WPR/RC60/SRl4
SUMMARY RECORD OF THE FOURTH MEETING (Grand Ballroom, Lower Level I, Kowloon Shangri-la Hotel) Wednesday,23 September 2009, at 09:00
CHAIRPERSON: Dr P.Y. Lam (Hong Kong, (China))
CONTENTS page 1.
Progress reports on technical programmes: Asia Pacific Strategy for Emerging Diseases and the International Health Regulations (2005) ............... . Health Financing Strategy for Asia and the Pacific 2010-2015 ............................ . Consideration of draft resolutions ............................................................................ . 3.1 Proposed Programme Budget 2010-2011 ....................................................... . 3.2 Global financial crisis and health impacts in Asia and the Pacific
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4.
Regional Action Plan for the Tobacco Free Initiative in the Western Pacific (2010-2014) ................................................................................... .
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1.
PROGRESS REPORTS ON TECHNICAL PROGRAMMES: ASIA PACIFIC STRATEGY FOR EMERGING DISEASES AND THE INTERNATIONAL HEALTH REGULATIONS (2005): Item 15 of the Agenda (Document WPRlRC60/1 0)
Presenting the progress report on the Asia Pacific Strategy for Emerging Diseases (APSED) and the International Health Regulations (2005), the REGIONAL DIRECTOR reminded the Regional Committee that it had endorsed the Strategy in September 2005 as the framework to guide development of core capacities at the national and regional levels to detect and respond to emerging infectious disease threats. To date, the Western Pacific and South-East Asia Regions were the only WHO regions to have developed such a strategy. Using APSED as a guide, all of the Region's Member States had designated national IHR focal points. That had proven invaluable in preparing for Pandemic (HINl) 2009. WHO's annual pandemic readiness survey showed that nearly 90% of the countries and areas in the Region had the minimum surveillance capacities in place. The Regional Director said that, consequently, he believed that all Member States in the Region had seen the benefits of APSED and the International Health Regulations (2005), or IHR (2005). There was, however, a need to accelerate implementation of the Strategy and the Regulations over the coming years in order to remain vigilant in the fight against emerging and re-emerging diseases. Although the session had originally been planned for Member States to have the opportunity to consider progress on APSED and IHR (2005) implementation, he invited the Regional Committee to feel free to extend the discussion to Pandemic (HINI) 2009. Dr Myrna CABOTAJE (Philippines) confirmed the commitment of the Philippines to the full implementation of the International Health Regulations (2005), as well as the Asia Pacific Strategy for Emerging Diseases. To further attain the objectives ofIHR (2005), a national focal point had been designated in the Philippine Department of Health and was functioning as a continuous communication channel with WHO, consolidating information and disseminating it to all concerned stakeholders, both locally and internationally. It took into account the expertise, views, implications and f'wictions of government agencies in communications sent to and received from WHO, as well as ensuring that obligations under IHR (2005) were being fulfilled. Such unswerving commitment had led to: the notification ofEbola Reston virus infection in swine and humans, as well as of Pandemic(H I Nl) 2009 outbreaks, cases and deaths through the WHO secure Event Information Site; responses to WHO requests for verification of events; the application of the decision instrument in Annex 2 to IHR (2005) in assessing and notifying events; the establishment of surveillance and response systems for Ebola Reston virus and HINI; the sharing of best practices with WHO and Member States; and a review of APSED and its implementation. The Philippines was steadfast in maintaining global health through the fulfilment of its obligations under IHR (2005). Dr RAHMAH SAID (Brunei Darussalam) said that Brunei Darussalam had reported its first case of Pandemic (HINI) 2009 on 20 June 2009 and, to date, there had been more than 1000 cases. The pandemic was testing, not only the resilience of the health system, but also its level of preparedness and the response capacity. Despite some difficulties, the experience had strengthened national interagency collaboration, cooperation and networking, as well as public cooperation, all of which wt:re critical in the overall management of the situation. Regional communication via national focal points was also a significant responsibility under IHR (2005). Work towards fulfilling the requirements of IHR (2005), guided by APSED, had begun prior to the
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pandemic. Over the previous few months, further progress had been made in identifying gaps and key areas for attention, development and strengthening. WHO leadership and guidance would be needed to help fulfil all the requirements ofIHR (2005), in the face of the challenges and uncertainties ahead. Dr CHONG Chee Kheong (Malaysia) said that Malaysia had developed its own plan of action (MySED), adapted from APSED. Awareness of APSED and IHR (2005) had increased among health personnel, and existing capacities had been assessed usingAPSED-based checklists. Use of existing surveillance mechanisms was also part of implementation. In the area of surveillance and response, most of the minimum standards or core capacity requirements had been fully met within the specified time frame. A workplan for zoonoses