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The work of WHO in the South-East Asia Region: Forty-third annual report of the Regional Director, 1 July 1990 - 30 June 1991

October 30, 1991 World Health Organization

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Chapter 15 SUPPORT SERVICES Organizational Structure The organizational structure of the Regional Office, as of 30 June 1991, is given in Annex 1. 15.1 GENERAL Seminar on Management and Administrative Procedures in WHO A Seminar on Management and Administrative Procedures in WHO, vis-a-vis country programmes, was held in Yangon, Myanmar, from 22 to 24 October IVM. Thc objcclive of thcSeminar was togive oricnlation to national health staff onvarious aspects related to management and administrative procedures of the Organization lor cffeclivc planning and management of government1WHO collaborative programmes. Participants were central-level staff of the Ministry of Health involved in the planning, implementation and evaluation of governmentiWH0 collaboralive programmes. Visitors and Visits Dr H. Nakajima, Director-Gcneral, WHO, visited the Regional Office in September 1990 in connection with the forty-third session of the Regional Committee. During his visit to Thailand, the Director-General presented the HFA gold medal lo Her Royal Highness Somdech Phra Srinagarindra Boromarajonani, Princess Mother of Thailand. During his visit to Indonesia, the Director-General presented the HFA gold medal to H.E. Mr Soeharto, President of Indonesia. Other important visitors to the Regional Office during the year included: H.E. Mr 1.K Gujral, Miter ofExternal Affairs, Government of Indii; HE. Dr M.P. Shestha, Minister of Health, His Majesty's Government of Nepal; H.E. Dr Kim Yong Ik, Vice-Minister of Public Health, DPR Korea; H.E. Dr G. Dashzeveg, First Deputy Minister of Health, Mongolian People's Republic; H.E. Mr Rasheed Mascnd, Minister of Stale for Health and Family Welfare, (;overnment of India; Dr J.R. Hanncssy, President, International Commission on Irrigation and Drainage, UK; H.E. Mr B.C. Gangopadhyay, Secretary-(kneral. Afro-Asian Rural Reconstruction Organization, New Delhi; Prof Demissie Habte, Director, International Ccntre for Diarrhoea1 Diseases Research, Bangladesh; Dr A.K.N. Sinha, President, Medical Council of India; Dr B. Ramamurti Presidcnt, National Academy of Medical Sciences; Dr Arvind M. Shah, President, Indian Medical Association; Mr R.N. Mirdha, President, lndian Federation of UN Associations; US Congressman Mr Jim McDcrmolt, accompanied by Mr Charles M. Williams, Legislative Director, and Mr Miles Lackey, Legislative Assistant; Mr S.J. Rana, Ag Secretary, Ministry of Health, His Majesty's Government of Nepal; Mr R.L. Misra, Secrelary, Ministry of Health and Family Welfare, Government of India, and Dr C. Gopalan, Presidcnt, Nutrition Foundation of India. The Regional Director attended thc International Conference on HIV/AIDS in Asia and the Pacific, held in Canberra, Australia, from2 to 8AugustIY)O. In March 1991, the Regional Dircctor visited Havana, Cuba, to attend thc Third International Seminar on Primary Heallh Care. During the year, the Regional Director visited Geneva to attend the fifteenth and sixteenth sessions of the Programme Committee of the WHO Executive Board, the thirtieth session of Global ACHR, the eighty-seventh and eighIy-eighth sessions of the WHO Executive Board, the Director-General's meetings with the Regional Directors and the Forty-fourth World Hcalth Assembly. Within the Region, the Regional DirectorvisitedPyongyangin October 1YX)loatlend the Fifth National Conference on Acupuncture and Moxibustion, and held discussions with the national authorities on the WHO collaborative programme. He also visited Thailand, Myanmar, Nepal, Sri Lanka, Maldives and Indonesia to have discussions with the national authorities on WHO collaborative programmes in the respective countries. The Regional Director also joined the Director-General on his official visits to Thailand and Indonesia. Meetings Attendedllnaugorated by the Regional Director The Regional Director inaugurated and participated in a number of important meetings, symposia and workshops - national, regional, and intercountry - as well as those organized by other agencies. He delivered a lecture on "Relevance of Research on Primary Health Care" at the Central Drug Research Institute, Lucknow (India), the Dean's Lecture at the London Schoo\ ol Hygiene and Tropical Medicine, U.K., entitled "Health Problems and Programmes in Asia, with particular reference to WHO'S activities in the South-East Asia Region", and the Public Lecture organized by the Indian Socicty on Tobacco and Hcalth, New Dclhi. 15.2 PERSONNEL As of30 June 1991, the Regional Office had 135 established professional posts in thc South-East Asia Rcgion as comparcd lo 133 on 30 June 1990. Tahlc 12shows the numhcr of postsin thc prolcssi(~nnl cntcgory in the Region, fundcd from all sources, and the number actually filled as of30 June 1991 Table 12. Nlr~ilber ofprofessiurlalposls, by localiur~, us of 30Jlllle 1991 . . I~~lablishcd Posts frozen Filled hy appointment' 61 Still to lbc lilled: A list of projccts in npcration during thc year is included as Anncx 2. ol which: (a) candldatea rclcclcd (I,) candidates yet lo he aelcrted During the period under rcview, 183 consultants were cmploycd in various projccts for periods rangingfrom one week to 11 months. This represents decrease 016.67 pcr ccnt in the number of consultants employed, compared with the previous year. Fourteen professional and 12 gcncral scrvicc slall mcmhcrs scp:rratcd from WHO scrvicc. 1 10 .I 8 5 18 Three professional and one general service staff membcrs left the SEA Region on reassignment to other regions of WHO or other UN Agencies. Three professional and two general scnice staff members died during the year. As of 30 June 1991, 57 nationals were employed on Spccial Service Agreements Staff 1)evelopment and l'raining At a meeting of the SDTCommittce, held on 27 November 1990, the SDT plans and activities of the Regional Office were reviewed with the Programme Manager of the Staff Development Programme from WHO headquarters. About 40 staff membersin the Regional Office have been trained in 'WordPcrfect'. It is hoped to continue the training so that the majority of the secretarial staff arc ahlc to handle correspondence through word processors. The computer training of selected general service staff from the WHO Representatives' offices and the Regional Office was continued. Trainingwas imparted to three general service staff in desk-top publishing and to one general service staff in stores management in August 19'90. Three WHO Representatives participated in the Interregional Seminar for WHO Representatives, held in Gencva from 22 October to 2November 1990, and one WHO Representative-designate attended a similar seminar in Geneva from 27 May to 7 June where Director, Programme Management also participated as facully member. A stalf training seminar for new professional staff was organized in the Regional Office on6 Novemhcr 199010 providc orientation into theOrgani.t.ation's procctlurcs on report writing, linancial and personnel management, etc. A Senior Staff Management Seminar was organized on 23-24 Noveml~cr 1990 a1 Surajkund, near Delhi, to promote and encourage the sharing of ideas and experiences in areas of coordinating role of WHO Representatives, external resources mobilization, and human relations in staff management. Three professional staff attended thc On-entry Group Briefing organized in WHO headquarters - two in February 1W1 and one in June 1W1. Mr R. Gieri, Secretary, United Nations Joint Staff Pension Fund, New York, visited the Regional Office in February 1991 and held discussions on pension matters with the Support Programme staff. He also addressed a meeting of staff from WHO and other UN Agencies, including UN pcnsioncrs. 15.3 GENERAL ADMlNlSTRATlVE SERVICES Kegional Oflice Ruilding The installation of a second standby generator was complelcd in carly l'Nl and it is fully operational. I1 provides full back-up for all Regional Office electrical rcquircments. The upgrading of fire prevention and safety installations is in the final stages of completion. The standby 80 KVA uninterrupted powcr supply (UPS) has been commissioned to provide power back-up to all computers functioning in the Regional Office. Old cables connecting all the power points in the main building have been replaced with new cables. Also, new distribution boards with miniature circuit breakers (MCB) have been installed to upgrade the old eleclrical powcr system. The lift in [he Annex to the main building has been upgraded by providing a micro-processor control unit. An addilional projjccl to renovate and upgrade the existing telephone system in the Regional Oifice was approved by the Forty-third World Hcalth Assembly in May l!BOandis expected to be implcmcntcd during 1991. Office Automation Efforts arc being conccntratcd on the development of computer programmes for routine activitics handled in Personnel and Medical Supplies Units, which will lead to more outpu~ and saving of staff time. A Local Area Nelwork (LAN) is proposed to be installed in the Regional Office. The initial planning for LAN has been completed and orders placed with the suppliers for the purchase of hardware. This will become operational during 1991. Training in desk-lop publishing (DTP) has been organized for staff with a view lo preparing documents such as bullains, publications, books, clc., in-house. 15.4 BUDGET AND FINANCE The planned programme budget for the biennium 1990-1991 is US$80.7million from regular hudgcv,and the total,includingearabudgetary resourcesandv<>luntary funds, US$ 112.4 million. Thc lolal obligations for the period 1 January 19W to 30 June 1991 under all sources of funds, amounted to US$81 G93 672. Even though the Organbation is facing somc financial stringencies on account of currency fluctuations and tremendous cost escalation, it is expected that the planned programmes in countries will be implemented successfully. Since extrabudgetary resources (UN or otherwise) are made available during the course of the year, thc total extrahudgefary resources for the Region will also be finally much more by the end of the biennium than that shown at present. The regional Administration, Finance and Informalion (Af'l) system completed one year of successful operation. For the first time, the Regional Office provided its annual closure, as of end-December I'H, on the AFI sydem. Wilh the training of staff and through the process of "learning by doing", initial difficulties arc bcing overcome. In this connection, support was obtained from WHO headquarters, EURO and From staff of the Western Pacific Regional Office. External Auditors External Auditors visited thc Regional Office in April 1Yll and discussed lhcir observations with the Support Programme staff. 15.5 SUPPLIES AND EQUIPMENT Medical supplies and equipment worth US$ 15 802 521 were procurcd during thc period July 1'30 - June 19'91. Figure 4 shows the procurement trends in rcccnl ycars. Apart from conventional items, such as drugs, laboratory equipment, hospital equipment, surgical instruments and office equipment, etc. , an increased number of requcsts For diagnostic kits and supplies wcrc processed during this period under lhc (ilobal Programme on AIDS. In tho area of health literature, the period a)n~inued to witness a signilicanl number of requests for CD-ROMs, particularly for projects related to medical research and environmental health. CD-ROMs, medical literalure and publications worth US$574 190 wcre procured, of which WHO publications accounted for US$30 802. In accordance with WHO'S Global Action Plan on Management, Maintenance and Repair of Health Carc Equipment, while proccssingrequests for sophisticated health care and laboratory cquipmcnl, aflcr-salcs aspccls, such ;is installation, maintcn;~ncc and availability of sparc parts to cnsurc long-term operational benefits to thc projccts wcre given full consideration. Emphasis was also laid on reducing delivery time and exploring cosl-effective alternatives for items requested. Local purchase, wherever feasible, was encouraged with a view to reducing delivery time and establishing direct contact with suppliers. As a rcsull of signilicant savings that accrued due to procurement of supplies from Figure 4. Procurement Trends Jul 88-Jun 89 = Total P, Jul 89-Jun 90 Perlod rocurement $Sf$ Lot Jul 90-Jun 91 :a1 Purchase lowl sources, available at cheaper alsts, projects could hc provided with more supplies within the budgeted amounts. Emergency Supplies To meet requests from Member Countries arising out of emergency situations such as epidcmics and calamities, supplies were arranged against rcquests from B;ingl:ladesh, Maldives, Mongolia, Myanmar and Sri Lanka. I'urchases Under the Revolving Fund and on a Reimbursable Basis Bangladesh, Bhutan, India, Myanmar, Nepal and Sri Lanka availed of the Organization's procurement services under its Revolving Fund scheme and on a rcimhursahle hiisis.

I I Section Ill i HEALTH SCIENCE AND TECHNOLOGY Chapter 7 RESEARCH PROMOTION AND DEVELOPMENT INCLUDING RESEARCH ON HEALTH- PROMOTING BEHAVIOUR The objcctives of the regional research programme are to strengthen national research capabilities and to promote and coordinate research activities on regional priority health problems, including those on socio-behavioural and economic aspects pertaining to health. In this endeavour, the WHO South-East Asia Advisory Committce on Health Research (SENACHR) serves as the main advisory body to the Regional Director on matters of policy. The Regional Office also receives technical advice from the subcommittees oISEA1ACHR as well as scientific working groups convened by the Regional Director from time to time. The biennial mcetings of Directors of Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relcvant Ministries (MRCs) serve as an important means of obtaining the views of Member Countries on the strategies for research promotion and development in general as well as information on the implementation status of specific research programmes. The scventccnth session of SENACHR was held in Yangon, Myanmar, from 21 to 27 April 1091. It reviewed the regional research programme as well as the report of thc Regional Office on the broad range of activities being undertaken to provide information support for research, especially the functioning of the HELLIS system, as well as the efforts of the Special Programmes. The Regional Office identified weaknesses in the HELLIS system, especially in the linkages within the countries, and SENACHR made a number of recommendations to further strengthen information support for research. SEAIACHR was also informed of the consultative meeting to 58 THE WORKOP WHO IN SEA .- develop criteria for the appraisal of HSR project proposals. Three sets of attributes for the appraisal of projects were described: the scientific, utility and contextual. Based on this framework, criteria pertaining to each one of these attributes were developed. SENACHR appreciated the importance of this consultative meeting for the development of health systems research in the Region. The framework and criteria for the appraisal of HSR will help in identifying HSR projects which are scientifically sound and relevant to user needs, and will be useful for promoters, supporters and evaluators of HSR as well as researchers themselves. The technical subjects discussed at SEAIACHR covered areas of research in health care delivery in villages and slums, research in the control of cancer in developing countries, and research into youth (and adolescent) behaviour as related to health. In discussing the follow-up actions to the WHO Technical Discussions at thc Forty-third World Health Assembly on the role of health research in the strategies for HFNW, and the World Health Assembly resolution on the subject, it called upon institutions andscientists in thecountries to respondeffectively to the challenges contained in the Assembly resolution and recommended that WHO cooperate with countries in developing national plans of actions in response to the resolution. ACHR also discussed the need to identify a strategic plan for its own activities for a period of five years and agreed on the need for greater emphasis in providing advice for research capability strengthening, especially with respect to overcoming the difficulties of translating the aims and objectives into practical programmes. This strategic plan would be linked to the operational paragraphs of the Assembly resolution. Theseventh meeting of Directorsof Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries (MRCs) was held in Kathmandu, Nepal, from 4 to 9 November 1W. It reviewed the collaboration between WHO and medical research councils in the South-East Asia Region, and affirmed that the present practice of conveningregular periodicmeetingsof Directors of National Medical Research Councils is useful and should be continued. Participants at the meeting were of the opinion that efforts should be made at the national level togenerate a climate conducive to the development of research culture. It was important to develop the infrastructure necessary for implementation of the recommendations of the meetings of Directors of Medical Research Councils while nationalmechanisms should be established for the coordination of research activities. Regular meetings at which the research community and health care managers arc fully represented would further the achievement of these objectives. In discussing the role of health research in the strategies for HFNUXW, the MRCs meeting endorsed the call for action embodied in the World Health Assembly resolution and the viewpoints expressed in the preamble. The meeting further called upon medical research councils and analogous bodies to respond effectively to the challenges contained therein, and agreed that health systems research is essential for every country irrespective of the level of economic development and is not a luxury. Participants called for the formulation of a plan for national action to respond to the Assembly resolution. They alsodiscussed mechanisms to promote national capability for self-sustained research and the role of traditional systems of medicine in health care delivery. In response to the importance of nutrition in Health for All strategies, the Regional Office supported a meeting of concerned scientists inThailand. The first Consultative meeting of the South-East Asia Nutrition Research-cum-Action Network took place in Thailand in August 1990 One of the major objectives of this Network was to help bridge the gap between rcsearch scientists and health managers. The former often felt that decision-makers could make better use of their results in planning nutrition programmes; the latter, on the other hand, feel that more research to help solve operational nutrilional problems should be undertaken. The other objectives of the Network include the identification of major nutritional problems in the South-East Asia Region; strengthening of nutrition research- cum-actioncapabilities; promotion of selected priority research-cum-action nutrition projects; promotion of training programmes; and cxchange of experts, scientists and programme managers to facilitate realization of the above objcctives and to share information on priority nutrition research-cum-action matters of mutual interest and concern to the countries of the Region. Several priority operational issues in nutrition at the primary health care level, and amenable to research-cum-action projects, have been identified jointly by Member Countries and collaborating centres. Four important areas identified are: weaning foods to overcome protein-energy malnutrition in young children, anaemia in pregnant women, reduction of the prevalence of vitamin A deficiency and nutritional monitoring. The Regional Office will support some of the Network activities. The dengue haemorrhagicfever (DHF) vaccine development programme, supported by the Regional Office, has been progressingsatisfactorily at the WHO Collaborating Centre for Dengue Haemorrhagic Fever (DHF), at the Department of Pathology, Mahidol University in Bangkok, Thailand, where work is in progress on the development of dengue vaccine and immunological reagents. Since vaccine development is a major project being supported by the Regional Office, a peer review mechanism has been set up to provide direction in this research effort. The Eighth WHO Peer Review meeting was held at the WHO Collaborating Centre for Research on the Immunopathology of Dengue Haemorrhagic Fever, Mahidol University, Bangkok, Thailand, on 29-30 September 1990. One hundred and fifty-nine human subjects have received one or more of the candidate attenuated vaccines. There have been no disabling untoward effects, and up to 90 per cent of subjects have 60 - THE WORKOP WHO IN SEA seroconverted and maintained neutralizing antibody for a period of years. After a review of the datapresented, it was recommended that another trial of the trivalent vaccine be conducted in flavivirus nonimmune adults using the dilutions of vaccine in a total volume of 1.0 ml. The members also recommended that once an acceptable combination of Dengue 1,2 and 4 vaccines is found for adults, a study may proceed in children. The dengue vaccine development programme is now receiving international recognition. The sixteenth session of SEAJACHR, held in April 1990, reviewed the research programme in tuberculosis and recommended renewed thrust and intensification of research. Based on this recommendation, the Regional Office convened a meeting of a Task Force on Research in Tuberculosis in December 1M. At this meeting, lacunae in the research programme in relation to the problem of tuberculosis in the Region were analysed and research protocols dealing with nine important areas were developed. These included the identification of risk factors for diseases; the risk factor for infection; operational research for improving the cure rate; programme monitoring and disease surveillance; assessment of the protective effect of BCG revaccination; the role of X-ray examination of the chest; centralized sputum examination to improve the quality of coverage; the use of combined drug tablets for the treatment of tuberculosis; and operations research for the attainment of a high cure rate in district TB control programmes. These protocolswill be circulated to the countries for their consideration and use in promoting research on tuberculosis. The Regional Office continues to support investigator-originated as well as collaborative research projects. A total of 34 new research proposals were received in 1990 and, up to March 1991, eleven had been funded. Seventeen projects are still awaiting revision by the Principal Investigators and further review. Sixty-seven research projects are currently being supported; of these, 38 are concerned with communicable diseases (acute respiratory infections, dengue haemorrhagic fever, diarrhoea1 diseases, Japanese encephalitis, liver diseases and malaria), 3 with environmental health, 4 with health of the elderly, 6 with health manpower development, 7 with maternal and child health, one eachwith mental health, nutrition, operational research and primary health care, and 5 with other things. Research capability strengthening has been an inherent part of the RPD programme from its inception. Fourteen awards were made for Visiting Scientist Grants and Research Training Grants during the period 1990-1991. The fields of research of these grants were tuberculosis, hepatitis, diabetes and statistical methods, among others. There are a total of 66 active WHO collaborating centres with a wide scope of functions ranging from health programme development to cardiovascular diseases. Some 20centres are related to the programme areas of disease prevention and control as compared to 16 centres concerned with diagnostic and therapeutic technology. A KLSMKCH PROMOTION AN11 DI.VFI.OPMF.NT 61 -- Directory of WHO Collaborating Centres in South-East Asia, giving the terms of reference, institutional profileand information on thegeneral activities of the Centres as well as on the specific activities undertaken as a WHO Collaborating Centre was published in 19!M. Thc South-East Asia Regional Office now lays grcatcr emphasis on thc promotion and development of hci~lth systcms research. A separate budgcl line has been provided for l!M-1991 for the strengthening of rcscarch capability of institutions in the Region, especially for undertaking hcalth systems research through a system of providing institutional strengthening grants (see Section 3.3 for details). The Research Promotion and Development programme of the Regional Office thus encompasses activities ranging from promotion of research through scientific meetings to research capability strengthening through the provision of visiting scientist grants and research training grants; establishment of WHO collaborating centres; promoting mechanisms for rcscarch promotion and development at the national level; and providing direct support to research projects, including projects initiated and monitored by the various technical units in the Regional Office (details of which arc provided in the respective reports of these units). However, this is only one facet of thc total rcsedrch effort of WHO. These activities have to he considered together with sevcral other inputs. Substantial contributions arc also made by the various WHO Special Programmes such as the Programme for Research, Dcvclopment and Training in Human Reproduction (HRP), the Programme for Research and Training in Tropical Diseases (TDR), and the Global Programme on AIDS (GPA). In addition, some Member Countries utilize the WHO country budget to promote and support research activities. It is clear that the total of all efforts for research promotion and development is considerable.

Chapter 10 PROTECTION AND PROMOTION OF MENTAL HEALTH 10.1 PSYCHOSOCIAL AND BEHAVIOURAL FACTORS IN THE PROMOTION OF HEALTH AND HUMAN DEVELOPMENT Collaborative efforts continued to focus on the identification of families most in need of assistance for health protection and promotion, and on the development of interventions within the PHC infrastructure to reduce the impact of these risk factors on the well-being of mothers and on the healthy development of children. A draft manual on special psychosocial skills which may help to improve coping capabilities and well-being of mothers has been prepared. The impact of such counselling support on cognitive development and nutritional status of children in risk families is being evaluated in a multicentric study, with the support of the Indian Council of Medical Research (ICMR) and UNICEF. In related work, the same psychosocial skills are being evaluated in families where malnutrition in a child has occurred and in families which, according to the results of a previous Regional Office coordinated multicentric study on psychosocial factors in malnutrition, are likely to generate malnourished children. It was considered appropriate to add this complementary study because the predictive value of the Home Risk Card for childhood malnutrition was found not to be sufficiently high since only about 20 per cent of the variance was found to be shared between HRC scores and the nutritional status of children. It is hoped that through these intervention trials in families at risk of generating childhood malnutrition and in families where malnutrition has already occurred, effective psychosocial interventions to reduce childhood malnutrition will be developed, in addition to 76 I'Hli WOKK OF WtiO IN SEA gaining more insights into the behavioural causation of childhood undernourishment. So far, groups/centres in India, Indonesia, Sri Lanka and Thailand have committed themselves to implement these studies. These study protocols were developed during an intercountry meeting of investigators in Jakarta in November 1990. In a further study, the impact of similar psychosocial interventions is bcing evaluated in risk families where one of thc home risks is alcohoVdrug abuse in the father. This complementary study to the two related studies above was considered appropriate because it is felt that some additional specific interventions can be developed for such families. They include simple harm reduction efforts as far as the alcohoVdrug abuse of the father is concerned. The outcome measures for evaluation are again scores on the subjective well-bring inventory (SUBI) of mothers, and cognitive dcvclopmcnt and nutritional status of children, in addition to a measure of thc severity of the alcohol/drug-related family problems. In this set of multicentric studies, previous Regional Office coordinated work on subjective well-being, on home risk for healthy child development, and on psychosocial factors in childhood malnutrition, havc now converged on the development of interventions which hold promise to effectively reach the hithcrto unreachcd or unreachablc. A second lntcrcountry Workshop on Social and Bchavioural Research lor the containmcnt of AIDS was hcld in Madras, India, in October 19'H). Spccilic intervention trials for female and male sex workers and for prison inmatcs wcrc developed and are bcing implemented in some parts of India, Indonesia, and Sri Lanka. It still seems very difficult to find investigators or 'strcet-corner- epidemiologists' willing to collect related qualitative, intervention-linked data on homosexual men, another high-risk group which has been, in many industrialized countries, the first in which HIV infection took roots. To date, no country in thc Region includes this group in sentinel surveillance for reasons of lack of access to, and collaboration with, this community. 10.2 PREVENTION AND CONTROL OF ALCOHOL AND DRUG ABUSE The UNFDAC-supported and WHO-executed drug abuse control programmes in Myanmar and Sri Lanka havc continued with satisfactory rates of implementation. A project document for a second phase of the Sri Lankan project has been prepared and additional funds have been provided by UNFDAC on an ad hoc basis to bridge the time until the beginning of the second phase, without interruption of the activities. Equally, the project activities in Myanmar, which, according to the projcct document, arc to end in June 1991 will continue with unspent project funds. The project may continuc into a fourth phasc, its importance havingincreased with the spread of HIV PI<OIWIION AND PROMOTION OF MENTAL HEALTII 77 infection in injecting drug users. The UNDP-funded project to establish a monitoring system of drug use in Sri Lanka has been extended for one more year with substantial additional funds. This project will then merge with the UNFDAC-supported project for demand reduction. The latter was favourably reviewed on the occasion of a tripartite review, and considerable expertise in drug use and dependence has now accumulated in Sri Lanka. Also, innovative ways of community involvement and the use of volunteers have successfully been explored. An agreement to WHO execution of demand reduction programmes has been signed between the new Division of the Programme of Substance Abuse (PSA) in WHO headquarters and UNFDAC, now merged into the new and comprehensive United Nations International Drug Control Programme (UNIDCP). It is hoped that, following thisgeneral agreement, WHO-coordinated demand reduction programmes can start in other countries of the Region, especially in Bangladcsh and Nepal, where preliminary explorations of thc possibilities for collaborative programmes have takcn place for several years. The HIV epidemic has led to the acceptance of the new approach of harm minimization instead of the insistence of full abstinence from drugs in some affected countries. Thailand has takcn the lead in this direction by evaluatingthe effectiveness of methadone mi~intenancc as a means of protecting drug users and their sexual partners against AIDS, and tcsting out programmcs of bleach decontamination of injection cquipmcnt and ofcducational programmes to reconvcrt injecting drug uscrs to inhaling. Thcsc approachcs arc all the morc important because drug users have bccn shown to havc an esjiecially high transmission capability to other population groups by virtue of their often high sexual promiscuity in the early phases of drug use, and their frequent involvement in sex work. Alcohol abusc lcads to substantial hcalth problems in a numbcr of countries of the Region. Howcvcr, thesc problems tcnd to have a low visibility in vicw of the high polilical visibility of thc abuse of illicit drugs and of lohacco. Some innovative approachcs towards a reduction of harm due to cxcessivc alcohol use havc bccn initiated in India, partially supported by WHO, in Sri Lanka, and in Thailand. Such activities need more attention. In Sri Lanka, amodulc on substance abusc is hcingdevcloped and tested for inclusion into the curricula of mcdici~l schools, with WHO support. 10.3 PREVENTION AND CONTROL OF MENTAL AND NEUROLOGICAL DISORDERS Recognizing the importance in terms of lasting morbidity and family burden due to mental disorders, and aware of the need to share experiences and expertise in this field, six countries of the Region have specific country programmes within the WHO country budgets, and a further three have explicitly included mental health in their umbrella PHC programmes. WHO continues to focus its collaborative activities on the development oi national mental health programmes. WHO-supported workshops in India and Sri Lanka have reviewed and updated their national mental health programmes. However, as in thc past, such programme reviews have not always avoided the pitfalls of recommending to others what they should be doing rather than focusing on a detailed formulation of what should be done in the actual situation and with the existing resources. Also, the participation of mental hospitals in provincial or district mental health programmes is still limited or non-existent in some parts of the Region. A reorientation of postgraduate training in psychiatry towards public mental health is under serious consideration in Indonesia and in Sri Lanka.

