained immunization coverage and improved disease surveillance, many vaccinepreventable diseases have been controlled. Poliomyelitis, neonatal tetanus and measles are on the verge of elimination. Leprosy elimination is within reach. All Member Countries have initiated health systems reforms in order to ensure universal access to quality health care. Such initiatives include expansion of the health infrastructure, introduction of alternative health care financing schemes, decentralized decision-making and improvement in governance, promoting private sector participation and increased involvement of the nongovernmental sector. The rapid liberalization of international trade has affected health systems development, especially in countries with weak trade practices and legislation. While a large proportion of the population does not have access to quality essential drugs and vaccines, there is an increasing trend of irrational and indiscriminate prescribing practices, often leading to multidrug resistance and adverse drug reactions. The escalating trend of tobacco and alcohol use, especially among the younger population, has had an adverse affect on overall morbidity and mortality. Mental disorders and substance abuse, diabetes and cardiovascular diseases continue to be major problems accounting for nearly one-fourth of the burden of noncommunicable diseases. Countries have made commendable efforts towards creating conditions that promote health and self-reliance. They have undertaken health sector reforms, including health care financing reforms to generate more resources for health. Steps have also been taken to monitor environmental and other risks to health and alleviate them. However, due to inadequate health actions beyond the traditional bounds of health service provision, the prevalence and incidence of diseases caused by degradation of the environment, inadequate water supply and waste management, unrestrained developmental efforts, including deforestation and other ecological changes, continue to pose serious challenges. In the area of health ethics, countries of the Region have focused attention on ethics in health research for which guidelines have been developed. They have also strengthened their capacity for managing health research. However, rapid developments in the field of genomics continue to pose new ethical questions. Countries have made concerted efforts to broaden the involvement of other sectors in health policy planning and management, particularly through high-level intersectoral committees. However, inadequate advocacy for enhancing the level of political support and commitment has limited the efforts to place health at the centre of development. Health continues to be under-funded, with most countries spending less than 5 per cent of their GDP on health.
SEA/RC56/10 Page 5
The roles played by other sectors in health development continue to be minimal. The future outlook, however, seems brighter following the publication of the report of the Commission on Macroeconomics and Health, furnishing the evidence base needed for advocacy. Epidemiological surveillance systems and the response to epidemics, especially new and emerging diseases in the countries of the Region, are at varying stages of development. An effective disease surveillance system is necessary for early detection of any new disease or any threatening disease outbreak. Countries need to quickly initiate effective responses to such impending epidemics. In order to have effective epidemiological surveillance systems, countries need to strengthen their health infrastructure, including the public health laboratory services. Most countries have updated the lists of notifiable diseases and mechanisms for their regular reporting from the peripheral level to the central headquarters which have to provide appropriate feedback. With advances in telecommunications, countries can establish early warning and rapid responses. They, however, also need to strengthen their policy actions to combat ill-health and to develop healthy societies. The main focus should be on: (a) reducing excess mortality, morbidity and disability by addressing the specific priority communicable diseases (like malaria, tuberculosis, HIV/AIDS, dengue and DHF, vaccine preventable diseases, leprosy, filariasis and other locally-endemic diseases) which have a major impact on socioeconomic development and also a disproportionate impact on the lives of the vulnerable population, especially the poor, women and young children; (b) enhancing efforts, both within and outside the health sector, for the prevention and control of noncommunicable diseases, such as diabetes, CVD, cancer, iodine deficiency disorders (IDDs), injuries and accidents; and on oral health. (c) expanding the coverage of health care with the ultimate aim of universal coverage, through an appropriate mix of three inter-related health care financing functions: i.e. investing more revenue for health resources; increasing the pooling of health and financial risks; and promoting strategic purchasing, correcting the imbalance and reducing the irrelevance in training, recruitment, deployment and management of human resources for health; (d) reducing risk factors to human health by initiating and advocating action to promote and strengthen healthy environments within the framework of sustainable development; enhancing the provision of adequate and safe water supply and sanitation services, promoting health actions in order to protect people from biological, chemical and physical hazards in various human environments, facilitating self-care, community empowerment and action for promoting health through adoption of healthy life styles; and creating an environment that would enable the health sector to raise the awareness of the community on health risks through public awareness campaigns (including awareness days/weeks); (e) creating an institutional environment by articulating consistent and evidence-based policy and advocacy positions, strengthening the governance of the health infrastructure within the framework of decentralized planning and decision-making, enhancing partnerships with external and internal development partners to effectively move the national health development agenda further, and improving the capacity and providing appropriate incentives for generating evidence-based
SEA/RC56/10 Page 6
information through effective epidemiological surveillance and health information systems. The role of WHO is critical to health development in the Region. It has both the mandate and the commitment to collaborate with the countries in addressing the problems that confront them individually and collectively. A critical role for WHO is to ensure that the nature, principles and moral imperatives of "health for all" are understood. The Organization should also help guide the formulation and trials of different options for implementation throughout the Region.
5.
POINTS FOR CONSIDERATION
The Progress Report is now submitted to the 56th session of the Regional Committee for its consideration, noting and guidance. The report has also been submitted to the 21st meeting of the Health Ministers for their guidance. Their observations will be reported to this session of the Regional Committee by the Regional Director while introducing this Agenda item.
REGIONAL COMMITTEE
Provisional Agenda item 13
Fifty-sixth Session 10-13 September 2003
SEA/RC56/Inf 3 9 July 2003
DECLARATION ON HEALTH DEVELOPMENT IN THE SOUTH-EAST ASIA REGION IN THE 21ST CENTURY: REVIEW OF PROGRESS (PROGRESS REPORT)
PREFACE While the determinants of health in Member Countries of WHO's South-East Asia Region is varied and complex, there are several commonalities in terms of the unfinished agenda and challenges. The Ministers of Health of the Member Countries of the Region, after reviewing health development in the context of implementing national, regional and global health-for-all strategies, at their 15th Meeting at Bangkok, Thailand, in August 1997, adopted a “Declaration on Health Development in the South-East Asia Region in the 21st century” (the Regional Health Declaration). At its 50th session, held at Thimphu, Bhutan, in September 1997, the Regional Committee endorsed the policy actions of the Regional Health Declaration. The Regional Committee, vide its resolution, SEA/RC50/R4, urged Member States to take necessary steps to further adapt and integrate the policy guidelines laid down in the Declaration. Since its adoption by the Ministers, all countries have taken concrete steps to implement the policy actions enunciated in the Declaration. Many have incorporated these policy actions into their medium and long-term health development plans. Most have achieved notable successes in several areas. This report provides a review of the progress made by countries in addressing the challenges within the framework of the policy actions stipulated in the Declaration and identifies the areas that need further attention. Incorporating observations and comments made at the 8th meeting of Health Secretaries, held at Kathmandu, Nepal, in April 2003, this report is now submitted to the 21st Meeting of the Ministers of Health for their information and guidance. The report will also be submitted to the 56th session of the WHO Regional Committee to be held at SEARO, New Delhi, in 10-13 September 2003, for its consideration and further guidance.
CONTENTS Page EXECUTIVE SUMMARY ............................................................................................................i 1. 2. INTRODUCTION ...............................................................................................................1 PROGRESS OF HEALTH DEVELOPMENT ....................................................................2 Challenge 1: Closing the gaps and inequities in health..............................................2 Demographic and Economic Changes.......................................................................3 Double Burden of Diseases ........................................................................................4 Malaria.........................................................................................................................5 Tuberculosis................................................................................................................6 Global Fund to Fight AIDS, TB and Malaria ...............................................................7 HIV/AIDS .....................................................................................................................7 Diseases Prevented Through Immunization ..............................................................9 Leprosy......................................................................................................................13 Other Communicable Diseases ................................................................................14 Noncommunicable Diseases ....................................................................................15 Nutritional Disorders .................................................................................................17 Multi-disease Surveillance........................................................................................18 Challenge 2: Creating conditions that promote health and self-reliance ...............19 Health and Environment ...........................................................................................19 Food Safety ...............................................................................................................23 Health Care Waste Management .............................................................................23 Emergency Preparedness and Response ...............................................................24 Challenge 3: Ensuring basic health care to all...........................................................25 Reduction of Child and Maternal Mortality................................................................26 Women's Health........................................................................................................28 Human Resources for Health ...................................................................................29 Essential Medicines: Access, Quality and Rational Use..........................................30 Promotion of traditional medicine .......................................................................32 Blood Safety and Clinical Technology ......................................................................33 Health of the Elderly..................................................................................................34 Enhancing Community Actions for Health and Partnerships ...................................35 Challenge 4: Upholding and enforcing health ethics ................................................36 Health Research Management .................................................................................36 Upholding Health Ethics ...........................................................................................37
Challenge 5: Placing health at the centre of development .......................................38 Health Care Financing Reforms ...............................................................................39 Investment in Health .................................................................................................41 3. NEW CHALLENGES.......................................................................................................42 Globalization and Health ..................................................................................................42 Response to Emerging Disease Outbreaks ....................................................................43 Achieving the UN Millennium Development Goals ..........................................................44 Tobacco Control ...............................................................................................................45 Mental Health and Substance Abuse...............................................................................47 Injury and Violence Prevention.........................................................................................48 4. 5. POLICY ACTIONS ..........................................................................................................49 ROLE OF WHO ...............................................................................................................51
Suggested Reading..................................................................................................................52
EXECUTIVE SUMMARY WHO’s South-East Asia Region now consists of 11 Member Countries, with the addition of Timor-Leste in May 2003. While the determinants of health in the countries of the Region are varied and complex, including different population growth rates, economic development, cultural practices, environmental factors, and social settings, there are several commonalities in terms of the unfinished agenda and challenges. The Ministers of Health of the Member Countries of the Region, after reviewing health development in the context of implementing national, regional and global health-for-all strategies, at their 15th Meeting at Bangkok, Thailand, in August 1997, adopted a “Declaration on Health Development in the South-East Asia Region in the 21st Century” (Regional Health Declaration). The Ministers had identified the following five foremost challenges: • • • • •
Closing the gaps and inequities in health in our societies, Creating conditions that promote health and self-reliance, Ensuring basic health services to all, especially the poor, women and other vulnerable groups, Upholding and enforcing health ethics, and Placing health at the centre of development.
The Regional Health Declaration stipulated policy actions for initiating health sector reforms and development of healthy public policies, including, among others, the following: •
Ensure universal access to quality health care through health sector reforms through strengthening infrastructure and equitable financing, decentralizing decision-making and governance, promoting private sector participation and improving emergency preparedness and response. Develop regional self-reliance so as to increase the capacity of each country and of the Region to be more creative and innovative in developing health and medical sciences, medical technology and health care services, through regional solidarity and intercountry cooperation. Advocate intensively for health to underscore that health is central to development and that sustained development is important for health and to ensure health to be placed high on the political agenda of governments and on the social agenda of people.
•
•
The Region has made significant progress in health development with a steady increase in life expectancy. This trend is also reflected in the Region with the percentage change of average life expectancy over the same period – 72.4% in Bhutan, 61.8% in India, 73.6% in Indonesia, 65.8% in Maldives and 62.9% in Myanmar. While old scourges like leprosy, kala-azar, malaria, tuberculosis are still rampant, vaccine-preventable diseases like poliomyelitis, measles, diphtheria, tetanus and hepatitis B remain major killers and cripplers. Emerging diseases like HIV/AIDS and dengue/DHF continue to affect the vast majority of people, especially the poor and underprivileged, thus tending to widen the health gaps.
SEA/RC56/Inf 3 Page ii
In order to ensure basic health services to all, especially the poor, women and other vulnerable groups, countries of the Region have strengthened community action for health. They have also implemented targeted programmes such as ‘making pregnancy safer’, and conducted special campaigns like NIDs in order to reach the difficult-to-reach groups. Lack of financial and human resources have hampered these efforts. Due to improved and sustained coverage of expanded immunization and improved disease surveillance, many vaccine-preventable diseases are under control. Poliomyelitis, neonatal tetanus and measles are on the verge of elimination. Leprosy elimination is within reach. All Member Countries have initiated health systems reforms in order to ensure universal access to quality health care. Such initiatives include expansion of the health infrastructure, introduction of alternative health care financing schemes, decentralized decision-making and improvement in governance, promoting private sector participation and increased involvement of the nongovernmental sector. The rapid liberalization of international trade has affected health systems development, especially in countries with weak trade practices and legislation. While a large proportion of the population does not have access to quality essential drugs and vaccines, there is an increasing trend of irrational and indiscriminate prescribing practices, often leading to multidrug resistance and adverse drug reactions. The escalating trend of tobacco and alcohol use, especially among the younger population, has had an adverse affect on overall morbidity and mortality. Mental disorders and substance abuse, diabetes and cardiovascular diseases continue to be major problems accounting for nearly one-fourth of the burden from noncommunicable diseases. Countries have made commendable efforts towards creating conditions that promote health and self-reliance. They have undertaken health sector reforms, including health care financing reforms to generate more resources for health. They have taken steps to monitor environmental and other risks to health and alleviate them. However, due to inadequate health actions beyond the traditional bounds of health service provision, the prevalence and incidence of diseases caused by degradation of the environment, improper water supply and waste management, unrestrained development efforts, including deforestation and other ecological changes, continue to pose serious challenges. In the area of health ethics, countries of the Region have focused their attention on ethics in health research, for which guidelines have been developed. They have also strengthened their capacity for managing health research. However, rapid developments in the field of genomics continue to pose new ethical questions. Countries have made concerted efforts to broaden the involvement of other sectors in health policy planning and management, particularly through high-level intersectoral committees. However, inadequate advocacy for enhancing the level of political support and commitment has limited efforts to place health at the centre of development. Health continues to be under-funded, with most countries spending less than 5% of their GDP on health. The roles played by other sectors in health development continue to be minimal. The future outlook however looks brighter following the publication of the report of the Commission on Macroeconomics and Health, furnishing the evidence base needed for advocacy. Epidemiological surveillance systems and the response to epidemics, especially new and emerging diseases, in the countries of the Region are at varying stages of development. An effective disease surveillance system is necessary for early detection of any new disease
SEA/RC56/Inf 3 Page iii
or any threatening disease outbreaks. Countries need to quickly initiate effective responses to such impending epidemics. In order to have effective epidemiological surveillance systems, countries need to strengthen their health infrastructure, including the public health laboratory services. Most countries have updated the lists of notifiable diseases and mechanisms for their regular reporting from the peripheral level to the central headquarters which have to provide appropriate feedback. With the advancement of telecommunications, countries are now able to establish early warning and rapid responses. The countries also need to strengthen their policy actions to combat ill-health and to develop healthy societies. The main focus should be on: (a) reducing excess mortality, morbidity and disability by addressing the specific priority communicable diseases (like malaria, tuberculosis, HIV/AIDS, dengue and DHF, vaccine preventable diseases, leprosy, filariasis and other locally-endemic diseases) which have a major impact on socioeconomic development and also a disproportionate impact on the lives of the vulnerable population, especially the poor, women and young children; (b) enhancing efforts, both within and outside the health sector, for prevention and control of noncommunicable diseases, such as diabetes, CVD, oral health, cancer, iodine deficiency disorders (IDDs), injuries and accidents; (c) expanding the coverage of health care with the ultimate aim of universal coverage, through an appropriate mix of three inter-related health care financing functions: i.e. investing more revenue for health resources; increasing the pooling of health and financial risks; and promoting strategic purchasing, correcting the imbalance and reducing the irrelevance in training, recruitment, deployment and management of human resources for health; (d) reducing the risk factors to human health, through initiating and advocating action to promote and strengthen healthy environments within the framework of sustainable development; enhancing the provision of adequate and safe water supply and sanitation services, promoting health actions in order to protect people from biological, chemical and physical hazards in various human environments, facilitating self-care, community empowerment and action for promoting health through adoption of healthy life styles; and creating an environment that would enable the health sector to raise the awareness of the community on health risks through public awareness campaigns (including awareness days/weeks); (e) creating an institutional environment, by articulating consistent and evidencebased policy and advocacy positions, strengthening the governance of the health infrastructure within the framework of decentralized planning and decision-making, enhancing partnerships with external and internal development partners to effectively move the national health development agenda further, and improving the capacity and providing appropriate incentives for generating evidence-based information through effective epidemiological surveillance and health information systems. The role of WHO is critical to health development in the Region. It has both the mandate and the commitment to collaborate with the countries in addressing the problems that confront them individually and collectively. A critical role for WHO is to ensure that the nature, principles and moral imperatives of "health-for-all" are understood. The Organization should also help guide the formulation and trials of different options for implementation throughout the Region.
1.
INTRODUCTION
The South-East Asia Region of the World Health Organization now consists of 11 Member Countries , with the addition of Timor-Leste in May 2003. While the determinants of health in the countries of the Region are varied and complex, including different population growth rates, economic development, cultural practices, environmental factors, and social settings, there are several commonalities in terms of the unfinished agenda and challenges. The Region bears a significant share of the global burden of diseases, partly due to the sheer size of its population, exceeding 1.5 billion, and the low social and economic conditions of a large proportion of the population. The Ministers of Health of the Region, at their 15th Meeting at Bangkok, Thailand, in August 1997, reviewed the progress in implementing national and regional strategies for health-for-all by the year 2000 (HFA 2000), and identified future challenges as well as unfinished agenda anticipated for the 21st century. The Ministers also noted the gaps in health development in the Region, and affirmed their unstinted commitment and support for accelerating health development through enhancement of policy actions. They identified the following five foremost challenges. • • • • •
Closing the gaps and inequities in health in our societies, Creating conditions that promote health and self-reliance, Ensuring basic health services to all, especially the poor, women and vulnerable groups, Upholding and enforcing health ethics, and Placing health at the centre of development.
After a thorough debate, the Ministers adopted a “Declaration on Health Development in the South-Asia Region in the 21st Century” (Regional Health Declaration). The Regional Health Declaration stipulated policy actions in the areas relating to health sector reform and healthy public policy, including, among others, the following: •
Ensure universal access to quality health care through health sector reforms, responding to the broader concept of health and contemporary core values, to ensure the new role of government in relation to health, which emphasizes policy formulation, facilitation, regulation, and coordination functions, in addition to the traditional provider role. This includes strengthening the infrastructure, equitable financing, decentralized decision-making and governance, promoting private sector participation and improving emergency preparedness and response. Develop regional self-reliance so as to increase the capacity of each country and of the Region to be more creative and innovative in developing health and medical sciences, medical technology and health care services. Such regional self-reliance calls for regional solidarity and intercountry cooperation. Enhanced support for research and development in the Region, with particular attention to quality assurance, affordability, and accessibility was stressed. Advocate intensively for health to underscore that health is central to development and that sustained development is important for health and to ensure that health is placed high on the political agenda of governments and on the social agenda of people.