had been developed with the assistance of the Working and Technical National Committee of Zoonotic Control. Malaysia had also developed a web-based application for laboratory-based surveillance, which was currently being piloted in seven hospital laboratories, two public health laboratories and one research institute. A final draft of the National Strategic Plan for Infection Control had been completed but still needed approval by the National Infections and Antibiotics Committee. Malaysia was involved in providing training in risk communication, including the training of trainers and of health education officers, and a national risk communication strategy had been drafted. Capacity-building to help in the implementation of IHR (2005) had included the training of 138 health officers. The current influenza pandemic had shown that collaboration among countries and with WHO, communication and verification of information regarding public health risks, and routine inspection and control at designated international points of entry had been adequate. Malaysia had evaluated the three national points of entry in 2007, and was evaluating the international points of entry. It remained to be seen whether the economic situation would affect a plan to designate more points of entry, to make them more geographically representative, and to upgrade core capacities by 2012. Dr Keiko YAMAMOTO (Japan) appreciated the efforts made by the Regional Office for the Western Pacific to implement APSED in order to prepare for the pandemic as well as develop the core capacities required under IHR (2005). The ability to respond to emerging diseases had increased significantly in all the countries of the Region. In the midst of the pandemic, the Member States of the Western Pacific Region had reaffirmed the importance of sharing information, and she was pleased to see that the WHO network was functioning well. Communication was flowing between WHO and Member States, and the sharing of virus samples with WHO was speeding up the development of vaccine. Solidarity was a necessity, not a lUXury. The pandemic, like the earlier SARS outbreak, was not only a test of capacity, but also an opportunity to strengthen the ability to respond. By continuing to prepare to respond to the pandemic, countries would make another step forward in achieving the core capacities required under IHR (2005). WHO should continue providing support to Member States in that respect. She welcomed the initiative of starting to look beyond APSED, as discussed recently at a meeting of programme managers, and hoped that WHO and the Regional Office would continue to lead the control of infectious diseases in the Asia Pacific region. Dr YU Jingjin (China) said that priority should be given particularly to zoonoses in order to be ready to respond rapidly to emerging diseases. Regarding the influenza pandemic, China had joined the WHO International Influenza Surveillance Network in 1981 and, by September 2009, had set up a network of 411 laboratories and 556 influenza hospitals. In early 2008, China's Center for Disease Control influenza laboratory had submitted an application to WHO to become an influenza reference and research collaboration centre. He called on WHO to continue to give financial and technical support to developing countries in high-risk areas, in order to increase their capability to cope with the influenza pandemic. China would,
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as always, support and participate in WHO interregional lmd intergovernmental collaboration regarding emerging diseases, and would improve its surveillance and laboratory capacity. He stressed the importance , of strengthening infonnation-sharing, in order to exchange infonnation on new methods and technologies to combat pandemic influenza. Ms GOODSPEED (Australia) said that Australia was committed to continue working collaboratively at the national, regional and international level to contribute 10 the prevention of, and response to, emerging diseases and potential public health emergencies. She welcomed the progress being made in implementing APSED and llIR (2005), recognizing the concerted efforts by countries, and the strong technical support provided by WHO and other development partners. Those efforts should be maintained, and WHO should examine mechanisms that might enable parties to improve coordination and harmonization, in order to improve strategy implementation. The fourth meeting of the Asia Pacific Technical Advisory Group on Emerging Infectious Diseases, held in July 2009, had made recommendations on programme implementation, including: to improve coordination between the Regional Offices for the Western Pacific and for South-East Asia; to enhance monitoring and evaluation systems; to address gender at all levels; to accelerate APSED implementation; and to improve communication with partners. In turn, partners had agreed to explore the development of a unified reporting system. Those recommendations should be implemented as a priority. In particular, she urged WHO to strengthen the management of APSED and its responsiveness in the sharing of implementation infonnation with stakeholders. APSED should be evaluated as soon as practical, in order to better infonn the new strategy. At the subregional level, WHO should continue to strengthen its cooperation with the Secretariat of the Pacific Community to more effectively support Pacific island countries and areas in responding to the current and any future pandemics. Efforts to broaden pandemic and emerging infectious disease planning and response beyond avian influenza had assisted the response to Pandemic (HINI) 2009.