Chapter 9 PROTECTION AND PROMOTION OF HEALTH OF SPECIFIC POPULATION GROUPS 9.1 MATERNAL AND CHILD HEALTH, INCLUDING FAMILY PLANNING WHO'S collaboration with Member Countries in the delivery of an integrated MCHJFP component of primary health care continued in close liaison with UNICEF, UNFPA and professional and nongovernmental organizations. An emphasis on maternal care, initiated after the International Conference on Safe Motherhood, was evidenced by all countries of the Region during the reporting period. Increased efforts, including the encouragement of meetings at the country level, are being made by the Regional Officc to work out appropriate strategies and plans of action for functional integration of associated child health programmes, such as EPI, CDD and ARI, into MCH. Efforts now being directed at improving maternal health have focused on the need to adopt a holistic approach in the delivery of MCH services. While more emphasis is being laid on perinatal care as a whole, some specific problems in the early neonatal period, namely birth asphyxia and hypothermia of the newborn, are receiving closer attention. Both conditions have specific adverse effects on low birthweight infants and, given the high incidence of low birthweight in the South-East Asia Region (the average is approximately 25 per cent), these conditions assume great importance. Though accurate data are not available, estimates suggest that about 1.2 million infants die and an equal number suffer from brain damage each year in developing countries due to birth asphyxia. Interventions being promoted commence during pregnancy and delivery with the detection of risk factors, followed by proper management of birth asphyxia and prevention of hypothermia, strengthening of 68 THE WORK OF WHO IN SEA referral systems, training and operational research. Specific reference needs to be made to two studies supported by WHO, namely, a hospital-based study on thermal control of the newborn in Nepal, and a community-based KAP study of delivery practices related to the management of birth asphyxia and hypothermia in Indonesia. An extensive a$sessment oC maternal care was launched by Indonesia in the last quarter of 19% The one-year WHO-executed project titled "Development of a National Strategy and Plan of Action for Safe Motherhood is the first step in the assessment process. Expected outputs include a systematic assessment of midwife training curricula, facilities and development; an analysis of existing constraints (socio-cultural and other) impeding the effective delivery and utilization of services; specific provincial strategies for reducing maternal mortality in high-risk groups; and a five-year plan of action with resource estimates for achieving set targets. Both national and international consultants have been fieldcd for the review and assessment activities. After the August 1990 National Seminar on Safe Motherhoodin Maldives, plans havc been drawn up to train medical officers and senior community health workers in essential obstetric functions. In addition, recognizing that child-spacing is an important factor in the reduction ofboth maternal and infant mortality, senior family health workers have been upgraded with three months' intensive training in order to supply contraceptives a1 the island level and to supervise and assist foolhumas (traditional birth attendants) in safe delivery practices. To further reduce maternal mortality in Mongolia, emphasis is being laid on child spacing, with senior medical officers visiting China and the Republic of Korea to exchange information and gain experience. The objectives of a newly-formulated UNFPA project "Strengthening of Family Health Services" in Mongolia (1992-1995) include increased use of modern contraceptive methods, training of doctors at the Aimak and inter-Somon levels in modern contraception and evaluation of thc impacl of population-related activities. A national conference on family planning and safe motherhood is being planned for the third quarter of 1991. The family planning programme in Bhutan has been expanded with the use of long-acting injectables after successful clinical trials in three areas, and medical officers will be trained in non-scalpel vasectomy. Under a special project in maternal health care, Bangladesh plans to train 62 doctors in essential obstetric functions. The project "Family Planning Clinical Supervision Team" continucs to assist the Government of Bangladesh in the maintenancc of quality of voluntary sterilization and clinical contraceptive se~ces. The project had its final four-partite review in March 1991. A reduction of infant mortality has been seen in most countries of the Region as a result of the collaborative child health activities that have been undertaken. During this reporting period related activities have included postpartum care and

Chapter 6 PUBLIC INFORMATION AND EDUCATION FOR HEALTH Information and Education for Hcalth, recognized as an integral component of thc hcalth care systcm, was further strengthened through various collaborative projects with Member Countries. The recommendations made at the lntercountry Consultation on Health Education Strategies in South-East Asia in the Context of HFA/2OlW, with spccial reference to the Prevention and Control of AIDS, held in the Regional Office in Dccembcr 19W, should providc the necessary impetus to the programme. The recommendations covcred, among other aspects, thc functions and roles of hcalth educators and the strategies to bc adopted to make hcalth education more cffccctive in the current decade. Senior health education officials from all the Member Countries of the Region participated in this important Consultation. At the country level, WHO'S collaborative activilies were aimed at strengthening the hcalth education infrastructure, training, production and use of health education materials and involvement of the media. To facilitate IEH activities in thc Rcgion, countries were providcd with necessary audiovisual equipment, public address systems, vehicles, teaching books and journals. There is however a strong need to make health communications more effective in the Region by improving interpersonal communication techniques, and with more appropriate use of the media. Local broadcasting and audience research are particularly needed. New directions include building alliances with other 52 THE WORK OF WllO IN SEA development sectors, including nongovernmental organizations, women and youth groups. In Bangladesh, steps are beingtakcn by the Ministry of Health to integrate thc Bureau of Health Education with the Family Planning Unit, while in Bhutan, an IECH (Information, Education, Communication for Health) Bureau will be established shortly. Toexpand the availability of trained human resourcesin health education, fellowships to provide short-term training, master's certificates and diplomas in health education were availed of by Bangladesh, India, Indonesia, Myanmar, and Sri Lanka. Activities are also taking place to rcvicw training programmes and health education curricula, as in Thailand, and provide in-service orientation courses to sanitary and health inspectors, as in Bangladesh. Hospital health education is also gaining attention; various programmes in hospital health education were conducted in Sri Lanka and technical guidance was provided in Maldives. In keeping with the growing awareness of the need to strengthen school hcalth education in the Region, a case report on school health education in Nepal has been added to the list of reports received earlier from four other countries - India, Indonesia, Sri Lanka and Thailand. InSri Lanka, trainingwas imparted to300teacher trainers from the Education Department. Intersectoral collaboration for school health education is conceptually accepted but there is an urgent need for strong advocacy to further strengthen joint involvement of the health and education sectors. With WHO collaboration, health education organizations in the Region continue to produce a wide range of prototype health education materials, including video films, as in India and Thailand. In Thailand, efforts are also being made through training workshops to mobilize folk artistes to carry health messages. Health hehaviour research is being planned in Myanmar while other research activities include conducting studies on the utilization of health education materials and the compilation of an annotated bibliography on health and health education in India. Field tests of tools developed in Bangladesh for undertaking evaluative studies in health education are also being undertaken. In Thailand, research into the country's history of medicine and public health is being undertaken with the production of a pictorial document which will contribute to future public health policy and development. To optimize material production and use, there is an urgent need for intrasectorai collaboration between the health education bureaux and other health programmes. Thisis alsonecessary for more planned efforts in reaching messages out to the people. PIJIII.IC INFORMATION AND EDUCATION I'OR HFAL.TH 53 As in previous years, specific activities were carried out on HIVIAIDS education and counselling. An intercountry Workshop on Developing Counselling Procedures and Materials for Prevention of AIDS was held in New Delhi in November 19%l and was attended by counsellor traincrs and health personnel from nine countries. This was followed by a national workshop on counselling skills in Maldivcs for health workcrs, tcachcrs, the mcdia, national security service personnel, NGOs, etc. Tcchnical guidance was also provided for the establishment of a national cancer control programme in Maldives. Incollaboration with the World Assembly ofYouth (WAY), it is planned to further involve youth in health through an intercountry workshop focusing this time on their mobilization for the prevention and control of AIDS. With the health education bureauxlunits in Member Countries as focal points for the production and dissemination of information and education materials in the national AlDS prevention and control programmes, a wide range of both public information and education materials, as well as training materials for health and other workers have been produced. In addition, seminars for women's groups, teachers, etc., have been organized. A campaign against AIDS through the trade unions is being organized in Thailand in collaboration with ILO. The Sri Lanka AlDS Health Education Programrnc was reviewed and assessed in June 1991. Anti-smoking cducation programmes were particularly significant during the period under rcvicw. Thc World No-Tobacco Day was observed across the Region on 31 May 1991 In Bangladesh, India, Indonesia and Thailand, anti-smoking activities were specially reported in the areas of surveys conducted on various aspects of smoking, awareness raising programmes in schools, exhibitions, media competitions and national conferences. In Bangladesh, the Health Education Bureau provided leadership in a number of action areas including a ban on advertising of cigarettcs ovcr thc mcdia and a ban on sponsorship of sports activities by tobaccomanufacturing firms. Nominations for the 'Tobacco or Health' medals were received from Bangladesh, Bhutan, Indonesia, Myanmar and Thailand. Involvement of the media for IEH in Member Countries has accelerated with the increasing use of radio, TV and newspapers in disseminating health information. Journalists and media persons in Indonesia and Sri Lanka were provided orientation on important health issues through regular media seminars. World Health Day, No-Tobacco Day and World AIDS Day generated extensive media interest in the Member Countries with wide coverage of important health-related issues in newspapers, and by radio and television. These days were observed equally enthusiastically by nongovernmental organizations and academic institutions involved in health and health-related work through exhibitions, talks, seminars, rallies, essay and painting competitions, etc. Information kits on the themes pertaining to the days were distributed throughout the Region by the Regional Office. Two additional kits on 'Safe Motherhood' and 'Drug Dependence - The Dead End', prepared by the Regional Office, were also distributed. A special issue of World Health magazine dcvotcd to thc South-East Asia RL~' ' 71on and with contributions from nationals was published. The folio containing a sample of health education materials developed in the Region for the Prevention and Control ofAIDS, published earlier, was reprinted to meet country requests as was the briefing booklet, Essence of Cooperation. World Health Day this year focused on Disaster Preparedness and evoked widespread interest in the Region, by the governments, media, academic institutions and nongovernmental organi/ations. To mark the day, activities reported from thc countries included exhibitions, seminars, health talks, poster and painting competitions, panel discussions, etc. Information kits on the theme were widely distributed and adapted in the Member Countries. The Regional Director's World Health Day broadcast was beamed by All lndia Radio tomany countries in thc Region and tapes of the broadcast as well as the Director-General's message, both for radio and television, were sent to Member Counlries for their use. Information on WHO'S activities was provided to an increasing number of pcoplc through briefings in the Regional Office as well as through the provision of materials, includingvideo tapes, to various government and nongovernmental groups. A source book of health education materials for drinking water supply and sanitation projects is being prepared. Collaboration with other agencies continued. Together with UNICEF and UNFPA, WHO is part of the resource group responsible for the design and display of an exhibition based on the small family norm and age at marriage lo be pul up at thc India International Trade Fair in New Dclhi in November 1991. In Octoher I'Ml, WHO contributed to ESCAP for their Regional Plan of Action in support of Education For All. The WHOIUNESCO AIDS Education and Health Promotion Materials Exchange Centre for Asia and the Pacific, established at UNESCO PROAP in Bangkok, issued, in January 1991, the first edition of a resource directory containing organizational profiles and an inventory of materials received from India, Mongolia, Nepal and Thailand. The Region participated in the Pacific Rim Youth Conference organized by the Students Initiatives in Community Hcalth in Sydney, Australia, in August 19%. Health administration and health education specialists from countries and the Regional Office participated in the 3rd International Conference on Health Promotion, Sundsvall, and in the XIV World Conference on Health Education, Helsinki, held in June 1991. . - Health Education The emphasis of health education and information activities is on helping people to protect and promote their health. Involvement of women and children in IEH activities is increasingly beina strenothened in the Region. Nutrition Promoting theuseofappropriateand available weaningfoods is a major emphasisof health workers in the~r interaction with mothers to tackle the severe problems of undernutrition in the Reg PIJIII.IC INFORMATION AND EDUCATION FOR 11EALTIX 55 Health promotion for the staff of the Regional Office received special attention. Beginning with a panel discussion on an integrated approach to health promotion activities, including creating staff awareness on lifestyle diseases and their prcvention are being carried out. Even though health education has contributed to a significant cxlenr to the health litcra~y of the populations in the Region, new directions and strategies must be considered to mobilize communities for health action. Advocacy roles for health educators and efforts towards social mobilization for health must receive special attention.

Chapter 4 ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE Since thc concept ofacomprehensive healthcare system based on the primary health care approach has become the main thrust for total health development, all the Member Countries of the Region have madc great efforts in reorienting and restructuring their health system infrastructure, which is an essential element of national strategies for attaining the universal goal of HFN2000. Further efforts have been made to promote appropriate organization and effective operation of the comprehensive health systems, so as to provide efficient health care to the entire population. Special efforts have been made to improve health infrastructure and increase health care coverage in the unserved and undersewed areas. WHO has continued to collaborate in these national efforts to achieve the goal of HFN2000, and considerable resources have been allocated from donor agencies in this endeavour. All countries of the Region had adopted strategies that call for social and political action, such as leadership development, restructuring health organization, including decentralization, empowering people, alternative health care financing, reaching the unreachcd, strcngthening planning and management capabilities at (he district level and below, adoption of appropriate technology, etc. Greater emphasis had been placed on the transformation of these strategies into reality. 1. Reorientation of Health Systems Infrastructure In the era of the worldwide economic crisis, the countries of the Region, especially thc five least developed ones, are reviewing their current patterns of resource 34 THE WORKOF WHO IN SEA allocation in the health sector and reorienting their spending priorities, including the allocation of any additional resources in support of primary health care giving preferential attention to the underprivileged. As the target of HFAI2000 is moving closer, it is necessary to achieve total population coverage by health infrastructure based on primary health care. However, budgetary and infrastructure constraints and the lack of adequate and suitably trained human resources hinder programme implementation. Efforts are being made to identify practical problems and constraints being encountered in the implementation of HFA strategies as well as ways to overcome them. WHO'S efforts are aimed at initiating, developing and strengthening district health systems based on primary health care, through technical and policy meetings, seminars, conferences, training workshops, reports, guidelines and manuals. The intensification of health development, focusing on the district level, has been pursued with commendable results. Efforts are being made to achieve greater equity in the distribution of health facilities, especially in rural and urban populations. Health care coverage through the health infrastructure has increased in almost all countries as a result of improvement of the planning and management process, especially at the district level. In Indonesia, Myanmar, Nepal and Thailand, WHO has not only used the standard conventional approach of providing tailor-made planning and management training for improving specific services, but also used the 'learning-by-doing' approach wherein the national core group of staff are involved in planning, management, monitoring and evaluation, with the technical support and collaboration of experts. The product of the latter approach is a firm understanding of management methods, and a realistic programme plan or project proposal which can be used for funding and management. The experience gained thus far indicates that health development programmes aimed at serving the most seriously undersewed and vulnerable sections of the population - should receive priority. It is, therefore, necessary to give greater attention to social relevance as also to the management of the health care revolution by combining high technology with the primary hcalth care approach and using the existing health infrastructure with an integrated approach to optimize the use of available resources. Due attention has been paid to thc development of human resources for health through training and retraining of health workers, includingvolunteers. It is also being stressed, in the planning and implementation of health programmes, that greater involvement of sectors other than health should be secured, as well as much more involvement of the community. ORCiAN17A'l'lON OF 1IEAI.TH SYSTEMS EASED ON PtiC 35 WHO collaborated with all Member Countries of the Region in enhancing their capabilities to plan, manage, and evaluate health development programmes at the district level and below, particularly through micro-planning and middle-level management training, and transferring knowledge and practices through practical manuals, so as to help district managers play a leading role. WHO support in Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand also involved a review of district health development, promotion of research-cum-action- oriented programmes for strengthening community involvement and intersectoral coordination. In order to improve understanding of the scope of self-care and current practices in the home, an operational framework for the promotion of self-care at home, in the context of primary health care, was developed, and critical obstacles as well as strategies to be undertaken by countries were identified. The Regional Office has plans to initiate field research in Member Countries. In Thailand, WHO is supporting further expansion of local initiatives for self-managed primary health care by local communities dealing with various health problems. WHO also supported Myanmar, Bangladesh and Thailand in the development of a proper referral system at various levels, primarily at the first referral level. Planning and evaluation workshops were held in Bangladesh, Myanmar, Nepal, Sri Lanka and Thailand to re-examine the health care systems. Fellowships in hospital planning and administration, medical stores management, nursing and medical care, including specialized medical care, were awarded to nationals from Bangladesh, Bhutan, India, Indonesia, Sri Lanka and Myanmar. Support was also provided to national authorities for the preparation, revision and production of hospital procedure manuals in Bangladesh and Myanmar. A Hospital Sanitation Manual was finalized and printed in Indonesia for distribution to district hospitals. In-country training on advanced biomedicaVclinica1 engineering and practical maintenance of modern electromcdical equipment was supported through consultants in Bangladesh and Myanmar. 2. Strengthening ot1)istrict Health Systems Countries of the Region are being supported in reviews of their health system infrastructures, especially in the development of district health systems and in finding measures which lead to better planning and management. The focus of improvement has been on the integration of programme delivery, coordination within the sector as well as with other related sectors, and increasing population coverage aimed at reaching the underserved and unreached populations. Activities carried out in the first year of the biennium contributed to health development at the community and health centre levels and aimed at improving the capability of local-level health staff 3h THE WORKOF WHO IN SEA in respect of planning and management and also at improving the quality of health services. WHO continued to support the development of district health systems in Member Countries. Assistance was provided to Bangladesh for improving operational management at the Upazilla level, and the country is now expanding its activities to eight districts. Technical support was given to Sri Lanka for strengthening the three-tier health care delivery system at the district level. A consultant was assigned for the development of the district health system in Nepal. Model district health projects, such as the Mongar project in Bhutan and PHC strengthening in the Huvsgul Aimak of Mongolia, were getting into their evaluation stages, and wereshowing their success in achieving the targets. A modeldistrict health system was being developed in the Regional Office to assist the countries in reviewing district health development and in accelerating the developmental process. Mechanisms for the self-assessment of district health development were progressing in Indonesia through the stratification of performance of health centres, and in Thailand through the Basic Minimum Needs movement. Research capability of the WHO Collaborating Centre in District Health Systems in DPR Korea has been strengthened through the provision of some equipment, study tours for staff and research grants. Under the UNDP project 'Intensification of Action Programme for Primary Health Care', baseline surveys have been completed and national and district health development work plans developed in all the countries. An integrated learning module, prepared by the Regional Office, was used in training health managers, supervisors and workers in the project districts. Workshops for health managers were held in all the participating countries. In-service training of health workers and health supervisors has also been conducted using integrated learning modules. Training in laboratory diagnosis for the control of diarrhoea1 diseases and acute respiratory infections has been completed in Bangladesh, Bhutan, DPR Korea, India, Indonesia, Mongolia, Nepal, Sri Lanka and Thailand. Nongovernmental organizations, especially women's organizations, are closely involved in project implementation in Bangladesh, Bhutan, India, Indonesia, Mongolia, Myanmar, Sri Lanka and Thailand. An evaluation of the project showed that significant advances have been made, resulting in the strengthening of primary health care, and concluded that this was an extremely ambitious project with high objectives, and that important results had been obtained. It was also seen that chances of real success and sustainability are much higher with efficient management at the country level. Some countries, e.g. Bangladesh, DPR Korea, Indonesia, and Thailand, appreciative of the favourable outcome of this project, are considering plans for sustaining the efforts and action as well as replication to additional districts. Health System Infrastructure Member Countries are organizing effective health systems strengthening their health infrastuctures and increasing coverage, especially in underselved and unsewed areas. numan Resources for Health Member Countries are givlng due attention to the appropriate training of all categories of health personnel. The effective utll~ratlon of different types nf health learning materials is also recognired as being crucial for the successful implementation of health development programmes. ORGANIUTION OF HFALTH SYSTEMS BASEDON PHC 37 Indonesia and Thailand have been implementing health development activities with the support of community participation and intersectoral action. They are now embarking on policy formulation in other sectors with a view to reducing the negative impact on health. Thailand is now stressing environmental issues, drug abuse and AIDS, while Indonesia is dealing more with urban slum issues and how to reach the unreached. In Sri Lanka, the Janasaviya movement, with its health component, the Suvasaviya programme, is being supported. 3. Community Participation The main thrust of the health development programme relies upon the extent of community involvement. Many of the WHO collaborative programmes in primary health care are geared towards it. The Posyandu approach in lndonesia is an extension of health care delivery organized by combining the services of health centres. Community participation in terms of volunteers for health activities under primary health care is progressively expanding. WHO support continued for the training of ten-household health workers and their trainers in Myanmar, while in Bangladesh the training of community health volunteers, selected on a neighbourhood basis, was initiated. Nearly two-thirds of the health volunteers were women, reflecting a social change at the village level. Fellowships to nationals from India, Sri Lanka, and Bangladesh were arranged for studying community involvement in health development, with emphasis on community health financing and basic minimum needs, in Thailand. 4. Urban Primary llealth Care WHO supported a nation~~l workshop in Indonesia in March 1W to discuss the development of urban health care delivery system. This was followed by a country case study of three selected big urban areas to study the issues and implications of public policies and urbanization, the results of which were submitted to a national meeting held in May 1991. WHO also continues to support Thailand in its application of the PHC development model in low-income urban communities and in the community financing scheme in two urban areas of the country. Support was provided to Bangladesh for a rapid assessment of urban health needs, designing of the health se~ces, and formulation and implementation of an action plan for the population of an urban slum area of Dhaka municipality.

Chapter 11 PROMOTION OF ENVIRONMENTAL HEALTH Countries of the Region continue to accord high priority to community water supply and sanitation in the contea of primary health care. There is, at the same time, in many countries, agrowing awareness of environmental problems and their close links with health and socioeconomic development, particularly in those countries experiencing rapid urbanization and industrialization. Concern for pollution of drinking water resources from toxic chemicals and solid and hazardous wastes is receiving increased attention in the Region. Many countries, while continuing to pursue the goal of safe water and sanitation as part of HFN2000, have also initiated activities related to the improvcment of environmental health in rural and urban development and housing, prevention and control of health hazards from environmental pollution, chemical safety and control of poisoning, health risk assessment and risk management, environmental epidemiology and food safety. To assess current scientific knowledge on the consequences to human health of environmental factors linked to socioeconomic development, the Director-General of WHO established a high-level technical expert Commission on Health and Environment. The Commission has focused its attention on environmental determinants affecting hcalth in the areas of energy, industry, urbanization, food and agriculture. The report of the Commission, likely to be available later this year, is expected to suggest general strategies to prevent or mitigate adverse effects of the changing environment on health. The Commission's report will not only form thc basis for WHO'S newglobalstrategy for environmental health, but will also be WHO'S input to the 1992 UN Conference on Environment and Development. WHO participated in the ESCAP Ministerial-level Conference on Environment and Sustainable Development, held in Bangkok in October 1990. The Conference reviewed the state of the environment and policies in Asia and the Pacific, and 80 THE WORK OF WHO IN SEA endorsed the broad framework for regional strategy for environmentally sound and sustainable development in Asia and the Pacific region, issuing a ministerial declaration to that effect. 11.1 COMMUNITY WATER SUPPLY AND SANITATION A Global Consultation on Safe Water and Sanitation, held in New Delhi inSeptember 1990, reviewed the International Drinking Water Supply and Sanitation Decade (1981-1990) and issued the New Delhi Statement that appealed to countries for concerted action to enable people to obtain the basic needs of safe drinking water and environmental sanitation. The New Delhi Statement's challenge was "Some for all, rather than more for some", and it recommended four guiding principles for countries in formulating strategies for the 1990s. These strategies were: environmental protection to safeguard health by integrated management of water resources and wastes; strengthened institutions for sustainable development; community management empowering people to own and control their systems; and sound financial practices for better management. Following up on the Global Consultation, countries of the Region are engaged, with WHO support, in a comprehensive review and evaluation of Decade achievements and shortfalls to be addressed in preparing their sector strategies for the 1990s and beyond. This information will be an input to the new WHO global strategy on community water supply and sanitation, which is a component of the new global environmental health strategy that is being developed. Countries and external support agencies have been urged to collaborate to formulate and implement action plans to incorporate the guiding principles of the New Delhi Statement. Consequently, WHO collaborated closely with the UNDPtWorld Bank Decade programme on water supply and sanitation by assisting in the preparation of sector review and development documents, development of MIS and an information management system to strengthen national planning and coordination in the sector, and in areas of environmental sanitation and drainage. As a result of the agreement between WHO and UNICEF to jointly support country-level water supply and sanitation monitoring for improved sector management, WHO is supportibg the development of national sector information management within the framework of thc CESI micro-computer data base system. 1. Manpower Development WHO continued to support manpower development relevant to countries' needs through fellowships, special courses, observation tours within and outside the Region and through other group educational activities. PROMOTION OF ENWRONMEKTAL HEALTH 81 Training in the country of subprofessionals and professionals in low-cost sanitation, network design, handpump operation and maintenance and communily participation in the management of water supply and sanitation systems was organized in Bangladesh, India, Indonesia, Myanmar and Nepal. A workshop for planning in environmental health, based on the national five-year plan, and a seminar on health education aspects for community water users were held in Indonesia. A national-level workshop on the use of micro-computers for planning and design of water supply and sanitation facilities was organized in Bangladesh with the participation of engineers from Indonesia and Thailand. Training activities to strengthen village-level institutional development as part of the ongoing water supply and sanitation projects continued in Indonesia on handpump installation, rehabilitation of water supply systems, operation and maintenance as well as other aspects of health improvements. On-the-job training was provided in Mongolia in the operation and maintenance of wastewater treatment plants and in water quality laboratory testing. In Myanmar, evaluation workshops on latrine construction and on water supply and sanitation programmes at state and division levels were planned, and an orientation workshop on construction of latrines at the township level was held. A source bookof health education and communication support materialsfor drinking water supply and sanitation in India has been finalized. 2. Institutional Development Support was provided for thc strengthening of institutional capabilities in the areas of manpower development, management information systems, improvement of operation and maintenance, water quality surveillance and monitoring, etc. The institutionalstructure of the Department of PublicHealth Engineeringin Bangladesh was studied for improving its capability, especially in coordinating with other sector agencies. A water supply and sanitation sector review was carried out in Nepal and preliminary plans and programmes up to 2000 A.D. were formulated. The development of national water supply and sanitation management information systems was undertaken in Bangladesh and Nepal. Manuals for basic health workers for the operation and maintenance of sanitary latrines were being prepared in Myanmar. 3. Water Quality S~~weillance National standards and codes of practice for drinkingwater quality were revised and formalized in a ministerial decree in Indonesia. District laboratories in Bengkulu and Lampung provinces of Indonesia are being strengthened as part of the development of a model system for water quality monitoring and surveillance to be replicated in other Water quality laboratory equipment installation and training were provided in Mongolia as part of the development of the Central Reference Laboratory. 82 THE WORKOF WHOIN SFA 4. Research Research studies for the improvement of performance in the various aspects of water supply and sanitation were being carried out in India, Indonesia, Myanmar, Sri Lanka and Thailand. 11.2 ENVIRONMENTAL HEALTH IN RURAL AND URBAN DEVELOPMENT AND HOUSING Most SEAR countries are faced with the problems associated with rapid population growth and urbanization, resulting in squatter settlements, overcrowding in existing settlements and unplanned growth in urban peripheral and fringe areas with deteriorating environmental conditions and senices such as water, excreta disposal, waste water and solid waste collection as well as disposal facilities. A healthy city project proposal to improve environmental conditions and senices in slums and squatter settlements in five cities of SEAR was therefore prepared jointly with ESCAP for donor funding. The Regional Office has collected and reviewed solid waste management status reports from Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand and prepared an overvicw to be used as a background paper at the Regional Consultation on Solid Waste Management, planned for October 191. The Consultation will enable exchange of experience on solid waste management and formulation of a national agenda for action. In addition, a workshop on the same subject has already been organized in Kathmandu, Nepal, in collaboration with GTZ, in which officials from Bangladesh, Bhutan, India, Indonesia, Myanmar, Sri Lanka and Thailand participated. Waste water drainage is another common problem faced by most SEAR countries. A regional workshop on drainage is planned to be held jointly with the UNDPNorld Bank Water Supply and Sanitation Group in South Asia in late 1991 to discuss issucs and problems of drainage and evolve a regional drainage strategy. Country status reports and regional overview papers have been prepared. 11.3 HEALTH RISK ASSESSMENT OF POTENTIALLY TOXIC CHEMICALS WHO'S efforts in this sub-programme area were focused on technical cooperation for manpower training on riskassessment, dissemination of information on potentially toxicchemicals being used inSEAR countries, and oncontrolof environmental health hazards, food safety and workers' health. PROMOTION OF ENVIRONMWI'AL HEALTH 83 1. Manpower Training Anlntercountry Course on Risk Assessment/RiskManagement was held in the WHO Regional Office for South-East Asia, New Delhi, in October 1990, with participants from India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. The course included the IPCS teachingilearning module for risk assessment, emergency preparednesslemcrgency response, survey techniques, health monitoring and environmental epidemiology. A National Course on Health Risk Assessment in Chemical Safety, supported by IPCS, was also organized by the Directorate General of Drug and Food from 26 November to 1 December 1990 in Indonesia. A national Course on Environmental Epidemiology, sponsored by IPCS, was held at the Industrial Toxicology Research Centre, Lucknow, India, in October 1990. Participants of this course included medical inspectors of factories and people from medical colleges and statc pollution control boards. 2. Institr~tional Development Under the UNDP-assisted project "Safety and Control of Pollutants and Toxic Chemicals", the establishment of poison control centres supported by a data base on toxic chemicals was being implemented in India, Indonesia and Thailand. Hardware and software equipment were provided. Project formulation framework documents for UNDP assistance were prepared for Bangladesh and India. 11.4 CONTROL OF ENVIRONMENTAL HEALTH HAZARDS WHO'S collalx~ralion with Member Countries was mainly directed ar strengrhening institutional and manpowcr capabilities through technical cooperation and other support. The UNDP-funded intercountry project "Safety and Control of Pollutants and Toxic Chemicals" enteredits third year of operation and addressed the countries' respective priority problems of chemical safety and pollution. The second phase ofthe UNDP-fundedproject on "ControlofEnvironmenral Health Hazards" became operational in DPR Korea in April. The project is expccted to further upgrade the capability of the Central Hygienic and Anti-Epidemic Station in controlling pollution by toxic organic compounds or heavy metals from industrial and agricultural sectors. The municipality of Delhi, India, is pursuing the recommendations made by WHO in respect of the city's environmental pollution problems. 84 THE WORKOF WHO IN SEA 1. Manpower Training Management approaches for reducing health risks, hazardous wastes and chemicals were covered in the Intercountry Course on Health Risk Assessment and Risk Management, held in the Regional Office in October 1990. A second national workshopon intersectoral cooperation was held in Thailandin April 1991 with aview to strengtheningenvironmental control programmes related to indoor pollution from toxic chemicals. A course developed by the Regional Office for training trainers of community health workers in India in the diagnosis and treatment of pesticides poisoning was held in April-May 1990. Similar courses will be presented in Indonesia and Thailand later this year. A hvo-month special course on water and air pollution control aspects was organized in the Netherlands for ten officials of the Indian Central Pollution Control Board. 2. Institutional Development WHO assistance in water, air and soil pollution monitoring and control was provided to the Central Hygiene and Anti-epidemic Station Laboratory in DPR Korea. Computer hardware and software were provided for information management related to toxic chemicals and hazardous substances as well as other essential laboratory and field monitoring equipment for national programmes in India, Indonesia and Thailand. A data base on chemicals in use in Indonesia is being established in Indonesia with the assistance of a consultant. Another consultant assisted India, Indonesia and Thailand in preparing strategies on chemical emergency preparedness and emergency response. A third consultant reviewed hai-ardous waste management practiccs and recommended improvements in implementing waste management procedures in the industrial regions in India. 3. Global Environmental Monitoring Under the Global Environmental Monitoring System (GEMS), water quality monitoring activities continued in Bangladesh, India, Indonesia and Thailand. Air quality monitoring activities continued in India, Indonesia and Thailand. In connection with the preparations for the United NationsConference on Environmenf and Development in 1W2, the Regional Office assisted WHO headquarters in compiling information on air quality, and motor vehicle and energy-related air pollution in five megacities ofthe Region. Food contamination monitoring continued in Thailand. Health effects monitoring continued in Central Bombay, India, under the Human Exposure Assessment Location (HEAL) project. Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand are participating in the Global Environmental Health A new global community water supply and sanitation strategy veloped for better planning and implementation of sustainable sectoral activities to ensure safe adequate sanitation facilities for all. is being de water and Expanded Programme on Immunization Sign~fcant progress has becn madr in the Reglor1 towards ach~evinq the main object~ves of €PI and the goal of iln~versal Child lmniun17ation through an integratcd approach. Environmental Radiation Monitoring Network (GERMON) on monitoring levels of radioactivity in the environment. 4. Research In Thailand, various national studies are being carried out on such aspects as agricultural chemical use and effects, motor vehicle emissions, plant extract insecticides, environmcnt;~l problems in newly industrialized areas, and guidelines development for sca food-related wastes from households. 1 1.5 FOOD SAFETY WHO assistance to MembcrCountries in the field of foodsafcty covered aspcctssuch as strengthening of food legislation for monitoring and inspection of food contaminants, strengthening of laboratory facilities for microbiological and chemical examination, training of manpower on various aspects of food safety control pr~igrammcs, training of analystsichcmists and food inspectors, food standardization and control scrviccs, and dcvclopmcnt of information material for cducaling food manufacturers and user communities in food s;~fcty measures. The est;~hlishmcnt of intcrscctoral coll;~horation for effcctivc implcmcntation ofthc monitoringsyslcm and dcvcloprnent or harmonization of national food standards using the Codex Alimentarius standards wits emphasized. With a vicw to identifying possible arcas of WHO assistance to countries, the Rcgional Office initiated a study to assess national food safety programmes and prepare a regional overview with thc assislance of a consultant. Officials from Myanmar and Thailand participated in thc Codex mccting held in Rome in March 1991, while officials from India, Indoncsia and Thailand attended thc First Asian Conference on Food Safcty in Malaysia in September 1990, during which issues and stratcgics for the 1990s were dealt with. Nationals from Indonesia were awardcd fellowships to htudy food laws, standards and an;~lytical monitoring techniques. In Indoncsia, :I training course on food hygicnc was organized for food inspectors from provinces and another training course on quality control of manufactured food com~nodities was held for provincial food inspectors and administrative officers. Support was given to the preparation of training modules and health education in the subject. In India, food analystsichemists from seven state food laboratories were trained in the analysis of food additives and contaminants. In Sri Lanka, public health officials were trained in food inspection and sampling techniques and on lcgal procedures related to food safety. R(, 111E WOKKOF WHO IN SEA In Indonesia, an interministerial workshop on food standardization and control services was held in October 1990 with a view to strengthening inter-agency coordination. A revision of the national food sanitation programme was completed. The revised decree on the inspection and classification of eating establishments and food catering services was reviewed. The translation of the Codex Alimentarius and other relevant literature was completed. A consultant assisted in the strengthening of food inspection in low-acid canned food. In India, a review of food safety laboratories was completed and a chapter on the food laboratory was prepared for incorporation into the statutory provision of the national food laws. A training course on good manufacturing practices was developed and a manual preparcd for harmonizing national standards with Codex standards. Electronic laboratory equipment for the ccntral food laboratory was provided. 3. Information Support In response to various queries from governments, the Regional Office provided health-related information on such substances as the use of hexane as a cleaning solvent used in edible oil, brominated vegetable oil for soft drinks, food colouring for ice creams, sanitary practices for mineral water production and lactoperoxidasc for milk preservation.