•
•
SEA/RC56/Inf 3 Page 2
After reviewing health development in the Region in the context of implementing healthfor-all strategies, including the findings and recommendations of the Regional Health Declaration, the 50th session of the Regional Committee, held at Thimphu, Bhutan in September 1997, endorsed the policy actions and urged Member Countries to take necessary steps to further adapt and integrate the policy guidelines laid down in the Declaration. As a follow-up, WHO organized a regional consultative meeting in Colombo, Sri Lanka, in February 1998, to review and suggest necessary steps in implementing the policy actions stipulated in the Regional Health Declaration. The meeting recommended that Member Countries should ensure wider dissemination, together with national plans of action, and to strive to integrate principles and policy actions within national health development plans. Following the Colombo meeting, the progress of health development in the countries in implementing the policy actions of the Declaration was regularly followed up by the Health Ministers’ Forum. In addition, the Regional Office followed up on the progress of health development in the Region and made regular reports on the progress in general as well as specific technical areas. The Regional Office and Member Countries periodically published various health situation progress reports on specific disease conditions. The Regional Office also regularly issued reports on significant health developments. One such report entitled, “Health Situation in the South-East Asia Region, 1998-2000”, issued in 2002, shed ample light on the progress made by the countries in adopting and integrating the principles and policy actions of the Regional Health Declaration into their national health development plans and in taking concrete steps to implement them. Considering that over five years have elapsed since the Declaration was adopted, it is deemed appropriate to review the progress and to report to the Health Ministers. This paper provides a review of the progress made by countries in addressing the challenges within the framework of the policy actions stipulated in the Declaration and identifies the areas that need further attention. It also highlights future challenges facing Member Countries. Based upon the review of the progress, this document suggests priority policy actions for the countries in accelerating health development. Finally, it recommends an enhanced role of WHO in support of health development in the Member Countries.
2.
PROGRESS OF HEALTH DEVELOPMENT
Since the adoption of the Ministerial Declaration, Member Countries of the Region have incorporated the health policy actions into their national health development policies and plans within the stipulated policy framework. They have addressed the five foremost policy challenges identified in the Declaration. Despite significant progress, some challenges persist as an unfinished agenda while new ones have emerged. The following sections describe the progress under each of the five policy challenges, highlight significant achievements and identify the unfinished agenda.
Challenge 1: Closing the gaps and inequities in health Health development in the Region has improved in many ways, particularly in terms of reducing disease morbidity and increasing life expectancy. Despite this achievement, inequities in health status continue to exist within and amongst countries, the main reason being the disparities in the determinants of health and access to health care.
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Demographic and Economic Changes Since the late 1990s, the Region has witnessed demographic transition at varying paces. The total population of the Region continued to grow rapidly crossing 1.6 billion by 2002. Six countries in the world accounted for 50% of the annual increase, of which three (India, Bangladesh and Indonesia) are from the Region. India’s population reached 1 billion in 2000. Indonesia and Bangladesh are the next largest populated countries with 238 million and 168 million respectively. According to UN, the total population of the Region will reach 1.75 billion by 2010, and 2.06 billion in 2025. With the continuing increase in life expectancy and the decline in fertility, the age structures in most countries will change reflecting an increase in the productive population and the elderly. Countries need to adopt appropriate education and employment policies to exploit the booming productive population, while absorbing the increasing burden of older age groups. Six countries – DPR Korea, India, Indonesia, Maldives, Sri Lanka and Thailand - had already achieved life expectancy at birth over 60 years by 2000. They expect to attain the level beyond 70 years by 2025. The remaining countries would achieve life expectancy higher than 60 years by that time. Three mega countries - Bangladesh, India and Indonesia - will have 8-12% of their population above 60 years by 2025. This demographic transition will lead to epidemiological changes with increasing incidence of degenerative, vascular, chronic diseases and neoplasm. The latter half of the twentieth century also witnessed an unprecedented, rapid growth in urban population, due to rapid migration of people from rural to urban areas. The largest urban population was in DPR Korea (60.2%) and the lowest in Bhutan (7.1%), with an average of 29.6% for the Region. There were no mega cities in the Region in 1975. But by 2000, the number had reached five (Mumbai, Kolkata and New Delhi in India, Dhaka in Bangladesh and Jakarta in Indonesia). This number will increase to seven in 2015 with the addition of two cities (Hyderabad in India and Bangkok in Thailand). This rapid population growth in urban areas is mainly due to the people’s perception that there are increased opportunities for better life and improved income with stable and lucrative employment. The rapid urbanization has also brought in its wake major health problems due to inadequate provision of safe water, sanitation, electricity, garbage disposal and health care, which has put an added burden on the already burdened municipalities and local governments. Another phenomenon is the temporary and permanent external migration of people from one country to another. These external migrants usually have minimal skills to venture out in search of employment for higher income. Some countries even promote external migration (mostly of a temporary nature) to have an increase in foreign exchange earning through repatriation by these temporary migrants. The rapid changes in the political, social, economic, environmental, technological, demographic and epidemiological situations taking place in the Region and elsewhere have posed unprecedented health challenges. The financial turmoil, during the mid- and late nineties, created chaos in the economies of several countries of the Region, particularly Indonesia and Thailand, where millions of people lost their jobs. Most countries have continued to maintain steady GDP growth rates, per capita around 5-8% since the late 1990s. While there is an increase in overall economic growth, the gap between the ‘haves’ and ‘have-nots’ is widening not only among countries, but also between areas within the countries. While five countries in the Region are categorised as leastdeveloped (LDC), the rest are in the lower middle-income category. Two countries (DPR Korea and Timor-Leste) have not yet been fitted into any category. There is wide variation in
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the rate of improvement in Human Development Indexes (HDI) by countries of the Region (Figure 1). The Region still harbours nearly half of the world’s poor who have limited capacity to cope with health and financial risks. Figure 1: Trends of development as per HDI values, 1975-2000
1.0
HDI value
0.9
1975 Year
1980
1985
1990
1995
2000
0.8
0.7 Medium HDI
0.6
0.5
0.4 Low HDI 0.3
0.2 Bangladesh Source :
Nepal
Bhutan
Myanmar
India
Indonesia
Sri Lanka
Maldives
Thailand
UNDP, Human Development Report 2002
Double Burden of Diseases The Region presently faces the double burden of diseases, posing serious challenges to the health systems and calling for considerable changes in the allocation of already scarce resources. There is still a significant gap in the data on the burden of diseases that hinders the assessment of a country’s priorities for public health action. Figure 2: Healthy life expectancy (HALE), expectancy of disability (DE), and life expectancy (LE) at birth, by WHO Region, 2000 80 Global LE = 65 years
DE HALE 60 +
LE 8.6 9.2 61.9 62.4 11.2 65.0 9.0 71.6 71. 9 9.0 73.0 9.8
Years lost due to disability
Life expectancy (years)
8.5 40
Global HALE = 56 years
47.3 63.0 52.7 20 38.8 51.2 56.0 62.9 63.2
0 Africa South-East Asia Eastern Mediterranean WORLD Western Pacific Europe Americas
Source : WHO Geneva,
EIP Cluster
World Health Reports, since 1999, provided a summary measure for population health called “Disability-adjusted Life Expectancy” or “DALE”. It was later changed to “Healthadjusted Life Expectancy” or “HALE” in order to reflect the inclusion of all states of health.
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“HALE” is the expected years of life at birth, with the adjustment of time spent in poor health. It is easily understood as "the number of years in full health that a newborn can expect to live, based on current rates of ill-health and mortality." The global average of “HALE” at birth was 56 years [9 years less than the total life expectancy at birth] in 1999. The Global HALE for women was 57.8 years [2.0 years higher than that for men]. In the Region, the overall life expectancy was 61.9 years while HALE was 52.7 years (Figure 2). According to WHO estimates, the Region accounted for nearly 30% of the global disability-adjusted life years (DALYs) losses (Note: One DALY loss is one year lost of "healthy" life). The leading causes of DALYs were Group II conditions (which included cardiovascular diseases and neuropsychiatric diseases) accounting for 46.1% of the global burden. Group I conditions (infectious diseases) which accounted for 41.5% of the total global DALYs, while Group III (injuries) accounted for the balance 12.4% of the global DALYs. Communicable diseases like malaria, tuberculosis, HIV/AIDS, and many vaccinepreventable diseases are highly prevalent and play a significant role in slowing down the health development in the Region. Respiratory infections and diarrhoeal diseases continue to be major causes of morbidity and mortality among young children and the elderly. Successful implementation of immunization and diarrhoeal diseases control programmes in the recent past in all countries has been instrumental in dramatically reducing the incidence of these childhood diseases. While infectious and parasitic diseases may still be the leading cause of DALYs, noncommunicable conditions like cardiovascular diseases and neuropsychiatric disorders are rapidly becoming important causes of premature death and disability in the Region. Of the individual conditions, cardiovascular diseases are the biggest crippler and killer (28.9%) in the Region. Infectious and parasitic diseases account for 20.3%, respiratory infections 9.6%, malignant neoplasms 7.8%, and perinatal conditions for 7.1%. The changes in life styles which have resulted in sedentary habits, poor physical activity, unhealthy diets and smoking have all contributed to a high prevalence of cardiovascular diseases in the Region. Malaria Malaria continues to be a major killer and crippler. An estimated 1.2 billion people or 85% of the total population of the Region are living in malaria-risk areas, and a few million people suffer malaria every year with many not able to get full access to essential care. The predominant malaria parasitic infection is P. vivax followed by P. falciparum , the latter accounting for a major proportion of all malaria-related deaths. Over the decades, malaria prevalence has stabilized around 3 million reported cases annually, although estimated cases fluctuate around 20 million. All countries in the Region except Maldives have indigenous malaria transmission. After many years without malaria, DPR Korea has reported P. vivax outbreaks every year since 1999. While the malaria situation in Bangladesh, India, Thailand and Myanmar became better, the situation in certain parts of Bhutan, DPR Korea, Indonesia (Java), Nepal, Sri Lanka started deteriorating. In 1999, India accounted for 77% of the incidence of malaria. In Myanmar, 64% of the deaths reported were due to severe malaria in 2000. P. falciparum resistance to anti-malarial drugs has slowly but steadily progressed and now affects all countries of the Region. The problem is becoming acute with the progression from mono-to multi-drug resistance. The appearance of chloroquine resistance in P. vivax in India, Indonesia and Myanmar poses a serious challenge. An estimated 400 million people are at risk of contracting drug-resistant malaria.
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Bangladesh, India, Indonesia, Nepal, Myanmar, Sri Lanka, and Thailand have revised their national strategies based on WHO’s Global Roll Back Malaria (RBM) initiative. Twentyfour pilot districts have been selected covering a population of 15.57 million. Roll Back Malaria offers a great opportunity for joint action at regional and country levels, and in addressing cross-border challenges. The RBM-Mekong Initiative reflects a range of partnerships in which the governments of the six Mekong countries, i.e. Myanmar, Thailand, Cambodia, PDR Laos, Viet Nam, and China (Yunnan Province), are committed to work jointly to achieve the goal to halve the global malaria burden by 2010. Tuberculosis Tuberculosis (TB) is another priority disease, being the biggest killer of young adults, the age at which they are economically most productive. The Region carries 38 per cent of the global burden of TB, with three million new cases and nearly three-quarters of a million deaths occurring every year. Rising trends in HIV infection in some countries, together with the emergence of multidrug resistant strains of tuberculosis, pose additional threats . Directly Observed Treatment Short course (DOTS) strategy now extends to over 66 per cent of the Region’s population. Over 700 000 patients are being put on DOTS every year with a success rate of around 80 per cent under programmatic conditions in areas where the strategy has been applied. The quality of diagnosis has been good; however, the number detected is still low - fewer than 40 per cent of estimated cases. It is necessary to further expand and intensify activities in order to increase case detection and ensure that increasing numbers of those suffering from TB are successfully treated and cured. Epidemiological issues relating to this are being analysed. Considerable progress has been made with DOTS strategy expansion during this period by all countries (Figure 3). Among high endemic countries, Bangladesh covered virtually the entire country with DOTS treatment. The case detection has been intensified. India expanded the National TB Control Programme rapidly incorporating DOTS strategy, covering 460 million people by December 2002. Currently, the National TB control programme in India is the second largest in the world after China. India plans to cover 80 per cent of the population by 2004. Indonesia is rapidly expanding DOTS coverage. Myanmar implemented DOTS in 85 per cent of the districts. With WHO’s support and the Global Drug Facility (GDF), it would cover the entire country by end-2003. Thailand has achieved 86 per cent coverage. Its TB control programme has focused its attention on the joint TB/HIV-AIDS activities and on strengthening key components of DOTS during the ongoing health sector reform. Figure 3: DOTS implementation in the SEA Region, 1997-2002 70 66
60
56
50
45
40
30
27
20 10 10
18
0 1 1997 Source:HIV-AIDS/TB/SEARO
2 1998
3 1999
4 2000
5 2001
6 2002
Source: HIV-AIDS/TB/SEARO
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Among the low burden countries, Bhutan achieved full population coverage, improving the delivery of ambulatory DOTS in the difficult terrain and ensuring accurate reporting. DPR Korea has rapidly expanded DOTS coverage to around 66 per cent. Maldives maintained the DOTS coverage of over 85% since 1995. Nepal achieved a similar level in July 2002. Sri Lanka achieved 95% coverage with DOTS in mid-2002 and a fully ambulatory DOTS programme was introduced in 13 districts. With improved cure rates, it is expected to achieve the global targets by 2004. Continuing constraints for national TB programmes are: lack of adequate technical and managerial expertise to sustain and improve the core functions of DOTS; transitional difficulties in the implementation of DOTS programmes during the process of health sector reform, including insufficient commitment to TB control, particularly at the level of local governments in countries where health care has been decentralized; and the need to meet emerging challenges such as HIV associated TB and MDR-TB. Partnerships with other key sectors have to be further developed. In addition, operational research to increase the reach and utilization of DOTS must be undertaken. The required key interventions have been identified and considerable resources committed by bilateral donors and partners as well as the Global Fund. Given the current impetus and additional resources, it is expected that the Region will reach global targets set for TB control by 2005. Global Fund to Fight AIDS, TB and Malaria HIV/AIDS, TB and malaria, which are closely linked with poverty, have had a devastating global impact. To address these problems, a Global Fund to fight AIDS, TB and Malaria (the Global Fund) was established at the initiative of the UN Secretary-General, to mobilize and rapidly disburse additional financial resources through a new public-private partnership. The aim of the Fund is to make a significant contribution to the reduction of illness and death, and thereby contribute to poverty reduction. For the South–East Asia Region, which bears an extremely high burden of communicable diseases, the availability of additional resources could make considerable difference. The Fund, therefore, presents a good opportunity for the countries to substantially enhance effective interventions to combat these priority health problems. Member Countries are now applying new and revised proposals for consideration at the third round of proposals. WHO worked closely with the Country Coordinating Mechanisms in order to secure larger resources from the Global Fund as most countries in the Region need to accelerate efforts in combating the three main diseases. Over the past year, the Regional Office supported Member Countries in preparing proposals and in mobilizing resources from the Global Fund. This resulted in an amount of US$ 1.4b allocated over five years during the first round of proposals, of which US$ 282m was allocated to countries in the South-East Asia Region. In addition, the Global Fund Board, in January 2003, approved the second round of proposals including 9 components from 6 countries in the Region (Bangladesh, Timor-Leste, India, Myanmar, Nepal, Thailand) with an allocation of US$ 275 million over 5 years. HIV/AIDS Looming darkly over the Region is the HIV/AIDS pandemic which continues to place unprecedented demands on the health, social and economic sectors. HIV infections have spread rapidly in the Region. According to WHO estimates (as of May 2003), there were more than four million HIV-infected people. Over 267 000 AIDS cases were reported by March 2003. More than 95% of the reported cases were from Thailand, India and Myanmar.
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Globally, India has the second highest estimated number of HIV-infected people, next only to South Africa. The epidemiological patterns of HIV/AIDS are diverse in the Region ranging from HIV epidemics with HIV prevalence in pregnant women attending ANC (>1% in Myanmar, Thailand and six states of India); to concentrated epidemics in Nepal and Indonesia (>5% HIV prevalence among high risk behaviour groups); and low level epidemics in Bangladesh, Bhutan, DPR Korea, Maldives, and Sri Lanka (Table 1). Table 1: HIV prevalence and predominant modes of Transmission, 2002 Reported AIDS cases1 172 13 0 48 9333 3568 9 5 623 624 4052 208 456 267 000 Estimated number of HIV cases2 13 000 <100 <100 3 970 000 120 000 <100 420 000 58 000 4 800 670 000 4 653 000 Mode of transmission Heterosexual + + -+++ + + +++ + + +++ Injecting drug use + --+ ++ -++ ++ -++
Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand SEAR Total (approx.) 1 2
As of December 2002 As of year 2001 3 As of March 2003 (--) Unknown or minimal HIV transmission; (+) limited HIV transmission; (++) moderate HIV transmission; and (+++) major HIV Source: HIV/AIDS Unit, WHO SEARO
However, there is a potential for rapid spread of HIV in all countries as risk behaviours and vulnerabilities, which fuel the spread of the infection, exist in all countries. Many countries, such as Indonesia and Nepal, recently experienced a rapid increase in HIV prevalence among injecting drug users and subsequently commercial sex workers after a prolonged period of low prevalence. Thus, the epidemic in the Region can be considered highly dynamic. Member Countries have made considerable progress in fighting the epidemic. They implemented national strategic plans with the involvement of a number of government sectors, the private sector and nongovernmental organizations. Priority is being given to scaling up effective targeted interventions such as 100 per cent condom use at situation of risk coupled with management of sexually transmitted infections and harm reduction among injecting drug users. Interventions to decrease HIV transmission in the general population are being implemented in a number of countries including the prevention of mother-to-child transmission (PMTCT), and voluntary counselling and testing (VCT). India and Thailand are scaling up PMTCT programmes to national scale. VCT is being implemented nationwide in
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Thailand and eight additional countries of the Region are in the process of scaling up VCT services. Bangladesh, India, Myanmar, Nepal and Thailand have undertaken behavioural sentinel surveillance (BSS) in order to monitor the risk behaviours among selected population groups. Increasing attention is also being given to cross-border spread of the infection with preparation of joint plans of action for cross-border interventions between India, Nepal and Bhutan as well between Thailand and Myanmar. The participation of nongovernmental organizations and the private sector is increasing steadily. Even though there is a high level commitment to the AIDS problem, only scaling-up interventions will have an effect on HIV incidence. The coverage of interventions to prevent HIV and provide care for people living with HIV/AIDS, including second generation surveillance and programme monitoring, is still low in most countries of the Region. A prioritization of interventions in countries where resources are limited is needed. Forty per cent of the world’s TB burden is in countries of the Region and there is epidemiological evidence that HIV fuels the TB epidemic. The major challenge is to contain the HIV epidemic urgently in most affected countries. This disease is a threat to all countries and effective preventive measures need to be taken now. All countries have developed national HIV/AIDS control programmes with multisectoral strategies. WHO also developed a global HIV/AIDS strategy for the health sector, in order to respond to the pandemic within the framework of United Nations system-wide efforts to combat the disease. WHO is working closely with the affected Member States to mobilize new resources from the Global Fund. WHO continued its leading role in providing technical support in the health sector aspects of HIV/AIDS, such as surveillance, targeted condom promotion in situation of risk, STI prevention and care and blood safety. It also increased its efforts in supporting countries in scaling up harm reduction among IDUs, VCT, PMTCT and care including antiretroviral treatment for people living with HIV/AIDS. As a follow-up of the UNGA Special Session on HIV/AIDS, WHO is developing a regional health sector strategy in order to define and strengthen the health sector’s role within a multisectoral response. The involvement of people with HIV/AIDS in this response will especially require further strengthening. Continued advocacy and mobilization of resources as well as prioritization of effective interventions, preparation of health systems and allocation of sufficient trained human resources for scaling-up such interventions remain major tasks for all stakeholders at regional and country levels. Diseases Prevented Through Immunization Poliomyelitis eradication In 2002, the Region accounted for 84 per cent of the global burden of wild poliomyelitis infection, with India as the only country, in the Region, which still has wild poliovirus circulation. India reported 1 599 confirmed polio cases in 2002, representing an over five-fold increase compared with 268 cases reported in 2001. The number of districts affected grew from 63 in 2001 to 159 in 2002. The epidemic occurred largely because of an accumulation of susceptible children in Uttar Pradesh and other states, due to the insufficient scale and quality of supplementary immunization activities. Bangladesh, Nepal and Myanmar have been polio-free since 2000, with a good surveillance system for Acute Flacid Paralysis (AFP). Bhutan, DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand are all polio-free for more than four years. In other parts of the world, Nigeria, Pakistan, Egypt, Niger, Afghanistan and Somalia also reported poliomyelitis cases due to indigenous transmission.