Mr IP Peng Kei (Macao (China» said that Macao (China) had, in 2007, developed a plan to meet the core capacity requirements ofllIR (2005) and complete the preliminary evaluation of core capacity in surveillance and response. llIR (2005) had been brought into force in Macao through Dispatch No. 4/2008, and new regulations were being drafted for implementation. An interdepartmental committee on port health would be fonned to develop, strengthen and maintain core 'Capacity in surveillance and response at points of entry. New mechanisms and documents on health inspection at ports had already been developed. The Health Bureau had also recruited and trained new staff, revised contingency plans for public health emergencies, conducted joint exercises on controlling communicable diseases, and actively participated in regional cooperation. Sir Terepai MAOATE (Cook Islands) observed that the media reaction to infectious disease outbreaks, rather than leading to an organized response, tended to produ,;e a state of panic. A sensationalist approach was bad for tourism, which was important to his country. He believed the health authorities were too slow in informing the public, and instead had at times inadvertently panicked the public with announcements. He wondered how to deal with the media on such issues. Dr SKILLING (Federated States of Micronesia) reported that her country had completed its national llIR plan in accordance with the protocols of llIR (2005), and had designated a national focal point for communication between WHO and the Department of Health and Social Affairs. The national pandemic influenza plan had been adopted. Three national pandemic influenza summits had then been held, and that had
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made for a coordinated response to Pandemic (HlNl) 2009 and improved surveillance. The country had also endorsed a national infection control plan, with quarantine regulations based on IHR (2005). The Federated States of Micronesia supported the actions proposed in APSED. Ms MAlTHEW (Marshall Islands) endorsed the actions proposed in the document and commended WHO for opening an office in Micronesia, which had proven helpful to the Marshall Islands, especially since the outbreak of Pandemic (HINI) 2009. Her country was finding one or two new cases ofIDV infection each year, and a high level ofTB-IDV co-infection, in addition to multidrug-resistant TB. She thanked WHO, the Secretariat of the Pacific Community and others for their continuous support.
Mr KHAW (Singapore), in response to the point raised by the representative of Cook Islands, said that media spin could do more harm than the problem it addressed. The situation would become worse, since every citizen was now a journalist who could text and "tweet" on any subject. Silence from politicians was not the correct response to romour. However, technical jargon was off-putting, and a message of "don't panic" only made things worse. Nevertheless, Asians could show that, as in tai chi, the best response was not to meet force with force but to deflect attacks with subtlety. The REGIONAL ADVISER IN COMMUNICABLE DISEASE SURVEILLANCE AND RESPONSE said he was encouraged by the conclusion that the emergence of Pandemic (HlNI) 2009 had been taken as an opportunity to further strengthen capacity. The framework document was based on rapid assessment and on the APSED checklist, and pandemic response should contribute to IHR core capacity-building. Because of Pandemic (HlNl) 2009, the point of entry was an important consideration, and an upcoming meeting with countries of the Association of Southeast Asian Nations would provide guidance on that. Communication was indeed important, and the framework for action identified communications, along with surveillance, response and interventions, as key factors. The DIRECTOR, COMBATING COMMUNICABLE DISEASES welcomed the progress that had been made in many countries. APSED had indirectly helped build core capacity as recommended by IHR (2005). Two indicators illustrated progress: since 2007, the time from onset to reporting of an outbreak had been cut from 18 to 11.8 days, while the proportion of countries with minimum surveillance capacity had risen from 33% to 90%. Support to countries to increase capacity was being provided. Risk communication was emphasized in the Strategy, and consultations were taking place at country level. The current strategy would end in 2010, but should be expanded into surveillance of nonmedical emergencies. As the representative of Australia had remarked, coordination and harmonization were important, and WHO was working with partners, such as the Secretariat of the Pacific Community, and with the WHO South-East Asia Region, since APSED was a biregional plan. Donors and WHO had discussed .coordinated reporting. Since much about Pandemic (HINt) 2009 remained unknown, information sharing and immediate response were needed. WHO had to know what was happening with the disease, if there was any drug resistance and-when immunization began-what adverse effects were being observed. The Director thanked partners and countries for their work, and promised further cooperation in the coming months.
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2.
HEALTH FINANCING STRATEGY FOR ASIA AND THE PACIFIC 2010-2015: Item 11 of the Agenda (Document WPRlRC60/6)
The DIRECTOR, BUILDING HEALTHY CO~TIES AND POPULATIONS observed that the document had been prepared after consultation with countries at the mid-term review of the previous strategy. Many people in the Region faced barriers to health care; universal coverage of quality health care was a guiding principle and the best way to extend health gains to those most in need. The Strategy detailed the essential building blocks of the health system. It advocated better use of existing resources and further reductions in out-of-pocket payments by the poor and vulnerable. The Strategy also recognized countryspecific actions for countries in transition to universal coverage. WHO realized the need for countries to set their own realistic targets. Dr DUQUE (philippines) reported that, in the Philippines, the Department of Health, together with the Philippine Health Insurance Corporation, had developed the Philippine Healthcare Financing Strategy for 2010-2020. Like the draft health financing strategy being discussed, it advocated universal coverage and aimed to reduce out-of-pocket expenditure to 30%, and pursued 100% coverage of the population with social health insurance, and a doubling of public health expenditure from 1.2% to 2.5% of gross domestic product (GDP). The Department of Health was continuing to work to increase investment in public spending for health, and was updating its Health Sector Expenditure Framework 2010-2012, defining the resources available for the medium term; it would serve as an input to the country"s medium-term expenditure framework. The Healthcare Financing Strategy 2010-2020 had been finalized alnd was ready for implementation. To improve the effectiveness of aid for health, a sectorwide approach to reforms had been adopted in an attempt to reduce the fragmentation of donations, sustain institutional development and cut the cost of evaluation and planning processes. The Department of Health had identified priority programmes in an attempt to improve efficiency by rationalizing health expenditure. An expenditure tracking system was being used, and the provincial investment plans for health were being coordinated with provinces and municipalities. A Congressional Bill has been proposed that would require the national government to pay the health premiums for the poor while local government would enrol the "near poor" working in the informal sector. The Philippines was seeking WHO assistance for the sectorwide approach to health, specifically to align all United Nations assistance to the Philippine health sector programme. Assistance was also being requested in data analysis and to aid in the development of legislation on the Healthcare Financing Strategy that would ensure that the national Government pursued the r<:commended health care financing targets for the medium term. Dr Prasongsidh BOUPHA (Lao People's Democratic Republic) supported the draft Health Financing
Strategy. A major challenge to the Lao health sector was the inadequate level of finance. Cost recovery had been introduced in the early 1990s, with a drug revolving fund. The user fee was an important element of that system, but also a substantial barrier to health services for the poor. A health equity fund had been piloted in several provinces, thanks to the Asian Development Bank, the World Bank and the Government of Luxembourg. In addition, there were formal insurance schemes such as that covering civil servants, and community-based insurance with support from WHO and the Government of Japan. Gaps in coverage remained, however, which would require the technical and financial assistance of external partners.