Section II HEALTH SYSTEM INFRASTRUCTURE Chapter 3 HEALTH SYSTEM DEVELOPMENT 3.1 HEALTH SITUATION AND TREND ASSESSMENT The second evaluation of the implementation of strategies for Health for All by the Year 2000 was completed by all Member Countries before the target date of 31 January 1991. Country reports have been prepared in the countries by multisectoral working groups guided by coordinating committees, with ministries of health playing a leading role. These reports contain extensive analyses of the achievements and constraints in accordance with the reporting structure of the WHO Common Framework for the Second Evaluation (CFEI2). Comprehensive information on the monitoring and evaluation process and mechanisms, development of health systems, availability of primary health care, international cooperation, health and socioeconomic status as well as on research, technology, plans for future action and other developments and activities, show that the evaluation process is indeed becoming an integral function of national health management processes, and the findingsof this exercise are pointers to further action. TheRegional Office has prepared the Regional Report on Evaluation of the Strateby for Health for All by the Year 2000 (Eighth Report on the World Health Situation), based on country reports. The report consists of two parts - regional evaluation, and country reports. The latter part includes significant achievements of Member Countries in the implementation of HFN2000 strategies, as also the weaknesses of health information systems in supporting the decision-making process for health management. 24 YHL: WOKKOF WHO IN SEA It may be stressed that in some countries health programme managers still maintain health information in a vertical and compartmentalized manner. It also seems that not enough systematic renew is done by decision-makers, programme managers and operational health personnel at different levels to identify the information they need. These factors, as well as the poor quality of data and the lack of disaggregated information, often make it difficult to use the information at district and lower levels to identify priority managerial actions for underserved groups of population. Member Countries continued their efforts to strengthen their health information systems. The decentralization process taking place in some countries made it possible to make the existing health information systems less vertical and to improve the utilization of data at operational levels. More stress was laid on the generation and use of disaggregated information. Further steps have been taken in India and Nepal to extend the areas of operation of the new district-oriented health information systems which were pretested during 1988-1990. Collaborative efforts to improve the quality of mortality statistics are continuing in India, Mongolia, Sri Lanka and Thailand. The introduction of the 10th Revision of the International Classification of Diseases, which will come into use in 1993, should help to improve the quality of mortality and morbidity statistics. It seems that thc three-character version of ICD-10 will be the most suitable for the South-East Asia Region. Preliminary steps have been taken by Indonesia, Mongolia, Myanmar and Thailand to involve themselves in the application and strengthening of future trend assessment approaches and methodologies. Tentative methodologies to identify the underprivileged in health have been outlined. Epidemiological Surveillance WHO continued to collaborate with Member Countries in developing and strengthening epidemiological surveillance and services for the effective prevention and control of communicable diseases. The immediate requirement of this region is to meet the training needs of managerial, mid level and lower level health personnel in epidemiological surveillance in order to promote better use of epidemiology for health development. Activities during the reporting period were directed at making use of epidemiology as a management tool for disease surveillance and control, setting of priorities, and for programme evaluation. Most of the SEAR countries benefited through fellowship awards and provision of supplies and equipment for strengthening the existing epidemiological units at the national level. HIALTH SYSTEM DEVELOPMENT ?.5 Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand have specific programmes for promoting epidemiological surveillance activities. WHO supported external evaluations of the Field Epidemiological Training Programme (FETP) in Indonesia and Thailand. The first external evaluation of FETP in Indonesia was conducted from 25 August lo 7 September 1986, and in Thailand the first evaluation was held from 9 to 20 December 1985. In Indonesia, the second external evaluation was conducted from 16 July to 3 August 1990. The main recommendation of the second evaluation team was the institutionalization of FETP within the Ministry of Health. Because FETP represents long-term training, the administrative needs of FETP are best met by placing the programme within the Centre for Health Manpower Education. According to the evaluation team, the operational aspects of FETP should remain closely linked with the Directorate General for Communicable Diseases Control and Environmental Health (CDC and EH), in ordcr to make FETP an institution that is recognized as a structural entity and is accessible to all within the Ministry of Health. The evaluation team recommended the establishment of an ad hoc task force to facilitate follow-up of the evaluation recommendations and efforts to improve administrative and financial problems in order to attain self-sustainability after external assistance is withdrawn. The second external evaluation of FETP in Thailand was held from 29 October to I0 Novcmbcr 1YX1. The evaluation tcam found evidence of substantial achievements by FETP since the previous evaluation. Even though FETP in Thailand is a self-sufficient and sustainable programme, WHO continues to support it through country regular budget resources. The evaluation results showed that FETP has made distinct contributions in Thailand to improving public health. Examples include the establishment of the national HIVIAIDS weekly surveillance report, the epidemiological annual summary and the annual national epidemiology seminar (1990 was its eighth ycar). The Bangladesh Field Epidemiological Surveillance and Disease Control Project is supported by UNDP. his project includes the establishment of sentinel surveillance in 20 selected districts and various training activities for district epidemiological unit - - members and laboratory technicians of sentinel districts, with the assistance of an eleven-month consultant. In Bhutan, the epidemiological unit was strengthened through subsidy support to increase the outputs of epidemiological and information staff. In India, the National Institute of Communicable Diseases conducted a workshop on epidemiology training for district health offices, and a national official was included in the delegation to China in connection with an epidemiology workshop. In Indonesia, epidemiological surveillance training for all chiefs of district health offices was conducted from July to October 1W. Technical assistance was provided 26 THE WORKOF WHO IN SEA in the designing, conduct and analysis of epidemiological studies and/or workshops and curricula in epidemiology. A number of Indonesian officers received training through the fellowships programme and attended international meetings such as the FETP-INCLEN-IEA Meeting in Mexico. A long-term staff member assisted the Surveillance and Immunization Sub-Directorate in the translation of WHO training materials for sentinel surveillance. Project assistance has been directed towards the development of epidemiological studies for the prevention and control of AIDS through the establishment of a computerized data base. A series of five training courses for a total of about 400 district-level chiefs of surveillance and disease control were held between 30 July and 31 October 1990. In Myanmar, technical assistance was provided to the Epidemiological Unit in the strengthening of epidemiological surveillance and control of communicable diseases and in conducting in-service training of medical officers, through a consultant in October 1990. In Nepal, study tours and fellowships were supported with a view to strengthening training. In Sri Lanka, training programmes for senior officials on epidemiological surveillance were conducted during June-September 1990. Assistance was also provided for computerizing epidemiological information. In Thailand, support was extended for conducting a four-week introductory course in epidemiology for field epidemiologists. A national epidemiological conference was organized in August 1990. Through a technical services agreement the FETP project was supported in training field epidemiologists, strengthening epidemiological services and utilizing epidemiological information. 3.2 MANAGERIAL PROCESS FOR NATIONAL HEALTH DEVELOPMENT 1. Overview WHO collaborated in all aspects of the Managerial Process for National Health Devclopment. In most countries, review and formulation of national health policy, formulation of medium-term health plans in the context of economic realities, and a shift towards improving the management of health care at operational levels were noted. Keepinginview the constraints of the health sector and in pursuance of World Health Assembly andRegionalCommittee discussions and resolutionson the subject, WHO initiative on intensified technical cooperation was undertaken in Bhutan, Myanmar and Nepal. Support was provided for the formulation of medium-term IltAL'lH SYSTEM DEVELOPMENT 27 health plans in Bhutan, Indonesia and Thailand and an overall review of the present capacity of health planning units in the countries was undertaken. A number of activities to improve training and skills in health economics of staff in the ministries of health were supportcd. Studies to identify organizational and managerial constraints that limit the effectiveness of health care institutions were also undertaken. Spccific support to review the enactment of new health legislation was offered in two countries, while efforts to promote review and updating of old laws in support of health development were continued. 2. National IIealth Policies Most countrics reviewed t heir health policy, formulating and updating as necessary, and prepared guidelines for the implementation of their national health politics. There was new emphasis on equity of services, with particular concern for the health problems of the underprivileged. In Bangladesh, a national health and population policy was drafted and subjected to public debate. In Myanmar, WHO assistance was provided for a review of the national health policy and People's Health Plan in the context of changes in the hocio-political and economic situation. 3. National Ilealth 1)evelopment Plans All countrics continued lo formulate, implement and review their medium-term national health plans as instruments for implementing national health policies and strategies. WHO collaborated in the preparation of the health sector component of thc Seventh Five-Year Development Plan in Bhutan. In Bangladesh, support was provided for thc assessment of the rclcvance, progress and achievements of the health infrastructure and health services with a vicw to determining the nceds for thc Fourth Five-year plan pcriod (lW-1995). WHO also collaborated in the preparations for the formulation of the Second Long-Term Development Plan (1993-2018) and the Sixth Five-Year Plan in Indonesia. A number of working groups reviewed past experiences and made future projections for the next 25 years. WHO collaboration was provided for the development of an interim two-year National Health Plan (1991-92) in Myanmar. In Thailand, support was provided for the preparation of the Seventh Five-Year Health Plan (1992-97), following a review of the output of the Sixth Plan. In Nepal, a study on country health resources and priorities was completed, and support was provided for a comprehensive study for the reorganization and restructuring of the national health system to meet the Basic Minimum Needs and HFAi2000 goals. A Regional Consultation on Health Planning was organized in Bangkok from 3 to 10 June 1991 with the objectives of reviewing the current situation in health policy formulation and national health planning in Member Countries and formulating a 2R THE WORK OF WHO IN SEA regional plan of action for further development and strengthening of health planning mechanisms. The main components of the regional action plan included human resource development, research and development, institutional strengthening, information support and networking. There was a consensus on the restructuring of human and material resources and on the methodology of health planning in the changing context of economic, political and social conditions. The need to establish a regional institution on training in health planning was underscored. 4. Strengthening of Health Economics As a matter of high priority for Member Countries and WHO, alternative approaches to health care financing and mobilization of resources to build and sustain health infrastructures are being studied. At the same time, there has been a serious effort to improve efficiency and effectiveness of service with the available resources. The Regional Consultation in Health Economics, held in the Regional Office in October 1990 and attended by senior health economists and administrators of the Region, identified five main areas for action, viz. research and development, human resource developmcnt in health economics, information support, institutional strengthening and networking. Indonesia made significant progress in health financing by simplifying procedures in financial administration and instituting alternative financing such as compulsory health insurance for civil servants, workers'health care, and maintenance, etc. WHO has been collaborating in these efforts, and in the development of management audit methodology. An organization and management study, a detailed manual for recovering financial shortfalls, and training in auditing techniques and procedures were also~upported.~echnical assistance was providedto strengthen the information system for the coordination and monitoring of foreign assistance. Thailand commenced the training of Provincial Chief Medical Officers and Directors of community hospitals in health economics with WHO support. A cost analysis oE training of paramedical personnel in Khon Kaen, Thailand, is in progress. Research studies on different aspects of health economics have been developed and are being reviewed for funding by WHO. Myanmar developed proposals for alternative financing of health care in the course of preparation of the National Health Plan. WHO support has been provided to India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand in the field of training and research. Countries have utilized WHO resources in the development of manpower in health economics through fellowships, study abroad and in-country training activities. HEAL711 SYSTEM DEVELOPMENT 29 5. Intensified WHO Cooperation with Countries in Greatest Need In view of the serious economic problems faced by many developing countries, WHO took the initiative on intensified technical cooperation with countries in the greatest need. WHO headquarters and the RegionalOffice staff supported Bhutan, Myanmar and Nepal, who expressed interest in this new WHO initiative. In Nepal, with the completion of the study on country health resources and priorities, 1990.1995, with WHO support, draft proposals on human resource development and on health financing to increase the capacity of the Ministry of Health in economic analysis of health policies, including alternative approaches to health financing and accelerated development of the health information system, were prepared for WHO support. In Myanmar, health policy analysis, a country resource utilization review, and health care financing were the identified activities for WHO'S initial support. A framework For national hcalth development was the broad overall aim of these collaborative activities. The initiative on intensified WHO cooperation with countries in the greatest need is expected to act as an umbrella under which diverse programme activities will be integrated to support national health development. 6. Strengthening of Operational Management In most countries, extension and expansion of the health system infrastructure was so rapid that the management capacity came under strain. As a component of improved management of operations in the health services, the preparation and printing of a manual of office procedures on operational management and supervisory system was supported in Bangladcsh. Support was provided for job analysis ofvarious categories of hcalth personnel as well as development of job descriptions and introduction of the 'contract' systcm to encourage equitablc distribution and increased pr(iductivity of health worker5 in Indonesia. Also, astudy to identify organizational and managerial constraints limiting effectiveness of health centres was supported. A personnel administration data base was designed to support health manpower information systems. Support was also provided for the implementation of a uniform record system. Overall improvement in managcment has been accomplished with these activitieb. In Myanmar, management training modules have been developed and management lrainingcoursesorganized. In India, support wasprovidedforimparting hcalth managcment training to health workers at various levels, and to include managerial aspects in postgraduate training in preventive and social medicine. Workshops in planning and management and hcalth team building at the primary health care level were also conducted. Nepal received support for training in supervision, and for monitoring and evaluation in various districts; and Sri Lanka received support to review ongoing national and district-level monitoring processes andactivities. There was anencouraging trend ofimprovingoperational management 30 THE WORKOF WHO IN SEA in most countries though some countries have accomplished their objectives better than others. In the area of decentralization of decision-making, Member Countries have been engaged in the development and strengthening of district-based health systems. WHO support has been made available for detailed programming at regional, district and more peripheral levels and for the development of management information systems. Fellowships support has been provided to DPR Korea for training in computer applications for developing automated information systems. Assistance has also been provided for the translation of relevant MPNHD documents for use in the country. However, most countries need to make sustained efforts to strengthen district health management and undertake health services research in management for improving efficiency and effectiveness. 3.3 HEALTH SYSTEMS RESEARCH AND DEVELOPMENT In accordance with the recommendations made by the Regional Committec, the South-East Asia Advisory Committee on Health Research, the meetings of the Medical Research Councils and Analogous Bodies, the Global Advisory Committec on Hcalth Research and the Forty-third World Health Assembly, greater emphasis is now being laid on the promotion and development of health systems research in the Region. As part of this greater effort, a separate budgetary provision has been made for the strengthening of research capability of institutions in the Region, especially for undertaking health systems research. The scheme for institutional strengthening has now been implemented in Bangladesh, DPR Korea, Myanmar and Thailand, while consultations are being held with Ncpal. A more expeditious response and active collaboration to this initiative would result in more rapid and better implementation of the scheme, which, at present, has not taken off well. Another step in line with the ideaof strengtheninginstitutions for HSR is that of ajoint effort between the Regional Office and WHO headquarters with the objective of strengthening an institution in thesouth-East Asia Region so that it can bensed asa model for replicationelsewhere. An institutional strengthening grant has been provided to the ASEAN Training Centre for Primary Health Care Development at Mahidol University, Salaya, jointly funded by the Regional Office, WHO headquarters and other agencies, including Mahidol University itself. In order to establish health systems research within a more institutionalized framework, the Regional Office is promoting consultative meetings attended by senior administrators and scientists not only for the assessment of priority health systems research needs in Member Countries but also to identify multi-disciplinary HEALTH SYSI'EM DEVELOPMENT 31 research teams which will include personnel from ministries of health as well. Such national health systems research needs assessment meetings have been held in two countries of the Region. The WHO Collaborating Centre for Health Services Development (located at the Health Services Research and Development Centre in Surabaya, Indonesia) is engaged in the preparation of a detailed work plan for the next two years. The Centre will convene a more limited consultative meeting to asses health systems research needs in Surabaya province. As a further step towards institutionalizing health systems research, a consultative meeting to develop criteria for the appraisal of HSR project proposals was convened from 2 to 4 April 1991. At this meeting it was possible to construct a conceptual framework for the appraisal of health systems research (in contradistinction to biomedical and clinical research). Based on this conceptual framework, criteria for the appraisal of health systems research project proposals were developed. It was accepted by the consultative meeting that these criteria would be applicable globally at least as a general framework, and hence would be useful to various bodies concernedwith healthsystems research, both at national andinternational levels. The development of appropriate criteria and peer review mechanisms for the evaluation of HSR projects and results was one of the means suggested for its institutionalization by the panel on health systems research at the Technical Discussions held during the Forty-third World Health Assembly in May 1990, and this product is one example of Regional Office efforts to follow up on the resolution of the Forty-third World Health Assembly on health research. In fact, the Regional Office had already taken the initiative and presented draft criteria for discussion at the Interregional Workshop on Health Systems Research, held at Arusha, Tanzania, from 4 to 13 July 1W. Hcalth systems rcscarch projects supported from intercountry funds, during the period under review, covcr areas such as ageing, health manpower development, community participation, health care delivery and health economics. An attempt has been made within the Regional Office to incorporate health systems research in the research activities promoted by the technical units. Expert assistance was provided to Member Countries for research pertaining to health policy formulation and health planning, health management and utilization of health services, economic analysis of expenditure for health and family welfare services at the district level, and self-care. Three countries of the Region (India, Indonesia and Myanmar) have made specific provision for health systems research amounting to a total of US$260 000 for 1990 and US$196 700 for 1991 in their country budgets. The Regional Office actively collaborates with WHO headquarters as well as other bodies in promoting HSR, including the training of research workers. One Member Country and the Regional Office were represented at the Interregional Workshop on Health Systems Research ;it Arusha, Tanzania, where learning modules for research 32 THE WORKOF WHO IN SEA managers were tested. The Regional Office also co-sponsored, with the International Development Research Centre, a Symposium on Essential National Health Research on 4-5 March 1991 in New Delhi. Collaboration with other WHO programmes, such as the Special Programmes on Tropical Diseases and Human Reproduction, continues as before and has resulted in several health systems research projects, including field studies, being supported in the Member Countries. 3.4 HEALTH LEGISLATION The role of legislative support in the improvement of health policy formulation to provide guidance to national health development and plans of action is of great importance. Most countries are aware of this need for support. However, promotional efforts are still necessary. India and Indonesia had intensive collaboration with WHO. Support was provided to India for organizing workshops on health legislation, organ transplantation and brain death, which underscored the need for the enactment of law in the area of human organ transplantation. The meeting of an expert committee to review the Dentist Act and a workshop to update it also received support. A national consultant was assigned to suggest and draft amendments to existing acts and formulate proposals for ncw legislation. In Indonesia, support was provided for organizing a workshop on medical records and formulating draft legislation on informal consent. WHO support was provided to Mongolia for drafting a Tobacco Law which will be used to establish a tobacco control programme, prohibit advertisementsin tobacco and its products and establish non-smoking areas. In Nepal, the preparation of a document on health-related laws and by-laws has been supported. In its endeavours against discrimination to HIVIAIDS cases, WHO provided consultancy support to Thailand to review draft legislation on AIDS. The negative impact and futility of highly discriminatory legal measures in respect of HIVIAIDS was underscored during discussions with senior policy-makers, academicians, legal experts and nongovernmental organizations. Therc has been close collaboration with WHO headquarters in the promotion and support for renewing and introducting health legislation. Relevant documents and working materials have been distributed to Member Countries. There has been close collaboration with WHO headquarters, which has beenprovidingrelevant documents and working materials for distribution to Member Countries.

Section IV PROGRAMME SUPPORT Chapter 14 HEALTH INFORMATION SUPPORT 14.1 HEALTH LITERATURE AND LIBRARY SERVICES ( INCLUDING HELLIS) IleaIth Literatare, Library and lnfnrmatinn Sewices (HELLIS) The Regional HELLIS (Health Literature, Library and Information Services) Network is now estahlished in nine Member Countries. It has continued to provide relevant health literature information to users by the provision of free photocopies of rcfcrenccs that arc not available in counLries on request, including MEDLARSI MEDLINE searches. Through this rcsourcc-sharing mechanism, it has been possiblc for users in Member Countries to have easy access to both regional and international health science literature information. A complete MEDLINE data base (1966.10 date) on CD-ROM (Compact Disc Read Only Memory) has now been made available to HELLIS National Focal Point (NFP) libraries of Bangladesh, India, Indonesia, Myanmar and Sri Lanka. Efforts are being made to provide a complete CD-ROM MEDLINE data base along with the CD-ROM drive to the HELLIS NFPs of DPR Korea, Mongolia and Nepal. A Regional HELLIS Workshop was held from 29 September to I October 1990 in the Regional Office, including a HELLIS-ESCAP Joint session on 1 October 1'40, to review the status of the HELLIS system and the relevant recommendations of the 6th International Congress on Medical Librarianship (61CML), and to determine the training needs for effective introduction of newer technologies. The seventeenth session of ACHR reviewed the situation with respect to informalion support For rescarch and made a number of recommendations lor improvcmcnt. WHO also supported participation from Member Countries in the 6ICML as well as in a Pre-Congress Seminar. Unfortunately, the rising cost of books and periodicals has restricted the sharing of resources. Besides, there are weaknesses in the links between some parts of the network. The availability of MEDLARSIMEDLINE data bases onCD-ROM system has, to some extent, cnablcd difficulties previously encountered in rapid responses to requests for MEDLINE searches to bc overcome. The Index Medicusjor WHO Sourlt-East Asia Regio11 (IMSEAR) Volume 5, covcring 139 regional health science periodicals published in English, or with abstracts in English, from seven countries - Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand - has been compiled and published with the active participation of National HELLIS Focal Points. It contains 6 752 annotated citations and covers the period January-December 1985. Although access to health literature information and its availability has improved, further concerted efforts need to be made in the areas of adoption of newer technology and strengthening of resources of participating libraries of the HELLIS network in Member Countries. Regional Omce Library The Regional Office Library continues to provide technical inform;~tion/litcr~~turc support to WHO staff, Member Countries and other researchers as required by way of photocopies, loan of publications, MEDLARSiMEDLlNE searches, rcfcrcnce and current awareness services. As a part of HELLIS activities, the compilation of the Inder Medicus for WHO Sotrtlt-east Asia Region (IMSEAR) and publication of a HELLIS Newsletter were undertaken. Further progress in the field of automalion of library services has been made. It is expected to increase efficiency in bibliographic searches and response to requests. A complete MEDLARSIMEDLINE data base on CD-ROM has been installed in the Regional Office Library. The Library staff helped to organi~c the 6th International Congress on Medic:~l Librarianship and the Prc-Congress Seminar in New Delhi from 24 to 28 Scptcmhcr 1990 and the Regional HELLIS Workshop in New Delhi from 29 September lo I October 1993. 14.2 PUBLICATIONS AND DOCUMENTS The Chief of Distribution and Sales, WHO headquarters, and the Director, Medical and Health Information, Eastern Mediterranean Regional Office, visited the Regional Office and discussed matters of mutual interest. Two new titles and revision of one publication were issued under the SEAR0 publications series, while non-priced documents, including reports of various kinds, were produced and distri\)uted (Table 10). The sale of WHO publications increased over the previous year. Table 10. Prod~rcfiori of doc~mterlls, 199lX91 'I'ranslations and l'sblicutions Support was given to India for the translation of Cancer Pain Relief, and Guidelines for Nursing Management of People Infected with Human Immunodeficiency Virus (HIV), into Hindi, and for the translation of Adolescent Reproductive Health: An Approach to Planning Health Service Research, Treatment and Prevention of Acute Di:irrhoca, and The Conimunity Health Worker and Primary Child Care, into Bengali: 10 lndoncsia for tr;~nslati~n into Bahasa Indonesia of Anacsthcsia at thc District lIospit;~l, Concepls, Issues and Country Expericncc, Rapid Assessment of Sources of Air, (;cncritl Surgery at the District Hospital, Health Systcm Decentralization: Water and Land Pollution, Manual of Epidemiology for District Hcalth Management, The Community Health Worker, Drugs Used in Anaesthesia, Early Detection of Occupational Diseases, Respiratory Infections in Children: Management in Small Hospitals, Treatment and Prevention of Acute Diarrhoea: Practical guidelines, Manual of Radiographic Interpretation for Gcncral Practitioners, Conjundivilis of the Newhorn, and The Growth Chart; to Nepal lor translati<~n inlo Ncpalesc ol(;uidclincs for Nursing Managcmcnt ofPc<iple lnfectcd with HIV, (;uidclincs forTraining Community Hcalth Workersin Nutrition, Weaning from Breast Milk to Family Food: A Goidc for Health and Community Workcrs, Protecting, Promoting and Supporting Breastfeeding, Treatment and Prc\cntion of Acute Diarrhoea: Practical Guidelines, Food, Environment and Health: A Guidc for Primary School Teachers, and Nutrition Learning Packages: Joint WHOIUNICEF Nutrition Support Progriimme; and to Thailand for translation into Thai of Cancer Pain Rclicf, Educirtion for i-lc;ilth, (;uidclincs for Counselling ahoitt tI1V Infection and Disc;lsc, Appropriate Usc of Fluorides for Human Hcalth, Sclf-asscssmcnt for ManagcrsoSHcalthCarc: Howcanl hea Bcttcr Manager, Oral HealthSurveys: Basic Methods, and Prevention of Oral Diseases. The Regional Officeissued the fourthvolume of Reorientationof McdicalEducation, (SEAR0 Regional Publication No. 18) and the third volume of Research Abstracts (Regional Publications No. 16). The third edition of Clinical Management of Acute Malaria (WHO Regional Publications No. 9) was published. llrnl -. Asslgnn~enl rcports Reports of group educat~onsl activirles Terminal reports of UNDP projects l'oe~ Nunlher 91 28 - 12 131 - I'nges rdilrd 1821 1 M>3 - 513 3 097 I'iuges prinfrd 1 '126 786 - UJ 3 156 . Documents The loose-leaf List of Technical Documents Issued since 1979 was updated in January, and again in June, as also the Handbook of Resolutions and Decisions of the WHO Regional Committee for South-East Asia. Dengue Newsletter, Vol. 16, was issued. Lists of documents received from other regions and from other UN agencicc and distributed by the Regional Office were issucd periodically. Sales A number of approaches to achieve optimal dissemination of information under the Organization's publications programme were tried. These included participation in five important medical conferences, taking over of the marketing of WHO video cassettes on hcalth, a policy dccision to stock and market publications of all thc regions, and broadcning thc base of the distribution network through commercial channels. The five conferencesicongresscs where displays of WHO publications were arrangcd included the Global Consultation on Safe Water and Sanitation, New Dclhi, 10-14 September 1990; the 6th International Congress of Medical Librarianship, New Dclhi, 24-28 September 10!)0; the Sixty-sixth All-India Medical Conference, Ahmedabt~d, 25-30 December 10YO; the lntcrnational Symposium on Prevcntivt: Cardiology and Cardiovascular Epidemiology, New Delhi, 10-14 January 1901; and the Asian Conference on Health Care Management -Challenges and Response, New Delhi, 21-23 February JWl. The number of subscriptions registered in the calendar year 1930 increased by nearly 20 per cent over the 1989 figure. A regional catalogue of WHO video cassettes on hcalth was prepared and disseminated widely to mark the beginning of the distribution and sales arrangements for video cassettes. Negotiations started with selected distributors for appointing them as distributors of WHO publications. A record number of45 agrccmcnts covcring 51 titles were signcd granting reprint righ~s to puhlishcrs in respect of low-priced local editions of WHO publications. Details of the financial turnovcr during 1989-1W are reflected in Table 11. Table 11. Sales of WHOp~rblicafio~ls, 1989-1990 July 90-June 91 11s $ 63 3'15 126 231 - I89 626 - Ilrn, . Subscriptions Other p~lblieations Tot.11 NOTE The above figures represent actual receipts alter deduction of all discounts and applications ol canrcrional mnversion rate 01 (ieneva cover prices to Indian rupees. 1989 11s S 85 124 71 095 156219 1990 US $ 7') 3UX 81 409 160 717