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High routine immunization coverage is an important strategy for controlling polio and many other diseases. The Regional Office is helping governments expand and improve their surveillance systems and routine immunization services – building on the infrastructure put in place by polio eradication activities. During the last year, all countries in the Region conducted supplementary polio immunization rounds, with Bangladesh, India, Nepal, DPR Korea, Myanmar and Indonesia conducting National Immunization Days (NIDs) which were synchronized as far as possible. In addition, Bangladesh, Bhutan, India, Maldives, Sri Lanka and Thailand conducted SubNational Immunization Days (SNIDs) in high-risk areas and provinces. It is particularly reassuring to note that more children were reached during SNIDs and NIDs in India compared with earlier rounds in all states. This was attributed to better microplanning for SIA activities, improved Information Education and Communication (IEC), greater government ownership and better monitoring of activities. IEC efforts will be continued to reach the unreached, particularly children of underserved communities in Uttar Pradesh and West Bengal. WHO organized an independent AFP surveillance review in Myanmar during 2002. In India, during January and February 2003, rapid AFP surveillance assessments were conducted in the states where resurgence of poliovirus cases occurred in 2002. An additional AFP surveillance review was conducted in Indonesia during June 2003. These reviews verified the quality of the surveillance data and emphasized opportunities for further strengthening of surveillance as necessary. All 17 laboratories in the Polio Laboratory Network of the Region are fully accredited, including the Global Reference Laboratory in Mumbai, India. The laboratories provide timely and accurate information to allow targeted and appropriate planning and virus response, within the framework of WHO’s guidelines for the implementation of laboratory containment of wild poliovirus. To date, nine countries have a finalized plan of action for containment. In response to the geographical restriction of areas with intense transmission of polio virus and the need for multiple rounds of large-scale supplementary poliomyelitis immunization activities, WHO and the affected Member Countries have revised the strategic approach for eradication of poliomyelitis for the period 2003-2005. This new approach aims at mobilization of more funds in achieving the global eradication. Table 2: Estimated resource requirements for polio eradication in 2003 Country Bangladesh DPR Korea India Indonesia Myanmar Nepal TOTAL OPV 5.69 0 79.01 0 0.65 1.48 86.83 Operational 2.63 0 76.72 0 0.16 1.58 81.09 AFP and laboratory 1.05 0.62 11.05 1.53 0.49 1 15.74 Total required (US$ in m) 9.37 0.62 166.78 1.53 1.3 4.1 183.7 Committed Shortfall (US$ in m) (US$ in m) 9.37 0.62 136.88 1.21 0.6 3.3 151.98 0 0 29.9 0.32 0.7 0.8 31.72
Source: IVD Unit, WHO SEARO 2003
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The estimated resource requirements for polio eradication activities during 2002 in the South-East Asia Region were approximately US$ 152m (Table 2). Contributions came in the past year from a wide variety of bilateral and multilateral sources, including AusAID, Bill and Melinda Gates Foundation, CDC, DFID, DANIDA, EC, Italy, Japan, KfW Germany, NORAD, Rotary International, UN Foundation, the World Bank, UNICEF and WHO among others. Funding the cost of implementing additional polio eradication activities, particularly in India in 2003 following the epidemic outbreak, until the Region is certified polio free, will be a major challenge. The estimated resource requirement across the whole Region in 2003 is US$ 184 million. During the last two years, WHO assisted 8 eligible countries in the Region to successfully apply for funding for hepatitis B vaccine from the Vaccine Fund through the Global Alliance for Vaccines and Immunization (GAVI). Over the next five years, approximately US$ 200 million will be provided from the Vaccine Fund to SEAR countries for activities in three areas: immunization services, injection safety and introduction of new vaccines (Table 3). Table 3: Status of GAVI applications, SEA Region, June 2003 Strengthening of immunization services Approved Not eligible, DPT3 > 80% Approved Application not submitted To apply in 2003 Approved Approved Not eligible, DPT3 >80%) To apply in 2003 Introduction of new vaccines Approved Approved Approved Approved Approved Approved Approved Approved To be decided
Country Bangladesh Bhutan DPR Korea India Indonesia Myanmar Nepal Sri Lanka Timor-Leste
Injection safety Application pending Approved Approved Application not submitted Approved Approved Approved Approved To be decided
Source: IVD Unit, WHO SEARO 2003
Within the framework of the Expanded Programme on Immunization (EPI), four countries in the Region (Bhutan, Indonesia, Maldives and Thailand) had introduced hepatitis B vaccine into their routine immunization programme prior to 2001. With funding from the Vaccine Fund, six countries in the Region will introduce hepatitis B vaccine in 2003. TimorLeste will also apply for funds to strengthen immunization services, in 2003. Through the Regional Working Group on Immunization for South-East Asia, WHO provided technical support to these countries in training, advocacy and monitoring activities. The longer-term challenge will be to develop plans for financial sustainability to ensure that this necessary vaccine programme is continued. Other immunizable diseases One of GAVI’s main goals is to achieve DTP3 coverage of 80 per cent in all districts in at least 80% of GAVI eligible countries by 2005. GAVI will also provide support for strengthening routine immunization, including the introduction of auto-disable (AD) syringes. WHO has committed itself to assisting countries as they strive to achieve this.
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The reported coverage of DPT immunization has always been above 70-80% of the target population for decades, and the coverage of TT immunization among pregnant women in the Region with two doses of TT is around 70%. Despite such achievements, sporadic outbreaks of diphtheria, pertussis and tetanus were reported in a few countries. In 2000, around 4 500 cases of diphtheria and 40 000 cases of pertussis were reported. These figures might be underreported due to problems in diagnosis and poor quality of routine reporting. Survey data indicated an estimated incidence of DPT in the Region as high as 8.5 million cases and 90 000 deaths each year. Five countries – Bhutan, DPR Korea, Maldives, Sri Lanka and Thailand – have reached the neonatal tetanus elimination goal of less than one case per 1 000 live births. Capacity building of the National Regulatory Authority (NRA) is a priority area to ensure continuous use of high quality vaccines in all immunization programmes in the Region. By 2002, NRA assessments were carried out in 9 of the 10 countries. It is also critical for countries to have a surveillance system for Adverse Events Following Immunization (AEFI). Support was provided to develop AEFI reporting systems in several countries, including the production of guidelines and reporting forms. Cold chain reviews in Bhutan and DPR Korea showed how breakdowns in the system could potentially damage the potency and quality of vaccines. The review in DPR Korea led to a joint initiative between WHO and UNICEF’s supply division, in partnership with the country offices of both agencies, to develop a project to procure and install 50 solar refrigerators. While the total number of reported measles cases declined, with some countries experiencing more than 99 per cent reduction in incidence, sporadic outbreaks of measles among school-aged children were reported in a few countries. Measles continues to be a major cause of death and disability with 89 841 cases reported in 2000. The actual incidence would be much higher, and improved surveillance is the key to better-targeted immunization activities. The coverage of immunization against poliomyelitis generally exceeded 80% in countries of the Region, as per formal reporting. Measles accounts for an estimated 202 000 deaths/year in the Region and five countries (India, Nepal, Bangladesh, Myanmar and DPR Korea) have not yet eliminated MNT. In late 2002, the Region looked analytically at the strategies it employs to control measles and NT. The infrastructure available to the programme is impressive, drawing as it does on a large investment in the context of polio eradication activities. A revision of the Regional Strategic Measles Mortality Reduction plan was undertaken. The plan envisages measles and NT control campaigns across the Region based on improvements in national surveillance and laboratory capacity. Regional training workshops were held with the goal of establishing a measles laboratory network by 2003. A sub-national measles campaign began in Myanmar and WHO investigated a major measles outbreak in Maldives. These investments should enable an expansion of measles control activities in other countries of the Region. EPI managers committed themselves to eliminate NT and cut measles mortality by 50 per cent by the end of 2005. The major challenge is to ensure that the Region maintains the momentum of investments in immunization to make systems sustainable in the long term. To achieve this, Member Countries need an appropriate framework for the provision of affordable and quality vaccine from the Region. This requires political commitment and an allocation of national resources, including appropriate human resources, to immunization services. With guidance from the regional task force, a regional policy framework for vaccines was developed to have a standard on safe injections, the disposal of sharps waste in an
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environmentally sound way, internationally competitive vaccine manufacturing, management, and quality control systems. The regional vaccine policy offers a possible road map for technology transfer and long-term sustainability and independence for regional immunization systems. The framework also served for vaccine research and development. The policy will be used to give guidance on vaccine security and sustaining immunization programme in the Member Countries. Leprosy All endemic countries have made concerted efforts in eliminating leprosy as a public health problem starting from the mid-1980s. Apart from India, Nepal and Myanmar, Member Countries in the Region reached the global elimination goal of reducing the prevalence rate of one leprosy case per 10 000 population by 2000. The Region accounted for 74 per cent of the globally registered and 80 per cent of the new cases detected in 2002. India alone accounts for 90 per cent of the regional and 66 per cent of the global caseload. Bangladesh, Bhutan, DPR Korea, Indonesia, Maldives, Sri Lanka and Thailand achieved the elimination goal (prevalence rate <1 per 10 000 population) at the national level, before the target date of December 2000. India, Nepal and Timor-Leste are targeted to achieve the goal by 2005 (Table 4). Table 4: Leprosy situation in the SEA Region (as of March 2003) Newly New case Cumulative Year of Registered Prevalence detected detection cured with reaching leprosy rate/ cases in rate/ MDT since elimination cases 10 000 2002 100 000 1982 target 8 143 35 330 880 16 837 19 4 965 7 291 1 639 1 905 249 372 049 0.63 0.50 3.10 0.81 0.70 0.94 3.02 0.86 0.31 2.93 2.98 11 287 19 617 993 13 286 25 8 231 8 020 2 280 797 N.A. 661 938 8.73 2.90 42.00 6.50 9.20 16.60 34.10 11.90 1.30 N.A. 42.88 131 101 940 9 814 686 257 690 1 268 226 698 83 243 34 534 56 561 N.A. 10 606 618 1998 1997 2005 2000 1996 2003 2005 1995 1994 2005 2005
Country
Population in ‘000 129 248 659 1 067 482 207 840 270 52 827 24 154 19 086 61 879 849 1 564 294
Bangladesh Bhutan India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand TimorLeste SEA Region
Source: WHO/SEARO, Leprosy Unit, March 2003
Myanmar achieved the global goal of leprosy elimination at the national level by January 2003. Ten of the fourteen states/divisions also achieved this elimination target. WHO supported leprosy elimination campaigns (LECs) in 120 townships in 2002. Support was also provided to strengthen monitoring and supervision at the township level and “cleaning” of registers.
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In India, the prevalence of leprosy is above 5 per 10 000 population in four states, 2 and 5 per 10 000 population in six states, and below 2 in the remaining states. Most states have integrated leprosy control activities into the general health services. WHO recruited state/zonal coordinators in the most endemic states and provided anti-leprosy drugs to the entire country and monitored its supply to the states. Leprosy elimination monitoring (LEM) exercise was carried out in the 12 most endemic states. WHO provided technical inputs and supported the simplification of new leprosy information system being implemented since November 2002. In order to strengthen the national programme, a joint WHO/Indian Government meeting was organized in February 2003 in Yangon in conjunction with the third meeting of the Global Alliance for Elimination of Leprosy (GAEL). This meeting was useful in determining priorities and the steps that need to be taken for achieving the target of leprosy elimination by 2005. In Nepal, there were 7 291 registered cases as of March 2003, giving a prevalence rate of 3.02 per 10 000 population. The prevalence is high in central, eastern and far-western regions. Support was provided for intensified leprosy elimination activities covering several areas. In Timor-Leste, a total of 249 cases are registered as of March 2003, giving a prevalence of nearly 3 per 10 000 population. The high prevalence is considered to be due to unstable political conflict which severely affected health care delivery systems. Support was provided for the preparation of a strategic plan for the elimination of leprosy and for capacity building to strengthen the National Leprosy Programme. To advocate and enhance political commitment towards leprosy elimination in the Region, an Intercountry Meeting of National Programme Managers for Leprosy Elimination was held in Colombo in November 2002. The meeting evaluated the progress towards the goal of leprosy elimination and made important recommendations. These included further strengthening the integration of leprosy, phasing out vertical structures within a definite timeframe and undertaking measures to prevent operational factors like “over-diagnosis” and “reregistration” of cases leading to a high level of new case detection in some countries. WHO will continue to provide technical support and supply free MDT drugs to Member Countries. WHO is continuing intensive work with partners, including The Nippon Foundation, Sasakawa Memorial Health Foundation, Novartis, NGOs, the World Bank, DANIDA and others to attain the goal of leprosy elimination in the Region. Other Communicable Diseases During the last few years, the Region witnessed major outbreaks of communicable diseases such as cholera, acute diarrhoeal disease, dengue/dengue haemorrhagic fever, malaria, Japanese encephalitis, anthrax, rabies, hand, foot and mouth disease (HFMD) and influenza. The burden of hepatitis B (HBV) varies widely among the countries, with around 14-16 million people infected annually. With an estimated 98 million HBV carriers (almost 6 per cent of the total population of the Region), all countries need to include HBV immunization as part of the routine EPI programme, as in Thailand and Bhutan. The Region continues to account for approximately 70 per cent of the estimated 50 000 annual human deaths due to rabies that occur globally. The disease is endemic in eight of the 11 countries of the Region, with India accounting for about 85 per cent of the deaths due to rabies in the Region. The disease is invariably fatal but is preventable through an effective vaccine. Member Countries are being encouraged to give priority to rabies control. A Steering Committee for Rabies Control in Asia has been established to provide advice and guidelines.
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Four countries - Bangladesh, India, Myanmar and Nepal - continue to produce and use the outmoded nerve tissue vaccines. A policy decision, however, has been taken in all countries to phase out these vaccines and shift to modern tissue-culture vaccine (TCV). WHO is promoting the use of intra-dermal administration of TCV which is as potent and more cost-effective compared to intra-muscular administration. Outbreaks of Japanese encephalalitis are reported annually in India, Nepal, Sri Lanka and Thailand. Sporadic cases have also occurred in Bali (Indonesia), Myanmar and TimorLeste. The affected countries are being supported in developing JE surveillance and appropriate outbreak response. The strategies for prevention and control of JE include health education, capacity building of concerned health staff, vector control and vaccination. Though effective vaccines are available, none are pre-certified by WHO. However, in view of the need, WHO recommends the use of vaccines produced in Japan and Korea. With regard to plague, three countries - India, Indonesia and Myanmar – have rodent plague foci. The last outbreak occurred in Himachal Pradesh, India, in February 2002, which was successfully contained within a short period. In order to assist Member Countries in establishing and strengthening plague surveillance and prepare them for appropriately tackling outbreaks, an intercountry consultation was organized in Bangalore (India) in July 2002. During the consultation, draft regional guidelines for plague surveillance and control were prepared; these are now being processed for printing. Leptospirosis is an infectious disease caused by "leptospire", a group of bacteria and is mainly transmitted through human contact with the urine of rats. This is an emerging public health problem in some countries of the Region. In 2002, outbreaks occurred in Jakarta and in some states of India. WHO assisted Indonesia in the development of a fact file on leptospirosis. The regional programme for the elimination of lymphatic filariasis is expanding to cover 38 million people living in lymphatic filariasis endemic areas in eight endemic countries by mass drug treatment with a combination drugs. This prevalence accounts for 60 per cent of the global burden of lymphatic filariasis (LF). Around two billion people, mostly in developing countries, harbour worm infestations, while 300 million are severely ill. Of these, at least 50 per cent are school-age children. This group of infections, caused mainly by round worms, whipworms and hookworms, is a major public health problem in all the countries of the Region. Globally, 2.5 billion people live in areas in dengue-risk areas. It is estimated that 50 million people have dengue infections each year, with 500 000 DHF cases and at least 22 000 deaths, mainly among children. Dengue/DHF is endemic in eight countries in the Region. As per information received up to August 2002, there were 85 197 reported cases and 252 deaths. WHO has created an Internet-based global surveillance system called “DengueNet” to collect and analyse standardized information in a timely manner and to present epidemiological trends as soon as new data are entered. Noncommunicable Diseases Noncommunicable diseases (NCDs), including cardiovascular diseases (CVDs), cancers, chronic pulmonary diseases, diabetes mellitus, and other chronic diseases are assuming alarming proportions and becoming the leading causes of mortality, morbidity and disability in the Region. In 2001, they accounted for 50 per cent of deaths and 42 per cent of the disease burden measured in terms of DALYs. Further increases are projected. This situation is due to the demographic and socioeconomic transformation taking place in the Region which, in turn, has resulted in profound lifestyle changes.