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Dr FENG Yong (China) supported the draft Strategy, with its emphasis on equity, affordability and accessibility. It also provided a basic foundation for evaluation. The document was similar in spirit to Chinese health reform, through which the proportion of out-of-pocket expenditure had fallen from 51.97% in 2001 to 42% in 2008. Over the same period, the relevant share of GDP had increased from 4.58% to 4.7%. By the end of 2009, 90% of the population would be covered by the basic scheme. Nevertheless, improvement was needed, and the programme planned an increase in expenditure to RMB 550 billion (US$ 80 billion) at various levels of government, so as to provide health care, insurance and drug supplies to urban cind rural areas; the scheme was to be extended to government-owned hospitals. China called for further support from WHO in the technical aspects of health reform financing. Dr Revite KIRITION (Kiribati) said that, as there was no private practice in his country, Kiribati had achieved the first of the four indicators proposed to monitor and evaluate overall progress in attaining universal coverage, with no out-of-pocket spending on health care. Furthermore, total health expenditure represented 7% of GDP, which was higher than the suggested 40/0-5%. Nevertheless, Kiribati continued to have some of the poorest health indicators in the Region, indicating that efficient, effective use of funding was the main problem. He looked forward to WHO assistance and guidance in that area.
In his country, the Government, with the support of the European Union, had established public health care centres within 500 kilometres of every village in the country. Unfortunately, however, the quality and the range of services provided at those centres was poor, and he looked forward to guidance and support from WHO and other development partners in that regard. He also looked forward to guidance from WHO on improving financial management for policy through budgeting and resource-tracking tools, such as national health accounts. Ms GOODSPEED (Australia) commended the Secretariat on the consultative manner in which it had prepared the draft Health Financing Strategy and welcomed the directions outlined. Her country considered that a medium-term approach should be adopted to increase use of government systems while managing fiduciary and development risks appropriately. While her country endorsed the draft Strategy, she asked whether sufficient resources had been allocated to provide the support that would be required by Member States over the 2010-2011 biennium to adapt the Strategy to their requirements.
Mr PHAM Le Tuan (Viet Nam) said that his Government provided or subsidized health insurance for disadvantaged populations and children under the age of six years and had also invested in high-quality health care services, annual expenditure in that sector having increased by 280/0-30% over the previous year. His country's goal was to provide health insurance for all by 2014. The private sector was being promoted, and decentralization of health services had resulted in healthy competition between the public and private sectors and improved treatment and examinations, giving the people more choice in health care. The long-term aim of the health care sector in Viet Nam was to ensure equality, effectiveness and development of health services. Dr KUARTEI (Palau), referring to Table 1 in Annex 1 of the report, in which countries in Asia and the Pacific were grouped by level of total health expenditure as a percentage of their GDP, asked why some countries with good health care systems spent less than others. As the answer probably lay in greater efficiency, he asked them to share their best practices with other countries in the Region. He noted that the report did not provide a model for effective use of aid to address national priorities, such as through negotiated agreements. That was essential, as regional funding programmes were sometimes inappropriate for small island countries.