Chapter 2 WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT 2.1 REGIONAL DIRECTOR'S DEVELOPMENT PROGRAMME The Programme continues to meet the special and emergent nceds or Member Countries in areas not covered by specific project activities. Several emergem situations arose during the year necessitating urgent and priority assistance under the Programme in resolving unpredictable health problems. The cyclone which lashed Bangladesh was the most devastating, causing extensive damage to life and property. WHO rushed emergency kits, drugs and other materials to the country. Resources under the Programme being meagre, and the magnilude of assistance nccdcd being large, WHO successfully coordinated the mobililation of international assistance for providing relief to Bangladesh. In the case of Maldives, which was affected by storm waterlsurges, emergency kits were provided to the country, and WHO coordinated relief efforts with UNDP, UNICEF, WFP and FAO. Assistance was also provided to Myanmar and Bhutan to mcct emergent needs (for details sec Section 2.4). 2.2 GENERAL PROGRAMME DEVELOPMENT The flexibility of programme management in WHO has been further streamlined to improve the responsiveness to national health programmes. WHO representatives, with WHO country-based staff, and with support from staff in the Regional Office and WHO headquarters, prondcd technical cooperation at the country level. The WHOSGENERAL PROORAMME DEVELOPMENT AND MANAGEMENT 7 joint government/WHO coordination mechanism, the Consultative Committee for Programme Development and Management (CCPDM) and the Country Support Teams (CST) continued to play important roles in the above process. Besides six-monthly review of the implementation of WHO'S collaborative programmes in the Member States, the CCPDM examined and endorsed an outline and frame for the preparation of annual detailed plans of action to be agreed between WHO and individual Member Countries, and addressed the issue of joint governmentiWHO evaluation of selected national health programmes. The CCPDM also reviewed the implications of the operational activities of the United Nations System at the country level, as provided in the UN General Assembly resolution 441211, and the likely inlplication of the financial situation of WHO upon the 1~-1Y~1 rcgional programme. The Regional Committee, at its forty-third session in 19!M, approved the outline and frame for the annual detailed plan of action to implement the programme budget for the 1992-1993 biennium. The two annual detailed plans of action in a biennial period replaced the erstwhile detailed biennial programme budget. This provided flexibility in the use of WHO'S resources, particularly at the country level, and allowed the specification of specific collaborative activities nearer the implementation period, taking into account thc actual rcquircmcnts. The Country Support Teams provided support to these activities. Realizing that the joint government/WHO evaluation of priority national health programmes carried out during 1984-1986 had been useful, the CCPDM, at its meeting in September lYM, recommended the continuation of the exercise during 1991-1993. The existing framework for the evaluation, with some modifications, was also endorsed by the Committee. The second round of joint programme evaluation commenced. The evaluation is intended also to cover the economic aspects of health programmes in terms of their utility and cost-effectiveness. The Regional Office for South-East Asia participated in the WHO initiative for intensified cooperation with countries and peoples in the greatest need. A joint HQ and Regional Office mission held extensive discussions in three countries and identified several country-specific priority actions to accelerate national health development plans. Preparations are afoot to mobilize and coordinate WHO'S own and external resources in support of the participating countries. The mission visited Myanmar and identified priority actions within the frame of intensified WHO cooperation. In Nepal, support was provided to complete a health resource priority study and the updating of an earlier country resource utilization (CRU) review. WHO support was provided for the preparation of proposals for a study on human resource development, financing of health services and accelerated development of health information systems. In Indonesia, a National Health Conference was organized by the Ministry of Health in February 1991 with a view to reviewing the 8 THE WORKOF WHO IN SEA implementation of Repelita V and to identify actions required to improve the quality and efficiency of services. The Conference was opened by H.E. Mr Soeharto, President of Indonesia. Assistance was also provided to Bhutan in the formulation of a national health manpower policy and strategy and in the preparation of the health sector component of the Seventh Five-Year National Development Plan as an input to the country's presentation in the Round Table Meeting to be held in 1992. The possibility of extending similar support to a few other countries in need is being studied. The preparation of WHO'S Ninth General Programme of Work for the period 1996-2001 has commenced. The Regional Office contributed to its preparatory consultation phase on the subject of the utility, use, programme classification and content of the WHO General Programme ofwork. The Regional Office emphasized, ir~rcr alia, the need to undertake meaningful consultation with Member Countries in order to contribute substantively to the natureand content of the ensuing NinthGPW. The Regional Office contributed ideas to the formulation of the conceptual and operational framework of a new health paradigm initiated by the Director-General of WHO, with a view to achieving the health-for-all goal in the rapidly changing political, economic and environmental conditions. 2.3 EXTERNAL COORDINATION FOR HEALTH AND SOCIAL DEVELOPMENT Extensive and effective United Nations interagency coordination and cooperation continued to influence development cooperation with Member Countrics, particularly in areas of major concern such as the deteriorating environment, the growing populations, and urban migration, persisting illiteracy etc. In 1990, WHO established a technical expert commission to prepare a comprehensive assessment of the consequences to human health of the current and anticipated environmental changes resulting from agro-industrial and socioeconomic development. This will be a contribution to the United Nations Conference on Environment and Development (UNCED) in 1992. The Regional Office participated in the global Consultation on Safe Water and Sanitation, marking the end of the Decade, to delineate the future strategies. WHO made technical contributions to the Ministerial Conference on Environment and Development, convened by ESCAP, to ensure a place for health concerns in the Conference Declaration. WHO worked closely with the UN Disaster Relief Organization and others in supporting the activities within the International Decade of National Disaster Reduction (INDNR), both at country and regional levels. WIIO'S GENEKAI. Pl<O(iRAMME DEVELOPMENT AND MANAGEMENT V The views expressed by the Regional Committee at its forty-third session on the implications of the UnitedNationsGeneral Assembly resolution 441211 were brought to the attention of the WHO Executive Board at its eighty-seventh session, held in January 1991. The Executive Board reviewed the regional committees' recommendations and urged WHO tocontinue its constitutional role in actingas the directing and coordinating authority in international health and to maintain its direct and privileged access to national health authorities. The Executive Board recognized that the Organization's existing mechanisms for the development andimplementation of its collaborative programmes were in consonance with national aspirations and their involvement, which the UN General Assembly resolution 441211, in essence, intended to promote. 1. Collaboration with the United Nations System United Nations Development Progrnrnme (UNDP) WHO maintained collaboration with UNDP in support ofhealth sector development within the broad areas of human resource development, transfer of technology, and institutional strengthening through UNDP-funded country and intcrcountry projects. Duringthe year,the RegionalOfficeexecuted 11 intercountryand36country projects with a total UNDP input of about US$5.6 million. Additionally, the Regional Office continued to participate in UNDP-funded interregional projects, namely, 'Technical Cooperation among ASEAN countries in Pharmaceuticals', 'Control of Diarrhoea1 ~is~ases' and reven en ti on and Control of AIDS in Asia and the Pacific' The WHOIUNDP alliance to combat AIDS provided the policy and operational basis for joint collaborative work at all levels. AlDS has emerged as a major public health concern. WHO gave extensive support to national medium-term plans (MTP) for the prevention and control of AlDS in collaboration with UNDP. WHO was involved in the interregional project to study development implications of HIVIAIDS in Asia and the Pacific funded by UNDP. WHO provided technical support for the health sector in the UNDP country programming excrcises in Indonesia, Nepal, Bangladesh and Myanmar leading to the determination of priorities and formulation of health sector projects. A comprehensive review conducted by a WHO team in Indonesia during 1990 resulted, i~lfer alia, in projects for safe motherhood and primary health care in Irian Jaya and Maluku. Other projects, in nursing education, environmental health and food safety, were in the pipeline. In DPR Korea, WHO collaborated in a UNDP project on Control of Environmental Health Hazard, as the cooperating agency. WHO also collaborated in the UNDP country programming excrcise in Maldives, Sri Lanka and Thailand. 10 THE WORKOF WHO IN SEA UNDP's new strategies aim at a sM from the project to the programme-oriented approach, concentrating on a few selected themes of development which could result in large programmes in the cooperation package. Under its changed programming process for the Fifth Intercountry Programme, UNDP started consultations with governments. These consultations are the entry points for the eventual inclusion of health programmes and projects in UNDP intercountry programmes. WHO has urged the national health authorities and the WHO representatives to articulate health concerns and priorities adequately in these consultations, with a view to mobilizing UNDP resources for the health sector. United Nations Population Fund (UNWA) WHO'S collaborative programmewith UNFPA continued to support national efforts in developing and strengthening the infrastructure for the integrated delivery of maternal and child care and family planning services. The Regional Advisory Team on MCHIFP and other technical units in the Regional Office provided technical back-up to UNFPA-funded projects in the countries. WHO participated in the UNFPA programme review and strategy development mission in Sri Lanka and also in the formulation, joint monitoring and evaluation of programmes and projects in response to requests from the governments and UNFPA. During the period under review, the Regional Office executed one intercountry and seven country projects funded by UNFPA, with a total budget of about USS1.4 million. UNFPA started significant changes in its programming and operational strategies for the programme cycle commencing in 1992. These include the setting up of Country Programme Technical Support Teams under the control and supervision of UNFPA which will replace the edsting Regional MCH/FP Advisory ~eam in the Regional Office. WHO is at present examining this proposal critically. United Nations Children's Fund (UNICEF) WHO and UNICEF worked closely together towards the common goals of child survival and development, maternal and child health, safe drinking water and sanitation. As a follow-up to the declaration bythe World Summit for Children, held inSeptember 1990, WHO has been collaboratingin the preparationof plans of actions for child survival and development in the framework of HFA strategies. Specific WHO-UNICEF collaborative actintiesin the Region during the periodwere the Joint Nutrition Support Programme (JNSP) in Myanmar and Nepal, the programme for accelerating the implementation of primary health care and the expanded programme on immunization. WIIO'SGENERAL PKCXjRAMME DEVELOPMENT AND MANAGEMENT I I WHO and UNICEF are participating in the 'Rural Cohort Study on Child Survival' in Maharashtra, India. The study is of four years' duration and will be completed in 1994. Collaboration was maintained through programme-specific informal meetings, joint reviews and exchange of information on issues of common interest. Economic and Social Commission forAsia and the Pacific (ESCAP) WHO collaborated with ESCAP in the fields of human resources development, integrated rural development, population, environment, drug abuse, and rehabilitation and in prcparing plans toameliorate the health problemsof Cambodian refugees. WHO identified institutions for providing the necessary technical support for the management of disaster-related emergency preparedness and response. WHO participated in a meeting with senior officials on Drug Abuse Issues in Asia and the Pacific, organized by ESCAP in Tokyo from 13 to 15 February 1991. WHO strongly supported the in~plementation of the Jakarta plan of action on human resources development, adopted in 1988. A new project proposal on drug abuse information system, with special reference to intravenous transmission of AIDS, was being formulated. WHO and ESCAP earlier implemented a joint project on the control of drug abuse. United Nations Ed~icntionnl, Scientific and Cult~~rnl Orgnnizntion (UNESCO) The Regional AIDS Education and Health Promotion Centre was set up jointly by WHO and UNESCO in Bangkok through an agreement. United Nations Fund for DrugAb~ise Control (UNFDAC) WHO continued to execute the health components of the UNFDAC-funded Drug Abuse Control Programme in Sri Lanka and the Drug Abuse Control Programme in Myanmar. WHO cooperated with the World Food Programme (WFP) in promoting health and nutrition components of WFP assistance and maintained close relations with other UN agencies, including the International Labour Organisation (ILO) and the Food and Agricultural Organization (FAO). 12 THE WORKOP WHO IN SEA 2. Collaboration with Development Banks and Funds WHO participated in the World Bank appraisal mission and collaborated in the formulation of its fourth population and health project in Bangladesh. In Nepal, WHO collaborated with the World Bank and UNDP in formulating a project on 'Strengthening Resources Allocation, Planning, Formulation and Implementation in Health Sector'. WHO also provided technical support to the World Bank in preparing the population and health project for Nepal, particularly in such components as MCH, malaria control and prevention of communicable diseases. In addition, the Organization collaborated with the World Bank in Indonesia and Thailand on health and health-related projects. The Arab Gulf Fund (AGFUND) has continued to support the WHO-executed programme for prevention of blindness and deafness. 3. Collaboration with Bilateral Agencies A number of health and health-related development projects in the Region werc supported by bilateral agencies. WHO-executed projects funded by these agencies were in the fields of epidemiology, leprosy, malaria, TB, biomedical research, etc. The malaria, tuberculosis and leprosy control programmcs in India, funded by thc Swedish International Development Authority (SIDA) and executed by WHO, terminated in June 1990. However, SIDA remained in further support for innovative activities in malaria and leprosy control programmes in India. Projects were being developed by the Government of India for the next phase of SIDA assistance. In Bangladesh, the 'Family Planning and Clinical Supervision Team' project, executed by WHO with support from the Norwegian Agency in International Development (NORAD), will terminate by the end of 1991. The Organi7ation will participate in implementing the fourth population and health project in the areas of WHO'S competence. WHO collaborated with DANIDAISIDA in the essential drugs project in Bangladesh, which ended on 30 May 1990. The winding-up operation is expected to continue until 15 September 1'9'91. Thc Finland International Developmcnt Agency (FINNIDA) support to a work plan on vaccines and drugs in Bhutan will continue for the period 1'81-1997. FINNIDA continued lo fund the essential drugs and vaccine programme in Myanmar. These programmes were implemented in collaboration with WHO. WHO maintained close contacts with various donor agencies for Bangladesh, such as ODA, SIDA, Belgian, Dutch, DANIDA, JlCA and USAID, on priority health components of the Fourth Five-Year Plan of the Government of Bangladesh, for WIIOSGENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT 13 which a resource mobilization meeting will be organized by the Government of Bangladesh. The Canadian International Development Agency supported the AIDS Control and Prevention programme in Thailand and continued to fund the WHO-executed vector-borne disease control programme in Myanmar. The biomedical research programme in Sri Lanka continued with assistance from CIDA. 4. Collaboration with Nongovernmental Oqanizations (NGOs) The Japanese ship-building Industries Foundation, the Christoffel Blinden Mission and Helen Keller International assisted in the prevention of blindness in SEAR countries. WHO made efforts to enhance the participation of NGOs in the prevention and control of HIV infection and AIDS. A meeting of NGOs was organized by the Regional Office in October 1990 to promote the participation of NGOs in AIDS control and prevention activities. Collaboration with Rotary International was strengthened in the fields of poliomyelitis control and 13PI. WHO also collaborated in the Eye Sight Programrnc of the International Association of Lions Club, particularly in the organization and conduct of eye camps, training of ophthalmic auxiliaries and educational campaigns on prevention of blindness. WHO pioneered the integratedapproach to prevention ofdisabilitiesin collaboration with the IMPACT Foundations of India and the UK. Theorganization collaborated in the Karigiri Disability Prevention and Limitation Programme in Leprosy (DISLEP) project, fundcd by the IMPACT Foundation, UK. The Regional Office collaborated with 21 NGOs in India in the fields of leprosy, traditional medicine, immunization, MCH, drug de-addiction, mental rehabilitation, prevention of blindness, and other areas. 2.4 HEALTH EMERGENCY PREPAREDNESS AND RESPONSE Disaster Vulnerability and Risk Disaster due to natural and other causes continued to afflict several countries of the Region, including Bangladesh, India, Indonesia and Nepal where cyclones, floods, landslides, volcanic eruptions and earthquakes created emergency situations of 14 711E WOHKOP WHO IN SEA varying degrees. Such situations need appropriate measures to tackle the massive health problems generated in the wake of disasters. WHO provided both technical and material support to Member Countries in their efforts to meet the immediate requirements following disasters as well as to build up long-term preparedness and health sector capabilities to respond to future challenges. The cyclone which hit Bangladesh in April this year was the most devastating natural disaster in the Region in the last two decades. It caused extensive damage to life and property in the coastal areas and the offshore islands. WHO provided emergency kits, drugs and equipment for immediate relief work undertaken by the Government. WHO also provided technical support for the assessment of the short- and long-term healthneeds ofthe affected areas, and participated in the UNlnteragency TaskForce set up by the Secretary-General of the United Nations for the preparation of a consolidated and comprehensive report on short- and medium-term needs. A joint WHOIltaly mission visited Bangladesh for appraisal of the situation and to explore possible Italian assistance for short-term and long-term emergency relief and re pa redness programmes. Another important initiative of the Organization was the mobilization of resources in support of the Bangladesh cyclone emergency relief and rehabilitation programme in the health sector. Up to 31 May 1991, pledges of over US$300 000 had been confirmed by donors. Prior to this, during 1990, Bangladesh was provided with necessary support in the health sector for formulating policy/guidelincs for disasters, assessing health sector capabilities, and preparing a working manual and training programme. WHO also provided support for the training of 12 000 health workers. In India, WHO provided financial and technical support for a national meeting on disaster preparedness with the long-term objective of involving national institutions in regular training programmes in health impacts of disasters for personnel of health and other scctors. WHO is also providing technical input, in terms of consultants, for thcpreparationofa health sector national disasterplan with the aim ofintroducing it in regular five-year national plans. WHO acquired technical capacity in the Regional Office for providing assistance to Member Countries in formulating plans, policies, and training programmes, and for promoting the International Decade for Natural Disaster Reduction (IDNDR) as well as other activities related to disasteriemergeney situations. In response to the United Nations General Assembly launching thc 1YNs as the International Decade for Natural Disaster Reduction (IDNDR), Sri Lanka has developed a draft plan for disaster management in the health sector. Bangladesh, Indonesia, India, Mongolia, Ncpal and Myanmar initiated steps for IDNDR by formulating national committees and national action plans. With the aim of generating awareness about the health impacts of disasters in policy makers of countries of the ESCAP region, WHO actively participated in a meeting organized jointly by ESCAP, IDNDR secretariat and UNDRO in February 1991. In order lo WllOS GENEML PRCGRAMME DEVELOPMENT AND MANAGEMENT IS meet the interests of various Member Countries, the necessary education material, slides and videos on health aspects of disasters were sent to them. During IW, mini kits containing medical supplies and life-saving equipment worth US$25 000 were supplied to Sri Lanka to meet emergency situations. WHO laid emphasis on emergency preparedness so that Member Countries can face the challenges of disaster situations through their own infrastructure and resources using international support and collaboration. However, the necessary material support has been provided in cases of need to meet emergencies. 2.5 HEALTH FOR ALL STRATEGY COORDINATION Health For All Strategy Coordination encompasses the whole health sector and also intertwines with development in other sectors. Consequently, advantage is taken of inputs in other programme areas such as the Managerial Process in National Health Development, Inlormalion and Education for Health, Health Systems Development, etc. Many of the activities undertaken in diverse programme areas constitute valuablc inputs into the main streani of health policy and strategy development. WHO provided active support to all Member Countries in their evaluation exercises using the Common Framework for Evaluation (CFEl2). Most countries have also started using the results of the evaluation for taking a fresh look at their health development process. The recommendations arising out of the technical discussions on Health of the Underprivileged, as endorsed by the forty-third session of the Regional Committee, have also been taken serious note of by all Member Countries. A pragmatic approach to health development, taking into account not only the strengths of the health system but also its weaknesses, and utilizing opportunities and resources as and when they arise or become available, with due concern for all human life, should be the hallmark of a coordinated and cogent effort in health development. This has in fact become evident in most Member Countries, who are now adopting a sagacious and down-to-earth approach for health development, keeping in mind the principle of equity and social justice in the process of development. There are still pockets of population in all developing countries whose health parameters are far below the national averages. These populations constituting the 'health underprivileged' should now become the focus of special attention, so that not only their health status is improved in the next ten years, but also the social and human potential of such populations is enhanced in order to contribute in a greater measure to overall progress. Thus, following the technical discussions during the forty-third session of the Regional Committee, WHO is working with Member Countries in the identification of underprivileged populations and their health problems, in carrying I6 .I'liE WORKOP WHO IN SEA out country-level studies on constraints and strategic options for achieving the health of the underprivileged, and in organizing nationaland sub-nationalgroupeducational -. activities fo; and strate& development. This effort will be strengthened and will continue in the Ninth General Programme of Work. It will be complementary to many of the other activities supported by WHO, particularly the new initiative of the Director-General to support people and countries in the most need. Efforts in the last ten years to follow a cogent and orchestrated policy of health development by developing coherent national strategies, keeping in new the goal of Health For All by the Year 2000 and the basic premise of the PHC approach, have brought about both quantitative and qualitative improvements in the health of the peoples of the Member Countries. This is evident from the reports on the second evaluation undertaken by Member Countries, which will be consolidated as ihc Eighth World Health Situation Report. In Bangladesh, a draft national health policy, a comprehensive national health referral system, and a draft medical education policy were developed. These, however, have been kept in abeyance due to the changing political situation. They are expected to be reviewed and adopted with necessary modifications. Bangladesh has also developed a training module for intersectoral action, with emphasis on equity, based on data collections of major health and social indicators. This underlines the need for an analysis of vulnerability and formulation of intervention, giving particular attention to undersewed and wlnerable areas. The dificulties and constraints faced in the implementation of the national health plan at different levels, particularly in the contexts of decentralization of executive power and resources for Upazillas, are being analysed with a view to overcoming them. Bhutan aims at providing equitable distribution of senices to all segments of the population by preferentially allocating resources for PHC to inaccessible groups of population. Here again, decentralization is a key concept in the process of development. Powers and funds are being decentralized to districts and blocks so as to pursue the national goals of development in consonance with the local requirements. In India, the emphasis in the Eighth Five-Year Plan will be on consolidating the gains already achieved and on improving the quality of services with minimal expansion. Efforts are also beingmade by the health sector to avoid waste and to ensure optimal utilization of the available resources. There is also a new emphasis on expansion of the health management information system to cover all states. In Indonesia, major developments have taken place in regard to policies for health services, health manpower, health financing and community participation. The priorities focus on the development of basic infrastructure to sustain economic activities and development. There is a stress on quality and equitable distribution of WIIO'S GENEHA1 PK(KiKAMMF I)EVl<l.OPMENTANI) MANAGEMIIn' 17 health resources, decentralized management, improvement of health manpower, efficient use of funds and greater reliance on community health financing. Preparations for the nea long-term health development plan are already under way with the formation of various working groups to review the situation from the beginning of the First Five-Year Plan. It is also expected that projections for the next 25-year period, based on the development so far, will be made. Indonesia has also published, for public use, bookson Challenges towards Attainment of Health For All by the Year UXX) in Bahasa Indonesia. It has also taken steps for active dissemination of its national health policy. The Ministry of Health in Maldives has been entrusted with the responsibility of welfare services. The budgetary allocation has more than doubled, from 6 per cent in 1989 to 13 per cent in 1991. Recognizing that there are still significant differences between the morbidity and mortality rates of the urban and rural populations, specific programmes for addressing these differences have been incorporated in the national plan for 1992-1W3, resulting in the development of specific island development programmes. In Mongolia, the whole processofhealth development is under active revicw following the large-scale change in the political order,which has ushered in democratic proccsscs. The Fourlh Congress of Health Workers, held in November 1990, approved the Principal Dircclions of Health Development for improving the health of the population. The basic tenet is to make health and sanitary services available to all by the expansion of coverage. It also emphasizes expanding the use of Mongolian lraditional medicine in combination with the modern allopathic system. The whole system is in a state of flux and the new policies, which are in tune with democratic aspirations, take into account the sparsely distributed population living in far-flung areas. In Myanmar, the Third People's Health Plan was completed in 1989-90. For the period 1991-92, a National Health Plan has been developed following a series of meetings at all levels. A significant shift in this Plan is that it involves all health-related sectors and is not centred on a departmental structure. The Plan also provides a set of 15 indicators in which changes are expected to be meaningful and substantial. Further, emphasis is laid on border area development, including health development of the population living there. This is being supported by the allocation of adequate financial resources and deployment of medical and health personnel. WHO has supported the development of the National Plan, particularly its revicw and formulation. Nepal has undergone a political transformation from monarchy to parliamentary democracy. The new constitution, promulgated in November 1990, has provision for strengthening the rights of citizens, incliding the right to health. ~t~givcs added strength to the existing national hcalth policy which, ir~ferolia, aims at improving the IS THE WORK OF WHO IN SFA physical and mental health of the people, increasing their life expectancy, reducing mortality, and controlling population growth. Nepal has also adopted a national conservation strategy which has a long-term perspective for natural resources management and is based on a recognition of the effects of environmental factors on health and quality of human life. A new Five-Year Plan is under formulation, which is expected, among other things, to extend health services coverage, strengthen the district health system, and provide for the transfer of knowledge and skills to the population, etc. Nepal has alsoutilized the results ofthe study on information support for HFA strategy management, undertaken in two districts, and proposes to extend the same to other districts so as to generate more reliable data for better plan and policy formulation. In Sri Lanka, despite three years of disruption of normalcy and economic constraints, the health situation has continued to remain satisfactory. Sri Lanka gives pride of placc to full countrywide coverage for the community-based preventive health system with the primary emphasis on preventive health. The radical new programme of poverty alleviation (Janasaviya) covering 58 AGA divisions and which has been in implementation since 1988, now benefits 310 000 families. Its expansion to cover 7 million people will take place gradually over a period of ten years. The health component of this programme, Suvasaviya, ensures that the economic and social benefits obtainedby the population under the Janasaviya Programme are not frittered away due to adverse conditions of ill health. Research on the impact of the Janasaviya Programme on the health and nutrition of thc beneficiaries has been supported by WHO. Sri Lanka has formulated the National Health Plan for 1990-1991. WHO provided support for a workshop to develop the medium-term health development plan for the period 1990-1595. TheGovernment ofThailand hassuccessfully adopted a series of innovative measures to reduce disparities in health status among different population groups as part of its overall policy of health development. The new government, which assumed office in February 1991, is currently engaged in drafting policies to be pursued by it, which, infer alia, include policies on health development. The thrust of the new policies is likely to be towards reaching the underserved, unserved, vulnerable and underprivileged groups of population with stress on equity and social justice. The vibrant economic development that has taken place in the last five years has contributed both directly and indirectly to an increasing emphasis on betterment of health status, and to greater attention on social aspects of health development. Thailand increased the health budget from 11 787 million bahts in 1989 to 20 180 million bahts in 1591. A number of measures have been undertaken in the Seventh Five-Year Plan to provide free medical care for the poor, reduce disparities in health status among different population groups, increase the use of Thai traditional medicine, improve cooperation with private and other nongovernmental organizations and to obtain the involvement of people in improving their own health. The Seventh Five-Year Plan, covering the period 1W2-1997, takes note of the deficiencies and attempts to prioritize them in the light of the analysis of social, economic, demographic and technological changes, keeping in view the changes in health and health-related resources as well as the participation of communities in health development. The Plan, expected to be finalized by March 1992, will attempt to build on the progress already achieved. Health-for-All Leadership Development Ever since WHO launched the 'HFA Leadership Development Initiative' in 1985, activities to further strengthen HFA leadership at intermediate and lower levels have been pursued vigorously, both at regional and country levels. An Intercountry ConsultationiWorkshop on HFA Leadership Nctworking and Resource Development was held in Jakarta, Indonesia, from30July to7 August 1W0. The Consultation was organized with the aim of stimulating the crcation and strengthening of a regional network of institutional resources to promote and implement HFA leadership development. The participants, being in leadership positions, reviewed country, intercountry and global situations in relation to leadership development, and endorsed the need to further strengthen leadership training programmes with active support for potential institutions. There was a need to continuously create awareness of HFA leadership, review and monitor progress, improve HFA leadership activities, and share expcricnccs, information and expertise. In India, Indonesia, Myanmar and Thailand, HFA leadership development activities were initiated as specific country programmes, whereas in other Member Countries leadership development activities form part of the overall health development programme. Meetings, dialogues, training courses and workshops, using the adapted vcrsions of HFA leadership training modules, have been held in Member Countries. Learning and information materials adapted to local situations were also prcparcd and produced for utilization at various training activities in Bangladesh, India, Indonesia, Myanmar and Thailand, which were held in order to develop a critical mass of people capable of assuming leadership of the HFAI2000 movement within their own countries. In Bangladesh, Bhutan, Maldives, Myanmar and Nepal, meetings at the district lcvcl were organized to en;~hle exchanges among decision-makers of thcir experiences of successful district programmes, to create awareness of HFAIPHC concepts, and to offer approaches of how their concepts and stratcgies can he operationalized at the local level. Most Member Countries have identified potential national centres for arranging networks and formulating strategies for the development of future leaders. The Faculty of Public Health of Mahidol University in Thailand has been nominated as a WHO Collaborating Centre in HFA Leadership Development. This Faculty is 20 - rllE WOKKOb WHO IN SFA developing a common framework for country case studies which will be used to conduct case studies in all Member Countries of the Region. The case studies will highlight issues related to HFA leadership development which link with both successful and unsuccessful experiences of health development programmes. These case studies can be utilized as learning materials for HFA leadership training and also used as advocacy for social and political action. It is expected that, during the next few years, some institutions in the countries will be undertaking similar responsibilities. The review and development of tools for setting criteria for the monitoring and evaluation of leadership development initiatives have been initiated in India, Indonesia, Myanmar, Sri Lanka and Thailand through the WHO collaborating ccntres and national focal points for HFA leadership development. Whilc progress in HFA leadership development is evident in many countries, it is too carly to mention the impact of the activities because of the many influencing factors. There is a great need for intensified support for the large unreached or underserved populations still living in conditions of poverty and suffering from the lack of education and nutrition, leading to high morbidity and mortality. In ordcr to havc a strong political commitment for HFAi2000, attempts will havc to be made to incrcasc the awareness ofthe existing leaders. 'l'echnicnl Cooperation among Developing Cunntries There have been a large number of direct bilateral exchanges. Male, the capital of Maldives, hosted the Fifth Summit Meeting of the South Asian Association for Regional Cooperation (SAARC) which was attended by the heads of the Statcs/Governments of SAARC comprising Bangladesh, Bhutan, India, Maldives, Ncpal, Pakistan and Sri Lanka. Thc 'Male Declaration', emanating from this Summit Meeting, has a special portion on health dcvclopment. Indonesia undertook a TCDC multisectoral programming excrcisc in July 1990 with support from UNDP, both to make known its potential and also for seeking support in regard to improving some capacities. India, Sri Lanka and Thailand responded to this exercise. At the fourteenth meeting of Ministers of Health of the Non-aligncd and other Developing Countries, held in Gencva in May 1990, the Medium-term Programme for TCDC was adopted. This had been developed earlicr by a meeting of experts from non-aligned and other developing countries. The progress in the implementation of this Medium-Term Programme has recently been reviewed and submitted tothe fifteenth meetingofMinistersof Health ofthe Non-aligned and other Developing Countries, held in Geneva in May 1991 WHO5 GENERAL. I'KOGRAMMI DEVIIOPMENI'ANI) MANAOBMENI ?I 2.6 INFORMATICS MANAGEMENT The Informatics Management Programme aims at supporting programme development and management of WHO and Member States through the use of informatics technologies and training of users at regional and country levels. Most of the health programmes have introduced information technologies, and financial and technical management. The degree and level of sophistication in their use vary from one programme to the other. A few corporate data bases and computeri7ed programme monitoring systems are heing developed. These may become available to the WHO Sccrctariat andMcmber States in the near future Whilein the initialstages ministries of health acquired informatics and telematics technology for the central level only, thc same technology is today spreading to provincial and district levels. In the Rcgional Office, the new Administrative and Financial System (AFI) became fully operational at the end of 1990, and technical aswell as administrative proccdurcs arc being devclopcd in the Regional Office to link AFI with the ensuing Local Area Network of the Regional Office, providing programme managers easy access to financial and technical information. The Informatics Support Committee dealt with policy issues regarding informatics support dcvelopmcnt, as well as with technical, administrative and operational issues, in order to ensure standard proccdurcs and optimum use of WHO'S resources.

Chapter 8 GENERAL HEALTH PROTECTION AND PROMOTION 8.1 NUTRITION WHO has continued to support national activities and programmes to strengthen the sharing of the considerable experience that is available on nutrition programme implementation, promotion of relevant effective strategies against the major deficiencies, human resource development and appropriate research-cum-action. All the countries of the Region have programmes against the main nutritional deficiencies to which their people are prone: protein-energy malnutrition, iodine deficiency disorder (IDD), Vitamin A deficiency (VAD), and anaemia. The achievement of the nutrition goals of the Region demand, in largc part, action on behalf of families supported by service providers. Well-trained peripheral health workers can be important and effective change agents in achieving such family-level action. They complement the broader developmental policy actions needed to deal with the economic and agronomic causes of malnutrition. The importance of a cohcrent and problem-oricnted training programme in support of such family action has been clearly demonstrated by the Joint WHWUNICEF Nuttilion Supprl Programme (JNSP) in Myanmar. The report of this programme is being processed as a SEAR0 Regional Health Paper. The lessons demonstrated are replicable in other countries. It is now fully integrated with regular government services. The programme has proved sustainable as well as technically sound. Posts previously supported by JNSP are now included within the normal structure. Support was given to further streamline the nutritional (iENF.K/\I. lIEALl?l PROTF1710N AND PROMOllON 63 - monitoring and surveillance system to ensure that it serves both local-level needs and those for central planning, rapidly and effectively. WHO supported the strong emphasis on appropriate performance-based training in relevant nutrition through JNSP in Nepal so as to ensure that appropriate nutrition is included in the training of community workers (based on their newly-defined job descriptions) and of thcir supervisors. Nutrition was integrated within the existing training system a1 all levels. There is a renewed confidence that iodine deficiency disorders (IDD) as a major public health problem can be eliminated in all countries by the year 2000, as resolved by the Forty-third World Health Assembly in 1990. Countries in the Region have already made rcccnt studies in this respect. In October 1W, a workshop was held in Delhi at which progrcss was assessed and practical managerial issues discussed, new techniques for monitoring iodine in salt at the community level demonstrated, and conclusions drawn for national activities and regional support. Much research in nutrition has been undertaken over the decades by a number of renowned institutions in the Region. The results of some of this research have been utilized for improving programmes so as to achieve a better nutrition status for thc people of thc Region. But scientists are often frustrated that, in their view, decision-makersdo not use thcir results in planningprogrammeswhile plannersolten complain that thc research they need to help them solve their operational nutrition problems is not bcing undertaken. Partly to resolve this issue the South-East Asia Nutrition Research-cum-Action Network has been started. The first consultative meeting on the Network took place in Thailand in August 1990 with WHO support. The Network has six aims and objectives for the benefit of the Region, namely: (1) to identify major nutritional problems; (2) to strengthen nutrition rescarch-cum-action capabilities; (3) to promote selected priority research-cum-action projects; (4) to promote training programmes in the Region for nutrition research-cum-action; (5) to exchange experts, scientists and- programmemanagers, and (6) to share information on priority nutrition research-cum-action matters of mutual interest and concern to Member Countries of the Region. A mechanism for the Network consisting of focal points in each Member Country, and four collaborating centres in nutrition with the Regional Oflice acting as a clearing house, was devised. Research-cum-action projects have been designed to deal with priority operational issues in nutrition in primary health care decided on jointly by Member Countries and the collaboratingcentres. The first issue of a Newsletter was distributed in March 191. 61 lliE WORKOF WHOIN SEA The countries of the Region are all, to some extent, in a period of transition with regard to priority nutrition problems. While protein-energy malnutrition remains a serious impediment to human development, its epidemiology is changing. Urban migration means that millions of poor people are moving to a cash economy and have to adapt to new potential food ways. As female employment increases, there will be potential changes in the pattern of breastfeeding and weaning. Both these lactors influence the prevalence of protein-energy malnutrition. Data from various sources analysed in the Regional Office indicate that currently about half of the infants and under fireyear old children in the Region are stunted. Environmental destruction and degradation are expanding exponentially. This has, as yet unchecked, effects on the availability of food and water as well as on their quality, and, consequently, on the epidemiology of malnutrition. Some regional countries appear to be in a transition between a rural-based and an industrialized economy. Their increasing populations are becoming subject to lifestyle-related diseases now common in the already industrialized countries. A major lifestyle factor is diet. TheRegional Office isstudyingin depth issues pertaining to such a transition, and expects to report its findings next year. 8.2 ORAL HEALTH The lack of oral health manpower, inappropriate training of health personnel working at the different levels of the health service infrastructure in the prevention of oral diseases involving caries, poor oral hygiene and ineffective health education of the masses, coupled with the relatively low priority given to oral health are the major factors contributing to the deteriorating oral health status in the Region. Studies in Myanmar show that 80 lo '90 per cent of children between 6 and 12 years have gingivitis. In the 35-44 year age-group, oral hygiene was found to be poor and 25 per cent is estimated to have advanced periodontal destruction. A national epidemiological study carried out in India revealed that, in children of5 years of age, the number of DFT and DFMT varied from 5.3 in Assam to 6.4 in Meghalaya and Nagaland. InThailand, in children aged3 and6 years, the percentages of dental caries have been found to be as high as 67.2 and 81 respectively, with the average number of affected teeth being 4 and 5.5 respectively. The situation, which is similar in other countries, demonstrates the need for increased epidemiological and other fundamental research aimed at determining the most important socioeconomic, health, dietary and other factors contributing to the deteriorating oral health in the Region. The wide gap between the needs of the people and the availability of dental health care continues to be a concern for health authorities in the Member Countries. GENEKAI. HEALTH PROTE(TI0N AND PROMO'TITION 65 Epidemiological assessment and critical reviews of the existing health service infrastructures for oral health are essential for improving prevention, treatment and rehabilitation, reduction of incidence of periodontal diseases, and for improving the existing status of oral health. With this in view, WHO collaboration has mainly been focused on the training of national oral health personnel, enhancing the services through- better utilization of existing health service infrastructures and providing logistic support to improve institutional capacities. 8.3 ACCIDENT PREVENTION Rapid urbanization, industrial expansion and unprecedented increase of vchiclcs coupled with high traffic congestion, poor road condilions, inadequate enforcement of traffic rules and the lack of proper safety in industrialization and mechanization of labour in all spheres of life have contributed to increasing rates of accidents. For example, the fatality rate of 5.9 per 1000 vehicles in India, where the accident rate is more than 30 per 1 MYJ population, is found to be much higher compared to some highly industrialized countries. Existing knowledge and available technologies are still not utilizcd effectively for the prevention of accidcnts and injuries, which have emerged as one of the five leading causes of death in most of the countries of the Region. The Eighth International Congress on Burn Injury was held in New Delhi in November 1WO and the International Conference on Traffic Safety (ICOTS 91), sponsored by WHO, was also held in New Dclhi, in January 1W1. The latter adopted the "Delhi Dcclaration on Road Safety" with particular emphasis on"vulnerable road users". Based on the Dcclaration at ICOTS 91, a series of recommendations were made for implementation in the near future in India. Among othcr things, the establishment of a special intersectoral Road Safety Research Coordination Standing Committee, under the auspices of the National Road Safety Council, was recommcnded. In Indonesia, a national seminar on childhood injury prevention was conducted in November 1!Wl with a view to creating awareness in regard to childhood accidents and injuries. 8.4 TOBACCO OR HEALTH Though Tobacco as a health problem has been recognized by WHO for about two decades,this subprogramme area,withits ownidentity,wasintroduced intothe WHO programme classification only in the Eighth Gcnerdl Programme of Work, beginning M THE WORKOF WHO IN SEA in 1990. Twocountries of the Region,viz., Indonesiaand Thailand, have made specific budgetary provisions for Tobacco or Health (TOH) programmes. In other countries, activities related to TOH are funded from other country programmes, mainly those related to cancer control, noncommunicable diseases, or research. But even where specific TOH programmes have been initiated, it has become clear that they have to stay well integrated within general programmes for health promotion and disease control. As far as legislative and administrative measures for the control of tobacco use are concerned, these have been implemented with commendable speed in several countries of the Region. Smoking has been prohibited in all airconditioned public places, includingdomestic nights and buses, in Thailand. Indian airlines have decreed all domestic flights smoke free, beyond the previous limit of 1''~ hours flying time, while smoking in all government offices and health facilities is prohibited in a number of countries. The movement for a 'smoke-free Bangladesh' has continued in Bangladesh through NGOs, with the highest government support. The movement towards tobacco-free districts in Bhutan has proven to be a community-based rather than a centrally imposed activity, thereby considerably improving the chances of its sustainability. Three regional symposia on tobacco or health, to be followed by a national conference, will pave the way towards a National Tobacco Control Programme in India. With WHO assistance, Mongolia has taken preparatory measures for legislative and administrative action to reduce smoking in the country. A stepwise reduction in the import of tobacco has so far not led to any untoward reaction by the country's population. In a unique pecr-to-peer youth programme in Sri Lanka, a youth group in Ciampaha district has motivated hundreds of smoking youths to quit and to join activilies for a drug-free life. The fourth World No-Tobacco Day, 31 May 1991, was observed in all countries of the Region. The theme 'PublicPlaces - Better Be Tobacco Free'proved to be ofgreat gcneral appeal and received wide press coverage. It has become obvious that the right of non-smokers to clean air is a powerful component of the anti-tobacco movement.