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National NCD control programmes in the Region are aimed at important modifiable lifestyle-related risk factors like tobacco and alcohol consumption, physical inactivity, poor diet and nutrition, obesity and high blood pressure. The key components of the programmes include: (a) surveillance as an essential tool to quantify and track epidemics of NCDs and their determinants; (b) preventive activities to reduce the burden of premature mortality and disability; and (c) strengthening health care and supporting health sector management. Countries are still having inadequate NCD morbidity and mortality data, which are mostly institution-based. WHO SEARO recently published a regional profile on noncommunicable diseases which established a basis for developing sustainable databases for NCDs. The World Health Report 2002 on “Reducing Risks: promoting healthy life” highlighted the fundamental role of risk factors as a cause of ill-health. Five of the top ten risk factors to health identified are: tobacco, alcohol, high blood pressure, high cholesterol and obesity - all major risk factors for NCDs. These risk factors are now becoming increasingly prevalent in developing countries leading to a double burden of disease. Hence, the regional NCD surveillance programme focuses on NCD risk factors. This approach is regarded as the most feasible and appropriate way to strengthen regional health information systems and assist countries in health planning, advocacy and evaluation of NCD programmes. Eight countries, viz. Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand are currently supported in planning and conducting standardized NCD risk factor surveys using the WHO STEPS approach. The STEP-wise approach to surveillance of risk factors provides standard materials and offers a simple and flexible tool for the collection of risk-specific health data which predict the major chronic diseases. The approach is being adapted as a methodological and conceptual framework for NCD risk factor surveillance activities implemented in the Region. The current focus is on strengthening the capacity of Member Countries to plan and conduct standardized surveys and to analyse and utilize their results. Reduction of morbidity and premature mortality due to NCDs requires vigorous action and involvement of multiple sectors at all levels from primary prevention to treatment and rehabilitation. Interventions applied during the advanced stage of the diseases usually have a limited impact and are less cost-effective. Therefore, prevention is a more feasible option for low-resource countries. Although a majority of Member Countries implement various NCD prevention and control programmes, they are most often vertical, disease-specific and tertiary-care focused rather than integrated, oriented on population-based prevention and directed at addressing common determinants of NCDs and their risk factors. NCD programmes in the Region require a more holistic approach utilizing health promotion strategies, ensuring community empowerment, and involving multiple sectors. Some countries viz. Thailand, are relatively advanced in implementing an integrated NCD programme at the national level. The results of community-based NCD prevention projects implemented in developed countries have clearly demonstrated that even modest risk factor reduction through adoption of healthy lifestyles brings a huge public health benefit. Bangladesh, India and Indonesia recently initiated demonstration projects on integrated community-based NCD prevention with WHO support. Health promotion and disease prevention are more effective in an overall environment of suitable public health policy, appropriate legislation, supported by cost-effective interventions for established diseases and for individuals at greater risk. Four Member
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Countries - Indonesia, Maldives, Sri Lanka and Thailand - are being supported in capacity building and commitment for developing national NCD prevention networks. These networks will facilitate coordinated planning, implementation and evaluation of NCD prevention programmes. They will also help in promoting implementation of an integrated approach to NCD prevention and control and establishing sustainable mechanisms for intersectoral collaboration. Management of NCDs at the PHC level needs strengthening. One of the important WHO priorities in this area is developing simple practice guidelines to help improve standards and quality of care, improve cost-effectiveness of applied interventions and reduce costs of treatment by avoiding unnecessary investigations, procedures and medication. This will also help to emphasize the importance of therapeutic education and, thereby, improve compliance. Nutritional Disorders The Region made noteworthy progress in the area of nutrition promotion. The proportion of households having dietary energy deficits ranges from 40%-56%. Although per capita energy supply has increased, household food insecurity remains a major concern in all countries. The prevalence of protein-energy malnutrition (PEM) is stable. The incidence of low birth weight (LBW) babies decreased from 13%-68% to 7%-50% in most countries. The underweight (wt for age) prevalence has also decreased among children under-five years, varying from 47% in Bangladesh, India and Nepal, 26% in Indonesia to 19% in Bhutan. The stunting rate in children is decreasing gradually in Bangladesh, Bhutan, India and Maldives while it seems to have increased in Sri Lanka, Myanmar and Nepal. With regard to micro-nutrient deficiency disorders, iodine deficiency disorders (IDDs) remain significant public health problems, even though the total goitre rates (TGR) are decreasing. TGR in Bhutan decreased from 64.5% in 1983 to 5% in 2001 due to concerted efforts in expanding the coverage of iodized salt. Thailand has reduced its TGR from 19% in 1989 to less than 5% in 1997 for the same reason. Progress has also been observed in other countries in the reduction of IDDs, largely through universal salt iodization programmes. The percentage of households having access to adequately iodized salt varies widely, ranging from 95% in Bhutan and Thailand to around 60% in other countries. The major constraints are: shortage of iodized salt due to under-production, lack of appropriate monitoring of iodine content in iodized salt and, most importantly, the ineffective implementation of legislation for iodized salt. Vitamin A deficiency as a significant public health problem is decreasing, with 1.3 million children still at risk. Maternal night blindness is a proxy indicator of vitamin A deficiency, and it has been identified as a major issue in some countries e.g. Bangladesh, India and Nepal. All Member Countries are implementing various strategies in order to accelerate progress in combating vitamin A deficiency, particularly through vitamin supplementation and food fortification (wheat flour, sugar, oil). At-risk children are also provided with vitamin supplementation within the context of the integrated management of childhood illness (IMCI) programme and the immunization services during routine and national immunization days. A more sustainable solution would be to encourage dietary diversification and ensure higher dietary intake of vitamin A in the form of carotene-rich foods. The main cause of maternal anaemia is iron deficiency, which is still a major public health problem with a range of adverse effects including increased morbidity and mortality, pre-term birth, low-birth weight, delayed and impaired child-development, and decreased work productivity. In the South-East Asia Region, about 600 million adolescent girls, women of reproductive age and young children suffer from iron deficiency anaemia (IDA).
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It is generally acknowledged that poverty is a major cause and consequence of illhealth worldwide. Poverty, hunger and malnutrition are often inter-related, and prevent the socioeconomic development of countries. Many infants, children, adolescents, adults, and older persons bear this triple burden in developing countries. Another area of concern for the promotion of nutrition is infant and young child feeding. While the exclusive breastfeeding rate is still very low, inappropriate and untimely initiation of complementary feeding precipitates malnutrition in young infants. Inappropriate feeding accounts for at least one-third of malnutrition, and contributes significantly to morbidity and mortality among children under five. The South-East Asia Nutrition-Research-cum-Action Network, established in 1990, organized nutrition-related health research activities in priority areas such as infant and young child feeding, adolescent nutrition and diet-related noncommunicable diseases. A web site of the network has been developed to enable all network members to share information on research activities, training programmes and other nutrition development activities. Although maternal nutrition is not a new area, there is much that needs to be done, particularly regarding reduction of maternal anaemia. This programme in the SEA Region needs to be strengthened, taking into account a life-cycle perspective because of the intergenerational effects on child nutritional status, obesity, cardiovascular disease and diabetes mellitus in adult life. Maternal nutrition needs to be promoted more actively in “making pregnancy safer”, family planning, mother and child health, and child survival programmes. Multi-disease Surveillance All countries in the Region have multi-disease surveillance systems and information networks in varying stages of development. In most countries, surveillance systems have traditionally concentrated on communicable diseases, with a view to detect epidemics. In view of the growing burden, many countries have included noncommunicable diseases in their disease surveillance programmes. Most countries have lists of notifiable diseases and mechanisms for daily, weekly or monthly reporting from the peripheral levels through the district and provincial levels to the central level. In recent years, countries like India, Indonesia and Nepal have started upgrading their disease notification systems to early warning and rapid response systems. In the past, countries in the Region relied on vertical surveillance systems established over the years for individual diseases resulting in duplication of efforts and resources. Reports were often ad hoc and failed to address key surveillance issues or detect early warning signals of outbreaks. In order to address this issue, an intercountry programme was developed on “Multi-disease Surveillance and Response” as a priority area. The countries also developed a draft regional strategy for an integrated disease surveillance system (IDS) in 2002. The strategy envisioned that by 2010 all countries in the Region would establish a functional, effective and coordinated integrated disease surveillance system that would satisfy all disease surveillance partners and ensure continuous, accurate, timely and complete information for disease prevention, control, elimination and eradication. India has already developed national plans and initiated IDS in several states. Sri Lanka and Myanmar are planning to initiate IDS with WHO assistance. Many countries in the Region have noted the limited capacity at peripheral levels to analyse surveillance information. In addition, peripheral health care workers have a limited appreciation of the data they generate with regard to their relevance, utility and response
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thereto, resulting in untimely reporting and poor data quality. In order to address these issues, India has developed programmes for capacity building at district and state levels. Over the last few years, WHO, in collaboration with partners, has developed a framework to support countries in building capacity for surveillance and response. Within this framework, WHO headquarters and the Regional Offices are providing standards, guidelines and tools, and are supporting field epidemiological training. In addition to the notifiable diseases, some countries like Bhutan, Indonesia and Myanmar also gather routine information on other diseases with a view to monitoring disease patterns and epidemics. In general, routine reporting is done at monthly intervals. Some countries carry out sentinel surveillance for certain communicable diseases selected on the basis of criteria such as disease on the verge of eradication/elimination, or having a large social impact, as in the case of AIDS. Till recently, NCD surveillance activities in the Region were somewhat sporadic. At present, most countries lack an ongoing system for collecting data on noncommunicable diseases. Realizing that information on NCDs and their determinants has broad inadequacies and gaps, there is a need to identify common correctable risk factors for controlling NCDs. The possible approaches are: record-based NCD surveillance, national report-based surveillance, national periodic surveys, follow-up of community studies, and national death registries. Record-based surveillance has been implemented to measure cancer incidence through population-based registries in India and Thailand. All countries in the Region are applying report-based surveillance using hospital data. This provides information on the proportion and distribution of causes of deaths. With the exception of injuries and external causes it is regarded as a rather poor tool for measuring NCD morbidity. National death registries, which are an important supplement to NCD surveillance, have not been adequately developed in most of the low-resource countries. In the SEA Region, only Myanmar, Sri Lanka and Thailand reported coverage of at least 70% deaths. National periodic surveys and follow-up community studies have been implemented in India, Indonesia and Thailand and are regarded as a good tool for measuring morbidity and NCD risk factors. The strategy for the control of NCDs developed in the Region identifies major diseases, viz., cardiovascular diseases, cancer, and diabetes mellitus for integrated surveillance, prevention and community-based and primary health care-based management. The strategy targets common risk factors for integrated surveillance and community-based interventions. Most countries of the Region are conducting standardized NCD risk factor surveys, utilizing WHO's framework. Bangladesh, India and Indonesia recently tested the NCD risk factor surveillance systems in some pilot areas.
Challenge 2: Creating conditions that promote health and self-reliance The health systems in every country comprise all the organizations, institutions and resources that are devoted to health actions. Every health system is not only responsible for improving health but also for protecting people against financial risk for medical care and for providing care to them with dignity. Health and Environment Health is inextricably linked to the environment, which, in turn, is influenced by development projects. These development projects bring substantial benefits to the community and to the health of the people at large. However, a range of unintended impacts on human health
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invariably accompany the projects meant for socioeconomic development, which can potentially amplify the pre-existing high prevalence of hazardous conditions in the countries of the Region. More specifically, the World Health Report 2002 estimated this burden of disease, which is approximately 1.6 million deaths and 44.8 million DALYs in 2000. By the mid-1990s, unrestrained development in countries of the Region brought in its wake pollution and disease outbreaks caused by improper management of water supply, human and other wastes. It also led to deforestation and environmental degradation, exposing people to a plethora of serious health risks. Uncontrolled urbanization had overstrained the capacities of local governments and municipalities to provide basic amenities. In the rural areas, unsafe drinking water and inadequate excreta disposal, combined with contaminated food, were responsible for a majority of illnesses. Indoor air pollution and exposure to pesticides and herbicides also posed significant health risks. In the urban areas, environmental threats emanated mainly from rapid rural to urban migration and uncontrolled industrialization. Overcrowding in inadequate housing with poor ventilation added to the dangers of living in an unsafe environment. Environmental hazards such as pesticide poisoning, arsenic contamination of ground water and a variety of chemical exposures, including occupational ones, cause or contribute to the premature death of millions of people. They also result in the ill-health or disablement of millions more each year. Healthy Cities and Healthy Settings, including occupational health According to the World Health Report 2002, environmental hazards cause or contribute to the premature death of millions of people and result in the ill-health or disablement of hundreds of millions more each year in Member Countries of the South-East Asia Region. Environmental changes – both global and local – are having an increasing impact on health, particularly that of poor and vulnerable populations. The major environmental and occupational health problems in the Region are due to exposure to chemical hazards such as arsenic contamination of ground water, and misuse of pesticides, and to biological hazards such as vector-borne diseases related to poor sanitary conditions. Physical hazards are especially crucial at the workplace: extreme temperatures, humidity, noise and poor ventilation. These hazards are present in air, soil, water and food and are amplified during the process of development and industrialization. There is no strategic plan for occupational health and safety to cover the Region’s work force of nearly 750 million persons. The “Healthy Cities” and other “Healthy Settings” approaches provide operational frameworks for implementing intersectoral health development actions in many countries. The need to develop popular and political support, and institute coordination and implementation mechanisms at the local level, has been emphasized. Many urban centres in the Region have taken the initiative of the “Healthy Cities” programmes from the drawing board to ground reality. Successful “Healthy Cities” pilot areas include Chittagong, Cox's Bazar, Sylhet and Rajshahi in Bangladesh, Bangkok and Yala in Thailand, Kuleshwor and Banepa in Nepal, Badulla and Matale in Sri Lanka, Mandalay in Myanmar and Kottayam in India. A situation analysis of occupational health conducted in the Region indicated that in the agricultural sector, common occupational health problems included pesticide poisoning, snake bites, contact dermatitis, musculoskeletal disorders, malnutrition, anaemia, communicable diseases like diarrhoea and dysentery, malaria in endemic areas, and acute
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respiratory infection (ARI), among others. In the industrial sector, they included occupational respiratory diseases such as byssinosis among textile workers, silicosis among quarry workers, noise-induced hearing loss, chemical toxicity, organic solvent toxicity among leather-tanning, petrochemical and plastic workers, injuries due to non-availability of personal protective devices, trauma due to negligence, job dissatisfaction and occupational stress. In the service sectors, they included STDs among transport workers, road traffic injuries, morbidity and mortality due to negligence while on the job, e.g. electrocution and also occupational stress, among others. A healthy environment is one in which people are protected from risks associated with chemical pollution, environmental degradation and disasters; and where all have access to safe and sufficient food and water; adequate sanitation; and safe working environments. In order to provide a unifying concept in such a diverse programme and activities, the Regional Office has taken the strategic approach of exposure assessment, risk assessment and risk mitigation in each of the areas of work. A situation analysis was undertaken to assess impediments to Health Impact Assessment (HIA) in the Region. The Member Countries were assessed on the policy framework and procedures for HIA, existing infrastructure required to support HIA, the capacity for undertaking HIA and the potential for intersectoral collaboration. The findings highlighted that Environmental Impact Assessment (EIA) is being implicitly used as a substitute for HIA which is not explicitly or routinely conducted in virtually all countries of the Region. Therefore policy, infrastructure, capacity and intersectoral collaboration need strengthening for routine implementation of HIA. The challenge faced during this situation analysis was the lack of environmental data. These were, however, overcome by the constitution of expert committees and through meta-analysis. The next step is translating these findings into evidence-based action for mitigating the environmental impact on health. Water supply and sanitation Most countries in the Region need to cover significant gaps in water supply and sanitation facilities. The extent to which these deficiencies, in both the quality of water and coverage of services, contribute to the heavy disease burden from diarrhoea, poliomyelitis, hepatitis, intestinal nematodes and leishmaniasis is not clearly known. There are, of course, other factors like food safety and hygiene that affect the prevalence of these illnesses. While SEAR countries have made significant progress in water and sanitation coverage in general, the progress in sanitation coverage is much slower. In 2000, total water supply coverage in all countries exceeded 75 per cent, while total sanitation coverage exceeded this level in two countries only. While around 212 million persons lack access to improved water supply, more than four times that number lack access to improved sanitation. However, the basic need to introduce and sustain adequately supported sanitation programmes on a mass scale remains unfulfilled in many countries, even though there are several examples of grassroots sanitation success stories in many countries. Countries in the SEA Region differ widely in their progress towards establishing water quality standards. According to data reported by Member Countries to WHO in 1999, five countries have national drinking water quality standards equivalent to the WHO guideline values and three have standards that are less stringent. Two countries reported having no national drinking water standards. More than in setting standards, it is in monitoring and controlling them that the countries appear to be most deficient. Drinking water quality surveillance was still inadequate in terms of coverage and integrity in most countries of the Region. In most rural systems it was non-existent. In urban areas, many consumers had lost even the expectation that tap water could be safe for
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drinking. In a survey of some 50 water utilities in 31 Asian countries, including many in the SEA Region, 33 percentage of domestic consumers reported that they drank tap water without boiling, even though many of them considered its quality less than acceptable. Arsenic poisoning Groundwater is also a significant source of drinking water in many parts of the world. It is also notoriously prone to chemical contaminants such as arsenic from natural sources or by anthropogenic activities. To date, in the Region, arsenic contamination of groundwater has been reported in Bangladesh, India, and Thailand, and to a limited extent, in Nepal and Myanmar. Millions of people in the Region are exposed to arsenicosis. Studies have revealed that approximately 5 million people in West Bengal, India, consume groundwater containing arsenic exceeding 0.05 mg/L, the national standard. The arsenic crisis in Bangladesh has been described as one of the worst instances of mass chemical poisoning due to a natural process in world history. It is attributed to consumption of water obtained from some 8-12 million tubewells. The estimated number of people exposed to arsenic concentrations exceeding the Bangladesh national standard of 0.05 mg/L is around 25 million. About 10 000 people have developed signs of arsenicosis in Bangladesh. WHO's work in this area is still focused on providing norms and guidelines for the formulation of standard case definition, case management and surveillance protocols, as well as supporting the development of policies for arsenic testing and removal. Chemical safety Chemicals and poisons pose significant health threats to millions in the Region. The misuse of chemicals, particularly pesticides, is common. Exposure to chemical incidents and toxic substances in the workplace, and to toxins of poisonous plants and venomous animals are recognized as causes of growing health problems in the Region. Some countries produce large quantities of industrial and household chemicals. Studies have revealed that up to a third of these products do not meet quality standards. Many countries report cases of acute poisoning and chronic intoxication with chemicals. Millions of people are exposed to the risk of industrial accidents like the Bhopal gas tragedy of 1984. Keeping in mind the global scenario, Member Countries in the Region recognize the need to be better prepared for emergencies due to deliberate or accidental incidents involving biological, chemical and radiation (BCR) agents. While the Fifty-fifth session of the WHO Regional Committee for South-East Asia highlighted the need for enhancing capabilities to manage BCR threats at country and regional levels, the Fifty-fifth World Health Assembly in May 2002 also drew attention to the need for a public health response to such threats. In consequence, the Regional Office organized and conducted an intercountry meeting on the management of BCR emergency preparedness in Bangkok in March 2003. The participants agreed to incorporate BCR elements into existing EHA coordination mechanisms and to allocate additional funds not only to BCR issues but notably to public health preparedness as such. Very relevant to the area of chemical safety was the agreement to undertake/update national inventories of existing chemicals and to augment national capacity in management of poisoning. The meeting reiterated the need to continue promoting the establishment/updating of national profiles for the sound management of chemicals (to date being implemented in 7 SEAR countries) and the need for much stronger support to poison information centres (to date 15 such centres are functioning in 6 countries of the Region).