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The collaboration between Palau and the Secretariat of the Pacific Community in identifying technical and financial assistance to fill the gaps in his country's national strategic plan might be a model for other countries in improving aid effectiveness. The resulting data set could be used to identify gaps and opportunities for effective use of aid in the Region. Mrs GIDLOW (Samoa) said that preparation of her country's first medium-term expenditure framework and updating of its biennial national health accounts had giv(:n the Government a clearer idea of the cost of health care and of the available resources. An operational manual for monitoring and evaluation had recently been completed, which would allow evaluation of performance and of the achievement of expected health outcomes. She said that any financing mechanism should take into account its effect on household disposable income and other complex variables, such as equity, administrative feasibility, cultural acceptability and overall effect on the health system. Although the values and principles governing Samoan society guaranteed every Samoan the right to health care, irrespective of their ablllity to pay, there was growing recognition that the community should assume more responsibility for health (:are costs. Her Government considered that the proposed stratt:gic areas should take into account country experience and realities, as each country had developed its own health system since the introduction of health reforms. Any proposed reform of health financing should keep in mind the effect on prices and, consequently, costs. International experience had shown that health insurance options tended to raise prices and increase the demand for health care, thus leading to higher overall costs for the health system. Her country would use the proposed strategy to enhance its national strategy for health financing and to forge stronger links with regional initiatives. Mrs Brigitte ARTHUR (France) said that it was particularly important to ensure universal access to high-quality health care during the current global financial crisis. Ensuring universal coverage was the responsibility of the State in collaboration with partners. France attached great importance to the implementation of universal health coverage schemes within the development aid programmes that it funded. She welcomed the draft Strategy. Dr Zainal Ariffin YAHYA (Brunei Darussalam) said that his country had started decentralizing services from the hospital to the community in 2000--2001, which had strengthened primary health care by providing more comprehensive services throughout the country. An issue considered to be of great importance in his country was the sustainability of health care financing and the impact of the global recession. The Government was planning to strengthen decision- and policy-making by the use of appropriate data on health care financing. Such data were not yet readily available, and the necessary capacity and skills to conduct cost-related analyses to rationalize resource allocation and use were lacking. He therefore looked forward to benefitting from the technical expertise of WHO. He supported the draft Strategy and urged other Member States to adopt the measures outlined.
Mr KHAW (Singapore) said that, while it was clear that universal health coverage, i.e. health for all, was the primary goal of all health ministers, the level of out-of-pocket payments should be examined closely. If the level was too high, the poor would suffer; however, if it was too low, the system was open to abuse, with overconsumption or excess service by providers, especially if they were paid per volume of clients seen. The problem was a reflection of human behaviour: when a service was free (such as the sumptuous buffets provided by the hosts of the present meeting), there was inevitably wastage. When resources were wasted,
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it was low-income groups that suffered, as medium- and high-income groups had other options. It should be remembered that the entire health system was in fact financed by the people of a country, through taxes. If employers were not obliged to provide employee benefits, salaries would be higher. The solution, therefore, was to improve national economies, such that more and more people entered the middle- and high-income brackets. The role of governments would therefore be limited to looking after those who could not fend for themselves.
Mr zmE (papua New Guinea) said that the Strategy would provide a useful tool for lobbying for more health funding in his country; Papua New Guinea had not yet reached the 5% of GDP target for public health spending, which he was committed to seek increase from his Government. He thanked WHO and the development partners for their generous support, and emphasized his priority to strengthen primary health care and improve access to health services for the rural majority, a redoubtable task given the need to find funding for the country's debilitated health infrastructure and for staff. He wholeheartedly supported the draft Strategy. Dr JACOBS (New Zealand) applauded the Strategy's continued focus on the needs of the most vulnerable, the target of universal coverage and the importance of primary care in health system strengthening. The importance of primary health care in the prevention and early management of noncommunicable diseases could not be overemphasized in a Region where a number of countries spent up to 60% of their health budgets on curative care, with treatment overseas often being required. The three new strategic areas, on aid effectiveness, efficient use of resources and provider payment methods, would provide practical technical assistance to Member States. While sustained investment in health and further reductions in out-of-pocket spending were necessary conditions to achieving universal coverage, it was important to encourage Member States to make a concerted effort to ensure the most effective use of available resources. He asked WHO to provide technical support to Member States to help them prioritize to make the best use of resources while taking into account the needs of the most vulnerable; to provide authoritative evidence on the economic benefits of maintaining good popUlation health and primary health care services available to all to encourage long-term commitment to sustained investment in health; and to advocate development programmes targeting assistance for integrated primary health care and health system strengthening and to harmonize that assistance with national priorities and health systems. The Organization should also ensure that WHO-supported health initiatives with multi-donor funding focused on regional priorities and were integrated into country strategies and activities. He fully supported the draft Strategy. Dr Toshiyasu SHIMIZU (Japan) said that his Government firmly believed in providing appropriate funding to strengthen health care and access, and it had participated in formulating strategic planning to that effect earlier in 2009. However, countries were constrained to working within their specific circumstances and it might be of use to circulate a compilation of best practices in the various countries for general consideration. The target indicators for monitoring and evaluation of overall progress might not be possible for some countries. He hoped that WHO would examine factors other than health financing that had a direct or indirect effect on ensuring universal coverage. He hoped that all Member States would make good use of the Health Financing Strategy in their respective countries and offered to share Japan's experience. He supported the draft Strategy.