Section I 1 DIRECTION, COORDINATION AND MANAGEMENT Chapter 1 GOVERNING BODIES 1.1 WORLD HEALTH ASSEMBLY Thc Forty-fourth World Health Assembly was held in Geneva from6 to 16May 1991. The Minister of Health of the Mongolian People's Republic, H.E. Dr Pagbajabyn Nymadawa, was elected as its President. The Assembly considered a wide range of health matters and adopted 43 resolutions. The Assembly called for the elimination of leprosy as a public health problem by thc year 2000, and urged that efforts be stepped up against tuberculosis, acute respiratory infections, dracunculiasis and cholera, and for thc dcvelopmcnt of ncw children's vaccines, emergency relief, health of refugees, alleviation of the urban crisis, and women, health and development, besides considering various other issues such as health promotion of the least developed countries, human organ transplantation, smoking, and international programmes to mitigate the health effects of the Chcrnobyl accident, etc. The Assembly was informed that 36 per cent of the disease-specilic budget of the World BanklUNDPiWHO Special Programme for Research and Training in Tropical Diseases is being spent on malaria, in the development of new tools for the control and treatment of malaria, which is by far the largest disease-specific effort of the Programme. Among the prizes awarded during the Forty-fourth World Health Assembly, the Child Health Foundation Prize was awarded to Professor Namjimyn Gcndenjamts of Mongolia for his outstanding service in the field of child health. The Assembly urged countries, WHO and UNICEF to work to maintain interest and activities for the health of children and their mothers generated by the WorldSummir for Children, held in New York on 30 September 1990. This year's Technical Discussions at the Assembly were on the subject of "Strategies for Health for All in the Face of Rapid Urbanization". The Assembly urged Member States to prevent excessive urban population growth by developing national policies that maintain a balance between urban population and infrastructure and services. It called upon various agencies to assess the impact of health on their policies in order to better adjust them to promoting healthy communities and a healthy environment in cities. 1.2 EXECUTIVE BOARD The three Member Countries from the South-East Asia Region entitled to designate a person each to serve on the Executive Board are India (1989-lWl), DPR Korea (1990-1'992) and Myanmar (1991-1993). India was replaced by Maldives in May 1991 at the Forty-fourth World Health Assembly. The Programme Committee of the Executive Board mct in Geneva from 27 to 31 August I990 and reviewed the presentation of programme orjentarion by thc Director-General and the Regional Directors, as also proposals for global and interregional activities for the period 1992-1993. The Executive Board, in 1987, had requested the Programme Committee to review a number of issues including the management of technical cooperation activities. In 1988, the Director-General submitted to the eighty-fifth session of the Executive Board a note on the formulation of programme priorities describing the policy bases, processes and mechanisms followed over the years in determining programme priorities. At the requesl of thc Board, the Programme Committee again reviewed the matter in the light of the preparation of the Proposed Programme Budget for 1W-1991. Later, the Board considered the report submitted by a working group of the Programme Committee on the criteria used at different levels of the Organization with a view to identifying those which could bc used for the determination of priorities, including possible utilization of cost-benefit analysis. The report dealt with the evolution of criteria for priority setting in WHO in the light of its constitutional functions, the process of priority setting by the Regional Office in its programme budgeting, potential critcria for testingin the preparation of theNinth General Programme of Work, and a serics of operations concerning priority setting at country, regional and global levels with a view to improving the criteria for priority setting in WHO. Aftcr considering the report, the eighty-seventh session of the Executive Board, in a resolution, requested the Director-General to ensurc that adequate resources arc GOVERNING BODIES 3 allocated according to priorities identified and that support be reduced or discontinued for projects and programmes that have outlived their usefulness. The eighty-seventh session of the Board took place from 14 to 25 January 1991 under the chairmanship of Mr R. Srinivasan. The Board considered the Director-General's reports on the meetings of the WHO Expert Committees on the Control of Leishmaniases, Cancer Pain Relief and Active Supportive Care, Vector Biology and Control, Systems of Continuing Education, Biological Standardization, Educational Imperatives for Oral Health Personnel, Use of Essential Drugs, and the FAOiWHO Expert Committee on Food Additives, as also the reports of Study Groups on Diet, Nutrition and Prevention of Noncommuni- cable Diseases, Implementation of Integrated Health Systems and Health Personnel Development, and the Role of Research and InformationSystemsin Decision-making for the Development of Human Resources for Health. It also passed 26 resolutions on diverse subjects, such as eradication of dracunculiasis, leprosy, tuberculosis control, smoking and travel, health promotion for the development of the least developed countries and research and development in the field of children's vaccines. The Board also appointed Dr U KO KO as Director of the WHO Regional Office for South-East Asia for a further period of three years from 1 March 1991. Thc eighty-eighth session of the Executive Board took place on 20-21 May 1991. Among the items dealt with were the report on meetings of the expert committees and the report of the UNICEFIWHO Joint Committee on Health Policy at ils twenty-eighth session. The Executive Board agreed that a special session of the Joint Committee be convened in January 1992 to discuss follow-up activities to the World Declaration on the Survival, Protection and Development of Children, and the Plan of Action for implementing it, adopted by the World Summit for Children on 30 Septcmber 1990, as well as improvement of the management of the peripheral health system based on primary health carc. The Board decided to hold its eighty-ninth session in Geneva from 20 to 29 January 1992. It also decided that the Forty-fifth World Health Assembly would open in Geneva on 4 May 1992. 1.3 REGIONAL COMMITTEE The forty-third session of the Regional Committee for South-East Asia was held in the WHO Regional Office for South-East Asia, New Delhi, from 18 to 24 September 1990. It was attended by representatives from all the eleven Member Countries of the Region, five United Nations agencies, one intergovernmental and twenty-nine nongovernmental organizations having official relations with WHO. 4 THE WORKOF WHO IN SFA The session was declared open by Dr S.L. Leimena, Chairman of the forty-second session, and inaugurated by His Excellency, Air Chief Marshal (Retd.) Arjan Singh, Lt. Governor of Delhi. Mr M.S Dayal (India) was elected Chairman and Dr J. Norbhu (Bhutan) as Vice-Chairman. Dr U Tin U (Myanmar) was elected Chairman of the Technical Discussions, and Dr S.P. Bhattarai (Nepal) as Chairman of the Sub-committee on Programme Budget. The Regional Committee, in a private session, nominated Dr U KO KO as Regional Director for a further period of three years. While reviewing the Regional Director's Annual Report, the Committee expressed its views on several issues and emphasized continued collaboration in diversc important matters linked with health development and promotion activities. A resolution was adopted on the subject of Technical discussions (Health of the Underprivileged), urging Member States to assess the extent and distribution of underprivileged populations and the magnitude of their health problems, and to undertake integrated intersectoral activities to meet the essential needs of thc underprivileged in the context of health for all. The Committee deliberated on the implications of the United Nations General Assembly resolution 441211 relating to operational activities of the UN system. Whilc appreciating the objectives and principles underlying the resolution and recognizing the need for better coordination among UN agencies, the Committee expressed strong reservations on the practicability of several of its operative provisions. In particular, it felt that the move for central pooling of operations and technical cooperation funds of the UN system under a single agency would not only jeopardize but also disturb the established effective tcchnical cooperation arrangement that had continued satisfactorily for so many years. Besides, WHO, as a specialized agency, was a technical organization, unlike thc UN agencies. It had a technical and coordinating role, as mandated by its Constitution, involving technical work, which included advisory collaboration as well as operational activities in the countries. Noting that the involvement of women at decision- and policy-making levels was still very low and needed more attention, the Committee urged Member States to further pursue their policies for increased participation of women in decision-making in health systems. Expressing its concern that AIDS had shown increased prevalence in two morc countries of the Region, the Committee urged Member States to strengthen AIDS prevention and control activities, universalize sterilization of all injecting and skin-piercingequipment, and intensify surveillance measures for a correct assessment of the prevalence of HIV infection. Regional Committee Meeting The forty-thlrd session of the Regional Committee for South-East Asia was held in New Delhi. India, from 18-24 September 1990. Theinaugural address was del~vered by the Lt. Governor of Delhi, Air Chief Marshal [Retd) Arjan Singh. Meeting of Directors of Medical Research Councils The seventh meetlng of the Directors of Med~cal Research Counc~ls or Analogous and concerned Research FOCI in the relevant mlnlstrles of the South-East Asia Reg~on was held in Kathmandu. Ne~al from 4 to 9 November lssn World Health Assembly H.E. Dr. P. Nymadawa, Mnster of Health. Mongolia Health Assembly in May 1991 vas elected President ofthe 44th World Executive Board Mr. R ~f India (left) served as Chairman 1 Executive 1991 May 1990- GOVERNING nODlFS 5 Discussions were also held on technical subjects, including the evaluation of health-for-all strategies using the common framework for the second evaluation, and the control of tobacco use, besides the usual business of nominations to the various global-level coordination aimmittces, etc. While noting the programme budget pn)posals for 1992-1993 for the Region to be $87 million for the biennium, the Committee observcd that these had taken into account national health-for-all strategies and kept within zero-level growth of the Organization's regular budget. The Committee requested the Regional Director to transmit the Proposed Programme Budget, as contained in document SEARC4313 and Add. 1, to the Director-General for inclusion in his Proposed Programme Budget for 1992-1993. On the question of reporting by the Regional Director, the Committee decidcd to refer the suggestion to adopt a system for a long report in odd-numbered years covering a biennial period, and a short report in even-numbered years covering one year only, for study by the Consultative Committee for Programme Development and Management at its next meeting. The Regional Committee decided to hold its forty-fourth session in Maldives in Scptemlier 1Yj1, and its forty-fifth session in 1992 in Nepal. The topic chosen for the tcchnical discussions in 1991 was "Disaster Preparedness".

FORE WORD Another eventful year has gone by. This was a year which witnessed two major disasters, first a man-made one in the Middle-East, and another of unprecedented proportions in our Region, caused by nature. The regional conflict in the Middle-East was brought to a halt through the efforts of the intemationalcommunlty, thus kindlingonce again an etemalhope in the hearts of mankind for a better tomorrow. The severe repercussions of this conflict will be felt by the economies, particularly of the developing world, for a long time. It has also severely hampered the overall developmental efforts of the countries of the Region, including that of the health sector. A devastatingcyclone stnick Bangladesh inApril 1991, leaving in its trail rintold miseries of death, destruction and despair. WHO rose to the occasion and responded quickly by giving support in the form of drugs and emergency kits. WHO also coordinated relief efforts with UN agencies, such as UNDRO, and other donor countries in rushingaid to the country. The important lesson to be learnt from our experience in handling nat~iral disasters is that, even though resources rrre limited in our Region, comprised as it is of developing cormfries, a lot more could be achieved by adequnte preparation of the health sector, especially to meet such d~sasasters, ttrrorigh greatercoordina tion and cooper(rtion amongMember Countrit*~ in a spin't of "live and let live': WHO will, therefore, be emphasizing not only the promotion but also the enhancement of the capacity of Member Co~intries for health sectorpreparedness and response in meetingsuch natural disasters, in line with thisyear's World Health Day slogan "Should Dkasfer Strike - Be Prepared". It iv against this scenario that we must attempt to measure ourprogress in the achievement of thegoal of HFAl2000 through primary health care. Plimarily, progress and development depend on the inherent strength of a nation and its people, their ability, their resilience to absorb and adapt to new and appropriate patterns of behaviour, the amount of economic, social and other forms of freedom they enjoy, and the dent of happiness which they wish to pursue. No nation can be half unhealthy, half poor, half fettered and yet strive for rapid and meaningful development. Addressing the recent World Health Assembly, the Director-General of WHO warned the Member Countries of the likelihood of dwindling economic resources, political upheavals, war and civil strife, the threat ofAIDS, cholera epidemics and, last but not the least, natural disasters, all of which placed a heavy burden on Member Countries and the O'ganization, and threatened to dirncpt the march towards our goal. In order to meet this challenge, the Director-General advocated the concept of "a new paradigm for health" for realizing the social goal of HFA. The paradigm recognizes health as being central to development and to the quality of life. To translate this philosophy into action, it may be necessary for us to give a new orientation, a new dimension, and a new thrust to our strategies and approaches. We are just less than a decade away from our goal of HFA. The time is short and the task ahead is stupendous. It is not possible for an individual, an organization, 0r.a Member Country alone to accomplish this task in isolation. It calls for n cooperative effort, an unqualified commitment, involvement, and, above all, sustained and devoted action. lam optimistic that the "newparadigm for health" willclanfi many basic hues in the HFA movement, particular(yin operational matters, and will be instrumental in ushering in a new era of hope summoning us to move on towards sustainable development in the Region. Wdh these few thoughts, which I wish to share with you, I have great pleasure inpresentingthe Forty-third Annual Report on the Work of WHO in South-East Asia. Dr U KO KO Regional Director

WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT The Regional Committce's decision to adopt a single biennial programmc budget document and annual dclailed plans of action closc to the actual implementation period has introduced additional flexibility and realistic programming of resources in WHO'S programme development. The Country Support Teams provided the needed support to the WHO representatives and national health administrations in this undertaking. The satisfactory result of the first round of joint government-WHO evaluation of priority national health programmes, carried out in 1984-1986, was noted by the Regional Committee, which recommended a second round of such joint evaluation to be completed during 1W1-1993. The Regional Office undertook a fresh initiative to strengthen the established joint government-WHO programme development mechanism and process, along with strengthening of the resources of the WHO representatives in this regard. It also contributed to the initial thoughts on the preparation of the WHO Ninth General Programme of Work for the period 1996-2001. The Consultative Committee on Programme Development and Management (CCPDM) deliberated upon several important issues, such as implications of the UN General Assembly resolution 441211, besides undertaking a biannual programme management review. There were several significant developments in external coordination for health development. The CCPDM and the Regional Committee examined in detail UN THE WORK OP WHO 1N SEA General Assembly resolution 441211 and welcomed it in principle. Whie recognizing the need for better coordiiation among UNagencies, it was felt that there were many operational constraints and inappropriateness. It was also strongly felt that the existing close working relationship between WHO and ministries of health, the technical advisory and leadership role of WHO in health, and the direct technical cooperation by WHO through its regular budget should be maintained and further strengthened. WHO remained committed to supporting ministries of health in securing a greater share of national as well as international resources for the health sector in the context of development. It also endeavoured to improve the quality of health sector reviews, programme identification and project formulation. The UNDP strategy and methodology for theSth cycle programmeshifted from the project to the programme approach under a few pre-determined priority themes, which posed new challenges to the dovetailing of health protective and promotive programmes into the execution of UNDP-funded projects which, in WHO'S perception, was best applied keeping national governments' capacities and interests in view. WHO consistently supported increased flow of international resources to health development, irrespective of WHO executingthe projects funded by other agencies. WHO provided technical cooperation to Member Countries in health sector reviews, health programme formulation and project execution during the year under review. As regards the common WHO-UNICEF goals in child survival and development, maternal health and control of deficiency disorders, close cooperation was sustained at all levels. The role of NGOs has been highlighted in all community-based health activities that are consistent and complementary to national health programme objectives. More recently, WHO has enhanced collaboration with NGOswith respect to the control of HIV infection, especially in Thailand and India. Similarly, there was collaboration with Rotary International in the control of poliomyelitis. In other areas, such as leprosy, prevention of blindness, drug deaddiction and mental rehabilitation, the working relationships were maintained. Consultationswith the World Bank and the Asian Development Bank were improved through technical collaboration in World Bank-supported population and health projects in Nepal, Bangladesh and Indonesia, and generally in other countries. Considering the frequency and severity of consequences of disasters with significant health effects, WHO was collaborating in the implementation of the International Decade for Natural Disaster Reduction in the 1990s. Asexpected, WHO'smainfocus was on improving the national capacities for preparedness through training, planning and integration of health components into the total national disaster preparedness and response plan. The 1990s is the International Decade for Natural Disaster Reduction (IDNDR). Bangladesh, India, Mongolia, Myanmar and Nepal have initiated steps for IDNDR. April 1991 witnessed the worst ever cyclone disaster in Bangladesh. While the people EXFXUTIVE SUMMARY d and the Government of Bangladesh bravely battled to provide succour and mitigate hardship, WHO on its own and in partnership with the UN Disaster Relief team, provided immediate relief to avert large-scale ill health, and, at the same time, vigorously pursued the disaster preparedness programme being formulated. A pragmatic approach to health development, taking into account not only the constraints of the health system but also its weaknesses, and utilizing opportunities and resources as and when they arise or become available, with due concern for human lie, is the hallmark of a coordinated and cogent effort in health development. This has become evident in most Member Countries of the Region who are now adoptingsagacious and health-oriented approaches for human development, keeping in mind the principles of equality and social justice. Attention is also being sought for those pockets of population whose health parameters are far below the national averages. Thus in line with the recommendations of the technical discussions held during the forty-third session of the Regional Committee in 1990, the focus of special attention in the last decade of the century should be on the health of the underprivileged. The second evaluation of the implementation of the Strategies for Health for All by the Year 2000 has been completed by all the Member Countries. The country reports were comprehensive and dwelt on developments of health systems, international cooperation, health and socioeconomic status, research, technology, monitoring and evaluation processes, and plans for future action. Efforts to develop a critical mass of people capable of assuming leadership in the HFN2000 movement have been pursued vigorously in almost all Member Countries. In order to have a strong political commitment in taking decisions to further the cause of HFN2000, attempts should be made to increase the awareness of the existing leaders rather than to create new or potential leaders. Intensified actions should be carried out to make use of, and involve, communication forums in the introduclion of HFA leadership philosophy and concepts at all levels. The fast changing information technology has to be harnessed fully and taken advantage of. The informatic management programme has supported programme development and management in this area. Most of the health programmes, both in WHO and the Member Countries, have introduced information technologies both for financial and technical management. HEALTH SYSTEM DEVELOPMENT WHO continued to collaborate with Member Countries in strengthening epidemiological surveillance. Notably, during the reporting period, two external evaluations of the Field Epidemiological Training Programme were undertaken, one xii THE WORK OP WHO IN SEA in Indonesia and the other inThailand. Both the countries conductedevaluations for the second time since the initiation of FETP. In Indonesia, the evaluation team recommended the improvement of administrative and financial problems to attain self-sustainability after external assistance is withdrawn. In Thailand, the evaluation team found evidence of substantial achievements of FETP since the previous evaluation. It was found that FETP has contributed considerably to the improvement of public health. Health information in manv countries is still maintained in a vertical and - compartmentalized manner. There is also not enough system review at different levels to identify the information required at those levels. Poor quality of data and the lack of disaggregated information continues to make it difficult for information to be used as a tool to identify priority managerial action. Thus, even though health information systems have been strengthened and decentralization introduced, more efforts are needed not only in thc collection of information but also in the generation and use of disaggregated information. WHO has supported the development of district-oriented health information systems. WHO supported Member Countries in the strengthening of management of national health development with emphasis upon health policy formulation and health care financing. WHO technical collaboration was provided for the formulation of medium-term health plans in Bhutan, Thailand, Indonesia, Bangladesh and Myanmar. Cognizant of the urgency and importance of health economics, WHO convened a regional expert consultation which produced a regional programme of action in support of countries to improve their capacities in health economics and health care financing. WHO launched yet another initiative lor intensified cooperation with countries and people in the greatest need, which included Nepal, Bhutan and Myanmar. This initiative was aimed at concerted and coordinated cooperation by WHO and other partners to support countries whose needs are the most and who have been adversely affected by economic difficulties. Intensified WHO cooperation was an umbrella for bringing about the coherence of programme activities to meet priority needs and achieve a greater impact on primary health care in a short time. In view of the impact of socioeconomic and environmental conditions, conventional mechanisms and methods of health plan formulation proved inadequate. Taking this into consideration, WHO, in cooperation with national health administrations, conducted a review of health planning mechanisms and methods and identified, within a programme of action, ways and means of improving health planningwith new skills in health policy analysis in the changing economic context, and with new approaches to resource mobilization and utilization. In accordance with the recommendations of several WHO regional bodies as well as World Health Assembly resolution WHA43.19, greater emphasis is now laid on the promotion and development of health systems research in the Region. The scheme of providing institutional strengthening grants has been implemented in four countries but progress is slower than anticipated due to delays in responses and insufficient interest in some Member Countries. In order to establish HSR within a more institutionalized framework, the Regional Office is promoting consultative meetings attended by senior administrators and scientists for the assessment of priority HSR needs and also to identify multi-disciplinary research teams which will include personnel from ministries of health. A consultative meeting to develop criteria for the appraisal of HSR project proposals was held from 2 to 4 April 1991. A conceptual framework for the appraisal of HSR (in contrast to biomedical and clinical research) was constructed, based on which criteria for the appraisal of HSR project proposals were developed. HSR projects supported from intercountry funds cover areas such as ageing, health manpower development, community participation, health care delivery and health economics. Three countries in the Region have made specific provision for health systems research in their country budgets. ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE All the Member Countries are committed to the attainment of the goal of HFN2000 with primary health care (PHC) as the key approach. Considerable resources have been allocated for increasing the coverage, reorienting the health system infrastructure and for providing efficient and universal PHC. An evaluation of the HFNPHC strategies in l(W0 providedfurther impetus to the attainment of the HFA goals. Many developmental activities have taken place, such as reorienting health policies, restructuring and reorganization of ministries of health and lower level structures, establishment or strengthening of mechanisms for coordination within the health sectors as well as among health-related sectors, and expansion and reorientation of the health system infrastructure. The organization and management of district health systems have been strengthened with appropriate technical support in all Member Countries. Overall, there has been perceptible progress in the implementation of primary health care as well as improvement in the performance ofthe health infrastructure. More than90 per cent of pregnant mothers are provided with appropriate care and the same per cent are attended to at the time of delivery by trained personnel. A little more than one-third of the families have access to basic sanitary facilities in their homes or immediate vicinity, compared to merely one-tenth of the families in 1985. At least one-half of the infants are now protected from immunizable diseases in most of the countries, whereas some countries have an even better coverage of more than 80 per cent. dv TIlE WORK OP WHO IN SEA The challenge to the health sector lies not only in meeting the increasing demands from rural areas in the spirit of equity, by providing better access to services, but also in catering to the increasing urban health loads that are being placed on it by the process of urbanization. To meet the needs of the growing urban population, a number of important programmes are being implemented in urban areas. These essentially consist of sample surveys, case studies, workshops and seminars to identify issues and implications of policies and strategies and areas in need of improvement in urban health care delivery systems. WHO has continued to support efforts to develop and apply innovative approaches to community involvement in primary health care, micro-planning, and self-managed health care programmes, to promote and support intersectoral actions for health and to strengthen the information system so that it can support decentralized planning and management. The main thrust of the health development programme relies upon the extent of community involvement. Many of the WHO collaborative programmes for PHC are geared towards community involvement and such an activity has been built into the implementation plan. Community participation in terms of volunteers for health activities is progressively expanding and, in some cases, the contribution of community resources has also been a welcome feature. DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH Support was provided for strengthening the planning of human resources for health in all countries of the Region. Following the meeting of the WHO Study Group on the Role of Research and information Systems in Decision-Making for the Development of Human Resources for Health, held in Geneva in November 1989, a Consultative Meeting on a Minimum Set of InformationinSupport ofPolicy, Planning and Management of Human Resources for Health was convened in Bangkok in October 1990. Efforts will now bc made to support the development of information systems on human resources for health in a number of countries by the application of the concept of the minimum set. Efforts have also been made to strengthen nursing and midwifery human resource planning and management. Assistance in the upgradingof nurse-managers and other nursing and midwifery personnel continued through fellowships for advanced study, training and study visits in nursing management and clinical nursing. WHO hascontinued its efforts to increase the capabilities ofthe countries for carrying out research into the development of human resources for health. Towards this end, the Consultative Meeting on Management Research for Development of Human Resources for Health was held in Bangkok in September 1990. National workshops on research into thedevelopment of human resources for health were held in Yangon, EXECUTIVE SUMMARY xv Myanmar, in July 1990, in Chiangmai, Thailand, in August 1990, and in Jakarta, Indonesia, in October 1990. The promotion of research in nursing was further strengthened. An intercountry Consultation on Research in Nursing was held in Thailand from 24 to28 June 1991 to follow up on the recommendationsofthe fifteenth session of the South-East Asia Advisory Committee on Health Research regarding the development of research in nursing. Further progress was observed in the efforts of the Member Countries in strengthening and reorienting the medical education systems to achieve a closer quantitative balance and systemic relevance to their medical manpower development programmes. At the level of undergraduate education, the trends that were initiated in the past decade were further reinforced with greater community orientation of curricula, introduction of innovative education strategy such as problem-based learning, strengthening of educational management processes, experimenting with objectively structured clinical and practical examinations and the introduction of enquiry-driven strategy for accelerating changes in medical education. With WHO'S collaboration the Network of Community-oriented Educational Institutions organized the Second International Conference at Yogjakarta, Indonesia, under the theme of problem-based learning. Problem-based learning programmes have already been introduced on an experimental scale in a few schools in India, Indonesia, Myanmar, Nepal and Thailand. An intercountry workshop was organized to develop a nucleus of medical educational leadersin the Member Countries who will be able to prepare medical undergraduates for meeting the challenges posed by the emerging problem of AIDS in the Region. Specific curricular reforms on the lines recommended in the technical documents on the reorientation of medical education, published by the WHO Regional Office, arc also being undertaken. The momentum of change generated in the last decade in reorienting medical educalion systcms to produce physicians with competence and compassion, who can serve the needs of whole populations, continues to be maintained in the Member Countries. WHO continued to provide technical support to strengthen basic nursing education. Efforts have been made to strengthen institutional frameworks and educational policies as well as teaching-learning resources for the implementation of community-orientcd nursing curricula. Assistance in the upgradingof nursc-teachers was continued through fellowships for advanced studies or speciality training in educational methodology or clinical nursing speciality. Concern for ensuring the quality of nursing education in preparing nurses for national needs was further promoted in the Region. A critical appraisal of the use of distance education to meet such challenges was carried through an Intercountry Workshop on Distance Education for Nursing Personnel and other Health Workers, held in Thailand in October 1990. Particular attcntion was being devoted to the improvement of thc nursing and midwifery curriculum to better prepare graduates to comprehend the seriousness of AIDS/HIV infection. WHO continued its collaboration with Member Countries in consolidating the programme for the development of expertise of teachers of health professionals in their subject matter as well as in the basics of educational science and technology. The UNDP-funded, WHO-executed regional project to establish an intercountry network of institutions for the development of health learning materials started in January 1990. Since then, four more countries participating in the project have formulated national work plans and conducted a 'needs and resources' survey. An intercountry Workshop on Health Learning Materials Development was organized in Jakarta in February IWl. At thc eighty-seventh session of the Executive Board, held in January 1991, the Director-General presented a report on the implementation of WHO'S policy on fellowships. The report contained inputs from the South-East Asia Region. Thesc were based on the reports, using indicators and guidelines developed at the Third South-East Asia Regional Conference on WHO Fellowships, held in 1988, of eight countries that had submitted their self-evaluations. The Executive Board, in wcla,rningthc rcport, urgcd Mcrnhcr Countries to take demonstrable steps 111 cnsurc thc rclcvancc of WHO fellowships to thcir hcalth rcsourcc nccds and national health development, to introduce or strengthen mechanisms to establish policies for thc planning, production and management of their human resources for health and to evaluate their use of fellowships resources in order to ensure that their selection mechanisms are effective and that returning fellows are utilized in the best interests of the national health systems (EB87.RZ3). In order to assist the Member Countries, a revised Directory of Training Institutions was completed in 1W0 and copies sent to countries. Efforts arc being made ro updarc the information so that the Directory is more comprehensive and informative. PUBLIC INFORMATION AND EDUCATION FOR HEALTH Strategies to make health education more effective in addressing existing and emerging needs in Member Countries were the focus of information and education for health activities during the period under review. Emphasis was laid on advocacy efforts to lead to social mobilization for health and school health education. The development and dissemination of IEH materials on "World Days" continued both in the Regional Office and in Member Countries in collaboration with other technical units, media and headquarters. More can be achieved with necessary attention being paid to increasing training of human resources, including in the media, for more appropriate health education approaches at decentralized levels. RESEARCH PROMOTION AND DEVELOPMENT The programme of Research Promotion and Development encompasses several activities. These range from the promotion of research through scientific meetings to research capability strengthening by awarding visitingscientist grants and research training grants, and include the establishment of WHO collaborating centres, promotion of mechanisms for research promotion and development at the national level and provision of direct support to research projects. These activities should be considered together with the research programmes initiated and monitored by the various technical units of the Regional Office. In this endeavour, the WHO South-East Asia Advisory Committee on Health Research (SEAIACHR) serves as the main advisory body to the Regional Director on mattcrs of policy. At the seventeenth session of SENACHR, held in Yangon, Myanmar, from 21 to 27 April 1W1, apart from reviewing the regional research programme, the Committee discussed and made recommendations on research issucs pertaining to health care delivery in villages and slums, control of cancer in developing countries and youth (and adolescent) behaviour as related to health. The ACHR drew up a strategic plan for its own activities for the next five years. The seventh meeting of Directors ofMedical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries (MRCs) was held in Kathmandu, Nepal, from 4 to 9 November 1990. The need to generate a climate conducive to the development of a research culture at the national level was stressed. The importance of establishing both an infrastructure for implementation of the recommendations of the n~eetings of MRCs and also a national mechanism for the coordination of research activities was pointed out. Regular joint meetings of the research community and health care managers would subserve the achievement of these objectives. A South-East Asia Nutrition Research-cum-Action Network was established with thc main objectives of identifying major nutritional problems in the South-East Asia Region, strengthening nutrition research-cum-action capabilities, and promoting selected priority research-cum-action nutrition projects and training schemes. Among the several priority operational issues identified as being amenable to research-cum-action projects are weaning foods, to overcome protein-energy malnutrition in young children, and anaemia in pregnant women. The Regional Office will support some of the network activities. ~(VIII 'SIIE WORK OF WHO IN SEA The Eighth WHO Peer Review Meeting on Dengue Vaccine Development was held in September 1990. It was reported that 90 per cent of the human subjects who received one or more of the candidate attenuated vaccines showed seroconversion without any disabling untoward effects and maintained neutralizing antibodies for a period of years. Anolher trial of trivalenl vaccine (dengue 1, 2 and 4) in different dilutions was recommended, and as soon as an acceptable combination is found for adults, a study in children may be initiated. The vaccine programme is gaining international recognition. Further collaboration is under discussion. At a meeting of the Task Force on Research in Tuberculosis in December 1'240, lacunae in the research programme in relation to the problem of tuberculosis in the Region were analysed and research protocols were developed on: the identification of risk factors for disease; risk factors for infection; operational research for improving cure rate; programme monitoring and disease surveillance; assessmenl of the protective effect of BCG revaccination; the role of X-ray examination of the chest; centralizedsputum examination toimprove the quality of coverage; use of a combined tablet for the treatment of tuberculosis; and operations research for the attainment of a high cure rate in district TB control programmes. The protocols will be used for promoting research on tuberculosis in Member Countries. The Regional Office continues lo support investigator-originated as well as collaborative research projects. Of the 67 projects currently being supported, 38 are concerned with communicable diseases. As part of the research capability strengtheningefforts, 14 VisitingScientist Grants and ResearchTraining Grants werc awarded during 1990-91. GENERAL HEALTH PROTECTION AND PROMOTION Nutrition in the Region is in transition in response to demographic, environmental and socioeconomic changes. In an effort to prepare for the next century an in-depth assessment of priority nutrition issues in regional countries over the next few years is being carried out. National programmes for the control of IDD are developing rapidly; a regional meeting was held, concentrating on the managerial aspects. There was a useful sharing of experiences. A Regional Nutrition Research-cum-Action Network has been set up. Priority projects are starting and a Newsletter has been published. The Network brings together centres of excellence in nutrition research and training in the Region with national focal points in nutrition. The aim is to bring operational research to bear on priority problems in nutrition programming. Accidents and injuries, issues related to safety and healthy working environments, emerging socioeconomic and health problems of ageing, and diseases and conditions causing disabilities and handicaps, including blindness and deafness, continue to receive inadequate attention as compared to their effects on the social, economic and health statuses of the people. Fragmented, conventional type approaches to these problems have not yielded the results that could be expected from jointly planned and eflcctivcly coordinated efforts, using thc same financial, human and material rcsourccs available in the Member Countries. Much greater efforts are, thercfore, needed in this regard as well as towards cducation and creation of awarencss among populations and decision makers. Tobacco or Health has bcen introduced as a sub-programme area into the WHO programme classification only in the Eighth General Programme of Work, beginning in 1990. Already two countrics of the Region, viz., Indonesia and Thailand, have responded by making spccific budgetary provisions for Tobacco or Health (TOH) country programmes. In other countries, activities related to TOH arc fundcd from other country programmes, mainly related to cancer control, to noncommunicable diseases, or to research. As far as legislative and administrativc measures for the control of tobacco use are concerned, some of these have been implemcnted with surprising speed in several countrics of the Region, and full-fledged national tobacco control programmes are under preparation in some. These control measures focus on tobacco smoking since campaigns against this are facilitated by the knowledge about thc ill-effects of passive smoking. In addition to legislation and administrativc interventions, several districts in Bhutan have declared themselves tobacco-frcc in a spirit of community involvement. PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS WHO collaborated with Member Countrics, together with UNFPA and UNICEF, in the dclivery of integrated MCH/FP programmes, including adolescent health. All the countries laid emphasis on maternal health by promoting safe mothcrhood programmes, by intensifying training of human resources in safe delivery, by making services available at the grassroots and by improving the quality of services. Dissemination of information on safe motherhood, family planning and child survival and dcvelopmcnt was done by holding national seminars and formulating national strategies for the attainment of national goals on maternal and child health. Support was provided for the conduct of various research projects and operational rcscarch in safe motherhood as well as on low birth-weight. Technical support was provided for the development of the MCH/FP manual in Bhutan. Human Reproduction Research (HRP) has concentrated on long-term institutional development (LID) grants for research. In regard to countries where research facilities are limited, a new approach of strengthening research capabilities at the ia ?HE WORK OF WHO IN SEA country rather than at the individual institution level has been adopted. This implies close collaboration with national policy-makers. In line with these needs, two workshops have been held, in Sri Lanka and Myanmar. The programme also concentrates on support for research finding and developing new, safe, and effective methods of fertility regulation as also for improving the performance of the existing methods. The South-East Asia Region has received a number of rcsearch grants for the abovc. The issues of 'Women, Health and Development' were discussed in September 1990 at the forty-third session of the Regional Committee, which urged Member Countries to further pursue policies for increased participation of women in health decision-making, to allocate adequate resources for relevant activities and to further involve nongovernmental and private organizations. In collaboration with HQ, 'Leadership and Participation of Women in MCHFP Programme'has been initiated in India, Indonesia and Nepal. These countries have developed programmes as a follow-up of the interregional meeting held in Mauritius and Brazzaville. Self-care activities in homesetting are also being promoted as the mother is the key person in self-care. The document on 'Women, Health and Development' in South-East Asia has heen updated. Unregulated work, lack of education among workers and absence of facilitics arc thc major issues of workers' health in the countries of the Region, with low priority being given to health of the working people, particularly those employed in small-scalc industries and the agricultural sector. Consequently, there has not been enough or adequate development of occupational health policies. The rapid pace of increasc in the number of ageing people in populations in somc countries is affecting social and health care services. Apart from the need to furthcr study biomedical and psychosocial factors of health and of ageing, it is necessary to havc a better understanding of, and, if possible, a family and community apprcsach to, the solution of this problem. WHO has collaborated in the training of pcrsonnel through fellowships and group educational activities PROMOTION AND PROTECTION OF MENTAL HEALTH The special focus of WHO collaboration in this sub-programme area continued to be on the identification of families most in need of assistance for health protection and promotion, and on the development of interventions within the PHC infrastructure to reduce the impact of these risk factors on the well-being of mothers and on the healthy development of children. A manual on special psychosocial skills which may help to achieve an improvement in coping capabilities and well-being of mothers has been prepared. The impact of such counselling support on cognitive development and nutritional status of children in risk families is being evaluated in a multicentric study. In related work, the same psychosocial skills are being evaluated in families where childhood malnutrition has occurred and in families where, according to the results of a previous multiccnlric study coordinated by the Regional Office, undernourishment in children is likely to occur. It is hoped that, through these intervention trials effective psychosocial interventions to reduce childhood malnutrition will be developed, in addition to gaining more insights into the behavioural causation of childhood undernourishment. In a further study, the impact of similar psychosocial interventions is being evaluated in risk families where one of the home risks is alcohoVdrug abuse in the father. In this set of multicentric studies, previous Regional Office-coordinated work on subjective well-being, on home risk for healthy child development, and on psychosocial factors in childhood malnutrition, have now converged to the development of interventions which hold promise of effectively reaching the hith~rto unreached or unreachable. The UNFDAC-supported and WHO-executed drug abuse control programmes in Myanmar and Sri Lanka have continued with satisfactory rates of implementation. A second phase of the Sri Lankan project has been initiated, and the UNDP-funded project to establish a monitoring system of drug use in Sri Lanka has been caendcd for one more year. With the signing of an agreemcnt between WHO and UNFDAC regarding WHO'S role in thc execution of demand reduction programmes, supported by UNFDAC - recently merged into the new United Nations International Drug Control Programme (UNIDCP) - more WHO-executed country activities can be expected. Thc high risk of HIV infection through the sharingof injection cquipmcnt in injecting druguscrs, in addition to the incrcasedrisk through drugusingsex workers, has addcd a new dimension to the is.cuc of drug abuse. A vdricty of special behavioural interventions for risk minimization have been developed and are being promoted. Countries have reacted dil'fercntly to this new concern, and, in several public health concerns in relation to the AIDS epidemic, have begun to successfully compete with political and moral concerns related to drug use and other high-risk behaviours. Several countries uf the Region have established formal national mental health programmes. In these countries, WHO activities are geared towards facilitating the implementation of these programmes. They all contain the important component of training of non-specialist staff in basic mental health skills, thereby fostering integration. WHO support has also aimed at the promotion of health systemsresearch into the integrated delivery of basic mental health care. Variables studied and monitored in some countries or districts include not only coverage but also outcome measures and process indicators such as an appropriate flow of information. ~753 THE WORKOF WHO IN SEA PROMOTION OF ENVIRONMENTAL HEALTH While most countries continue to accord high priority to community water supply and sanitation, there is in the Region agrowing awareness of environmental problems and their close links to health and sustainable development. In countries experiencing rapid urbanization there is concern for: pollution of drinking water resources from toxic chemicals; prevention and control of health hazards stemming from air, land and water pollution; chemical safety and control of poisons; health risk assessment and risk management; and environmental epidemiology and food safety issues, particularly related to adulteration and contamination by chemicals. Notwithstanding the end of the International Drinking Water Supply and Sanitation Decade (1981-19!W), which was marked by the Safe Water 2000 UNDP Global Consultation in New Dclhi in lYM, countries are vigorously pursuing the Dccadt: goals of safe water supply and adequate sanitation, and are currently engaged, with WHO support, in a comprehensive review and evaluation of their Decadc achievements and shortfalls. In thc light of lessons learnt from Decade experiences, national agencies are formulating strategies for renewed efforts to enable people to attain safe water and sanitation in the 1990s and beyond taking - into consideration the principles of environmental protection, strengthening institutions for sustainable development, community management and sound financial management. In addition to fellowships and observation tours, WHO assisted manpower development for in-country training activities for professional as well as subprofessional staff in Bangladesh, India, Indonesia, Myanmar and Nepal on such aspects as design of facilities using microcomputer techniques, environmental health education for community water uses, rehabilitation as well as operation and maintenance of watcr systems, latrine programme development processes, etc. Strengthening of water supply and sanitation sector agencies' institutional capability was provided for by technical assistance in the areas of organizational development, managcment information systems for monitoring and planning, improved operation and maintenance approaches as well as the planning and development of national watcr quality surveillance infrastructure. Most SEAR countries are faced with environmental health problems associated with rapid urbanization that have resulted in mushrooming squatter settlements and unplanned population growth, creating enormous demands on such basic services as water supply, sanitation, waste and storm water drainage and solid wastc management. The increasing deterioration of environmental conditions in urban and peri-urban areas poses a major challenge to countries. WHO has continued to support, among others, institutional development, promotion of intersectoral cooperation with community involvement and the application of appropriate technology to address solid waste management and drainage problems and issues identified by the countries. Low-cost sanitation programmes were launched in a number of countries and a Healthy Cities project proposal for five major urban EXECUTIVESUMMARY dii centres of the Region was prepared jointly with ESCAP in an effort to improve the cities' environmental services, especially in slum areas. WHO'sefforts in the newsub-programme area of health riskassessment of potentially toxic chemicals focused on intersectoral manpower training on risk assessment, emergency preparedness and response, health monitoring and environmental epidemiology. Assistance was provided for establishing national poison control centres in India, Indonesia and Thailand as well as for the preparation of projects for UNDP assistance in the areas of chemical safety and poison control. WHO supported institutional development for the effective management of chemical safety programmes and chemical emergencies in countries experiencing rapid industrialization. WHO collaborative efforts in respect of control of environmental health hazards have been directed at strengthening national institutional and manpower capabilities. The UNDP-assisted intercountry project on Safety and Control of Pollutants and Chemicals continued to address priority problems of chemical safety and industrial pollution in five countries with training in managerial approaches to reduce health risks from hazardous wastes and chemicals and in developing environmental control programmes for indoor air pollution from toxic chemicals. WHO has supported institutional development for national agencies involved in the monitoringand control of environmental health ha7.ards in DPR Korea, India, Indonesia and Thailand. Information management related to chemicals was supported through technical assistance in setting up programmes and providing computer hardware and software in India, Indonesia and Thailand. Activities of the Global Environmental Monitoring System (GEMS) involved water quality monitoring in Bangladesh, India, Indonesia and Thailandwhile air quality monitoring continued in India, IndonesiaandThailand. WHO' s support to national food safety programmes covered such aspects as food legislation for monitoringand inspection of food contamination, development oflabo- ratory capabilities for microbiological and chemical examination, and food standards control measures. Training courses for food safety administrators and public health inspectors were held in India, Indonesia and Sri Lanka. A review of state food safety laboratories was made and a manual and a training course on good manufacturing practices were developed in India. An assessment of national food safety programmes is under way to identify further areas of WHO assistance to countries. DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY Strengthening of health laboratories is essential in health care delivery, particularly at the peripheral level. WHO has continued to support Member Countries in the mv 'ME WORKOF WHO IN SEA strengthening of health laboratory services through continuing training programmes, supplies and equipment and sustenance of qualiwassurance programmes. Re~ional . . . - - self-reliance iimbdern immunological and biological reagents, particularly for the development of rapid diagnostic tests for priority communicable diseases, has been supported through UNDP-funded projects. Under intercountry technical cooperation, the National Institute of Health, Thailand, provided diagnostic antisera; the WHO Collaborating Centre for Reference and Training in Streptococcal Diseases at the Lady Hardinge Medical College, New Delhi, supplied diagnostic reagents for streptococcal infections; and the WHO Collaborating Centre for Rapid Viral Diagnostics at the National Institute of Virology, Pune, India, distributed kits for the diagnosis of Japanese encephalitis to other countries of the Region. WHO continued to support proficiency testing and development of national capabilities in the sero-surveillance of AIDS. A workshop held in December 1W trained nationals for improving the safety of blood and blood products utilizing modern technology. Under the UNDP project for strengthening health laboratories in primary health care, covering six countries of the Region, national workshops were held for drawing up national policies for networking of health laboratory services. Under the same programme, national workshops for the introduction of appropriate technology at the peripheral level are in progress. WHO has initiated a programme for the promotion of novel techniques in the diagnosis of diseases. WHO has strengthened the essential drugs programme to improve drug availability at the primary health care level, quality assurance, rational use of drugs and manpower development. Capabilities in drug procurement, storage and distribution were further promoted. Essential drugs programmes, supported by voluntary funds, continued in Bhutan, Myanmar and Thailand. The ASEAN pharmaceutical project is progressing satisfactorily and plans are under way to continue the project up to 1996. Proper utilization of essential drugs has been promoted through the establishment of the standard treatment regimens in several countries of the Region. Additionally, rational use of drugs has been further promoted through national and intercounlry training programmes. Several essential drug programmes have adopted computer technologyfor drug management, drug information and adverse drug reactions. With the introduction of newer technologies the production of EPI vaccines has been promoted. Quality control, proper storage and distribution of vaccines have been supported. The WHO Certification Scheme on the quality of pharmaceutical products moving in international commerce has been promoted. The scheme helps to ensure the quality of pharmaceutical products for the importing country. Drug registration and regulatory control were strengthened to ensure drug quality, efficacy and safety. Training workshops were held to improve drug evaluation. Good manufacturing practice was promoted in the production of pharmaceuticals, particularly in regard to the improvement of manufacturing equipment, quality control and training of human resources. Traditional medicine was supported in several aspects. Institutional strengthcniny and human resources development continued with funding from UNDP. Standardization, quality control and utilization of herbal medicines are being promoted as a component of the ASEAN technical cooperation in pharmaceuticals. Standards and quality control procedures for selected medicinal plants were established. The manufacturing of traditional medicines is improved through the introduction of modern manufacturing equipment and technology. Research activities wcre supported for the integration and utilization of traditional medicines in primary health care. DISEASE PREVENTION AND CONTROL Remarkable progress in improving immunization coverage has been obscrvcd in Member Countries. By February 191, seven out of the eleven countries (Bhutan, DPR Korea, India, Indonesia, Maldives, Mongolia, Sri Lanka) declared the percentage of fully immunized children under one year of age as 80 per cent or more. EPI reviews conducted in Nepal, Mongolia, Thailand, Bhutan and Bangladesh confirmed impressive progress in the programme. The impact of immuni~ation coverage on the reduction ofpolio and neonatal tetanus is being witnessed. However, disease surveillance, epidemiological measures/disease control, supervision and monitoring of the cold chain, training of manpower, integration with MCHIPHC, quality assurance of vaccines, as well as immunization coverage, etc., require further improvements. Sustainability of EPI has become essential for continuingEP1 during the last decade of the century. An integrated approach and long-term plans for the development of HSI and mobilization of national resources as well as strengthening of national capabilities for self-reliance in vaccine production are necessary to assure the sustainability of the programme. Some progress has been madcin the control ofvector-bornediseases in the countries of the Region, but infections such as malaria, dengueldengue haemorrhagic fever, filariasis, Japanese encephalitis and leishmaniasis still continue to be leading public health problems. As of today, vector control remains the major operation to control these diseases. Although chemical pesticides continue to be used for disease vector control, it is recognked that there is great scope for the development of comprehensive strategies with a view to judiciously using alternative methods, mi THE WORKOF WHO INSEA including pragmatic bioenvironmental measures, in a cost-effective manner at community and national levels. The overall malaria situation in the countries of the Region has remained unchanged for the past few years thoughsome improvement has been observed in afew countries. However, the malariogenic potential has remained high in practically all endemic countries. The high incidence of falciparum malaria, including its resistant strains, continued to pose a major problem, compounded by widespread vector resistance to different insecticides and development of exophilic and exophagic behaviour by the principal malaria vectors. Epidemiological approaches through the primary health care system continued to be employed by all malaria control programmes of the Region in order to tackle the problems. To facilitate cost-effective implementation of malaria control programmes in the Region and strengthen the health infrastructures, WHO has been collaborating with the countries in conducting training and planning, implementation, monitoring and evaluation of malaria control activities, particularly in the studies on drug resistance, insecticide resistance. bioenvironmental methods, personal protection methods and the like. Special attention was paid to the development of methods of malaria stratification, mechanisms of monitoring large-scale population movements and establishment of epidemiological early warning systems to predict malaria outbreaksiepidemics. Support was provided to malaria control programmes in staff collaboration, development of manpower through fellowships, study tours, workshops and seminars and in the procurement of essential supplies and equipment. Visceral Leishmaniasis still continues to be a health problem in India, Bangladesh and Nepal, particularly in India where 56 971 cases and 607 deaths were reported in 1990. Chemotherapy trials with different doses of ivermectin in microfilaria carriers and patients were continued. Research studies in schistosomiasis under TDR were carried out in the Region. India, the only country infested with guineaworm disease in this region, continued to strive towards achieving the goal of zero incidence. To supplement their efforts, two more surveillance teams were deployed in the state of Rajasthan. The UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) has supported the Region in the achievement of good progress in the ongoing field trials of new drugs against malaria, filariasis and leprosy. As several countries in the Region have been identified as least developed (in tropical diseases research), research capability strengthening activities are being initialed in some of them, including the FIELDLINCS programme. Progress has also been achieved in the development of newer immunological test kits and DNA probes for the diagnosis and field trials of biological control agents in malaria. A constant follow-upon studies of transmission-blocking antigens ofP.vivar has been continuing in the field trials of the armadillo-derived WHO vaccine. The development of these products is being emphasized in the developing countries. Diarrhoea1 diseases continue to be a major health problem in the Region. National CDD programmes have been implemented in all Member Countries as part of the primary health care services. In addition to case management strategy to reduce mortality, the CDD programme is now also layingemphasis on selected interventions to reduce diarrhoea morbidity. Plans of operation are periodically heing revised in almost all SEAR countries, mostly in formal planning exercises or following comprehensive programme reviews, always in keepingwithprogramme achievements and progress. Training activities in programme management, supervisory skills and clinical management continue to receive high priority. Acute respiratory infections (ARI), especially pneumonia, together with diarrhoeal diseases and malnutrition, are still the leading causes of death among children, and result in the largest number of attendances at out-patients departments of all the health services. Since tl~c beginning of thc programme, various types of national committees or advisory groups on ARI havc been constituted in almost all the countries, for promoting prevention and control activities. The increased awareness ofthe problem has stimulated the countries to include in their health plansthe control of ARI in children as one of the most important components. Long-term plans of action have been prepared or revised for nine out of the eleven countries of the Region. The ncw suyervisory skills module "Management of a Child with ARI" and the training video, and thc new programme managers' course have given a ncw input and created interest in the programme. The manual on ARI for doctors is considcrcd to be technically very good and ausefulreferenccdocument for all thedoctors dealing with children. In all Member Countries, the reduction of mortality from pneumonia has bcen considered the main objective and the most important priority of their national programmes. For this reason some countries, such as India, Indonesia, Myanmar, Nepal and Sri Lanka, have decided to have a new policy which will focus on thc training of pneumonia only. Accordingly, the WHO modules have also been modified. In all countries, the ncw classification of ARI has been well accepted. Tuberculosis continues to be a major public health problem in the countries of the Region. The spread of HIV infection in countries like India, Myanmar and Thailand is likely to cause a resurgence in infection with tuberculosis bacilli. WHO has formulated a draft medium-term plan for implementing new strategies for thc control of tuberculosis. A mccting of the task force, formed at the Regional Office, was hcld in Deccmbcr 1994 to ident~fy areas of research on tuberculosis. In the South-East Asia Region, a major revolution is taking place in the attitude towards, and perception of, leprosy by communities on the whole and patients individually. The increase in awareness about leprosy and confidence in MDT is gaining momentum. Governments no longer see leprosy as an insurmountable problem likely to take up a large proportion of the meagre available resources while miii THE WORK OF WHO IN SFA not being able to produce any tangible results. As a result of these factors, most leprosy endemic countries of the Region have witnessed rapid expansion of MDT coverage. The WHO-recommended multidrug regimen has been firmly accepted as the drug regimen of choice, both by national programmesas well asmost programmes run by NGOs. As rapid decline in the case-load continues, individual programmes that were formerly hesitant to accept the integrated approach have now started to adopt the approach, fully realizing its cost-effectiveness. Early detection of cases through active and passive means and treatment with MDT are being seen as the most effective way of preventing disabilities. This is being achieved through the intensification of programme activities, including social mobilization and health education campaigns. At a recent intercountry Consultative Meeting of Leprosy Programme Managers from Member Countries, the participants expressed their confidence that the elimination of leprosy as a public health problem by the year 2000 is a feasible goal in this region. Zoonotic and food-borne diseases pose serious risks both to human and animal health. They affect national economies, especially in the countries of the South-East Asia Region where agriculture and animal products form the basic and primary means of economic development. The major zoonotic diseases occurring in the countries are rabies and brucellosis. Nepal received assistance from a nongovernmental organization of Francc, Veterinarians Sans Frontiers (VSF), in implementing a WHO-assisted project for thc control and elimination of rabies in thc country. Similarly, Sri Lanka received extrabudgetary assistance from AGFUND for the control of rabies in the country. Sexually-transmitted diseases continue to persist in several countries of the Region, with serious sequelae to individuals and the community as a whole. All countries of the Region have clinical and laboratory facilities to treat persons affected by thcsc diseases, and preventive steps, such as promotion of sex education, have been taken by them. However, inadequate reporting and recording systems are an obstacle in estimating the exact magnitude and dimensions of the problem. Thc major emphasis in vaccinology is on the attainment of self-sufficiency in EPI vaccines. WHO supported the production, quality control, and storage of EPI vaccines. Technologies in the production of viral and bacterial vaccines are being introduced where necessary. Transfer of technology for the production of hepatitis B vaccine is under way in Mongolia and Myanmar. Plans for clinical trials of denguc vaccine in Thailand and snake venom vaccine in Myanmar are now at various stages of implementation. The present dimension of AIDS, if not contained with appropriate measures, poses a threat to the achievement of Health for All by the Year 2000. It has assumed the status of a serious public health problem in Thailand, India and Myanmar. In India, where hitherto HIV infection was prevalent only amongst female prostitutes, the trend has changed to that where heterosexual transmission of HIV is prevalent. The number of injecting drug users (IDUs) positive for HIV infection has also increased, particularly in Manipur. Recent serological studies on riskwise and sexwise distribution of HIV-positive percentages for two different periods in respect of Myanmar indicate a sequential infection starting with lDUs and then spreading to other groups with high-risk hehaviour. In Thailand, the magnitude of the epidemic has changed over the past few years. Whereas the problem during 1984-1986 was mainly related to homosexual men, in 1987 the epidemic among IDUs rose sharply to 89 per cent in 1988. It has reached a plateau. Although the present group of IDUs continues to make up the vast majority of reported HIV infection, the trend in transmission related to sexual practices is increasing at an alarming rate amongst female sex workers. There is evidence of a sharp increase in the transmission related to heterosexual behaviour, both male and female. The experience so far in other parts of the world indicate that SEAR countries, where HIV infection is in a stage of low prevalence, should not be complacent in taking appropriate steps for the prevention and control ofAIDS, as otherwise they will miss the advantages now available for containing the disease. Most of the countries have completed short-term pl:~ns of action and have undertaken the implementation of mcdium-term plans of :~ction for the control of HIVIAIDS with emphasis on education, information and communication, and provision of safe blood and blood products. Viral hepatitis continues to he a public health problem inSEAR countries. Hepatitis A virus (HAV) infection amongst adults has increased in Indonesia and Thailand in recent years. The prevalence of Hepatitis B virus (HBV) continues to be a major public health problem in the Region. Hepatitis E virus (HEV) infection is an emerging problem in the Region. WHO continues its support for training, research and attainment of self-sufficiency in the production of reagents. Immunization against HBV is receiving greater attention by Member Countries. The training of health personnel in various aspects of eye care has been a major activity in the area of blindness. In most countries, though the reported break-up of prevalance of blindness varies from 0.5 to 2 per cent, with cataract accounting for more than 50 pcr cent, the underserved areas fare worse. Studies on the feasibility of setting up low-cost spectacle manufacturing units, setting up mobile units, and training personnel in public health ophthalmology have been carried out in different countries. As regards deafness, no reliable statistical data are available. An effort has been made to make a general overview of the national deafness programme by fielding a consultant in Indonesia, Myanmar, Nepal and Thailand. XU I HL WOKK 01' WllO IN SFA The increase in the recognition of cancer as one of the major causes of morbidity, particularly mortality, has led to the establishment of specific national cancer control programmes in more countries of the Region besides India, Indonesia, Sri Lanka, and Thailand. Unlike the more industrialized countries, in this region about 33 per cent of patients suffering from cancer come to the attention of health services in the late and incurable stages. Palliative carc and pain relief are therefore of great importance. As a consequence, several countries have facilitated access to potent pain killcrs, including oral morphine. WHO has therefore continued to support public education campaigns to reduce tobacco consumption and for self-examination ofthe oral cavity. With an increase in life expectancy, but probably also due to changes in lifestyles, the incidence of cardiovascular diseases in most countries of the Region seems to bc increasing. This is in sharp conlrast to their marked decline in most industrialized countries. WHO'S support in thcse arcas of emerging conccrn is mainly focused on the training and transfer of expertise through fellowships, consultants, and training programmes for medical officers. Large-scale control programmes like those for hypertension and diabetes arc still hampered by the substantial resources they require. However, the secondary prevention of rheumatic heart disease, still a scrious problem in most countries of the Region, has been shown to be feasible at low cost. SUPPORT SERVICES Support services with four main units - Administrative Services, Personnel, Budget and Finance and Medical Supplies - contributed successfully towards effective programme planning, management and evaluation. World Health House, seat of the Regional Office was maintained in the usual manner andcertainimprovements were made to theoftice by commissioninga standby powcr generator, installing a new fire alarm system and improving the lift in the annex to the building. Of the 135 established professional posts, 110 have been filled as of 30 Junc 1991. There has been an increase in the number of professional posts from 133 to 135, due to new posts funded by extrabudgetary resources and voluntary funds. A total number of 183 consultants were fielded during the year to provide valuable technical support. Steady progress has also been made in office automation, with more staff mcmbcrs given training and the Administration and Finance Information (AFI) complcting one year of successful operation. The planned programme budget for the 1990-1991 biennium from regular budget was US$80,7million. The total obligation for the first 18months of the biennium amounts to USB53.9 million and it is estimated that planned programme in countries will bc implemented by the end ofthis biennium even though there has been some financial stringencies due to currency fluctuations and tremendous cost cscalation. In rcg~rd to supplies and equipment, local purchase, whcrcvcr relevant, was encouraged. Further, care has hecn taken while proccssing requests for sophislicatcd equipment not only to rcduce delivery lime, but alsu to ensure after-sales services such as installalion, maintcnancc and spare parts. Emergcncy supplies to meet epidemics and disasters were arrangcd for Bangladesh, Maldives, Mongolia, Myanmar and Sri Lanka. Ministers and other important dignitaries visitcd the Regional Office during the year. Thesc visits enabled such persons in policy-making positions to hcttcr appreciate WHO'S support to the health development proccss. The Director-(kneral, Dr H. Nakajima, visitcd Thailand and Indonesia. During his visit to Thailand and Indoncsia, the Director-General honourcd Her Royal Highness Somdcch Phra Srinagarindra Boromarajonani, Princess Mother of Thailand, and H.E.Mr Soeharto, President of Indoncsiarespcctively, with the presentation of newly-minted prcstigious HFA gold medals. The Regional Director, in addition to attending meetings of thc Executive Board, Programme Committee and the World Health Assembly, also ettcndcd the International Confercncc on HIVIAIDS in Canhcrra, Australia, in August1000, and thcThird International Seminar on Primary HcalthCarein Huvana, Cuba, in March 1991. Hc also made a number of visits lo Member Countrics 10 discuss the progress of WHO collaborativc programmes. Thc ahovc is a brief dcscriplion of the aciividcs of WHO in the South-East Asia Rcgion, complcte details of which arc available in thc following pages.