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Food Safety Foodborne illness represents a big threat to public health in many countries of the Region. While several countries in the Region have appropriate legislation, well-defined national food safety policies and strategies have yet to be developed in many. The Fifth-third World Health Assembly in May 2000 urged Member States to strengthen their food safety programmes in close collaboration with applied nutrition and epidemiological surveillance programmes. The emphasis was on preventive approaches. The WHO Draft Global Strategy for Food Safety takes particular note of the need to amend national policies to take into account new technologies; the use of sentinel sites for foodborne disease surveillance and promotion of training in food safety through broader involvement of WHO collaborating centres. Technical assistance for food safety programmes is being provided and food safety legislation is being updated and reviewed in some countries. Regional and national capacities for establishing databases for food contamination monitoring and foodborne disease surveillance are also being strengthened. Meanwhile, a food hygiene training module targeting street vendors and their customers in four urban slums of Delhi is being developed. A comprehensive analysis of organochlorine pesticide residues in food commodities in the South-East Asia Region is also being undertaken. Health Care Waste Management Poor management of health care waste exposes health care workers, waste handlers and the community to infections, toxic chemicals and injuries. Indeed, improper disposal creates opportunities for the reuse of contaminated medical equipment and poor disposal practices damage the environment (release of toxics such as dioxins, furans and mercury). According to the World Health Report 2002, unsafe injection practices and needle reuse in the South-East Asia Region are estimated to be responsible for a significant amount of the disease burden. Between 22 and 53 per cent of hepatitis B cases, 31 and 59 per cent of hepatitis C cases and 7.0 and 24 per cent of HIV/AIDS cases are associated with these unsafe public health practices. The proportion of syringe reuse in the Region is very high as it is estimated to be from 30 to 75 per cent of all injections given, mainly among those given for therapeutic purposes. Health care workers are among the most exposed. With the introduction of single-use syringes for immunization injections in all countries, “immunization sharp waste management” has become a successful initiative. In India, WHO supported a review of successful non-incineration methods by a local environmental NGO in collaboration with the Ministry of Health and the Indian Pollution Control Board. Lessons learned on methods of final disposal will be compiled and shared with all countries in the Region. A pilot project to install locally-built small-scale, double chamber incinerators in Myanmar was also continued in 2002. Supported by WHO, a waste management committee was established with participants from the Ministry of Health, Ministry of Environment and representatives from various training institutes who devised an activity plan for a field trial of 15 incinerators. Technical assistance was provided to design the incinerator, to identify the location and the availability of construction material, to build prototypes and to train local engineers.
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With the renewed thrust to expand the reach and coverage of immunization programmes in the Region through the efforts of the Global Alliance for Vaccines and Immunization (GAVI), nearly all the 11 countries in the South-East Asia Region have submitted plans to introduce auto disable syringes. Considering the urgent need, the development of national legislation for the sound management of health care waste is being vigorously promoted. Nearly all countries in the Region have guidelines but only three have passed legislation. Particular attention will be given to the management of infected sharps at primary health facilities. Some countries agreed to initiate assessment reports on health care waste management (only three have done it so far), and to develop and hold regular training courses. A “basket” of technical options for final disposal of sharps was discussed to provide guidance for countries. Priority was given to non-burn technologies, central re-processing units and economic waste collection systems. Emergency Preparedness and Response The Region continues to be affected by natural disasters and complex emergencies, resulting in a severe impact on the health of affected populations. Over 80% of disaster events in the Region are due to mass accidents (37 per cent), floods (18 per cent), storms (19 per cent) and earthquakes (8 per cent). Floods are significantly associated with extended periods of excess morbidity from communicable diseases and storms/earthquakes cause displacement of large populations into temporary shelters for long periods. There is a need to focus on meeting long-term, post-disaster public health needs and the public health needs of displaced peoples. Nearly 95 per cent of morbidity and mortality in the first week after these events is due to trauma and only 5 per cent is due to disease (including mental health); policies and guidelines for mass cas ualty management are needed at the national level. Around 70 per cent of these events involve less than 50 trauma victims (deaths plus injuries); mass casualty management organizational capacity is needed at the provincial level. At least 60 per cent of these trauma victims need only simple first aid or primary medical care, 95 per cent of deaths occur before the victim reaches a hospital. Mass cas ualty management knowledge and skills are needed at the local level to save lives. Apart from direct interventions in a number of countries stricken by humanitarian crisis, support on preparedness activities is being extended to various countries, including Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand. As part of institutional strengthening and inter-regional cooperation, the Regional Offices for South-East Asia and the Western Pacific and the Asian Disaster Preparedness Centre (ADPC) signed a Memorandum of Understanding to continue organizing the training programme on Public Health and Emergency Management in Asia and the Pacific (PHEMAP ). In partnership with UN Agencies, the Government and NGOs, the health system in the North-East province in Sri Lanka was assisted to meet the short-term needs of conflictaffected communities, leading to mid- and long-term strategies for health systems recovery. WHO has been designated as the lead agency to coordinate and guide all other development partners to assist in recovering/reconstructing the health system in the NorthEast. With its field-level presence, WHO was able to effectively deliver the functions of a lead agency or implement EHA programme activities and to play a very strong coordinating role.
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Geographically, Indonesia lies in a potential area for natural as well as man-made disasters. Emergency preparedness and response constitute a substantial part of WHO technical collaboration in the country. While efforts continued to be focused primarily on crisis management, health relief and contingency planning, the country office was able to take a wider and longer-term approach to preparedness for the health sector. In India, capacity strengthening in four vulnerable states was initiated through institutional support, inter-state consultations, NGO partnerships and effective partnerships with UN agencies under the United Nations Disaster Management (UNDM) programme. Noting the effective WHO interventions and proactive initiatives, a number of donors showed increasing interest in supporting EHA activities. The European Union decided to support the appeal made to cater to the nutritional aspects due to the drought in the state of Rajasthan. Since 1997, the Emergency and Humanitarian Action Programme has been instrumental in channelling WHO assistance to DPR Korea. In 2001, the WHO Representative’s Office was opened in Pyongyang. The new arrangements allow for greater collaboration with the government and UN Agencies and a more explicitly developmental approach to the country's health needs. The UN Consolidated Appeal Process for DPR Korea for 2003 covers community health services, TB, essential drugs and communicable diseases. The project, “Health Coordination at Myanmar-Thailand Border”, implemented by WHO and funded by CHAD/DFID started in January 2001 for a two-year period with the aim to improve the health of the migrant population in Thailand along the Myanmar border. A joint WHO/DFID review mission was fielded in November 2002 to assess the effectiveness of the project, to recommend a forward strategy and to explore possibilities for a similar approach on the Myanmar side of the border. A review of WHO’s position and comparative advantage confirmed that WHO is well placed to contribute to health development of irregular migrants. Implementation of the project has resulted in several useful achievements towards three defined project products: assessment of health status to identify needs, improved coordination of health initiatives and enhanced distribution of health information.
Challenge 3: Ensuring basic health care to all The outlook for expansion of coverage of essential health care in the least-developed countries is not bright due to many uncontrollable factors (political, socioeconomic and financial). First, the external and internal resource inputs for health infrastructure expansion are scarce. Secondly, nearly 20-30% of the population, the most needy, are harder to reach, mainly due to economic or geographical reasons. The challenge thus is how to reach the unreached. Specific problem-reduction targets have been set in many countries and special national campaigns, such as national sanitation weeks, malaria or TB days etc., have been launched. These, of course, require considerable resources to achieve the targets. Efforts are being geared towards integrating local delivery of health care while, at the same time, ensuring the technical quality of specialized/ selective services. There is still a large gap in health development efforts, especially in the implementation of policies, financing, organization, management and delivery of health programmes. The balance and relevance of human resources for health is the main concern. There are imbalances in quality and quantity, appropriate mix, and deployment between urban and rural areas. A significant factor aggravating the situation in Member Countries is the
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increasing competition for human resources between the private and public sectors, undermining rural placement of health workers in the public sector. Reduction of Child and Maternal Mortality All countries have showed remarkable declining trends in respect of infant mortality rates (IMR). Between 1990 and 1999, Bangladesh, Indonesia and Nepal had an average annual rate of decline of over 5%. However, a considerable variation among the countries or between the provinces or districts within a country was also seen. While Sri Lanka and Thailand had an estimated IMR of 17 and 26 per 1 000 live births respectively in 1999, the rates in Bhutan and Myanmar were 80 and 79 respectively. Figure 4: Perinatal and neonatal mortality rates in the SEA Region, by country ( 1999 estimates) 100 90 80 70
Perinaral mortality rate (per 1000 total births) Neonatal mortality rate (per 1000 total births)
Mortality rate
60 50 40 30 20 1 0 0
MMR
BAN
BHU
MAV
NEP
IND
DPRK
WORLD
INO
SRL
THA
Source: WHO Geneva, Dept of Reproductive Health and Research, Perinatal and Neonatal mortality: Global, Regional and Country estimates, secon edition, Draft 5, Nov. 2001
It is estimated that over 10.5 million children under five years of age died globally in 1999. One-third of these deaths were from the SEA Region. Despite the sheer number and proportion of deaths among under-five children, the under-five mortality rates (U5MR) of most countries have showed a continuous decline during the last few decades. All countries, except DRP Korea which has witnessed a reversed trend, have experienced a continuous decline in the last 25 years. Only Indonesia (during 1995-99), Sri Lanka (during 1975-79) and Thailand (during 1980-84) have reached and maintained the HFA 2000 target of U5MR less than 70 per 1000 live births (Figure 4). More than 30% of global maternal deaths occur in the Region. Usually, the maternal mortality is difficult to measure as the system of recording vital events including maternal deaths in developing countries is deficient. According to the estimates by WHO, UNICEF and country reports, the maternal mortality ratio (MMR) (death of mothers during pregnancy and child birth per 100 000 live births) in the countries of the Region in 1998 varied from 23 for Sri Lanka to 539 for Nepal ( Figure 5).
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Figure 5: Estimated maternal mortality ratio in the SEA Region, by country, 1995 1,600
1,500 1,400 1,200
1,100 1,000 800 600 400 200 0
1,100
830 580 600 500 580 470 370 610 470 390 230 170 55 Myanmar Sri Lanka India Nepal Bangladesh Indonesia Maldives Bhutan
540 440 330
200
180
120 60 Thailand
44 DPR Korea 23.6 9.0
110 35
Source: WHO/UNICEF/UNFPA, Maternal Mortality in 1995 (Draft) Abouzahr & Wardlaw, 10 January 2001
Note: Values at Lower and upper ends of each bar indicate range of uncertainty of maternal mortality ratio estimate for that country.
The coverage of antenatal care, with at least one contact during pregnancy with skilled attendants ranged from 23% in Nepal to 99% in Sri Lanka, Thailand and DPR Korea (Figure 6). Attendance of births by skilled health personnel ranged from less than 10% in Bangladesh and Nepal to almost 100% in DPR Korea. A majority (70-90%) of the deliveries except in Sri Lanka, Thailand and DPR Korea were conducted at home. It is estimated that in 2000, there was an increase of 35% in the proportion of births attended by skilled health personnel, compared to 1990. 120.0
Figure 6: Coverage of antenatal care and births attended by, skilled health workers in the SEA Region during the 1990s 100.0 98.6 98.0 91.0 Antenatal 89.4 83.4 Births
100.0
96.0 90.0
80.0
76.4 71.0
Percentages
60.0
54.0
56.0 51.4 49.1
40.0
34.0 26.4
20.0
15.0 8.0
0.0 DPRK SRL MAV INO THA MMR BHU IND BAN NEP
Source: WHO/SEARO, Health situation in SEA, 1997-2000
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The relationship between maternal mortality ratio and the proportion of deliveries attended by skilled health personnel is clear – higher the proportion of births attended by skilled attendants, lower the maternal mortality ratio. With four countries having less than 40% of births attended by skilled attendants, the Region faces the biggest challenge of providing all pregnant women with essential health care during pregnancy and child birth by skilled personnel in the most resource-constrained settings. Improvement in the quality of maternal and newborn care is another challenge to be addressed in the Region. An enabling environment from the supply and demand sides is needed along with appropriate policies supporting the provision of effective care. Strengthening of maternal and newborn health programme management is another challenge to be addressed. Effective programme monitoring and evaluation is required as inputs for better implementation and improved programme planning and development. Access to essential obstetric care in most Member Countries, except in Thailand, Sri Lanka and DPR Korea is very limited, because of lack of transport, high cost of services, and lack of knowledge on danger signs during pregnancy, child birth and during the postpartum period. To address the problem of high maternal mortality in developing countries, the global Safe Motherhood Initiative was launched at an international conference held in Nairobi in 1987. Its aim was to draw attention to the dimensions and consequences of poor maternal health in developing countries, and to mobilize action to address high rates of death and disability caused by the complications of pregnancy and childbirth. In 1999, with WHO’s guidance, many countries launched the “Making Pregnancy Safer” initiative, aimed at reducing the burden of unnecessary death, illness and disability associated with pregnancy, child birth and the neonatal period, within the broader context of reproductive health. Indonesia was selected as a Making Pregnancy Safer “spotlight” country in the Region. It has developed a national strategy on making pregnancy safer, focusing on the deployment of more than 54 000 community midwives in every village throughout the country, building the capacity of health facilities to provide essential obstetric practices as well as basic and comprehensive emergency maternal and neonatal care at the primary care and first referral unit levels. Particular importance is placed on skilled attendance at delivery and the provision of an appropriate and effective continuum of care in all countries. Countries with high maternal morbidity and mortality need to readjust their policies in order to enhance the coverage of care to mothers with skilled health personnel. Evidence-based standards and norms for maternal and newborn health care services at primary health care and at first referral care levels have been introduced for adaptation and use in countries. Some countries conducted maternal death reviews in order to collect and analyse information on maternal death and use it for health action. The ultimate purpose of this surveillance process is to stimulate action, rather than simply count cases and calculate rates or ratios. Efforts to address the challenges identified by the UN Millennium Development Goals (MDGs) should pave the way to improve access to, and quality of maternal and newborn care, through strengthening existing partnerships and forging new ones for health development at all levels. Women's Health The health of women and men is determined not merely by biological factors or by factors related to individual life styles. Women, however, are affected disproportionately more than, and in ways different from, men. Women in every social stratum face gender discrimination, which results in fewer opportunities and more restricted access to resources. Some
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manifestations of gender discrimination are: the low investment in a girl's education, the pressure on girls to marry early, the restrictions on women's mobility that constrain their educational and income-earning opportunities, and the traditional laws and customs that deny women the same rights as men. The combination of poverty and gender discrimination increases women's health risks and limits their ability to take care of themselves when ill. Policy makers in the Region had recognized the linkages between women’s health and development, and identified gender equity as an important principle and special area of concern. The analysis of the situation published in 2001 in the publication, “Women in SouthEast Asia: A Health Profile”, provided the basis for future research, advocacy and sensitization. In 2002-2003, armed with solid evidence, Member Countries directed their efforts towards creating an enabling policy environment for investing in women’s health and incorporating gender concerns into policies and programmes. A number of initiatives were undertaken to raise awareness of women’s health needs, and the role of gender in women’s health status and access to health resources, among opinion leaders, policy makers, programme managers, and service providers. Three Member Countries focused on specific women’s health issues. These were: violence against women and health sector responses (Indonesia), sex-selective abortion (India), the needs of elderly women (Nepal) and health risk factors among female workers and women outside the reproductive age group (Sri Lanka). The steps taken so far have been aimed at raising overall awareness of gender equity and health, in order to create an enabling environment for incorporating gender concerns into policy formulation, programme design, implementation, and evaluation. Whether or not this has been achieved will become more evident when focused efforts to integrate gender into specific health policies and programmes are undertaken. Human Resources for Health One of the key factors contributing to health development in the Region is having a competent health work force, i.e. the right numbers and mixes of health professionals with the right knowledge, skills and attitudes at the right location and at the right time. As human resources for health consume as much as 60-70% of the health budget, it is essential that they are fully developed and optimally utilized. Very often, health professionals find it difficult to keep pace with new knowledge and skills. Hence, education and training of health personnel, whether pre-service, in-service or continuing education, needs to equip them with the requisite knowledge, skills and attitude to effectively keep up with the rapid advancement in health and other technologies as well as changes in health and societal needs. Another dimension of human resources is the imbalance in deployment between rural and urban areas. All countries in the Region have pre-service educational programmes to produce nursing and midwifery personnel for their own national health services. The nursing and midwifery education varies considerably between countries of the Region, ranging from a certificate or diploma course to a bachelor’s degree. Almost in all countries, nursing education includes a midwifery component, while some have separate midwifery training programmes. Each country is striving towards ensuring the quality and relevance of nursing and midwifery education. Increased attention is being given to the problem of continuing shortage and maldistribution of nursing and midwifery personnel along with inappropriate professional skills mix. Consequently, all countries have conducted an in-depth country assessment of their nursing and midwifery work force management.
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In the area of medical education, countries have established useful linkages for conducting collaborative training programmes among different institutions in the Region. A situation analysis of the allied health work force in the Region in 1998 provided a better understanding of the existing situation and identified effective strategies to strengthen allied health services and education. Countries are still confronted with issues such as (a) lack of clear national policies for allied health personnel development; (b) inadequate norms and standards for allied health professionals, resulting in an inappropriate mix of health personnel; (c) lack of mechanisms for the exchange of information on allied health professionals’ education and training; (d) lack of common standards for allied health professionals’ education and training in countries of the Region; and (e) absence of quality control mechanisms in allied health professionals’ practice. Numerous strategies have been identified to strengthen allied health services and education. These include, among others, development of a comprehensive human resources for health plan for allied health personnel; ensuring that curriculum prepares trainees to meet changing service needs and technology, and provide evidence-based and cost-effective care; ensuring uniformity in allied health education in the Region; establishing/strengthening regional training centres and establishing national and regional centres of excellence for allied health education that would address the changing health needs of the Region. After a comprehensive review of public health practice, education, training and research in countries of the SEA Region, the Regional Conference on Public Health in South-East Asia in the 21st Century, held in November 1999 at Calcutta, India, adopted a Declaration and a few sets of recommendations. The Calcutta Declaration is highly relevant for all Member Countries as a policy framework in further enhancing capacity of public health with appropriate human resources. It highlighted strengthening and reforming public health education, training, and research with networking of institutions and use of information technology. In order to strengthen the quality of public health education and training, Member Countries which have established public health graduate and post-graduate institutions met at the regional meeting organized by WHO in January 2002 in Chennai, India, and formulated various guidelines for accreditation of public health institutions. The countries in the Region used these guidelines in developing national standards. Networking of public health institutions in the Region was also initiated in March 2003 to strengthen the exchange of training experts, resources and to conduct joint research activities. Essential Medicines: Access, Quality and Rational Use Access to essential medicines has been, and will continue to be the core element of health care to the population in the Region. Within the framework of WHO's medicines strategy, Member-Countries are strengthening their national drug policy and food and drugs quality control in order to promote rational use, and to ensure quality, quantity, safety and efficacy. Currently all countries are initiating various activities related to the promotion of rational use, including setting up of national lists of Essential Medicines. Timor-Leste undertook it as one of the first tasks in the health sector. While India and Bangladesh manufacture their requirements of essential medicines, Nepal manufactures a major portion of its requirements. The recently invigorated manufacturing sector in DPR Korea had a strong focus on essential medicines too. Countries such as Myanmar, Maldives and Bhutan still import their requirements from manufacturers in the Region.