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Mrs SORENSEN (Tonga) said that her country spent over 5% of GDP on health. Referring to point 6 of the draft Strategy, she emphasized that limited financial resources, rather than weak capacity, hampered ministries of health in planning and managing health activities; those in smaller countries were skilled at managing limited financial resources. While Tonga had benefitted from a health financing strategy and programme of work supported by the World Bank, she urged that future programmes be more closely integrated with health system budgets rather than being developed in parallel, in order to enhance practical application. Private health care was an integral part of a health system as it freed up resources for public health. The draft Strategy did not specifically mention harmonization with the major financial partners and she asked that WHO ensure that that took place. Her Government was committed to continuing its work to strengthen sustainable and equitable funding for the health system in order to provide universal access to core health services, and she fully supported the draft Strategy. Dr OTGONJARGAL Baasanjav (Mongolia) welcomed the draft Strategy, which was of great help to Mongolia and other countries committed to universal coverage and access to quality health services to reduce out-of-pocket spending. It would provide important guidance in defining country-level activities to strengthen and improve resources for the Mongolian Citizens' Health Insurance Scheme. She fully supported the draft Health Financing Strategy. Mr CHANG Jaehyuk (Republic of Korea) said that his country's national health insurance system was financed by public spending of 6.5% of GDP and by out-of-pocket payments, rapidly reaching universal coverage and providing quality care comparable to other OECD countries. In 2007, WHO had implemented an ongoing study to analyse the Republic of Korea's's financing system for the national health insurance scheme, to help other Member States establish health financing systems along similar lines. That report would be published at the end of2009. He supported the draft Strategy. Dr SHARMA (Fiji) said that his country's budget allocation, at 2.5% of GDP, was the lowest in the Pacific subregion; however, the Government had endorsed a progressive annual increase of 0.5%, starting in 2010, to reach a target of7%. Fiji was aiming to reduce out-of-pocket expenditure from the current level of 45% to less than 30% and to investigate the means of providing social insurance, by 20ll, to the 50% of the population living below the poverty line. The country had established a multisectoral body to work with the Asian Development Bank and other international agencies to prioritize funding for health delivery; that body would subsequently become the national health policy unit by mid-2010. He supported the draft Strategy.
Mr SOALAOI (Solomon Islands) welcomed the draft Strategy and expressed the hope that it would be supported and implemented by all Member States in the Region. The focus on universal coverage, which was a prerequisite for health for all, should help countries to attain better health outcomes. In October 2009, Solomon Islands would be preparing its medium-term explmditure framework, in line with the health sectorwide approach he had mentioned during discussion of agenda item 10 and with support from two World Bank. consultants. Support was also being provided by the Secretariat of the Pacific Community. Dr TAM Lai-fan (Hong Kong (China» expressed support for the draft Strategy, which would guide Hong Kong (China) in its health care reforms. The Government was fully committed to universal access to good-quality health care and to the principle that no one should be denied health care because of lack of means. It was proud of its health indices, which had been achieved despite the pressures of an ageing population, a high burden of noncommunicable diseases, costly treatments and rising consumerism. The
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health system was essentially taxation based. Planned refonns would enhance emphasis on primary health care, intersectoral collaboration, community-based participation, public-private partnerships, evidence-based health care practice and cost-effective choices. Hong Kong looked forward to presenting the results of its refonns in the future. Sir Terepai MAOATE (Cook Islands) supported the draft Strategy and welcomed the progress reported in the 2008 mid-tenn review of the 2006-2010 strategy. He also supported the emphasis given in the fonner to the primary health care approach in the strengthening of health systems in order to achieve universal coverage. He endorsed the Regional Director's vision that health should be developed in the overall context of social development. He warned that use of overseas development aid to attain universal coverage was only a temporary solution. Investment in economic development would be needed to sustain such coverage and reduce out-of-pocket contributions. The legislative frameworks called for in strategic areas 5(4) and 6(4) must be realistic to ensure that they could be implemented by Member States. He endorsed the comments made earlier concerning duplication in strategic areas 7 and 8. His Government had increased the old age pension in 2008 and was planning to increase benefits to disabled people and newborn infants, and to extend child allowance to age 16. It was also taking steps to increase the minimum wage gradually. Health care was free for children up to age 14 and to adults above age 60, and the cost was subsidized for the remainder of the population. However, an affordable scheme for health insurance had not yet been found. He endorsed the comments made by the representative of Singapore regarding reductions in outof-pocket contributions, taxation and the high interest rates on borrowing that were hindering economic development. Mr ABDOO (United States of America) expressed appreciation for the work undertaken in developing the draft Strategy. However, the United States had concerns regarding some of the details. The draft Strategy appeared to advocate a one-size-fits-all approach to health care financing, namely that all Member States should increase the proportion of GDP spent on health care. The Strategy should reflect better the diversity of Member States in the Region. The mid-tenn