Chapter 13 DISEASE PREVENTION AND CONTROL 13.1 IMMUNIZATION Substantial progress in EPI has been made in the Region. Thc majority of thc countries achieved immunization coverage of 80 per cent or morc during the year 1990. The infant coverage in 1990 was 86 per cent for the third dose of diphtheria-pertussis-tetanus vaccine, 87 per cent for the third dose of oral polio vaccine, 80 per cent for measles vaccine and 95 per cent for BCG vaccine against tuberculosis. Tetanus toxoid coverage in pregnant women was reported as 68 per cent (Figure 1). In some countrics, the impact of immunization coverage on the reduclion of'diseascs, especially poliomyelitis, diphtheria, and pertussis, can be seen (Figure 2). In order to achieve reductions in morbidity, disability and mortality from the six EPI targrt diseases, it is important to sustain and augment activities for the control of EPI target diseases with a strong health services infrastructure and adequate financial support. An epidemiological approach for the control of EPI diseases will be stressed during thc 1990s. Much of the success of this approach is dependent upon implementation and improvement of survcillancc. The integration of thc Expanded Programme on Immunization with Matcrnal and Child Health and Primary Health Care continues to be encouraged. This will help to achieve self-reliance in the delivery of immunization services within the context of comprehensive health services. An Intercountry Consultative Meeting on Financial Management of EPI was held in New Delhi in January 1991 to strengthen EPI managers' capabilities in financial planning and management. Plans of action, country timetables and general guidelines on financial management were the outcome of the meeting. Figure I. Immunization Coverage ,IS 'Illti WOKK01. WHO IN St:,% . - F@re 2. Morbidity Rates in SEAR, 1974-19W) (pcr- IOU 000p,1p,pabrion) IlISIi4SE PKEVENI'ION AND (:ONI'ROL. V9 WHO supports self-sufficiency in EPI vaccines through indigenoub production. While viral vaccines are mostly imported, Bangladesh, DPR Korea, India, Indonesia, Mongolia and Thailand produce bacterial vaccines. Efforts are bcing made to develop national vaccine quality control systems to ensure that the indigenous production of EPI vaccines conform to the WHO standards. Efforts in measles and polio vaccine5 production are going on in India and Indonesia. The production of Edmonston-Zagreb strain (E-Z) of measles vaccine is being carried out at the Serum Institute,Pune, India, anda pilot study of LheE-Zvaccine isunderway at the National Institute of Virology, Pune. The recent results of oral polio vaccine potency testing in India are encouraging. Compared to previous results, improvement is significant with more than 90 per cent of samples meeting the minimum requirements. Similar results wcre reported by Thailand. Poliomyelitis Eradication/NeonataI Tetanus EIimination/Measles Reduction Initiatives The global targets (polio eradication by 2000, neonatal tetanus elimination by 1995 and measles reduction by 00 per cent by 1995) have becn cndorsed by all the countries of the Rcgion. However, the annual national targets and approaches differ from country to country, based on the local health infrastructure and available resources. Eradication of Poliomyelitis. Based on the annual country reports, thc regional polio incidence rate decreased significantly, even considering the factor of underreporting. In Sri Lanka, Thailand, Mongolia, DPR Korea, Bhutan and Maldives, with high sustained coverage, the trend in the incidence indicates that the targets of polio eradication could be achieved before 2000. Currently, polio-free zones are observed in parts of Indonesia, Mongolia, Sri Lanka, Thailand and Maldives. The use ~f epidemiological approachcs is nccessary to achieve results. High coverage is not enough. The concept of mopping up and special attention to high-risk arcas will be needed. The strengthening ofbasic health services management, improvemertt of surveillance and laboratory services, and enhancement of public awareness arc necessary to achicvc thc eradication of poliomyelitis. A regional polio laboratory network plan, which will be the basis for devclopinglaboratory diagnosticscrviccs for additional EPI and other infectious diseases, is being established. Elimination of Neon;tt;tl Tetanus. The target of eliminating neonatal tetanus can bc achieved by timely tetanus toxoid immunization of pregnant women and all women of child-bearing age and by aseptic delivery and post-delivery care. All countries in the Region are committed to the global elimination target. The integrated approach through MCH and PHC is considered to be essential. In 1990, tetanus toxoid immunization coverage of pregnant women increased lo a level of68 per cent. Thc IW THE WORXOF WHO IN SEA regional coverage excludes DPR Korea and Mongolia which do not at present have national policies on the use of tetanus toxoid for pregnant women. The majority of the countries in the Region follow the policy of immunizing pregnant women. The WHO immuni7ation schedule of 5 tetanus toxoid doses for all women in child-bearing age is being examined by the countries. A few countries have introduced tetanus toxoid immunization among all women of child-bearing age. Recording and reporting of neonatal tetanus cases are deficient. As a result, the true impact of tetanus Loxoid immunization and clean delivery practices on the incidence of neonatal tetanus is difficult to determine (Figure 2). Reduction of Incidence of Measles. Although EPI started in 1977, measles vaccination was introduced by some Member Countries only in 198411985, In 1990, a dramatic increase occurred in the regional measles coverage (52 per cent in 1988, 59 pcr ccnt in 1989 and 80 per cent in 1W). Some countries declared a coverage of over 80 per ccnt (Figure 1). The annual number of reported measles cases did not change during the period 1981-1990. This is duc to a number of problems, including very limited surveillance systems and inadequate routine reporting. Compnterized EI'I Information System (CEIS) Ten countries of the Rcgion havc established their vcrsion of the Computeri/ed EPI Information System (CEIS), based on national needs. The development ol CEIS software with more professional and sophislicated programmes is encouraged hy governmcntlnational programmers, REACH and other bilateral and international agencies, as well as private organizations. Software and hardware system improvements are needed for the sustainability of EPI management information systems. National and local computer programmers are needed to manage current programmes and to develop other software. For the next two years, outside programmers are needed in some Member Countries, and certain countries, such as DPR Korea and Mongolia, require hardwarc as well. Cold Chain and Logistics Adequate central cold stores arc established in most countries of the Region. Bangladesh, Nepal, India and Myanmar have established very good cold chain systems in spite of difficult geographical conditions. Reviews of the cold chain using cold chain monitors have been conducted in selected areas in India, Nepal, Mongolia, Myanmar, Bangladesh, Bhutan, DPR Korea and Sri Lanka. The Asian InstituteofTechnology (AIT), Bangkok, isaccredited as a WHOIUNICEF training centre for solar refrigerators. AIT conducted the first training course on solar refrigerator repair and maintenance in July 1990 and a second course in May 1991. SEAR countries are now making plans to use solar refrigerators in remote areas. Indonesia has already procured more than 100 solar refrigerators for use in small DISFASE PREVENTON AND CONTROL 101 islands and held its first national Solar Fridge Training Course in early 1991. Myanmar and Maldives received new Japanese-made equipment for field trials in 199011991. A solar-powered sterilizer was field-tested in India. Responding to the goal of country self-sufficiency for EPI, India, Indonesia and Thailand have produccd some of their own cold chain equipment. Two cold chain equipment testing centrcs in India and Thailand are accredited by WHO for testing the suitability of cold chain refrigerators and cold boxes for EPI. Training and Kesearch Following the Intercountry Consultative Meeting on Financial Management of EPI for National EPI Managers of SEAR countries, New Delhi, January 1991, emphasis was laid on national training workshops with coursc material suitably adapted to thc local situation. An intcgratcd approach to training was encouraged. New rcvised training modules were field-tested in Thailand in May 1991. The Eighth National EPI Managers Consultative Meeting on the main subjects of EPI sustainability and surveillance was held in Nepal in June 1991. EPI coverage surveys were organized in all the Member Countries of the Region. National EPI reviews were conducted in Nepal, Mongolia, Thailand, Bhutan and Bangladesh and it was found that impressive progress in the Programme had bccn achicvcd. 13.2 DISEASE VECTOR CONTROL Vector-borne diseases, i.c. malaria, denguclDHF, filariasis, Japanesc encephalitis and leishmaniasis, continue to be public health problems in several countries of the Region. Prolonged use of insecticides, both in agriculture and in the field of public health, together with accelerated rural economic development, rapid urbanization and other human activities, have resulted in changes to agreat extent in the ecology, bionomics and susceptibility status of many species of disease vectors. As a result, many of them arc not amenable to control with insecticides alone because of changes in their seasonal and geographical prevalence, behaviour or susceptibility to insecticidcs that have bccn commonly used in the past. Therc is undoubtedly a growing opposition to the use of insecticides by environmentalists as well as householders. The trend, thereforc, is not towards sole reliance on chemical control but towards integrated approaches for vector control. The International Irrigation Management Institute (IIMI), Sri Lanka, has been designated as a WHOIFAOIUNEP Collaborating Centre for Vector Control, to provide technical support lo the countries of this region. 102 THE WORKOF WHO IN SEA WHO confirmed its collaboration in research on the development and application of innovative and cheaper control methods in the context ofprimary health care through community participation. Malaria In spite of the long-term residual insecticide spraying of premises for malaria control, the control of malaria vectors still poses problems. The widespread resistance to the commonly-used insecticides in the vector population and refractory behaviour of some of the vectors, notably several sylvatic species in the forested hilly areas, are of concern and have resulted more often ina setback to anti-vector operations, primarily due to the decreasing coverage. Apart from vector resistance, insufficient and erratic supply of insecticides, increasing cost and unwillingness of householders to acccpt residual insecticide spraying are contributing factors for setbacks in vector control. Consequently, remedial measures supported by WHO are: stratification of the most affected areas for rational use of available resources; and promotion of cost-effective integrated bioenvironmental measures as an alternative to chemical wntrol. The use of impregnated bednetsicurtains and other personal protection methods, such as repellents and coils etc., which are useful components in integrated vector control interventions, are also being promoted. Field trials of these methods continuc to be undertaken in the countries of the Region. A WHO-supported study on the effectivencss of environmental measures against anopheline vectors in the Terai region in Nepal is in progress. A WHOIUNDP project to determine the impact of residual spraying with 75 per cent DDT wdp on malaria control in the highly malarious areas of Bangladesh, whcre A~~ol?l~eles dinrs is the principal vcctor, is in progress. WHO is continuing its support for the cylogenetic study of sibling specics,A~roplreles crilicifocies and Anopheles subpichrs, in Sri Lanka. Dengue Haemorrhagic Fever (DHF) DHF continued to persist in Indonesia, Myanmar and Thailand, where it is prevalent in endemic form and the control of its vector Aedes aegypti remains a challenge. Sporadic cases of DHF have also bcen reported from India, Maldives and Sri Lanka. The control of DHF has been far from simple. Greater community involvement is needed to prevent breeding places ofAedes aegypti in and around houses. Phase I of the multicentre project to control DHF vectors with community participation, supported by the Regional Office, was completed both in Indonesia DISEASE PREVENnON AND COKTROL 103 andThailand in 1989. The project in Myanmar was, however, interrupted and could not be implemented. A Technical Advisory Committee meeting was organized by WHO headquarters and the South-East Asia, Western Pacific and American Regions in Bangkok from 4 to 6 October 1990. Thirty members, including the WHO secretariat, participated in this meeting to update the scientific knowledge being gained in various aspects of DHF, including the vector situation and control. The WHO Dengue Newsletter (Vol. 16), brought out during the period under review, highlighted the latest information on the DHF situation and community-oriented control and prevention of the DHFvector Aedes aegvpli. Japanese Encephalitis (JE) Japanese encephalitis (JE) has become a major health problem in India, Ncpal, Sri Lanka and Thailand. Several culicine species seem to play a significant role during outhreaks of JE. The most prominent species are Cula Infaertiorliyrtchtrs.~, Culer gelidtrs, Ctrlex vishrtrii, Ctrlex psetrdovishrttri and Ct~lex fitscocephala. The virus has been recovered from approximately 30species of mosquitocs belongingto fivegenera, i.e.Clrlex,Artopheles, Aedes, Martsortia and Amtigeres. These mosquitoes generally breed in groundwater habitats, particularly in rice fields and major components of irrigation systems, groundpools and shallow ditches. The important factors governing the spillover of the disease to man arc the relative abundance of the vectors, the availability of the amplifying hosts, thc density and absolute number of infected mosquitocs, adequate man-mosquito contact and the longevity of the vector. Control measurcs in affected areas have been primarily devoted to vector control by focal spraying and fogging of outdoor tracts with insecticides. Limited insecticidal coverage achieved by ground application and space-spraying cannot be expected to achieve a significant impact on the overall mosquito population in these areas due to large-scale production of vector densities and immigration of mosquitoes. Larviciding is impracticahlc due to vast breeding habitats. Human vaccination has been triedin Sri Lanka for the control of Japanese encephalitis. Filarissis Lymphatic filariasis caused by Wtrdtereria bartcroffi is endemic in Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. India and Thailand present the diversity of filariasis in two forms, M bartcrofi and Bnlgia malayi, while Indonesia is affected by Brugia timori in addition to W. barlcrofi and B. ritalayi. I04 ME WORKOP WHO IN SEA Urban W. bartcrofli is mainly found in the slum areas of citiesltowns and transmitted by Culerqirinquefasciahrs while in rural areas it is spread by the species ofA~toplteles, in addition to C. qrrinq~refasciahis. The strains ofB. ntalayi are transmitted by Mansonia spp. and Anopheles spp. while B. ti~nori is localized in the Lesser Sunda Islands of eastern Indonesia and is transmitted byAnoplteles barbiroslris. At present, most of the programmes depend heavily on anti-larval measures for the control of filariasis. WHO-TDR continued to extend technical and financialsupport for the development of integrated approaches to the control of this disease, including various chemotherapy approaches. Research studies are in progress in India, Indonesia and Thailand. A national seminar was organized in Calicut, Kerala, India, in October 1990, with financial support from WHO, to review operational research needed to improve the efficiency ofvector control under the National Filariasis Control Programme in India. WHO provided support to the longitudinal study of filariasis in Nepal. Leishmaniasis (VL) Visceral leishmaniasis or Kala-azar continues as a public health problem in some parts of Bangladesh, India and Nepal. Although this disease virtually disappeared in the 1960s from these countries following intensive indoor spraying with DDT for malaria control, it has recently reappeared. The principal vector is Plrleboto~~i~is argentipes, but the possibility ofPlrlebotomirspapatasi as the secondary vector cannot be ignored. In India, Bihar and West Bengal states account for the highest incidence of thc cascs. A total of 56 971 cases and 607 deaths were reported in 1W. 54 000 cascs and 590 deaths were reported from Bihar and 2 917 cases and 16 deaths from West Bengal. In Bangladesh, 4 893 cases and 18 deaths were recorded. In Nepal, 327 Kala-azar cases and 14 deaths were reported during 1990 from several districts bordering Bihar state in India. The strategy for control is through DDT spraying, activelpassive detection of cases and trcatment. However, owing to administrative and financial constraints, the control of Kala-azar in these countries is not effective. Manpower in Entomology In view of the scarcity of qualified entomological expertise to deal with the complex nature of vector-borne diseases and more efficient deployment of entomology teams DISEASE PREVENTION AND CONTROL 105 in the context of primary health care, countries of this region are trying to strengthen their entomological manpower. WHO continues to promote the training of personnel in the field of vector biology and control through regular in-service training and refresher courses for various categories of entomological staff involved in vector-borne disease control programmes. The National Institute of Communicable Diseases (NICD), Delhi, India, conducts advanced courses in medical entomology for medical officers and entomologists from time to time. Assistance continues to three institutions in the Region, namely, the Vector Control Research Centre, Pondicherry, India; Mahidol University, Bangkok, Thailand; and Bogor University, Bogor, Indonesia. These institutions provide academic training in medical entomology (M.Sr. courses). 13.3 MALARIA All malaria cndemic countries of the Region continued to implement the revised malaria control strategy through the primary health care system. Special attention was given to the harmonic development of all components of malaria control programmes so as to avoid exclusive dependence on one particular measure, such as the use of residual insecticides. The malaria stratificationapproach hadbeen fostered by all malaria control programmes in the Region since it has proved to be useful, particularly in situation5 with limited resources. In the course of the malariogenic stratification exercise in the countries of the Region,various problems and constraints which were held responsil)le for the slow progress of malaria control have been identified. An analysis of these factors has resulted in the identification of malaria priority areas. Forests, forested foothills and hills, forest-fringe areas, and developmental project sites - dams, irrigation and road construction in the forest and border areas-were accorded the highest priority in almost all countries of the Region. Infants, young children and pregnant women have been identified as malaria high-risk groups, followed by mobile population groups, particularly those engaged in forcst-related economy, gem mining, fishing, industrial and road construction work and the like. Ethnic minorities, refugees, displaced persons, tourists and pilgrims constitute malaria high-risk groups in a few countries of the Region. Malaria control programmes have been fully integrated into the basic health services in Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal and Sri Lanka at the intermediate and peripheral levels, while at the national level a core group of specialists is entrusted with the task of planning, technical support and supervision, training, research and coordination. In Bhutan and Thailand, malaria control 1% -- THE WOKKOF WIIO IN SEA Figure 3. Profile of Malaria in Selected Countries of WHO South-East Asia Region, 1985-90 SEA RFGION *-... " SPUY BlRl ~. ~ .-.- ~-~p-~ 'I~~~~--~~ -5 4k q4 3t ------ *. --- + 13 21 42 ,t . ,,. 0 " ! 1 oL-~ ..... .- A. BS 86 81 Rti 89 90 Yea? "C., BANGLADES14 5 r..-.....- ~~. ~ I," rllDYI.nes, ;5 I :*o n 20 30L 130 : 15 . .A- 0 ---*- *- d $0 0 0 10; 5 ,L_ 85 86 8, 88 i4 90 ' i Yea7 INDIA Y.37 5C.~ ~ -. Il" mllllonrl l5 *- "enr :NOONES14 [JAVA 6 BAL11 "em,- I," r"o"ean6.l i5 ,a0 - - ---- - n 00 ; 60 d ro I z 20 rear O 85 85 81 88 89 90 "ear DISFC(E PRWEN11ON AND CONTROL 107 MALDIVES* +--+ 0 0 - - IP"X S'PI Pral car.. ,oral rmrer li ~ - .. 1 . . , ,*. ,' " 1 _ -* dl? ,, 0 85 86 UI dtl 89 90 86 86 87 88 B9 40 "mar Yes? NEPAL ,in tnousanes, .All cases detecled since 1984 are imported. NOTE SPR = Slide Posiliviy Kate (per hundred slides) SIR =Slide falciparvm Rate (per hundred rlides) 1990 Data: Provisional -6 2, A 4 ~. .~ ~ . ii O 05 Rb 8, 88 t(4 .to ,"aP "en? " o---- ~-~-~ ~. --~~~~ 5R1 LANKA ti,, t"n"ma"6s, 32- 24- '5 0. 40 >. , . , . 112 . 1 '.+ . . .24 1 :' -16 I" ,""i Y.. . .~ 85 in, aa nr sa '" ""er "as- it" k"0"rana.l 500r.. -. --p- ~- > i t .aOOL i >3 .. . . .. - ~ . 85 iih A; an "'4 iio '-85 86 81 RB 89 90 "cap ""a" 108 THE WORKOF WHO IN SEA continues to be implementedas aspecialprogramme, although effortsare being made to involve basic health service personnel in the diagnosis and treatment of malaria cases and in referring severe and complicated caseQto the appropriate institutions. Overall, the malaria situation in the Region has remained somewhat stationary for the past 5-6 years, with the case incidence remaining between 2.5 to 2.8 million cases and the slide positivity rate (SPR) remaining at about 3 per cent. The proportion of P. falcipamrl~ continues to be about 40 per cent of the total malaria cases, the highest being in Myanmar (more than 85 per cent) and the lowest in Nepal (about 10 per cent). There has been no indigenous case of Malaria inMaldives for the last few years. The malaria profile in the countries of the Region is shown in Figure 3. P. folcipan~rn resistance to various antimalarials, vector resistance to different insecticides and the development of exophilic and exophagic habits by the principal malaria vectors constitute the main technical problems to malaria control in the countries of the Region. In addition, large-scale uncontrolled population movement, increasing economic constraints, socio-cultural barriers and the like, played a major role in the transmission of malaria in the South-East Asian countries. The foci of P. folciporunt malaria resistant to various antimalarials in the malarious countries of the Region have been gradually spreading. The resistance to Caminoquinolines is most pronounced in all the countries except Maldives. Resistance of P. falcipanrn~ to sulfa-pyrimethamine combination (SP) has also developed in vast areas of Thailand, some parts of Myanmar, Bangladesh, Bhutan and Indonesia. An increasing trend of P. falciparum resistance to the triple combination of Mefloquine-Sulfadoxine- Pyrimethamine (MSP) has been reported recently from the Thai-Cambodian border, particularly from Borai district. Somewhat reduced sensitivity to quinine has also been seen in the same areas. The problem of insecticide resistance in malaria vectors has also been increasing in some of the countries of the Region, i.e. DDT resistance among the principal vectors in India, Indonesia, Sri Lanka and Nepal. Other major administrative and operational problems and constraints encountered during the programme implementation included the shortage of trained manpower, especially at the district level, and financial constraints and difficulties in procuring insecticides from abroad. The principal components of malaria control programmes in the Region continue to be case detection, drug treatment and vector control measures along with programme-oriented field trials and development of required manpower. Residual sprayingis still the main strategyforvector control in the malaria control programmes in the Region - DDT, malathion, HCH and a few other insecticides being widely used. Focal spraying in areas of unstable malaria is practised in some countries to prevent/control epidemic outbreaks. Attempts have been made recently by some of the programmes to reduce the use of residual insecticides, and savings resulting therefrom were being earmarked for development and operational use of bioenvironmental and personal protection DISEASE PREVENTION AND WNIXOL 1W measures. The use of larvivorous fishes was operational in Indonesia but was mostly confined to trial areas in India, Myanmar, Nepal and Thailand. Mosquito nets, coils and repellents increasingly attracted the attention of the national authorities for study and research, with the hope of using them on a larger scale. There has beenincreasing emphasison the diagnosis and treatment of clinical malaria cases with the objective of shortening disease episodes and preventing deaths, especially in areas where prompt laboratory facilities were lacking. Community involvement in simple drug treatment and referring severe cases to nearby health centreslhealth institutions, as well as intersectoral collaboration have been progressing in many countries. The establishment of malaria clinics in inaccessible areas, particularly in areas with the problem of drug resistance, has facilitated quick microscopic diagnosis and treatment with appropriate drugs in Thailand. This approach is being gradually adopted in Myanmar and Nepal. III vitro and i11 vivo drug sensitivity tests are being carried out in all the countries except Maldives as no indigenous P.falcipanrrlt cases have been recorded in Maldives since 1976. These studies have proved to be helpful not only in providing a basis for early warning of reduced sensitivity of P.falcipanrm to antimalarials, but also in facilitating the development of national drug policies. The foci of resistant P. falciponrn~ have been promptly dealt with using the second or even third line of drug treatment and the monitoring of movements of malaria high-risk population groups. WHO collaboration in the smooth implementation of malaria control activities and in the solving of both technical as well as operational problems in thc Mcmbcr Countries was continued. Support was provided to the programmes in staff collaboration, manpower development, organizing study tours and workshops, procurement of essential supplies and equipment and in conducting programme-oriented field studies. Country long-term staff collaborated with the national programme authorities in the planning, implementation, supervision and evaluation of the control activities and in organizing staff training courses on malaria for mid-level staff. They also assisted in carrying out field studies. Efforts were made to improve trained manpower at all levels of the country programmes, using for this purpose either WHO country budgets or the assistance of bilateral agencies and international agencies. Fellowships were provided for regional as well as extra-regional training courses and study tours on malaria. A number of health services staff at the peripheral level in most of the countries were given training in malaria and malaria control activities. As usual, Thailandlltaly basic courscs on malaria and planning of antimalaria activities were held during January-April 1991 and were attended by middle-level staff engaged in the implementation of malaria control programmes. A series of seminars on the management of acute and complicated malaria was being conducted for both health services staff and private practitioners in India. The Regional Office published the third edition of 77le Clirticol Mo~~age~ilntl of Acufe Molaria (Regional Publication Series No. 9). Seminars were organized for architects and engineers engaged in the construction of water-resource 110 lWE WOKKOF WHO IN SEA development projects (WRDP) in India to prevent the creation of mosquitogenic potential in their respective projects. A travelling seminar, sponsored by WHOIUNDP, was organized in Thailand in December 19W for newly-appointed Directors of Malaria Control Programmes in Bangladesh, Bhutan, India and Thailand. Since drug resistance in their respectivc countries is an acute problem, they had an excellent opportunity to exchange views on epidemiological data and acquired experience on the subject. Moreover, the participants visited those areas on the Thai-Cambodia border where reports of reduced sensitivity to mefloquine had been recently reported. An informal consultative meeting on Forest-related Malaria in the countries of the SEA Region was organized in New Delhi from 18 to 22 February 1991. Participants included country representatives who were Directors of malaria control programmes andlor research institutions, epidemiologists and other senior level officials, and WHO malariologists working in the countries of the Region and in WHO headquarters, Forest-related malaria constitutes about 40 per cent of total malaria and about 60 per cent of the P. fulcipunrm cases in the countries of South-East Asia, and forests are becoming more accessible due to the exploitationof natural resources. Very often population movements result in malaria outbreaks. Malaria control in different forest settings is cxtrcmcly difficult since malaria transmission in the% arcas is intcnsc due to highly cfficicnt vectors, prolonged transmission, and drug resistance combined with large-scale uncontrolled population movement. Recognizing that the current general objectives of prevention of malaria mortality and reduction of morbidity are highly relevant in various forest settings and that the problem of forest-related malaria in the countries of the Region varies in magnitude and extent, it was recommended that the populations at risk in different forest settings be identified and stratified together with relevant information relating to malaria situations and vectors, to enable appropriate remedial measures to be adopted. In addition, studies may be taken up to investigate the impact of a changingenvironmcnt on various factors involved in malaria transmission, to identify the problems and to undertake possible control measures as suited to local situations. Programme-oriented operational research continued in the countries of the Region, particularly in the field of malaria control through the primary health care approach. Several research projects aimed at promoting biological, environmental and personal protection measures and projects on community participation in case-finding and treatment continued. New areas for operational research were identified in thc course of the meeting on forest-related malaria, and included the study of thc epidemiology of severe and complicated malaria as well as the impact and cost-effectiveness of the use of residual insecticides under different epidemiological situations, etc. International, bilateral and multilateral agencies, such as SIDA in India, CIDA in Myanmar, USAID in Sri Lanka and Nepal, ODA (UK) in Nepal and Bangladesh, IIISFASE PREVENTION AND CONTROL 111 and the World Bank and JlCA in Indonesia, are actively collaborating with the countries concerned in their malaria control activities. UNDP continued to provide funds for conducting training courses and seminars on in vitro microtechniques and for providing test materials. It also providrd support for manpower development and carrying out field studies in Bangladesh. A total of 733 supervisors and field staff were trained in malaria in 1M. Two field trials - one on the efficacy of antimalarial drugs (MSP vs Larium) and the other on the impact of DDT coverage plus chemotherapy vs chemotherapy alone - were carried out. 13.4 PARASITIC DISEASES WHO continued to providc technical cooperation to countries in thc conlrol and management of parasitic diseases, mainly intestinal parasitic infection, filariasis, leishmaniasis, schistosomiasis and guineaworm disease. Intestinal Parasitic Infections Intestinal parasitic infections continued to be a public health problem in this Region and arc closcly associated with undernutrition, poor pcrsonal hygiene and environmcntal sanitation. Many countries are engaged in research and control of these parasitic diseases through ongoing projects such as those in family planning, school health, etc. As a result of the studies carried out in India, Indonesia, Nepal, Sri Lanka and Thailand, mass treatment of children and women of child-bearing age, which are the main target groups for intestinal parasitic infections, has been rstablished in highly infected areas. In India, WHO supported a national Workshop on Intestinal Parasitic Diseases for District-Level Health Programme Managers, held in Calcutta in September 1990. Visceral Leishmaniasis (Kala-azar) Visceral Leishmaniasis continued to be a health problem of importance in the rural areas of the states of Bihar and West Bengal in India, as well as in Bangladesh and Nepal. In Bihar, almost 44 million people, covering 28 districts, and in West Bcngal 5.5 million people covering 8 districts, are at risk from Kala-azar. During 1993,54 000 cases with 590 deaths in Bihar, and 2 917 cases with 16 deaths in West Bengal, were reported. Sporadic Kala-azar cases have been detected in Uttar Pradesh, Assam and Delhi. In India, the total number of cases reported was 56 971 with 607 deaths. In Bangladesh, 4 893 cases and 18 deaths were recorded. In Nepal, 112 THE WORKOF WHO IN SEA 327 Kala-azar cases and 14 deaths were reported during 1990 from several districts bordering Bihar state in India. WHO supported a national Workshop on Visceral Leishmaniasis for Medical officers, on Efficient Management through PHC Services, which was held in Patna, Bihar, on 21 January 1991. A training course on visceral leishmaniasis, with special reference to epidemiology, diagnosis and treatment, held in Patna from 20 to 22 May 1991, was also supported by WHO. Sera-epidemiological studies, supported by WHO, were carried out in some endemic districts of Bangladesh, India and Nepal. WHO also provided laboratory equipment to ~angladeshwhile some research &dies were supported in Bangladesh and Nepal. Lymphatic filariasis continues to remain a public health problem in eight countries of the Region. In India alone, 374 million (275 million rural and '99 million urban) people are exposed to the risk of filariasis and 25 million are microfilaria carriers, whilc 19 million are suffering from filarial diseases. WHO continued to encourage integrated control strategies and facilitated TDR-sponsored operational projects in India, Thailand and Indonesia, especially those concerned with chcmotherapy trials of different doses of ivermectin in microfilaria carriers and paticnts with filarial diseases. WHO alsosupported a nationalSeminar onoperational Rebearch on Vector Control in Filariasis, held in Calicut, Kerala, India, on 9-10 October 1990. This seminar was attended by state-level National FilariaControl Programme officers, epidemiologists, entomologists and public health engineers. The seminar reviewed the problems and constraints in the implementation of filaria vector control measures, operational rescarch nccded to improve the efficiency of vector control under NFCP, and ihc feasibility of extending filaria control measures to rural endemic areas. Schistosomiasis Schistosomiasis is endemic in limited areas of lndonesia (Scltisrosorita Japo~~icrr~it) and Thailand (Scltisroso~na Mekortgi). WHO supported a national Seminar on Parasitology, held from 22 to 26 June 1990 in Surabaya, East Java. This seminar was organized by the Indonesian Parasitic Control Association. The results of filariasis and schistosomiasis research conducted by various institutions in lndonesia during the last two years were also presented in this Seminar. Control activities were continued in the endemic valleys in lndonesia and Thailand. Research studies were also supported under TDR. DISEASE PREVENTION AND CONTROL 113 Guineaworm Disease (Dracunculiasis) The problem of guineaworm disease is present only in India in the South-East Asia Region. The National Guineaworm Eradication Programme (NGWEP) was initiated in 1984 with WHO assistance. At the beginning of the programme, about 40 000 guineaworm cases were recorded in 1 284 villages of seven endemic states in India. Tamil Nadu has been frce from guineaworm disease since 1985. Andhra Pradesh, Gujarat, Karnataka, Madhya Pradesh, Maharashtra and Rajasthan continue to be endemic states. Gujarat is on the verge of being declared a 'no case' state. Major problems are faced by Rajasthan, which contributed 70 per cent of the total cases in 1990. Based on the latest evaluation report, 4 978 guineaworm cases were reported in 2 592 villages in I990 as against 7 881 cases in 3 596 villages reported in 1989. WHO supported the thirteenth Task Force Meeting on Guineaworm Eradication, held in Ncw Dclhi in January 1991. The meeting stressed the importance of active search, propcr survcillancc and community participation in the Programme. It was proposed to add twomore surveillance teams for Rajasthan to thc ten already cxibting. 13.5 TROPICAL DISEASES RESEARCH The UNDPiWorld BankiWHO Spccial Programme for Research and Training in Tropical Diseases (TDR) is a goal-oriented global programme with two main objectives: research and development to obtain new and improved tools for the control of major tropical diseases, and strengthening of research capabilities of endemic countries. The programme has identified four thrust areas for the 1990s, viz., field research; product development, including rational drug development; social and economic resci~rch; and research capability strengthening. In this context, emphasis is laid on malaria research out of thesix target diseases, while leprosy and tuberculosis are heing considered together in the search for newer drugs and other control tools and operational research. A Product Development Unit was established within TDR in order to better implement the various development activities such as determining priorities for urgently needed drugs, collaboration with industry, funding arrangements and emphasis on product development in developing countries. A fresh approach towards research capability strengthening (RCS) is heing considered and a policy paper on the Programme's RCS activities is being prepared for consideration by the Joint Coordinating Board. There is a shift in support to least developed countries in tropical diseases research. In this context too, the FIELDLINCS programme, which focuses on young researchers from developing countries, and their research project development, are emphasized. There are in effect 2 programme-based grants in Thailand, 1 TDR-Rockefeller Foundation grants in India, Sri Lanka and Thailand, and 114 THE WORK OF WHO IN SEA 4 long-term institutional strengthening grants in lndia (I), Indonesia (1) and Thailand (2). There has been good progress in the ongoing projects, and onc new ~- . grant was initiated. A new grant proposal for institutional strengthening was submitted by Nepal, which has not previously been supported. The number of training activities supported by the Special Programme has beeti substantial, i.e. 172 up to the end of 1990, with the result that institutions have benefited immensely from fully-trained personnel. Specifically, the training has had a strong local component and linkage with disease control. A total of 15 new R&D projects have been initiated in the South-East Asia Region. Malaria Among thc TDR target diseases, malaria received the highest share of its budget - almost one-third of the total research and development budget during 1YM-1YlI. Non-chemical methods of control of vector mosquitoes, including community participation and use of larvivorous fish, are being investigated, but it is too early to assess their usefulness. These ongoing antimalarial studies have been largely focuscd in India, Indonesia and Thailand. Studies to identify potentially uscful surface antigens for possiblc malaria vaccine development have been initiated in Sri Lanka. Leprosy The multicentre field trials of leprosy vaccine, including the armadillo-derived WHO vaccine recently initiated, is an important ongoing activity. Several projects with strong emphasis on the social sciences have been initiated in relation to the control of Leprosy. Most ofthe leprosy research activities are focused in India andThailand. Filariasis The evaluation of clinical trials usingivermectin in the treatment oflymphaticfilariasis has moved to the second phase where the drug is being compared to DEC in its eflicacy. The results of completed studies have indicatedgood microfilaricide activity and minimal toxicity. Five new designs for further study have been developed jointly by TDR and Indian and Sri Lankan scientists. These new projects arc both hospital-based and community-based, and emphasis is laid on the trcalrncnt and prevention of infection and disease. In Indonesia, a monkey modcl has bccn developed and is being used for screening newer antifilarial drugs. Future field trials of ivermectin will also be largely focused in India, Indonesia and Sri Lanka. A DNA probe for the detection of L.3 stage W. bancrofti has been developed in Sri Lanka. Further studies are in progress. DISEASE PREVENnON AND CONTROL 115 Leishmaniasis Leishmaniasis still continues to be a problem disease in three countries of the Region, i.e. India, Bangladesh and Nepal. So far, the support has been minimal, but greater participation is strongly encouraged, especially in the area of vector control, drug treatment and epidemiology. 