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The Fifty-fifth session of the Regional Committee restated the importance of essential medicines and encouraged countries to strengthen their Drug Regulatory Authorities to ensure safe and effective quality medicines. It also urged the countries to use regional bulk purchase schemes as a practical means of delivering the necessary medicines to the people. This resolution was a follow-up of the Health Ministers Meeting in Maldives in August 2001, which first discussed bulk purchase schemes. Countries in the Region are now considering various methods of implementing the resolution. A single uniform scheme would not be successful given the diversity of the pharmaceutical capacities in the countries. With the expansion of the private sector in health care, access to essential medicines has become an important issue. While most countries provide essential medicines in their public health sector, either free of charge or for a nominal fee, patients in the private sector have to pay the full cost. Countries in the Region have long-standing price control mechanisms for essential drugs. India regulates drug prices through the National Pharmaceutical Pricing Authority (NPPA). Sri Lanka and Bangladesh too have price control mechanisms. However, the low margin on essential medicines may drive manufacturers to drugs with a bigger margin. The balance to keep essential medicines affordable and provide a sufficient return to the manufacturer is a difficult one. The Regional Office has been encouraging information exchange between countries and evaluation of drug pricing systems. Drug prices are not the only issue in access. Trade Related Intellectual Property Rights (TRIPS) may prevent countries of the Region from obtaining new drugs essential for their public health needs in future unless suitable national legislation is enacted by 2005. Bangladesh, with its well-developed pharmaceutical industry but least developed country status, has to amend its legislation only in 2016. This has stimulated the country to evaluate its position carefully. Officials from the Drug Regulatory Authorities (DRAs) of the Region met in Hong Kong immediately after the International Conference of the Drug Regulatory Authorities in June 2002. The Regional Office supported this regional regulators forum, where the officials identified Good Clinical Practices (GCP) and counterfeit drugs as the two areas in which WHO assistance was required. GCP, used in clinical trials of new drugs, is rapidly becoming important to the Region as such trials are increasing and DRAs also have to evaluate them as part of the Global Registration dossier. The Regional Office, in association with the United States Pharmacopeia, organized a meeting for DRAs on quality of drugs in September 2002 in Hyderabad, India. The HIV/AIDS Drugs Pre-qualification Scheme (coordinated by WHO) served as a case study and also provided relevant material for the Region. As part of the continuing process of evaluating Drug Regulatory Authorities in the Region, the Authority of Sri Lanka was reviewed in July 2002 and that of Nepal in February 2003 by joint teams from the Regional Office and WHO headquarters. When country activities based on these evaluation reports are submitted, WHO is expected to support them financially and with technical advice. As a follow-up on activities in counterfeit drugs from 2001, a bi-regional Meeting for countries of the Higher Mekong Sub-Region was held in Bangkok in November 2002. Although not in the Mekong Region, the Regional Office facilitated Indonesian participation. The activities resulting from this workshop will be funded by AUSAID in 2003. The Delhi Society for Promotion of Rational Use of Drugs (DSPRUD), an NGO in Essential Medicines, has played a significant role in improving the medicines situation in the government sector in Delhi state. DSPRUD has now formed partnerships with institutions in other states and has promoted drug policies, essential drug lists (EDLs) and standard treatment guidelines (STGs) in these states. DSPRUD activities have been supported from
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WHO headquarters with coordination and technical support from the Regional Office. A joint evaluation team from WHO headquarters and the Regional Office reviewed DSPRUD activities for the past five years and noted significant progress, innovative approaches and useful tools. The team recommended continuing support for DSPRUD and also its better integration into the Government of India programmes to provide synergy and sustainability. This experience in the SEA Region has demonstrated a successful approach different from the traditional one of working through ministries. Timor-Leste had developed a Master Plan for its medicines sector as part of the reconstruction of its health system. An evaluation of the Central Medical Stores by a joint team from the Regional Office and WHO headquarters noted the progress as also the need for more pharmaceutical expertise and for refining the supply system to suit peripheral health care institutions. The Master Plan is now being modified in the light of these recommendations. Timor-Leste has also requested further WHO assistance in developing human resources as well as drafting national legislation for the pharmaceutical sector. Promotion of traditional medicine The Region has a rich heritage of traditional systems of medicine, which have a place in the health care of its people from time immemorial. Even though modern medicine is widely available, traditional medicine (TRM) is still popular and provides a sizeable component of health care. Member Countries have realized the potential of traditional medicine and have taken steps to promote it as part of the national health care system. WHO has been assisting the countries in developing their TRM, especially in the areas of policy formulation, research, standardization, regulation, quality control, human resource development and exchange of information. However, the task of integrating TRM into mainstream national health systems is far from being achieved. Each country has its own TRM, and some, such as Ayurveda, Unani and Siddha, are practised in more than one country of the Region. Homoeopathy, a system from outside the Region, is also practised in many countries of the Region. Indonesians practise a system known as Jamu, while Maldivians practice Dhivehibeys. Bhutan, DPR Korea and Thailand also have their own systems of medicine. Apart from these, many people in the Region practice yoga, acupuncture and other alternative systems of medicine. In the past, research on the efficacy of traditional medicines was based on anecdotal evidence and case studies. Recently, some countries have conducted systematic clinical research on various systems of traditional medicine. In India, research on TRM has identified several diseases where ayurvedic, unani and homeopathic medicines may have potential either as stand alone or in combination with other treatments. Bangladesh has conducted research in the use of medicinal plants in diabetes and diarrhoea. Myanmar has conducted research on standardizing traditional medicine preparations for the purpose of registration. The WHO Traditional Medicine Strategy, 2002-2005, is the key document that addresses most of these issues. In addition, there have been guidelines on research methodologies, regulation and training. WHO has also assisted countries in publishing monographs of their medicinal plants. In the past, the practice of TRM was passed down through apprenticeship. However, counties have now moved on to more formal training with India having well-established graduate and post-graduate training programmes. Bhutan, Myanmar, Nepal and Sri Lanka have also introduced formal training programmes. Until recently, individual TRM practioners produced their own recipes, mostly on a limited scale. Realizing the popularity and demand
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for these preparations, private, multinational pharmaceutical companies started manufacturing them on a commercial scale. Ensuring the quality of the products as well as proper advertising remains a continuing challenge to governments of the Region. Ensuring Good Manufacturing Practices are being discussed and, when properly implemented, will provide a boost to the industry. A few countries of the Region have wide networks for delivery of TRM services, both hospital and outpatient-care. Where integration of TRM and the allopathic system of medicine has occurred, it has been at the district level and below. Bangladesh has a 100bed hospital for ayurveda and unani medicine; Bhutan has a TRM hospital and TRM units attached to the district hospitals. DPR Korea has a TRM hospital at the central level and district TRM hospitals in all districts. India has a wide system of TRM hospitals and facilities. Myanmar has two 50-bed hospitals and several smaller TRM hospitals and OPD clinics in the townships. Nepal has two hospitals, district ayurveda health centres and a network of dispensaries. Sri Lanka has two teaching hospitals and a network of dispensaries. Legislation for licensing and registration of TRM is in place in some countries, with the support of official formularies and pharmacopoeias. Bangladesh, India, Myanmar, Nepal and Sri Lanka have statutory boards or councils for TRM, established by Acts of the respective legislatures. However, implementation of this legislation has not been vigorous. In most countries, a large number of traditional medicinal plants are being lost due to deforestation. A few countries have taken steps to reverse the trend. India has set up a Medicinal Plants Board to conserve medicinal plants. Myanmar, Sri Lanka and Thailand have established national and local TRM gardens for conserving medicinal plants. Most countries need to make greater efforts towards conserving the biodiversity in medicinal plants which is a part of their national heritage. Blood Safety and Clinical Technology Safe blood is one of the priority areas for WHO, both at the global and regional levels. The WHO Global Strategy aims at strengthening nationally coordinated blood transfusion services, promoting voluntary non-remunerative blood donation, reliable laboratory services for blood group serology and screening for transfusion transmissible infections, appropriate use of blood and its components, and implementing a quality system in blood transfusion services. The incidence of adverse reactions as well as transfusion transmissible infections can be reduced by optimal use of components of blood. Currently, less than one fourth of the collected blood is converted into components. A workshop was organized in Myanmar wherein national trainers from Bhutan, Bangladesh, Indonesia, Maldives, Myanmar, Nepal and Sri Lanka representing various clinical specialties were oriented in appropriate use of blood. To create an infrastructure for production of quality components, hands-on training was imparted at Thailand to professionals from Bhutan, Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, and Sri Lanka. Subregional quality management training courses for capacity building in quality management were organized in Bangladesh for Bhutan, Maldives and Bangladesh wherein 15 participants were trained as quality managers. Under the Quality Management Project WHO has, till date, trained 119 quality managers in all Member Countries. To provide continuous technical support to the trained quality managers and to monitor the progress made by them in ensuring quality in their respective blood transfusion services, the National Blood Centre, Thai Red Cross Society, provided technical support to Member
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Countries as a Regional Quality Centre. Two centres under the Ministry of Public Health, Thailand, are conducting an external quality assessment scheme for blood group serology as well as screening for HIV and hepatitis B for SEAR. Three cycles of this scheme have been completed. Sri Lanka has commenced an ambitious project for revamping its entire blood transfusion services with aid from the Japanese Bank of International Cooperation (JBIC). Technical support is being provided by WHO for the total duration of the project. Timor-Leste was similarly provided extensive technical support to establish a functional blood transfusion service. A comprehensive review of quality assurance activities in public health laboratories was carried out in which critical lacunae were identified and suggestions made to improve the quality of laboratory results. Support was provided to Timor-Leste in developing its public health laboratory system in capacity building in this area. Bioterrorism, especially due to anthrax bacilli, continued to be a topical issue during 2002. A Manual on Laboratory Diagnosis of Anthrax was published with inputs from various regional and global experts and distributed to all Member Countries. A rapid, user-friendly and economical screening kit for anthrax developed in the Regional Office was evaluated by a regional panel of experts and was made available to all Member Countries. The problem of chemical poisoning has become an issue of concern in some countries of the Region. A plan to strengthen the programme on prevention and management of chemical poisoning was developed in collaboration with the Medical Toxicology Unit, London. Workshops were held to strengthen capacity in India, Myanmar, Nepal and Thailand during the previous biennium following which another workshop was held in Indonesia. Health of the Elderly Member Countries have recently started giving attention to promoting the health of the elderly. Their actions are concentrated on partnerships and promotion of care in the community and home, promotion of traditional family ties, making optimal use of existing health care delivery systems and establishment of old-age homes. Some Member Countries have formulated national policies on ageing and health. A few have started collection and analysis of related information for advocacy, policy and programme development and for decision-making, dissemination to the general public, pensioners, health care professionals and policy-makers to promote appropriate services, advice and practice on healthy ageing. Efforts are also being made to develop an advocacy strategy with close collaboration among government agencies, NGOs and the media, aiming at influencing public opinion and encouraging support for community-based programmes for healthy ageing. A few countries have also organized research studies related to epidemiology, patterns of the ageing population and determinants of healthy ageing and improved the capacity of health care providers in the area of care of the elderly. The economic, social and health status of the fast-growing elderly population poses a great challenge to all sectors. The major difficulties in developing elderly care programmes include the lack of reliable data for programme planning, a virtual absence of national policies and strategies for the care of the elderly and an inadequate infrastructure to cope with their rapidly increasing health needs. There is a need to promote the concept of "active ageing" in a spirit of broad partnership with all actors, including governments, professional organizations, the mass media, the education sector, and international and national NGOs.
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The joint family system and family values are gradually being eroded in the Region. The number of the elderly living alone will increase with urbanization and migration of young people, coupled with decreased cohesiveness in family bonds. With regard to the health status, around 6% of the aged are immobile due to various disabling conditions. Approximately 50% of the elderly suffer from chronic diseases. Visual and hearing impairments are highly prevalent. At the same time, health services for the elderly are inadequate. Knowledge among health workers on the specific needs of the elderly is also minimal. Enhancing Community Actions for Health and Partnerships In the rapidly changing socioeconomic and geopolitical situation, an increasing number of countries are facing diminishing government resources for health. In addition, they have to cope with rising expectations and demands from a more enlightened and affluent general public for more services. Governments are finding it increasingly difficult to meet this challenge alone, and are therefore looking for partnerships with other sectors, communities and NGOs. During the past few decades, Member Countries have made many fruitful endeavours to enhance community actions for health with the full involvement of communities, political leaders and NGOs at various levels of health care delivery. The method and approaches involved vary from situation to situation and from country to country. Successful community health development programmes such as the Integrated Health Package Programme (Pos Pelayanan Terpadu or Posyandu) in Indonesia; the Village Health Volunteer Schemes and the integrated Basic Minimum Needs (BMN) programme in Thailand; and the Community Health Care Programme using a large force of health volunteers in Myanmar are at the crossroads due to changes in health care management with private-public partnership and decentralization. An appropriate district health system is the level where integrated health development can be managed easily in response to local conditions and needs, using the available infrastructure and resources. There is a need to expand and strengthen the role that individuals, families and communities can play in the promotion and protection of health. Countries of the Region have forged several fruitful partnerships with communities. Such partnerships help to promote a sense of ownership that is essential for the sustainability of health schemes. Expanded and effective community action is essential to address the emerging health challenges. New partnerships need to be developed. There has been a veritable blossoming of nongovernmental organizations (NGOs) in all countries of the Region working for the advancement of women in different ways. Their closeness to communities enables them to get a better understanding of the needs of women. Many of these NGOs work in collaboration with respective governments. The Bangladesh Women’s Health Coalition works primarily in the area of women’s issues. In Indonesia, PKK (Family Welfare Movement) is the most prominent, working in every village throughout the country, undertaking various activities relevant to the needs of village women. In Myanmar, the Mother and Child Welfare Association (MMCWA) is a very large voluntary organization working to improve the health and welfare of women, children and families. Similar organizations exist in all countries of the Region. Partnerships with schools have been important in health promotion. School health programmes have been functioning in the Member Countries and include components such as medical check-ups, health instruction and provision of latrines and water supply at schools. Today, schools present an extraordinary opportunity to help millions of young people acquire health supportive knowledge, values, attitudes and healthy behaviours. Over
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80% of children (6-14 years) of Member countries are enrolled in schools. Schools serve as a means of promoting health of children, their family members and the community. School children can promote health and reach a very large population in the Region. All countries have started improving their school health programmes with the focus on strengthening the capacity of schools and partnership mechanisms such as parent-teacher associations. Collaboration between the Ministries of Health and Education has been strengthened further through the health promoting schools programme. In most Member Countries, the education and health sectors are working together on health promoting schools at all levels.
Challenge 4: Upholding and enforcing health ethics As health research is the prerequisite for health policy formulation and decision-making, Member Countries have striven to strengthen the health research systems as an integral and essential part of health systems. Based upon the regional strategies for health research systems development, Member Countries analysed their national health research systems in the light of health sector reforms and globalization, and initiated policy actions to improve essential health research functions like knowledge generation, knowledge utilization, and also to improve appropriate governance of health research. Health Research Management Countries strengthened health research management through empowering health researchers in managing and coordinating research within new management structures and mechanisms. India, Myanmar and Nepal identified priorities in health research, using the conceptual framework developed by the Regional Office. Sri Lanka developed draft legislation for the establishment of a National Health Research Council. Bangladesh, Myanmar and Nepal assessed the complementarities between the national health policy and health research activities, including utilization of actual health research projects. Thailand conducted an assessment of health research infrastructure and the future scenario of national health research development. Myanmar commissioned another study on “development of a generic monitoring system for health research projects.” In order to evaluate how research methodology was being used in a formal educational setting, Bangladesh, Indonesia, Myanmar, Nepal and Sri Lanka conducted studies on “review of curricula on research methods and research-related issues used in medical and paramedical institutes.” Increasing use of WHO collaborating centres (WHOCC) and national centres of excellence (NCE) strengthened the collaboration within and among Member Countries and their national and international institutes. By February 2003, there were a total of 84 WHO collaborating centres in the Region – 7.4% of the global number. Over 600 researchers and scientists around the world attended the International Conference on Health Research, held in October 2000 in Bangkok, Thailand. The Conference adopted the Bangkok Declaration on Health Research for Development, which called for increasing investment on health research for priority health problems of developing countries, creating environments and networking for constant exchange of knowledge and improving capacity building in health research, especially in developing countries. At the conference, ten pioneering, health research institutions, of which four are from this Region, received the “Rockefeller International Health Research Awards” sponsored by the Rockefeller Foundation, COHRED and WHO. The award aimed to further support networking and cooperation among health researchers and institutions.
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Upholding Health Ethics Health ethics has been on the agenda of a series of meetings of the South East Asia Advisory Committee for Health Research (SEA-ACHR). At its meeting in 1996, the Committee recommended that further efforts were needed to promote health ethics as an integral part of health and health research practices. In 1997, a group of senior medical educators and health research experts from the Region formed a network – South-East Asia Health Ethics Network (SEAHEN), in order to establish national networks to promote ethical practices in medical education and health research. A multi-centred study on “Ethical Values in Teaching Hospitals” was conducted in Bangladesh, Indonesia, Nepal, India, Sri Lanka and Thailand, the results being published as “Health ethics in South-East Asia, Volumes 1, 2, and 3." In January 2000, an intercountry "Forum for Ethical Review for South East Asia and Pacific" (FERCAP) was established, to improve the communication among national ethical review committees in facilitating training opportunities and to assist in the development of national ethical guidelines. At the end of 2001, Indonesia conducted a study on “Mapping and profiling ethical review board”. The results provided valuable inputs for strengthening the capacity of national and institutional ethical committee Members in reviewing biomedical research proposals involving human subjects. Since 2000, the work on ethics in health research has received serious attention in the Region. Training alumni from India, Bangladesh, Nepal, Thailand, and Indonesia conducted similar training workshops in their respective countries, in collaboration with national institutes for health research and the universities. Many medical institutions in the Region have included ethics in the first year of medical education, due to the complexity of ethical issues. Much work has been done internationally for the development of guidelines for the proper conduct of health research involving human subjects. The Helsinki Declaration provides the most fundamental guidelines for clinical research where the responsibilities of data and those involved in the clinical research area outlined. It spells out the principles of ethics in health research. The CIOMS guidelines for biomedical research involving humans were focused on the principles involved in performing research. However, the various international guidelines in many circumstances are not always optimally suited to the real-life situations pertaining in SEA countries. It was abundantly clear that there was an urgent need to look at ethics in health research from a South-East Asia perspective. In this respect, the Central Ethics Committee on Human Research of the Indian Council of Medical Research (ICMR), India, and the Health Research Council, Nepal, finalized the National Ethical Guidelines for Research involving human subjects in 2000. These guidelines have since become cardinal in assisting the countries to deal with ethics in health research. Bangladesh has revised its mechanism of reviewing ethical issues in the institutions. Presently, national ethical guidelines are available in India, Nepal, and Thailand. The National Institute for Health Research and Development, Ministry of Health, Indonesia, conducted a similar national workshop on ethics in collaboration with the University of Indonesia. There is a need also to compile and collect case studies that are embedded in daily lives, in culture, norms and society. As it is clear, ethics in health research is crucially important and needs to be strengthened in the Region. A regional compendium of case studies in ethics in health research would be a useful tool for Ethical Review Board Members to improve their understanding and knowledge on ethical issues in health research and, at the same time, to discuss and analyse specific country cases on the ethical dilemmas in health research.
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The discussions and recommendations of the scientific debate on "Genomics and health" during the 26th session of SEA-ACHR, held in Bhutan in 2001 provided better insights on the ethical, legal and social implications of genetic research and health. The regional perspectives were further elaborated and shared at the Inter-Regional Consultative Meeting on “Genomics and Health” held at Bangkok in mid-July 2001. The conclusions and recommendations of all Regions were collated in the Report of the WHO Director-General entitled: "WHO Policy Paper on Genomics and Health". This report places strong emphasis on the need to ensure that developing countries benefit from the genomics revolution and proposes a series of recommendations by which WHO can play its role in achieving this aim.