review of the 2006-2010 strategy appeared to indicate that that strategy was not working as well as it might. It was not clear whether that was the fault of the strategy itself, lack of implementation by the Secretariat or poor uptake by Member States. It was difficult to see how the draft Strategy for 2010-2015 would fit with the 2010"':2011 Programme Budget and the indicator for health financing and technical assistance (l0.010WP01.01), with its baseline offive countries. Moreover, the Strategy did not provide sufficient detail on how successful implementation would be measured in tenns of indicators and targets. He agreed with the representative of Cook Islands that reliance on overseas development aid was not a sustainable way of moving towards universal coverage, especially as evidence indicated that government health budget allocations were often reduced when overseas donations were received. Dr Stephen HOMASI (Tuvalu) welcomed the draft Strategy, in particular, the three new action areas. His Government believed in sustained investment in health systems with a view to attaining universal coverage and was committed to providing the highest possible standard of health care. Despite the economic downturn, it was continuing to allocate 10% of the annual budget to health services, and recent planning for the 2010 budget indicated a rise in allocations for key areas of health service delivery, including core clinical and public health services. Tuvalu was developing national health accounts with the aim of improving the
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monitoring of health financing. Thanks to the commitment of the Government and support from WHO and donor partners, the country was making good progress in terms of key health indicators. However, there was no room for complacency and external support for sustained investment would need to be continued. Mr SOAKAI (Nauru), expressing support for the draft Strategy, endorsed the comments made by Australia regarding the resources that would be required to implement the proposed activities, and requested a response from the Secretariat. WHO support would be needed to guide development of a national health care financing strategy for his country. The REGIONAL ADVISER, HEALTH CARE FINANCING, thanked representatives for their support for the Strategy and for their constructive comments. He we:1comed the recognition that the Strategy was aimed at improving health outcomes by focusing on the attainment of universal health care coverage and access through an appropriate mix of public and private health financing. People should not suffer through excessive out-of-pocket payments at the point of care, and it was essential to seek ways of avoiding that and moving towards universal coverage through appropriate health care financing strategies. The Region shared common values, such as the desire for universal coverage, and should be able to agree on the basic requirements for health financing, including the levels of government expenditure on health and out-ofpocket payments needed to sustain universal coverage. While the level of spending was important, and then: was generally a good relationship between income and health expenditure, high expenditure did not necessarily equate to improved health outcomes. Careful analysis was needed to ensure that universal coverage was providing equitable access and goodquality services. It was hoped that the draft Strategy would provide guidance in that respect. Cost-recovery mechanisms should not create financial barriers to access. Community-based health insurance, mentioned by the representative of the Lao People's Democratic Republic, was one way of improving access, especially in rural areas. Clearly health financing was linked to the current global financial crisis. The four target indicators proposed for monitoring and evaluating progress in attaining universal coverage were complex and interrelated and should be analysed together. National health accounts were an important tool in undertaking such analysis. In reply to the representative of the United States of America, he said that further work was needed regarding the baseline indicators. The mid-term review of the 2006-201 0 strategy had provided useful evidence in developing the draft Strategy for 2010-2015. The Regional Office would disseminate best practices in the Region. The DIRECTOR, HEALTH SYSTEMS DEVELOPMENT, thanked representatives for their support for the Strategy and for their collaboration in its development. Many countrie~ were moving towards universal coverage and were ready to set benchmarks for various aspects of health financing and expenditure. The Strategy focused on universal coverage building on the primaty health care approach. It was not just a case of increasing health expenditure, however. It was essential, as ministries of finance would insist, to get the best value from that expenditure and from overseas development aid-in other words, to increase efficiency through harmonized planning, monitoring and evaluation. Several representatives had referred to their capacity to implement the Strategy, and perhaps lack of capacity had been one reason for the slow progress in implementing the 2006-2010 strategy referred to by
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the representative of the United States of America. While WHO could provide technical support, it was, of course, for Member States to determine how they wished to finance their health care. It was important to ensure good reporting in order to build on existing strategies. There were already