Challenge 5: Placing health at the centre of development Experience clearly shows that the success of health sector reforms depends on how the process is applied, and by whom, rather than the contents. The reform process in countries of the Region is proceeding rapidly, usually spurred by a desire to improve equity and quality of care, to expand coverage, to decentralize health care management, and also, in most cases, to contain costs. In some countries, the reforms became more complex due to the presence of a wide range of contracting partners, including external agencies. While every reform experience is country-specific and usually based on solid evidence, there are important lessons to be learnt from comparing options, identifying common issues addressed and the tools used, and evaluating effects of various reform initiatives such as: •
Making the overall human resources and structure of ministries of health smaller and less hierarchical (decentralization efforts in Indonesia, Nepal, Sri Lanka and Thailand); Separating the functions of service provision and service financing to enable better performance through competitive measures (e.g. expansion of health insurance coverage, service contracting, autonomous hospitals, functional groupings, integrating central health budget, setting up management boards at large public hospitals (Thailand, India, Indonesia, Myanmar, and Sri Lanka); Shifting the mix of staff and skills from an emphasis on technical and medical training to that of management, finance, and planning of human resources for health (most countries); and Legislation and regulations for the production and deployment of various categories of health workers including medical professionals (such as the Health Act of Nepal, a large-scale contracting of medical doctors, village midwives and other categories of health workers in Indonesia; compulsory conscription of medical doctors in Myanmar and Thailand). Not many countries have documented such experiences in reforms of health systems well.
•
•
•
As part of political and civil service reforms, decentralization is the most common reform in the Region. Experience, however, has shown that the central government cannot decentralize certain functions like selection of drugs that the centre authorizes for circulation in the national territory (drug regulation and registration), drug quality, and drug pricing policies, human resource recruitment and deployment, etc. Each country has to consider or identify an appropriate mix of centralized and decentralized functions, responsibilities, and/or authority to best meet policy objectives. The ministries of health cannot therefore view the issue of decentralization by isolation.
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Health Care Financing Reforms Most countries have initiated intersectoral health actions to achieve better health development, especially health actions influenced by other sectors. Many governments have created National Health Committees or Councils or inter-ministerial Task Forces or Units. Some have established separate Health Policy Units within the ministries of health from whom health policy-makers seek advice. Health care financing reform is a major component of health sector reforms in most countries. There are three inter-related functions of health care financing: (a) collection of revenue, (b) pooling of financial resources, and (c) purchasing of interventions. The challenge here is how best to harmonize these functions, in a way that health systems protect people financially in the fairest way possible and appropriate incentives are given to health care providers to motivate them. All countries rely essentially on the general public revenue, for financing of health care. Such public financing is a major component of health expenditure in almost all countries of the Region (see Figure 7). The proportion of government contributions as a percentage of total health expenditure in the countries ranged from 20to 60%, depending on the overall economy of the countries and the growth of private health care systems. The financing contribution through mandated social health insurance is very low (around 10%), even in countries where such schemes exist, such as India, Indonesia, Myanmar, Sri Lanka and Thailand. Low investment in health in most countries of the Region has not changed over the past few decades. In 1981, WHO Member Countries had set a target as part of the global health-for-all (HFA) indicators that each state needed to invest at least 5 per cent of its GNP on health. However, only four countries, namely, Bhutan, India, Maldives, and Thailand, are spending more than 5% of their GDP on health. Many countries in the Region as well as in other parts of the world have never achieved this global target till date. The Commission on Macroeconomics and Health (CMH), established by the DirectorGeneral of WHO, proposed in 2002, that on average the low-income countries should increase their budgetary outlays on health by 1% of GNP by 2007 and by 2% of GNP by 2015. The Commission also recommended an essential set of interventions with an average cost of US$ 30-40 per person. There is evidence that a health system which spends less than US$60 or so per capita finds it difficult to deliver a reasonable minimum of services. Figure 7: Private expenditure on health as % of total health expenditure (THE), in the SEA Region, 1995 and 2000 90 80
1995
2000
70 60 50 40 30 20 10 0
India Source: WHR 2002
Myanmar
Nepal Bangladesh Indonesia Sri Lanka Thailand DPR Korea Maldives
Bhutan
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A few countries have tried to add extra resources for health by earmarking a proportion of revenue collected from indirect taxation for health promotion and disease prevention (earmarked taxation or mandatory contributions dedicated to specific health development). Those countries which run state lottery services have used this kind of earmarked revenue for social services including health and education. Thailand has recently enacted legislation to establish a Health Fund which has specified a certain percentage of general revenue from taxation on alcohol and tobacco to be set aside for health promotion activities. Nepal has also introduced legislation – “sin-tax” by increasing taxation on health-risk materials such as tobacco and alcohol. Due to the economic crisis in the Region, some countries have decreased allocations for health. This could lead to a shortage of drugs and equipment, reduction in capital and recurrent expenditure, especially maintenance of facilities and in reducing human resources. National and international civil societies, including foundations, also play an important role in financing health, especially in the area of prevention as well as in the promotion of health care. The Rockefeller Foundation, Nippon Foundation, Rotary International, and many other international associations have helped the countries in programmes devoted to the prevention and control global priority diseases such as leprosy, tuberculosis, malaria, blindness, and diabetes. In addition, a few multinational pharmaceutical corporations contribute their products to assist in the elimination of certain diseases of global importance, such as lymphatic filariasis, helminthic infections, and trachoma. The recent entry of international entrepreneurs and multinational corporations like the Nippon Foundation, the United Nations Foundation and the Bill and Melinda Gates Foundation as well as many multinational pharmaceutical corporations like Novatis, as private philanthropists in the health and other social sectors have resulted in multi-billion dollar contributions to specified health programmes. However, their inputs have benefited only a few developing countries, as the funds are earmarked for special purposes. In most countries in the Region, various national, local and community trust funds and foundations were established in order to protect the financial risks for health care, especially for poor patients and also for supporting the treatment of chronic diseases such as cancer and renal diseases (National Cancer Foundation or National Kidney Foundation). In some cases, governments subsidized a large proportion in these trusts. Bhutan has established a national Health Trust Fund in order to safeguard public health activities and to secure essential drugs and vaccines. There are a few countries in the Region that have a compulsory social security system and/or mandatory social health insurance scheme as well as private health insurance, covering a certain proportion of the general population (ranging from 3-20%). Social health insurance schemes in these countries are part of social security schemes managed either by the ministries of labour or the ministries of health generally covering government employees or employees of state-owned enterprises from whom the premium could be easily collected. Increasing use of various forms of fee-for-service payments usually in the form of user charges at public health facilities has been the most noticeable change over the past few years in the Region. Many countries have introduced various systems of user charges to relieve the burden of public expenditure in hospitals and health centres. This was most evident in countries facing economic constraints and where governments were responsible for providing a substantial proportion of free health care. Most countries allowed the local health institutions to retain some proportion of the fees collected and to use them for drugs, services, and maintenance. Various mechanisms of exemptions for the poor are also in use, but most of these failed due to various political and administrative constraints.
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Many countries have promoted privatization efforts in the health sector with or without the active participation of health ministries. Some countries have attempted to reduce public involvement in the management and delivery of health services as part of their privatization efforts. They have introduced appropriate policies towards the private sector and have redefined government activities to cover policy formulation, monitoring, coordination, and regulation. Given the complexity of the public-private mix in the provision or financing of health care and the complementarities and partnerships between the public and private sectors, including civil societies, ministries of health should explore alternative financing of health care. They should introduce appropriate reform measures and ensure the quality of services and acceptable social responsibility of, and protection for the consumers, especially the underprivileged. Investment in Health Most countries receiving development assistance have linked their investment in health with a core set of essential health care packages. There has been a rapid expansion of some of the essential health care interventions in the Region during the past few decades. These selective health care interventions were related mainly to disease elimination and eradication programmes. External resources contributed by donors to the health sector are of key importance for health development. They have accounted for a significant proportion of total government health expenditure in some countries, ranging from 33.8% in Nepal to 11% in Bangladesh. In India and Indonesia, donor contributions account for a small proportion – less than 4%r of the total government health expenditure. They can, however, play a catalytic role in health sector reforms. Recently, the global trend in donors’ contribution to the health sector has witnessed significant changes. There has been a constant growth with health aid increasing from US$ 100 million a year in the past to several billions of dollars at present with a 3% annual growth and an increased share of 7% in total bilateral and multilateral ODA. The main features of aid have also shifted from small, supply-oriented and supportive projects to the policyoriented, capacity building and sector-work thrust projects. The total annual figure ranges from $3.5 billion to $6 billion, depending largely on the different definitions of aid to the health sector used and the discrepancies between the commitment made and actual disbursement. Asia is the largest recipient as it receives 50% of the total bilateral grants in support of the health sector. India and Bangladesh have been the largest recipients of World Bank/IDA assistance till date. Some multi-million and multi-year health development projects funded by aid from bilateral and multilateral donors to the countries in the Region in recent years are the National Population and Health Project from the World Bank and USAID in Bangladesh, the Health Trust Fund from ADB in Bhutan, the Health and Family Sector Investment Programme from the European Union in India, the Provincial Health Project from the World Bank/IDA in Indonesia, and the North- East Emergency Reconstruction Programme from the World Bank in Sri Lanka. Substantial international funding has also been initiated for immunization programmes in recent years. The Global Alliance for Vaccines and Immunization (GAVI) will provide more than US$ 200 million to all countries of the Region (except Maldives and Thailand) over the next five-year period. Expenditure across the Region of at least US$ 150 million annually from internal and external resources on poliomyelitis eradication activities is likely to continue until the target is achieved.
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WHO also mobilized external resources for its collaborative programmes at the regional and country levels. The extrabudgetary resources of WHO increased from US$ 53.4 million in 1996-97 to US$ 121 million in 2000-2001.
3.
NEW CHALLENGES
Globalization and Health Rapid globalization is the key challenge facing public health worldwide. There is increasing tension between the new rules, tools, actors and markets that characterize the latest phase of globalization and the scope for domestic actions to ensure the health of the people. The principal promoters of global market-based economic systems are multinational, international and intergovernmental agencies such as the World Trade Organization (WTO), the World Bank, the International Monetary Fund (IMF), as well as multinational and transnational corporations. One of the multilateral trade agreements having an impact on health is the Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS). The situation on national patent laws within the framework of TRIPS varies extensively in the countries of the Region. Until recently, a few countries did not cover pharmaceutical products under their national patent laws or otherwise protect them, and tried to meet their national drug requirements at a low cost through various technological means. Other countries with no pharmaceutical industries buy these drugs at competitive prices, contributing to the achievement of national health development objectives. Once the TRIPS agreement comes into force, the countries will have to change their national patent legislation in line with the agreement. A few countries have organized national workshops on the implications of the TRIPS agreement on health, with the emphasis on the need to ensure healthy public policies as a majority of the population lack access to essential medicines. Countries are framing or amending national patent laws and regulations in a manner to balance the rights and obligations of the patent holders and safeguarding of public health interests while maintaining the requirements of the TRIPS agreement. Each of them have designated focal points in the ministries of health to maintain proper liaison and coordination with other ministries relevant to WTO issues, and some have even created a national multisectoral coordinating mechanism to ensure national consensus on various issues in the implementation of the agreements and for future trade negotiations. The Fourth Ministerial Conference of the World Trade Organization, held in November 2001 in Doha, Qatar, also adopted a landmark Declaration on TRIPS Agreement and Public Health. It was for the first time in the 50-year history of GATT/WTO that a separate declaration on public health was adopted. The Doha Declaration, while defining the relations between the TRIPS agreement and public health, stressed that the TRIPS agreement needs to be part of a wider national and international action to address global health problems. It clarified the interpretation of the TRIPS agreement and defined public health crisis, especially that resulting from HIV/AIDS, tuberculosis, malaria and other epidemics, as the ground for compulsory licensing. The Doha Declaration also gave a mandate to the WTO Council for TRIPS, to find an expeditious solution to the problem of countries with insufficient and no manufacturing capacity in the pharmaceutical sector in making effective use of compulsory licensing and decided that the least developed countries will not be obliged to implement patent protection in pharmaceutical products until 2016. Although the TRIPS agreement aims to promote
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innovation by providing incentives to invest in research and development which are also required for new drugs, the discussions in these dialogues generated a lot of issues and questions which can be clarified and answered through situation analysis and monitoring. The WTO multilateral agreements, such as the General Agreement on Trade in Services (GATS), the Agreement on the Application of Sanitary and Phyto-sanitary Measures (SPS) and the Agreement of Technical Barriers for Trade (TBT) also have bearings on health and the health sector. The GATS agreement covers the movement of health service consumers and providers across borders, foreign direct investment in health services and the emerging areas of telemedicine. The SPS and TBT agreements affect national policies on disease control, food safety, and technical regulation and standards for pharmaceutical and biological products. Noting the needs for a public health perspective in international trade and for the evaluation of the impact of international trade agreements on public health, the World Health Assembly has in recent years, recommended Member States to explore and review their options under the relevant trade agreements and to take effective measures to ensure public health interests and safeguard access to essential drugs in the implementation of trade agreements. Member Countries are initiating national studies and reviews for monitoring the health implications of the multilateral trade agreements, to enable them to adopt appropriate healthy public measures on evidence-based information. The expansion of international markets and the increase in competition will have the potential to save millions of people in the Region from ill-health when these are linked with public health policy. On the other hand, they may also leave some unprepared countries vulnerable to unforeseen challenges. It is, therefore, vital that the health community in each country plays an active role in formulating the national policy on international trade to ensure a healthy public health policy.
Response to Emerging Disease Outbreaks Due to rapid and large movement of people across borders to improve trade amongst the countries, there is always the threat of diseases that could also go across the borders. The intercountry collaborative programmes for control of communicable diseases at the border areas have been progressing well in strengthening the planning and control of diseases at the local level. The emergence of severe acute respiratory syndrome (SARS) in recent months around the world has made people more aware of the importance of prevention and control of such new and emerging diseases. The result of the national disease surveillance, intercountry and regional disease surveillance network like Mekong basin and ASEAN disease surveillance system network, as part of the global health alert and response network has led to increasing awareness about the disease among the public, the media and the countries. It has also made an improved understanding of the cost of new diseases like SARS and how it may be spreading in many countries. SARS is a disease caused by a new corona virus with early symptoms similar to common colds but easily spread to many countries and several continents in a relatively short time. It is a worldwide concern as it causes deaths in some of the affected patients and many more infected persons need to be admitted to the hospitals for intensive care. The health workers and the people coming in close contact with those people suffering from SARS are more prone to get infections than others. As there is no treatment or vaccine available for curing or preventing the disease, the best way to contain it is to isolate and treat patients under strict precautionary measures and clinical management.
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WHO being an inter-governmental health agency, is taking the lead in containing the spread of SARS, as well as supporting studies to understand its genesis and dynamics of transmission. Global technical resources have been harnessed by WHO during the past few months towards the control of SARS and shared with all the member Countries. So far 62 daily updates have been issued which help countries in tracking the spread of infection and create awareness about the affected areas. WHO has distributed various technical guidelines on SARS globally through its web sites at headquarters, regional and country offices. These include: Interim guidelines for national SARS preparedness, Interim assessment tools for national SARS preparedness, Management of cases, Hospital infection control practices, Collection and transportation of clinical material for laboratory analysis, Technical training material on SARS and Checklist for countries to assess state of preparedness. Services of international experts have been provided to Member Countries on their request for enhancing their state of preparedness to combat SARS. WHO also advised countries on the use and availability of the personal protection equipment comprising masks, goggles, coveralls etc, including laboratory supplies for positive control RNA to facilitate PCR testing. Primers for the PCR test have been developed by WHO Global Network of Laboratories which also successfully isolated the causative agent. ELISA and IFA tests are under development and are likely to be available soon. The Regional Office has planned to organize a regional consultation to strengthen national response mechanism and a training workshop on good infection control practices during 2003.
Achieving the UN Millennium Development Goals At the United Nations' millennium summit in September 2000, representatives from 189 countries (and 147 Heads of States), adopted the United Nations Millenium Declaration (UNGA Resolution 55/2). The Declaration set out the principles and values that should govern international relations in the 21st century and identified seven areas in which national leaders made a series of specific commitments; peace, security and disarmament; development and poverty eradication; protecting our common environment; human rights, democracy and good governance,; protecting the vulnerable, meeting the special needs of Africa; and strengthening the United Nations. Subsequently, the UN Secretary-General submitted to the 56th session of the UN General Assembly the progress report which is the road map towards the implementation of the UN millennium declaration. In this road map, the UN Secretary-General set out the specific goals, targets and indicators in each of the seven areas identified in the Declaration, provided an overview of the current situation and suggested strategies by which the goals can be achieved. (UNGA document A/56/326). These goals set in Section 3 – development and poverty eradication – are now referred to as the UN Mellenium Development Goals. (MDG). The UN MDG are not undercutting in any way the agreements on goals and targets reached at any other international conferences or global summits in the 1990s and 2000s. They are limited in number, stable for a longer period and to be communicated clearly, to the broad audience. There are eight goals, eighteen targets and forty eight indicators originally set in July 2002. The United Nations has established various mechanisms and activities to support achievement of MDG by the Member States. The Fifty-fifth World Health Assembly reaffirmed its commitment to the Mellenium Declaration under its resolution, WHA55.19. The strategic directions outlined in the WHO's corporate strategy link closely with the development goals and WHO collaborative programmes at all levels are also linked with implementation for achieving MDG.
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Three out of the eight goals, eight out of eighteen targets and eighteen out of 48 indicators are related to health, indicating the importance of health as centrality to development and poverty eradication. The MDG are assuming increasing strategic importance for WHO and the Member Countries as the majority of the goals, targets and indicators are health-related. Concerted efforts will be made to achieve the goals through an extensive body of normative and technical work of WHO. Together with UN agencies, WHO and Member States are working closely in establishing complementary and coherent reporting procedures. With the full involvement and consultation with Member States WHO will establish appropriate databases as the main source of information in relation to goals. The annual produce of World Health Report will provide the status of progress from the eighteen health indicators, in addition to the WHO core health indicators routinely published in previous reports, while monitoring of the indicators would not increase the additional burden of reporting by the Member Countries.