reliable data available on out-of-pocket payments, expenditures as a proportion of GDP and prepayment mechanisms so that it should be possible to establish baseline indicators. However, information on that area should be more clearly presented in future reports. The REGIONAL DIRECTOR expressed appreciation for the considerable interest shown in the item, an important but difficult area, especially given the current global financial crisis. Health financing was a fundamental building block of health systems and efficient management of the funds available was crucial. Health financing also depended on a country's overall socioeconomic development, and the political will and determination of its society. Many of the targets set in the draft Strategy were ambitious, even aspirational. Nevertheless, Member States had a duty to try to attain them. Some in the Region had already succeeded in providing universal health care coverage and access, and others were approaching those goals. For those countries that had not yet progressed so far, the draft Strategy provided guidance on the steps to take and should prove a useful tool in arguing the case for health financing across govermnent sectors. Clearly, Member States in the Region were at different stages of socioeconomic development and would need to adapt the Strategy to their own circumstances on the basis of the agreed common goals. WHO stood ready to provide support and he hoped that he could bring his long experience in developing the health insurance and health care systems in the Republic of Korea to bear in helping countries to make progress in implementing the Strategy. The CHAIRPERSON requested the Rapporteurs to prepare an appropriate draft resolution for consideration later in the session. 3. CONSIDERATION OF DRAFT RESOLUTIONS The Committee considered the following draft resolutions. 3.1 Proposed programme budget 2010-2011 (Document WPRJRC60/Conf.Paper 1) The RAPPORTEUR FOR THE ENGLISH LANGUAGE announced that proposals for amendments had been submitted by Papua New Guinea and Australia. Papua New Guinea proposed that, in operative paragraph 2, the words "which have been developed with respective Member States" should be inserted after "detailed operational plans". Australia proposed that a fifth operative paragraph be added, to read "Requests the Regional Director to make further efforts to strengthen the indicators to more effectively demonstrate their impact." The SPECIAL ADVISER TO THE REGIONAL DIRECTOR explained that the draft resolution endorsed the proposed Programme Budget 2010-2011 and it was not possible to change the indicators for that biennium. He proposed amending the proposal by Australia to read "Requests the Regional Director, in the deVelopment of future programme budgets, to strengthen the indicators to more effectively demonstrate their impact." Mr ABDOO (United States of America) supported the amendment proposed by the representative of Australia. While operative paragraph 1 appeared to endorse the proposed Programme Budget 2010-2011,
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operative paragraph 2 requested the Regional Director to revise it. Given that apparent internal contradiction, if the Regional Director was being requested to "review and revise, as necessary", he saw no impediment to . that review and revision also including the indicators. The SPECIAL ADVISER TO THE REGIONAL DIRECTOR clarified that operative paragraph 2, which read "review and revise, as necessary, the budget allocations to countries and areas and the intercountry programmes", did not mean to review and revise the proposed Programme budget 2010-2011, but rather to review and revise the various operational plans that had been developed in the Regional Office and in the country offices in conjunction with the respective governments, which together made up the overall budget for 2010-2011. It was possible to revise certain allocations pertaining to specific activities without having to revise the overall programme budget or the figures in that programme budget relating to the strategic objectives. Mr ABDOO (United States of America) drew attention to previous discussions where a number of Member States had called for improved indicators; the proposed additional operative paragraph would mean that Member States would not have to wait for two years before seeing an improvement in those indicators. The SPECIAL ADVISER TO THE REGIONAL DIRECTOR noted the comments ofthe representatives of Australia and the United States of America and suggested that further work be done on the wording of a fifth operative paragraph. The CHAIRPERSON suspended discussion on the draft resolution on the proposed Programme Budget 2010-2011 and requested that the Rapporteurs prepare a revised text to be submitted to the Committee for discussion at a later date. 3.2 Global financial crisis and health impacts in Asia and the Pacific (Document WPRlRC60lConfPaper 2)
The RAPPORTEUR FOR THE ENGLISH LANGUAGE announced that proposed amendments had been submitted by Tuvalu: in subparagraph 1 (1) to insert "to continue" before "to advocate", and in subparagraph 2 (1) to insert "to continue" before "to provide support". Decision: The resolution, as amended, was adopted (see resolution WPRJRC60.Rl). 4. REGIONAL ACTION PLAN FOR THE TOBACCO FREE INITIATIVE IN THE WESTERN PACIFIC (2010-2014): Item 12 of the Agenda (Document WPRJRC6017) Introducing the draft Regional Action Plan for the Tobacco Free Initiative in the Western Pacific Region (2010-2014), the REGIONAL DIRECTOR explained that, since 2005, all eligible parties in the Region had ratified the WHO Framework Convention on Tobacco Control (WHO FCTC), the first public health treaty in the world, which reaffirmed the right of all people to the highest standard of health through an international regulatory framework to control tobacco. WHO had recently completed a consultative process with countries, experts, stakeholders and partners toward the new plan being presented to the Regional Committee, which would guide the Organization's work for the following five years: The Regional Action Plan for the Tobacco Free Initiative in the Western Pacific
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(20 I 0-2014). The plan contained clear guidance on what had to be done to achieve complete implementation of the WHO FCTC. Although the Western Pacific Region had already made significant progress in tobacco control, being the only Region to date to have achieved 100% ratification of the Framework Convention, there was still a need to move forward. For that reason, the draft Regional Action Plan provided clearer guidance as to precisely how Member States could implement the Convention. The plan set measurable targets and indicators for tracking progress. It also detailed specific strategies which could and should be adopted to counter the influence of the tobacco industry. The Regional Director called on the Regional Committee to consider and endorse the draft Regional Action Plan for the Tobacco Free Initiative in the Western Pacific (2010-2014) as a guide for action in the following five years and to use the plan as the basis for strengthening WHO's efforts in countries. The meeting rose at 12:00.