Tobacco Control The last decade has witnessed a major increase in tobacco-related illnesses and deaths worldwide. About four million people are killed every year. The Region became a lucrative market for the tobacco industry, and tobacco consumption is increasing rapidly, especially among the youth and the poor. In the absence of comprehensive tobacco legislation and effective implementation in many countries, tobacco use is reaching epidemic proportions. Thus, controlling tobacco use in the Region has emerged as a major public health challenge and it has created an upcoming issue for public and private debates as various political, economic and behavioural factors. Eight Member Countries grow tobacco in commercial quantities, and among them, India, Indonesia, Bangladesh, Thailand and DPR Korea and included in the list of world’s 25 leading producers of tobacco. According to a World Bank publication in 1999, there has been a 26% increase in production between 1994 and 1997 in India, Indonesia, Bangladesh and Thailand, with India being among the top five tobacco-producing countries in the world. India accounted for 65% of the Region’s total tobacco leaf production in 1990-91. This has increased to 71% in 1998-99. On the other hand, tobacco production in other countries of the Region decreased during this period. Cigarette production in the Region increased from 282 billion in 1990-91 to 432 billion in 1998-99. Indonesia continues to be the largest producer of cigarettes in the Region, followed by India, DPR Korea, Thailand and Bangladesh. Myanmar is the smallest producer, while Bhutan and Maldives do not have in-country production. Bidi production is also on the increase in Nepal, Bangladesh and India. During 1999-2000, these countries produced more than double of what they had produced in 1990-1991. The prevalence of smoking in the Region ranges between 25.7% and 59.6% among adult men and 1.7% and 28.7% among adult women. The prevalence differs significantly between and within countries. Female smoking prevalence in the Region was considered to be low (1.7–6.7%) except in Nepal (29%), Bangladesh (24%) and Myanmar (21%). Recent prevalence reports from Thailand, Indonesia and Bangladesh show increasing prevalence among females. Tobacco consumption among the youth is also increasing. The Global Youth Tobacco Survey (1999-2001) from India, Indonesia and Sri Lanka showed that 3.4%-46.7% of schoolgoing children in the 13-15 year age groups were ever cigarette smokers and 4.5-59% were current users of tobacco. Alarmingly, 12 – 87.8% of school children smoked cigarettes at the age of nine years or earlier; 13 – 62% of students who never smoked were susceptible to smoke the following year, while 70 – 81% of current smokers who bought cigarettes in a store were not refused despite their age.
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Exposure to second-hand smoke by the young was very high as one-third to two-thirds of the parents smoke. About 40 – 81% stayed around others who smoke in places outside their home. Effects of second-hand smoke in the Region (passive smoking) are more pronounced. The high level of nicotine and tar levels in cigarettes, bidis and kreteks, the poor implementation of laws banning smoking in public places, or smoking in overcrowded and enclosed working and dwelling places, together with the lack of knowledge of hazards of second-hand smoke, put non-smokers at a high risk of tobacco-related diseases. Extensive use of tobacco products containing high levels of tar and nicotine in the countries of the Region is a real health concern and poses a greater health risk for tobacco consumers in the Region. Cigarettes in most countries contain 18 to 30 mg of tar. Thai cigarettes contain relatively more tar (24-33 mg) than the regional average. Nearly nine out of ten smokers in Indonesia use only kretek (clove cigarette) which has a very high level of tar (58 mg, range 41-71 mg). Bidis also contain very high levels of tar (45-50 mg). Nicotine levels prevail in the range of 0.6-3.2 mg in different countries of the Region. Tobacco-related diseases and deaths are correspondingly on the increase in the Region. WHO estimates that over 500 000 tobacco-related deaths occur every year in the Region. Only Thailand has a comprehensive tobacco regulatory policy. India, Indonesia, Nepal and Sri Lanka have recently formulated comprehensive tobacco regulatory policies. Legislations for implementation are under process. A few countries in the Region have partial bans on tobacco advertisements. The ban in Bangladesh is limited to bidi and cigarette advertisements on Radio and TV only. In India, the ban on advertisement is limited to state-controlled electronic media only and continues unrestricted in the private media. In Sri Lanka, all cigarette advertisements must carry a health warning. The advertisements on TV are shown only after 9.30 pm and scenes of the persons smoking or the product (cigarette), cannot be shown in Indonesia. In Thailand, the advertisement ban applies to all national media. Countries are developing comprehensive policies that can reduce tobacco use. Thailand, with a comprehensive tobacco control policy, shows a decreasing trend in the per capita consumption of cigarettes, whereas Nepal, where such a policy does not exist, shows an increasing trend. Bhutan has declared 18 out of 20 districts tobacco-free. Two islands in Maldives have been declared smoke-free. Significant steps have been taken at both regional and national levels towards tobacco control, keeping in mind the magnitude of the tobacco problem, increasing consumption of varied tobacco products and the aggressive marketing strategies of the tobacco industry operation in the Region. Intensified and sustained advocacy, coupled with technical support for strategizing demand reduction measures, should be the focus of all countries in the coming years.
WHO Framework Convention on Tobacco Control Concerned with the increasing prevalence of diseases due to expansion of smoking and other forms of tobacco use worldwide, the World Health Assembly in 1999, paved the way for multi-lateral negotiations on the WHO Framework Convention on Tobacco Control (FCTC), utilizing its instrument under Article 19 of the Constitution of WHO. During the last four years, through a series of meetings by its technical working group and intergovernmental negotiating body, WHO is able to negotiate and draft FCTC. The Fifty-sixth World Health Assembly adopted the Convention as attached to its resolution WHA56.1. The FCTC is an international legal instrument that will circumscribe the global spread of tobacco and tobacco products. This is the first time that WHO has acted under Article 19 of its Constitution, which allows the Organization to develop and adopt such a Convention. The
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objective of the Convention and the protocol is to protect present and future generations from the devastating health, social, environmental and economic consequences of tobacco consumption and exposure to tobacco smoke by providing a framework for tobacco control measures to be implemented by the parties at the national, regional and international levels in order to reduce continually and substantially the prevalence of tobacco use and exposure to tobacco smoke. The Convention covers measures relating to the reduction of demand for tobacco such as tobacco taxation, protection from exposure to tobacco smoke, regulation of the contents of the tobacco products and regulation of tobacco product disclosures, packaging and labelling of tobacco products, education, training and public awareness, tobacco advertising, promotion and sponsorship, and other demand reduction measures concerning tobacco dependence and cessation. The FCTC also includes measures related to the supply of tobacco such as illicit trade in tobacco products, sales to and by minors and provision of support for economically viable alternative activities. The Fifty-sixth World Health Assembly requested the Director-General to provide secretariat functions under the Convention until such time as a permanent secretariat is designated and established and also to convene as frequently as possible meetings of the open ended inter-governmental working group for consideration and preparation of proposals on various issues identified in the Convention. The Convention is the groundbreaking step in advancing the national, regional and international action and global cooperation to protect human health against the devastating impact of tobacco consumption and exposure to tobacco smoke. Member Countries now have to join in the parties of the Convention and to work further on in preparation for entry into force of the Convention.
Mental Health and Substance Abuse An estimated 400 million people worldwide suffer from mental and neurological disorders and other psychosocial problems, such as alcohol and drug abuse. According to the World Health Report 2001, worldwide, an estimated 12.3% of all Disability Adjusted Life Years, were attributable to mental and neurological disorders in 2000, and in the South-East Asia Region, the estimate was 11% of all DALYs. Thus, it is clear that even the South-East Asia Region has a substantial burden of mental and neurological disorders. Three neuropsychiatric conditions, namely unipolar depressive disorders, self-inflicted injuries and alcohol-use disorders ranked in the top 20 leading causes of DALY for all ages. In young adults, i.e. in the age group 15-44 years, of the ten leading causes of disease burden, five were neuropsychiatric conditions. These conditions are unipolar depressive disorders, alcohol use disorders, self-inflicted injuries, schizophrenia and bipolar affective disorders. Disability in this most productive age group has serious social and economic implications. Studies from different parts of India in 1999 revealed that the prevalence of epilepsy varied from 9 per 1 000 in Bangalore to 3 per 1 000 in Kolkata. A survey conducted in Kandy district of Sri Lanka revealed a prevalence of 9 per 1 000. Studies in various part of India revealed very low prevalence of Alzheimer’s disease in people 65 years of age or older, ranging from about 1% in rural north-India to 2.7% in urban Chennai. Suicide rates vary from 8-50 per 100 000 population in countries of the Region. India and Sri Lanka record the highest number of suicide rates (11 and 37 per 100 000 population respectively) and occupy the 45th and 7th positions globally. Mental health disorders, such as dementia, depression and schizophrenia, generally affect the elderly. The burden of these conditions in the Region is expected to rise as the proportion of elderly people, 60 years and above, is expected to increase from 5.3 per cent in 1980 to 12.4 per cent in 2025. Eight Member Countries have established mental health policies, laws or programmes. However, some national policies, legislation and programmes are old and based on outdated
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knowledge and technology, and they all need to be updated keeping in mind advances in medical sciences. Bangladesh, India, Indonesia, Sri Lanka have already initiated steps to develop mental health legislation based on current knowledge. Mental health programmes in the countries of the South-East Asia Region have generally concentrated on hospital-based psychiatry. However, there is increasing awareness on the need to shift the emphasis to community-based mental health programmes. A major problem with the community-based approach is the lack of awareness among the community and lack of trained personnel, particularly community workers for basic disability work. WHO supported the efforts of many Member Countries in developing training programmes for community health workers, general physicians and PHC doctors in basic mental health services. Many countries of the Region have implemented innovative initiatives to address mental health, some with the involvement of NGOs and the community. In Bangladesh, the Protibandhi Foundation has been playing a key role in the area of mental retardation. The district mental health programme in Bellary district of Karnataka, India, has developed into a model that is being expanded to deliver mental health services at the district level elsewhere in India. In Nepal, the programmes of orientation and sensitization of traditional healers on mental disorders and epilepsy have been successfully conducted. In Sri Lanka, Sahanaya, a community mental health centre established by the National Council for Mental Health, provides a range of community-based mental health services by professionals and volunteers. Thailand has enlisted the support of village-level health workers in an intervention programme to prevent suicide. It has also developed a programme of “school counsellors” in public schools. Since time immemorial, in most countries of the Region, harmful substance and drugs like cannabis and opium have traditionally been used, in addition to alcohol, for ritual, religious or recreational purposes. Usually, traditional societies had very clearly drawn the line between acceptable use and abuse. Currently, the Region is particularly affected by the problem of substance dependence. Injected drugs have become a key factor in the spread of HIV/AIDS. Most countries have developed policies to control substance abuse. The focus on control of substance abuse is directed towards demand reduction and prevention of harm to substance abusers. Such programmes are inter-disciplinary and involve not only many departments within WHO but also other UN agencies such as UNDCP, UNICEF, ILO etc., many government agencies and NGOs.
Injury and Violence Prevention In response to rapid globalization, Member Countries opted for several development activities to fulfil the public demand and move with the pace of globalization. A huge amount of resource has been invested in developing road networks, a sharp increase in vehicles and traffic, construction of bridges, other infrastructure, industrialization and mechanization from rural to urban areas etc. These development activities have posed a significant and a different kind of threat to the general public. There is a sharp rise in injuries resulting from road traffic injuries in all countries of the Region. More people are dying in “accidents” on the roads, in factories and in construction sites, where simple preventive measures may have saved these precious lives. Many of these deaths and injuries are among economically active population resulting in tremendous economic loss. The ongoing development activities have also provided economic opportunities to millions. However, rapid urbanization, widening social inequity, rising unemployment and raised expectation of people has brought in several social maladies including rising incidents of violence within families, in the street and public places as well as organized violence at
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the community or country level. Children are exposed to more episodes of instigating violence or witnessing it in their real life. School children are more afraid of violent episodes than obtaining poor grades. Youths are involved in drug/alcohol abuse and violence. Violence has affected all sections of the society. Yet, health sector is at the receiving end, providing services to deal with its consequences. Development, therefore, should not only focus on economic growth, but towards strengthening social harmony and trust. In the Region, road traffic injuries are rising rapidly. A projection estimate on traffic fatalities and economic growth shows that South Asia will have the highest increase, of about 144 folds, in road fatalities by 2020 from the level of the year 2000. A recentlyconcluded study from Thailand (Burden of Disease and Injuries in Thailand) shows traffic injuries as the second leading cause of DALYs lost in Thailand in the year 1999. Other major causes of the burden among external causes of injuries include homicide/interpersonal violence and suicide. Member Countries in the Region are gradually taking up violence and injury prevention. However, the efforts have been very minimal in comparison to the gravity of the problem and its impact on health and development. On the positive front, Sri Lanka and Nepal are in the process of formulating national policies for injury prevention. In response to the recommendations of World Report on Violence and Health, Member Countries have been holding national discussions on violence as a public health problem. Despite these developments, there must be concrete effort and dedicated personnel while more resources must be allocated to the national health programme. Several UN Human Rights instruments consider the rights of an individual to be free from violence and abuse in all situations. Many of the countries in the Region have ratified these instruments. The global injury prevention community has proposed safety as a fundamental right of an individual. Therefore, pursuing injury and violence prevention in a rights-based approach is essential for obtaining commitment and action. Efforts are under way in responding to the needs of injured persons or victims of violence in the health system. WHO is supporting countries in developing a science-based approach for pre-hospital and essential trauma care. Several risk factors like alcohol and drug abuse, poor safety standards of public buildings, roads and industries are the potential threats for occurrence of injuries. While promotion of healthy life styles through information, education and communication (IEC) is very important, evidence has shown that these awareness campaigns alone do not have substantial effect on injury prevention. Member Countries in this Region have shown keen interest and some commitment for preventing injuries and violence. The injury surveillance system in Thailand is often quoted as an example in a developing country setting. Nepal and Sri Lanka have been developing a national policy framework for injury prevention. Several countries in the Region have discussed the World Report on Violence and Health, showing the commitment and interest of public health in violence prevention. A regional survey commissioned by WHO for human resource and infrastructure on injury prevention will provide a foundation on what resources are available and provides an opportunity for need analyses.
4.
POLICY ACTIONS
In order to overcome these challenges, the countries need to strengthen or enhance their policy actions to combat ill-health and to develop healthy societies. The main focus should be on:
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Reducing excess mortality, morbidity and disability •
Addressing the specific priority communicable diseases (such as malaria, tuberculosis, HIV/AIDS, dengue fever and DHF, vaccine preventable diseases, leprosy, filariasis and kala-azar), which have a major impact on socioeconomic development and also a disproportionate impact on the lives of the vulnerable population, especially the poor, women and young children. Enhancing efforts, both within and outside the health sector, for reducing excess mortality, morbidity and disability due to noncommunicable diseases, such as diabetes, CVD, oral health, cancer, iodine deficiency disorders (IDDs), injuries and accidents. Ensuring universal access to quality health care with appropriate interventions that can bring about a significant change in the burden of diseases. Encouraging the application of available scientific knowledge and technology and promoting new knowledge and technology.
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Enhancing the performance of health systems •
Expanding the coverage of health care with the ultimate aim of universal coverage, through an appropriate mix of three inter-related health care financing functions: i.e. investing more revenue for health resources; increasing the pooling of health and financial risks; and promoting strategic purchasing. Strengthening the health infrastructure, within the framework of decentralized decision-making and governance, in order to expand and ensure the availability of adequate and effective health interventions. Correcting the imbalance and reducing the irrelevance in training, recruitment, deployment and management of human resources for health.
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Reducing risk factors to human health •
Initiating and advocating action to promote and strengthen healthy environments within the framework of sustainable development. Enhancing the provision of adequate and safe water supply and sanitation services. Promoting health actions in order to protect people from biological, chemical and physical hazards in various human environments. Facilitating self-care, community empowerment and action for promoting health through adoption of healthy lifestyles. Creating an environment that would enable the health sector to raise the awareness of the community on health risks through public awareness campaigns (including awareness days/weeks).
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Creating an institutional environment
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Articulating consistent and evidence-based policy and advocacy positions. Strengthening the governance of the health infrastructure within the framework of decentralized planning and decision-making. Enhancing partnerships with external and internal development partners to effectively move the national health development agenda further. Creating the institutional environment for the health sector to enhance partnerships with nongovernmental organizations, community-based institutions and the private sector to address national health priority problems in an effective, coordinated and sustainable manner. Improving the capacity and providing appropriate incentives for generating evidence-based information through effective epidemiological surveillance and health information systems.
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5.
ROLE OF WHO
The role of WHO is critical to health development in the Region. It has both the mandate and the commitment to collaborate with the countries in addressing the problems that confront them individually and collectively. A critical role for WHO is to ensure that the nature, principles and moral imperatives of "health-for-all" are understood. The Organization should also help guide the formulation and trials of different options for implementation throughout the Region. The broad issues and challenges for WHO collaboration with Member Countries are: •
Articulate and advocate evidence-based policies and strategies: It is essential to ensure commitment to the values underlying health for all, including the universal right to health, and to articulate equity-oriented and gender-sensitive policies and strategies with ethical and scientific norms and standards for health and health care and to monitor progress in advancing health throughout the Region. Policy and decision-makers should have access to evidence-based information for formulating national strategies and implementing policies for enhancing health systems performance. Steps need to be taken to further develop WHO's capacity to critically analyse, organize and disseminate information on health policy initiatives, epidemiological surveillance and other health information to support decision-making. Maintain a high level of technical expertise for catalyzing change: The existing issues and emerging challenges in improving health demand a high level of technical expertise and support to Member Countries. To address these challenges WHO will need to: strengthen its collaboration with the regional network of national centres of excellence and WHO collaborating centres; advocate greater cooperation among Member countries; and facilitate support from other development partners. Through this collaboration the Regional Office needs to provide technical solutions suited to the needs of the Member Countries. Action to exchange experts among countries and facilitate rotation and mobility of staff between the WHO country offices, the Regional Office and WHO headquarters must be promoted. Enhance national and regional partnerships: Recognizing that the determinants of ill-health cover multisectoral concerns, there is a need to enhance partnerships with all development partners and forge new ones. Efforts are required to foster
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interaction among other government sectors, nongovernmental organizations, community-based organizations and the private sector in the areas of policy development, health planning and programme implementation. •
Sustain national and regional health development capability: Strategies are needed for strengthening the development of health and medical sciences, medical technology and health care services in the Member Countries. Regional solidarity and intercountry cooperation must be promoted as a means of achieving regional self-reliance in health development. Identify appropriate interventions for prevention and control of disease: The major determinants and appropriate interventions for the prevention and control of communicable and noncommunicable diseases need to be identified and widely implemented. Mobilize resources: The efforts of countries to mobilize resources for health development internally and from existing and potential development partners must receive enhanced support from WHO. Pursue WHO’s comparative advantage: In formulating collaborative programmes, WHO’s comparative advantage must be pursued, particularly in relation to the production of public goods; building consensus around policies, strategies, norms and standards; initiating and managing negotiations; and sustaining national, regional and global partnerships.
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It is through concerted action in these areas that WHO can provide the leadership at national, regional, and international levels to enable the countries of the Region reach the goal of health for all.
Suggested Reading 1. 2. 3. 4. 5. World Health Organization (WHO), Declaration on Health Development in the South-East Asia Region in the 21 st Century, WHO-SEARO, 1997 World Health Organization (WHO), Regional Consultation on Implementation of Regional Health Declaration, Colombo, Sri Lanka, 9-11 February 1998 (SEA/HSD/211) World Health Organization (WHO), Handbook of resolutions: WHO Regional Committee for SouthEast Asia, Volume 2 (1976-2000) WHO-SEARO, February 2001 World Health Organization (WHO), Health Situation in the S outh-East Asia Region, 1998-2000, WHO-SEARO, 2002 (SEA/HS/222) World Health Organization (WHO), Public Health in South-East Asia in the 21 st Century, Report and Recommendations of the Regional Conference, Calcutta, 22-24 November 1999, WHO-SEARO, 2002 (SEA/HSD/235) World Health Organization (WHO), World Health Reports – 1998 to 2000
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