13.6 CONTROL OF DIARRHOEAL DISEASES PROGRAMME Since 1979 the Control of Diarrhoea1 Diseases (CDD) has been one of the priority programmes of the countries of the South-East Asia Region with the primary objectives of reducing diarrhoea-associated deaths in children under 5 years of age and prevention of diarrhoea morbidity. The former objective is being promoted through effective case management at home and at health institutions, primarily with the use of oral rehydration therapy (ORT). The second objective is being addressed by the promotion of preventive measures such as exclusive breastfeeding, improved weaning practices, use of plenty of clean water, handwashing, use of latrines, proper disposal of babies' stools and measles immunization. WHO continues to assist the countries in achieving these objectives. In all SEAR countries, the national CDD programmes are being implemented as part of the primary health care services. National CDD programmeltraining plans were developedor revised during thisreportingperiod inThailand, Indonesia, DPR Korea and Mongolia. A comprehensive programme review was conducted jointly in Myanmar with the participation of the Government, UNICEF and WHO. Somc of thc highest priorities in the C'DD programme are training in clinical managcmcnt, programme management and supervisory skills. Intcrcountry clinical management courses were conducted in India, while an intercountry programme management course was held in Kathmandu in 1990. Training modules were translated into the local languages in Myanmar, Mongolia, Nepal and DPR Korea. Additional diarrhoea training units (DTU) were established in Bangladesh, India, Indonesia and Myanmar. During thc reporting period, national courses on different aspects of CDD werc conducted in most of the SEAR countries. Nine of the eleven SEAR countries produce ORS locally. The majority of ORS-producing countries of SEAR continue to strive towards self-reliance by improving their technical and managerial capabilities. In 1989, the most recent year for which data are available, SEAR countries produced over 106 millionlitrcs of ORS. 116 THE WORKOF WHO IN SEA National programmes are giving high priority to conducting CDD household case management surveys. Such surveys were conducted in Bangladesh, Indonesia, Maldives, Myanmar, Nepal, and Sri Lanka. In addition, a health facility survey to evaluate diarrhoea case management practices was carried out in Bangladesh. ORS acccss and ORT use rates are two common indicators used by all Membcr Countries to measure programme performance. In 1989, the ORS access ratca increased slightly to 64 per cent from 63 per cent in 1988. In six SEAR countrics (Maldives, Sri Lanka, Indonesia, Thailand, DPR Korea and Nepal) the access rate reached 80 per cent or higher. The regional ORT use rates declined in 1989 to 19 per cent from 28 per cent, largely due to more reliable estimates based on recent household case management surveys undertaken in Bangladesh, India and Indonesia. Health education, information and communication activities in the Region were further strengthened by country reviews. These were considered in detail during the programme managers meeting in 1W. CDD strongly promotes integration with primary health care and collaboration with other programmes in implementing CDD preventive strategiessuch as breastfeeding, improved weaning practices, use of clean water, handwashing, proper disposal of human excreta and measles immunization. Most diarrhoeal diseases research in the Region continues to focus on problem-solving-orientcd operational research. The WHO collaborating centres at the National Institute of Cholera and other Enteric Diseases (NICED), Calcutta, and International Centre for Diarrhoea1 Diseases Research, Bangladesh (ICDDR, B), Dhaka, continued to work closely with the Regional CDD Programme in the areas of training and research, while UNICEF, UNDP and US AID continucd their support for the implementation of CDD aclivilies at thc national level. 13.7 ACUTE RESPIRATORY INFECTIONS Acute respiratory infections (ARI), especially pneumonia, together with diarrhoeal diseases and malnutrition, arc still the leading causes of death among children and attcndancc at out-patient departments of all the health services. Sincc the beginning of the programme, national committees or advisory groups on ARI have been constituted in almost all the countries for promoting prevention and control activities. Increased awareness of the problem has stimulated the countries to include, in their health plans, the control of ARI in children as one of the most important components. In 199U and in the first months of 1991, long-term plans of action were prepared or revised, with the collaboration of the Regional Office, for DISEPSEPREVENnON ANDCONTKOL 117 nine out of the eleven countries of the Region. In all these countries, a national programme manager has been appointed. The new supervisory skills module 'Management of a Child with ARI' and the training video, field-tested in Thailand, and the new programme managers course, field-tested at a WHO interregional course in Thailand in 1989, have given a new input and created interest in the programme. The manual for doctors has been considered as a technically very good and useful reference document for doctors dealing with children. As a result of this, countries have now started sending their requests for bulk copies of this document for wide distribution. In all Member Countries, reduction of mortality from pneumonia has been considered the main immediate objective and the most important priority of their national programmes. For this reason, some countries, such as India, Indonesia, Myanmar, Nepal and Sri Lanka, have decided to focus on the training of handling pneumonia only. WHO modules have also been developed accordingly. In all countries, the new classification of ARI has been well accepted. One of the major concerns has been to have the agreement of paediatricians to the programme before starting it. In SEAR countries, national paediatric associations and professors of pacdiutrics at the university level have been involved in the programmes. Policy mattcrs have always been discussed with them to seek their agreement and support for the implementation of the programmes. In India alone, there were 40 meetings of the paediatric association, with a total number of 1 400 participants. The programme is being implemented in 15 districts in India. Though the coverage is still limited, implementation of the programme in 15 districts in a country like India means coverage of a population of more than 30 million people. Programme managers courscs were also organized in India, Indonesia, Myanmar, Sri Lanka and Thailand. Some of these were attended by participants from smaller countries such as Maldives. WHO had close collaboration with UNICEF. Some NGOs, such as CARE, DANIDA, PATH, USAID, John Snow and SWACH, were involved in planning and training activities. Thailand has been selected by UNICEF for an intensified ARI programme to which the Regional Office, along withJohn Hopkins University, hasgiven technical support. Supervisory skill courses were conducted in India, and were attended by 1 000 participants. Similar courses have also been started in Indonesia. It has taken a long time to have the modules adapted, translated, reviewed by paediatricians and finally printed. Bangladesh, India, Indonesia and Thailand have already produced their own modules and started training activities. In Myanmar, Nepal and Sri Lanka, the translation of the material into the local languages is under process. IIX THE WORKOF WHO IN SFA New training videos have been prepared in India and Thailand and in other countries (i.e., Bangladesh, Indonesia), the WHO videos are being dubbed in the local languages. Posters, leaflets and other communication material have been produced in almost all the countries. A monitoring system for training activities has also been set up in India, in collaboration with the SWACH foundation, Chandigarh, and the same methodology will also be utilized in other SEAR countries. An intercountry Meeting on Prevention and Control of Acute Respiratory Infections was held in Jakarta, Indonesia, in 1990, and was attended by programme managers of SEAR countries, UNICEF representatives and observers from NGOs. The objectives of the meeting were to review the progress of the programme; to stimulate countries that did not have a national programme to initiate activities; to ascertain the acceptability of standard case management of pneumonia at different health facilities levels; and to share experience in training, methodologies and materials utilized. In all SEAR countries, ARI will be an essential and integrated component ofthe PHC programme even if, being a relatively new programme, case management training on ARI needs more consideration. and more time has to be devoted to it. 13.8 TUBERCULOSIS Tuberculosis continues to be a major public health problem in the countries of the South-East Asia Region and yet most countries have achieved less than 50 per cent coverage in respect of case finding and consequential treatment. With the sprcad of HIV infection, countries such as India, Myanmar and Thailand, arc likely to have a surgr in infections with tubercle bacilli. WHO has recently formulated a draft Medium-Term Plan (1992-1995) for implementing new strategies for the control of tuberculosis and for promoting operation support, research and coalition building. Twomajor activities that WHO undertook during the reporting period need mention. First, a meeting on Tuberculosis Control and Research Strategy for the I1MOs was held in Geneva, on 26-27October 1990, which was attended by participants from lndia andThailand, besides a representative from the Regional Office. In this meeting, new strategies for implementing tuberculosis control, emphasizing operation support and research development were discussed. According to the new strategies, the primary objective of the tuberculosis control programme is to improve the cure rate and the second objective is to expand the coverage of tukrculosis services. Toachieve bctler DIStASE PREVENTION AND CONTROL I IY case treatment results the meeting recommended the introduction of 6-8 month short course chemotherapy (SCC). The second important activity was the Task Force Meeting on Research in Tuberculosis, held in the Regional Office from 3 to 6 December 1W to identify research priorities on tuberculosis in the countries of the Region. This meeting, held in response to the recommendations of SEAIACHR, anaiysed the problem of TB in SEAR countries and developed nine research protocols for the consideration of researchers. These protocols are in the areas of identification of risk factors for diseases, risk factors for infection, operational research for improving the cure rate, programme monitoring and disease surveillance, assessment of the protective effect of revaccination with BCG, the role of chest X-ray examination, centralized sputum examination to improve the quality of coverage, relative efficacy of different drug regimens, thc usc of combined drug tablets for the treatment of tuberculosis and operations research for the attainment of a high cure rate in district TB control programmes. In general, the countries were supported through fellowship placements, provision of supplies and equipment to strengthen projects and subsidies for holding national-level training activities. Bangladesh was assisted in the procurement of anti-TB drugs and X-ray films. Motivation units for TB patients havc bccn started in all the TB clinic to reducc thc default~.r ratc considcrably. Thcrc arc 44 static units with the facility topcrform thesputum AFB stain in the460 upazilla health complexes and 24 district hospitals. In Bhutan, tuberculosis ranks fourth among ten diseases which cause mortality. A review of the National Tuberculosis Control Programme was undertaken by the national TB Task Force members in September 1W. One of the recommendations of the review was to have short-course chemotherapy uniformly implemented throughout the country. India continued to receivc WHOISIDA assistance for improving casc finding and trcatment, including SCC and essential supplies and equipment. The second international Training Course on Tuberculosis was organized by the National Tuberculosis Institute, Bangalorc, from 14January to 22 March 1991. In this Course, six international WHO participants received training. One national was awarded a fellowship in TB and clinical epidemiology for 12 weeks in the USA. Laboratory facilities wcrc strengthened through the SKrE component of the National Tuberculosis Institute (NTI), Bangalore, and the Tuberculosis Research Centre, Madras. The national workshops for senior teachers of medical collegcs and state-level administrators were conducted by NTI, Bangalore, in November 1990, with WHO support. Inclonesi:~ usr prsnidcd tc:hnical ,upport through a consultant for onc month, in Jul) l')'/tl,tt~,~,>c>,:~n~l rc\,icu lhc Ndi<~n:tl'l'ti Pr~~gr.tn~n~c i~~tcrm~,~ithcFifth Fi\c.Y~.ir I20 THE WORKOF WHO IN SEA Development Plan of Indonesia. A national attended the WHO-Japan International TuberculosisCourse inTokyo from2July to 20 October 1990, followed by a two-week post-course study tour to South Korea. Support was extended for a participant to attend a workshop on tuberculosis treatment in adults and children in Geneva from 2 to 4 July 1990. Besides, the project was strengthened with the provision of a vehicle and an overhead projector. Mongolia received subsidies support for conducting a national Seminar on Early Diagnosis of Tuberculosis. WHO support also included supplies. The number of registered cases of active TB cases in the country as of 1 January 1990 was 10 897. Myanmar was assisted through fellowships and provision of supplies for sputum testing. During 1990,69535 persons were examined by theTB centres with a coverage rate of 35 per cent. In Nepal, reports on TB cases arc sent by health posts and other nongovernmental organizations to the National Tuberculosis Control Programme for compilation. Hospital treatment is done only in Kalimati Hospital by the Nepal Anti-TB Association located in Kathmandu. WHO support was extended for two participants to attend a Regional Seminar of the Eastern Region of IUAT, Beijing, from 16 to 20 October 1990. WHO assistance to Sri Lanka included the procurement of computers, an airconditioner and subsidy assistance for holding national-level meetings for the evaluation and monitoring of the TB Control Programme. Thailand was extended support for holding a meeting on accelerated case finding and application of short course chemotherapy in tuberculosis control in December 1990. 13.9 LEPROSY The South-East Asia Region has witnessed a steep decline in the registered cases of leprosy, from 3.7 million in 1985 to 2.7 million in 1990. Of these 2.7 million cases, 1.8 million or over 66 per cent are currently on MDT, and over 1.0 million patients havc already completed MDT. In Bangladesh, as of December 1990, about 25 000 leprosy patients were receiving treatment, out of which over 16 000 or 65 per cent were on MDT. During the past year, 21 technicians of upazilla health complexes were trained with assistance from WHO. WHO also provided an anaesthesia machine with accessories and other supplies and equipment as well as rifampicin and clofazamine. Leprosy control services are integrated with general health services, particularly with TB control activities. DISFASE PREVEKnON AND COmOL I21 Despite the constraints of communication and logistics, because of the difficult terrain, Bhutan has achieved93 per cent coverage with MDT. The prevalence, based on registered cases, has been reduced by 92 per cent over the past nine years. The incidence has also decreased by approximately 50 per cent during the same period. Political will and strong commitment at the highest level have been instrumental in achieving this. The National Leprosy Review Workshop, held recently with the participation of WHO, recommended that the strategy of the programme, which is currently based on domiciliary visiting, be reviewed with a view to integrating leprosy control senices with those of primary health care in a phased manner. In India, the estimated number of leprosy cases was 4 million in 1981. However, with intensified and effective programme implementation, this figure has been reduced to 3 million in 1990. The National Leprosy Eradication Programme aims at achieving arrest of the disease in all leprosy cases by the year 2000. To achieve this, MDT is being extended to endemic areas in a phased manner. During 1990,0.46 million new cases were detected and 0.64 million discharged as cured. At the end of December 1990,2.4 million cases were shown in the records of NLEP, of which 1.4 million were on MDT. So far, over onemillion cases have beendiicharged on completion of MDT. The relapse rate is less than one per cent of the cases who have completed MDT, and complications arc very few. The disability among new cases, especially in those districts which have been under MDT for five years or more, has declined significantly. At present, 130 endemic districts out of 1% have been brought under MDT through the vertical approach. The Programme has plans to partially integrate the leprosy control senices with the basic health system in the remaining 66 endemic districts. Field trials of several candidate vaccines for leprosy, including WHO vaccine, are being undertaken by the Indian Council of Medical Research, with WHO support. A request for conducting Oflaxine trials, with the support of WHO, from 8-9 leprosy institutes is under consideration by the Ministry of Health and Welfare, Government of India. Since 1969, the Leprosy Control Programme in Indonesia has been integrated into the general health services. All provinces are implementing MDT. As of March 1990, there were 107 271 cases receiving treatment (prevalence 0.59 per 1000 population) with an MDT coverage of 50 per cent. More than 64 000 cases have received or arc receiving MDT, of which 26 000 cases have been released after treatment. The long-term objective of the National Programme is to reduce the leprosy prevalence rate to 0.1 per 1000 population by the year 2000 in order that it wiU no longer be a public health problem. The prevalence of leprosy in Maldives has shown a steady decline from 12 per 1000 in 1979 (1 654 registered cases) to 1.24 per 1 MX) at the end of 1990 (273 registered cases). Out of202inhabited islands, 120islands were reported as havingactive leprosy 122 THE WORKOF WHO IN SEA cases in 1987. At the end of 1990, only 79 islands had leprosy cases. A unique ~ ~ programme of zero transmission~chemoprophylaxis for leprosy was launchedin Maldivesin March 1991. This programme includesthe survey of the entire population of each island and physical examination of each person. ~fi new cases detected are put on MDT and all healthy people with no contraindications are given a single dose (20lkg body weight) of rifampicin. In the first phase, the chemoprophylaxis programme will be implemented on 16 islands, and will be continued on other islands after evaluation if found feasible, given the existing constraints. In spite of some slowing down in 1990 due to unavoidable circumstances, the Leprosy Control Programme in Myanmar is progressing satisfactorily. MDT was first introduced on a mass scale in six hyperendemic divisions of the country in 1988. Out of a total of 185 townships in these 6 divisions, 150 townships are currently covered by MDT. An overall MDT coverage of registered cases (in these 6 divisions) of 55 per cent has been achieved. The Three-Year Plan, 1990-1993, has been approved by the Governmenl and envisages the integration of leprosy services with the general health services. In this connection, a number of training activities, with support from WHO, have been carried out. WHO is currently negotiating with donors with a view to obtaining the necessary drugs required for MDT in Myanmar. In Nepal, s~nce 1987, the Leprosy Control Programme has been intcgrdted in all thc 75 districts where the major responsibility lies with the District Public Health Olfice. and at the regional level with the Regional Health Directorate. The long-term objective of theProgramme is to achieve areduction in the prevalence rate of O.1/1000 by UMO. At the end of 1990, theprevalence rate was 1.36/1000 and an MDT coverage of 52 per cent (registered cases) had been achieved. In 1990, leprosy control efforts in Sri Lanka were intensified with the objective of detecting and treating at least 12 000 new cases by 1995, and reducing the active case-load to below 1000 by that time. A number of novel steps, such as a social advertising campaign launched in February 1990 using all available channels of the media, have been taken. This has led to a significant increase in self-reporting (from 10 per cent in 1989 to 42 per cent). Another step has been the training of all the basic health staff in the country and about 1000 doctorsin leprosy. As well, dermatologists and general practitioners have been provided with free MDT blister packs, in return for which they will provide anonymous patient information. In 1990 there were 3 000 patients on register, all of whom were on MDT. In Thailand, the Leprosy Control Programme has been integrated since 1972. As of 1 October 1990, an MDT coverage of 93.7 per cent has been achieved, with a total of 12 164 cases on MDT. The number of patients who have completed MDT since the beginning of MDT in March 1984 is 29 486. A reduction in the prevalence rate from 0.911 000 in 1984 to 0.24/1000 in 1990 has been achieved. The programme in future DISEASE PREVEKnON AND CONTROL 123 will concentrate on the strengthening of all aspects of leprosy control activities. A national programme of disability prevention will be launched in the near future. The development of biomedical research, especially in immunology and animal experiments, will be given emphasis. The Programme hopes to achieve the goal of a prevalence of 0.111 000 by the year 2WO. In spite of the satisfactory progress made by the leprosy control programmes in the Member Countries there are still a number of areas requiring further intensification of efforts. They are: to estimate the number of cases as accurately as possible, the urgent need to close the wide gap between the number of registered patients and the estimated number of cases, promoting more efficient use of available human resources, evolving cost-effective strategies for disability prevention and rehabilitation, improving coordination among all parties concerned with leprosy, and, above all, mobilization of adequate resources for the programme. 13.10 ZOONOSES Thecountriesof theRegion were assisted by WHO in their efforts tolaunch measures for the prevention and control of rabies and to take some steps for effective control of brucellosis. The Rabies Control Programme in India has been further strengthened. The Government constituted an intersectoral task force, including a WHO staff member, for coordinating the activities of the departments of Health and Agriculture and for providing further technical and financial inputs to activate the programme in several states. In Indonesia, preparatory activities for the rabies intcgrated reduction programme were conducted in West Java, South Kalimantan and Central Kalimantan. In August 1990, vaccinations were carried out and the coverage among the dog population ranged from 70 to 80 per cent. Plague surveillance activities were carried out in the plague foci in Central Java and East Java to detect human plague as well as Y. peslis among the rodent and flea populations. Surveillance activities were carried out in seven villages in the districts of Samarang and Boyolali in Central Java which have reported human anthrax cases. In a population of 23 000 people, 90 per cent of cutaneous type and 10 per cent of gastrointestinal human anthrax reported cases were confumed. Necessary manpower was trained in laboratory diagnosis, epidemiology and control of taxoplasmosis, and WHO provided assistance in obtaining information on the surveillance of Ebola virus in monkeys for the country. 124 DIE WOKKOF WHO IN SFA Eradication of plague and effective control of brucellosis are the main aims of the ZoonoticControl Programme in Mongolia. The services of two consultants, on vector biology and on brucellosis, were made available to the Programme. Three nationals were trained in vector biology, diagnosis and treatment of brucellosis and in epidemiological surveillance of plague. Supplies and equipment needed by the Programme were also made available to the country. A seminar on brucellosis wntrol is scheduled to be held in June 1991. In Nepal, the Control of Zoonoses and Food Safety Programme aims at strengthening the zoonotic disease control section of the Epidemiology Division, Ministry of Health, through developing and implementing a surveillance and wntrol programme of zoonotic diseases, strengthening food legislation and implementing food safetylsanitation activities. Preparatory work for the activities specified in the plan of action is in progress. Four nationals were trained in zoonotic disease control and study of meat-borne diseases in Thailand and India. WHO provided supplies and equipment to meet the requirements of the project. Surveillance, prevention and control of zoonoses and related food-borne diseases, including food safety sanitation, hygiene and sanitation of restaurants and hotels, are still in a rudimentary stage. The lack of food legislationlregulations and trained manpower in the field have been the major obstacles to the implementation of the project activities. In Sri Lanka, medical supplies, including journals and other publications, were madc available to the project. Production of a TV documentary on rabies in Sinhala, with Tamil translation, was scheduled for January-May 1991. The production of 5 000 pamphlets on rabies wntrol is also on the cards. A review of the rabies control activities with provincial staff has been in progress since January 1991. A consultant, supported by AGFUND, helped thecountry in the preparation oftheNational Rabies Control Programme. 13.11 SEXUALLY-TRANSMITTED DISEASES A high incidence of sexually-transmitted diseases continues to persist in many countries of the Region. All countries of the Region now have clinical and laboratory facilities to treat persons affected by these diseases, and preventive steps, such as promotinghealth education and banningprostitution, have been taken by them. Some countries have launched special programmes to control these diseases and have included them in the priority list. However, inadequate reporting and recording systems are an obstacle in estimating the exact magnitude and dimensions of the problems. The main problems are an increase in antibiotic resistance, the scarcity of physicians in remote areas, self-medication by patients, difficulties in case finding, poor community participation and motivation, and limited health education. WHO support was provided to assist the Government of India in organiring national workshops on clinical management of AIDS, in Delhi and Hyderabad. Laboratory equipment, reagents and chcmicalswerc supplied to Safdarjung Hospital, New Delhi, to strengthcn the Regional STD Reference L;~boratory. Two workshops werc held - one for district and peripheral level medical officers in Bangalore and one for nurses and hcalth cducators in Lucknow in August 19OOand nine fellowships werc providcd for highcr training in STI) contrnl. In Indonesia, the AIDS programme was integrated with the programme for STD control. A national Workshop on Yaws, held in 1989, resulted in the revision of strategies for the control and eradication of yaws. Surveys arc being conducted to focus on sch1111l childrcn of 6-12 years of age. During the liscal year 1989-90, 15 IM 'ISLS of yi~ws werc dctcctcd during surveys ciirricd out in all ihc pro\' c, ,. '~nccs. Assisl;~ncc w:rs provided to rcvicw the stalusof lhc STD Control Progr;tmmc in Nepal with the ol!jcctivc of dcvcloping close collahorati~m between the AIDS Conlrol Programme and the STD Control Programme. In Sri lank;^, the possibilities of intervention-linked research directed at reduction 0fHIV ir;~nsmission by STD con~rol amongst groups at greater risk of infection, wcrc supported. 13.12 RESEARCH AND DEVELOPMENT IN TIfE FIELDOF VACCINES WHO continued to support counlrics in the resc:irch and devclopmcnt of v;iccincs. Wilh technical and fin;tncial inputs, WHO has strcnglhcncd f;~cilitics for thc producl inn of hactcrial and somc of ihc viral v;~ccincs in India, ln~loncsia, illy;tnm;jr and Thailand. India has dcvcloped capabilities for the production of DPT, rabies and poliomyelitis vziccines. Several nationals wcre trained and new technology using fermentation was introduced. In Indonesia, excellent facilities have been established for the production of hactcrial v;~ccincs. In Th;~il;~nd, thcrc is scll'rcliancc in the production of bacterial vaccincs. Bi1;tlcral assist:~ncc has hcerr provided for establishing facililics for rhc produelion of viral vi~ccii~cs. Wl4O's major thrust in thc South-East Asia Region was to establish expertise in quality control of bactcrii~l and viral vaccines. Nationals from several countries of the Rcgion were trained in quality conlrol procedures and techniques. Intera~untry and national seminars wcre organized for training nalionals in qu;ilily control of DPT, poliomycliiis ;ind mcaslcs vaccincs. A nctwnrk of WHO collnhoraling ccrllrcs has been established in India, Indonesia and Thailand, where facilities are available for quality controlof DPTvaccineand training of nationafs in qualitycontrolprocedures. Dengue vaccine and snake venom vrrccine are now being developed in Thailand and Myanmar respectively. Plans for clinical trials of these vaccines are now at various ~tagcs of implementation, with support from WHO. In future, WHO will concentrate (In the transfer of technology for the development of newer vaccines, particularly viral vaccines for hepatitis and rabies, and ncw bacterial vaccines, and will develop training programmes for the production and quality control of thcse vaccines. 13.13 AlDS AlDS has now emerged as a serious problem in some countrics of the South-East Asia Region, particularly Thailand, India, and Myanmar. In Thailand, in 1987 less than one per cent (if a group of IVDUs wcre infected with HIV, hut by 1090, nearly 50 per ccnt of IVDUsseen in treatment facilities in Bangkok wercpositivc for HIVinfection. Similarly, less than oneper ccnt offemaleprostitutes in the various cities in Thailand, surveyed in 1987, were positive for HIV infection, whereas in 1990, the prevalence rate amongst female prostitutcs in at least three provinces ranged between 25 and 70 per cent in small groups in some areas. Mother-to-infant lransmission has also been recorded, both in Thailand and India. A sequential infection has been noticcd. Initially, rapid transmission among IVDUI was noted. After some lime, incrc;lscd prc\'alencc amongst fcmale prostitutcs was noted. Sobsequcntly, incrcascd prcvalcncc amongst proniiscuous persons visiting prostitutes, patients attending STD clinics and in the gcneral community was also reported. In India, in 1987, less than one per cent of fcmale prostitutes surveyed were infected, but now, in Maharashtra alone, 20 to 70 per cent of selected groups of prostitutes arc infected. The HIV serological surveys in India have not hccn comprehensive enough to allow an estimate of thc total HIV-infccted persons, but from thc trend it is clear that, with the high-risk bchavioor of pcrsons observed in a number of Indian cities, a rapid increase in HIV prevalcncc will occur. A new dimcnsion, in addition to the existing heterosexual transmission of HIV, has been noted with the rapid transmission of HIV infection amongst intravenous drug users in Manipur where, among 2 124 IVDUs, 1 Olhwere found positive for HIV infection (43.7 percent) as of 30November 1YN. Thc spread of infection to ncighhouring states from Manipur has also hccn observed. AIDS In theabsence of a cure for AIDS. attention continues to befocussed on prevention through education and information. Member Countriesarealso strengthening laboratory, surveillanceand counsellingfacilitiesfor prevention and control of AIDS. I ne nllessage of Good Health These happy triplets sing for health-health for all Myanmar, which had reported only one HIV positive belorc May 1988, started reporting large numbers of HIV positives amongst lVDUs by the end of 1989. The prevalenceof HIV attracts attcntionduring twopcriods. In the lirst phase, from 1985 [(I 1989, low heterosexual transmission occurred, while in the second phasc, from January to Augusl lOXI, si;.c;~hlc numbers of female prostitutes were round positive with an increase in hdcroscxual transmission. This was similar lo the trend observed in Thailand. The countrywisc situation of HIVIAIDS is given in Table 7 Table 7. Sitrrutio~r ofAIDS arrd HIVinfectiorl ~II SEAR cowltries (as of 4 June 1991) Ilangladeah I3hutan India Indonesia 111'11 Korea Maldtves Mongulla Myanmar Sepal Sri Lanka l'ha~land Month lilst rrporlrd WHO has heen supporting Mcmher Coonlrics in the implcrnenlation ol medium-tcrm plans, which arc now operational in India, Thailand, Nepal, Mongolia, DPR Korea and Myanmar. Bangladesh, Indonesia and Sri Lanka are being supported by WHO for implementing interim plans of action. The short-term plan of action was extended in Maldives pending the formulation of a medium-term plan. It is anticipated that MTP will bc initiated in these countries during 1991. WHO has been ;~ssisting the countries in rcsourcc mobilization for supporting medium-tcrm plans. WHO hasalso supported many interregional and intcrcountry (iEAs, not;~hlcami)ng lhcm hcing the Inlcrnalional C:onfcrcnce on AIDS in Asia and the Pacilic, held in Canberra, Australia, in August 1990, GEAs on thc involvemcnl of NGOs end women's organizations in the prevention and control of AIDS, and the Fourth International Course on Clinical Management of AIDSIHIV in Australia. Programme review is a continuing feature ol the mcdium-term plan. Table 8givcs the status of the various reviews th;~t have been conducted in diflercnt countrics. Table 8. Slulrrs ofprogmri~ri~e review urlder MTP irt differertl SEAR cor~rllrics Review Exkrnal rul~nlry MTP donon) nornlncr Myanmar lind 1991 - Tharland 1 1:;; 1 gm; Nepal Country Situation And Aciivilies WHO has intensified the rcgional activities in support of national AlDS prevention and control programmes taking guidance from discussions and resolutions of the World Health Assembly iind the Regional Committcc. The main programme activi~ics arc summarized hclow. I>one - Activities undcr thc short-term plan of action for prevention and control of AIDS in Bangladesh have bcen complclcd. The imporlant activilies included publicawareness through health educalion, sero-surveillance, blood transfusion services, and strengthening of laboratory services. At present, a work plan relating to the interim plan is being in~plementctl. A WHO c~,nsultant assis~cd thc government or Bhutan in integrating teaching of prevcntion and control ol AlDS and ST0 in the curricula for health and hcalth-rclatcd workers with thc introduc~ion of sex education in lho hcallh and population education cornponcnt of curricula. A WHO lahoratory scientist helpcd the national authorities plan lalx~ratory supplies. End 1991 - Allac~ivitiescnvisaged under the short-term plan for prevention andcontrolorAlDS in DPR Korca were completed. A medium-term plan (MTP) is now operational in the country. Done - India is the only country 111 the Region which has implcmen~cd the activiliescnvisagcd undcr the short-lcrm plan (STP) through its own resources. Activities undcr the medium-term plan (MTP) have been started. These focus on four metropolitan cities and north-castcrn states of Manipur, Nagaland and Mizoram. A WHO consulIan1 visited Indonesia in October 1990 111 carry out activitics for the prcven~ion ancl control of AlDS under an interim plan. A draft plan for HIV DISFXE PREVENTION AND CONTROL 129 surveillance was prepared by him. Another WHO consultant provided technical support in epidemiological surveillance activities, development of AIDS education and counselling and other supportive activities. Maldives is expected to formulate its medium-term plan (MTP) for prevention and control of AlDS during 1991. So far it has implemented activities under the extended short-term plan (STP). WHO assisted the country in organizing a Workshop on Counselling for Prevention and Control of AlDS in March 1991. Mongolia has signed the MTP project document. Steps have been taken to expand laboratory diagnostic facilities. Blood donors are screened regularly. The Government of Myanmar signed a project document with UNDP and WHO in early 1991 to support the implementation of the National AIDSISTD control programme through the provision of technical expertise, training and equipment. A mcdium-term plan (MTP) for the prevention and control of AIDS in Nepal has been approved by the Government. WHO consultants assisted the country in assessing the present status of epidemiological surveillance, STD diagnostic treatment, and in strengthening close links between AIDS and STD control programmes within the context of MTP. Sri Lanka is currently implementing activities for the prevention and control of AlDS under an interim plan. A medium-term plan has been formulated. Assistance of UNDPISIDA is being sought to support the medium-term plan in addition to WHO resources. Thailand is implementing activities under year 3 of MTP. A resource mobilization meeting was held on 6 March 1991. The programme was reviewed in January 1991 and a comprehensive review is planned towards the end of 1991. WHO, in consultation with the Member Countries, is promoting the concept and practice of sentinel surveillance for trend analysis. In some countries, particularly Thailand, sentinel surveillance is well established. Considering that most of the countries have implemented medium-term plans, WHO has been assisting the countries in the evaluation of the programmes. An external review by a team appointed by the Global Management Committee on AIDS, reviewed AIDS activities inThailand in April 1991 and in India in June 1991. A team from WHO headquarters visited India and Thailand in June 1991 to discuss with national authorities possible sites for the vaccine trials proposed to be conducted. Although, by and large, the programme is progressing in the anticipated direction, a sense of complacency has been noticed incountries that have low prevalences of HIV infection. his could be harmful to the programme as the three countries which now have serious problems of HIV infectionlAIDS too had low prevalences two or three years ago. I30 THE WORKOF WHO IN SEA 13.14 OTHER COMMUNICABLE DISEASES This group of diseases includes, amongst others, dengue haemorrhagic fever (DHF), Japanese encephalitis (JE), viral hepatitis and meningococcal meningitis. The reporting of thisgroup of diseases is not adequate as these are not notifiable diseases in many countries of the Region. Dengue Haemorrhagic Fever Although the case-fatality rate is on the decline, the number of cases reported during 1990 showed an upward trend in all the three endemic countries. Indonesia reported 13 043 cases and 458 deaths, Myanmar reported 5 200 cases and 178 deaths and Thailand reported 102 312 cases and 360 deaths (Table 9). Table 9. DHFcases, deaths artd case-fafalily rates (CFR) lit lr~dor~esiu, Myar~n~ar and 7Itailarzd, 1985-1990 For the control of dengue haemorrhagic fever, the Regional Office is supporting studies on the development oTan eKective vaccine against lour sero types ofdcnguc virus. The eighth Peer Review meeting was held in Bangkok on 29-30 September 1990. The results of trivalent vaccine Dl, D2 and D4 were discussed and it was felt that this vaccine is safe and its immunological response good in human beings. This is an imoortant milestone on the road to a auadrivalent vaccine. The Peer eroun . ~~ r ~ ~~ -, recommended trials again with different dilutions of each type of vaccine. The Peer group recummended a Phase 1 studv of D3 PtiMK30 passage and 3 passages in FR hl Indonesia - ~ to be conducted in adults. The Peer group approved the result of the study on the follow-up of volunteers who received monovalent Dl, and bivalent Dl-2, D2-4. A detailed report on the genetic stability ol virus isolates from Dl vaccine recipients, seed virus and stability of virus isolates from Dl vaccine recipients, and on seed virus and parental virus, showed genetic stability of the vaccine virus. The report on molecular studies, including Western Blot and Polymerase chain reaction tests, showed positive progress. No. 01 cases Myanmar Thailand I I No. 01 deaths No. of esscs CFR (%) CPR 1%) I I No. 01 deaths No. ol rases I I CFR (%) No. 01 deaths DISEASE PREVENTION AND CONIROL 131 An International Symposium on Dengue Fever and DHF was organized by Mahidol University, Bangkok, from 1 to 3 October 1990. It facilitated the obtaining of information on recent advances on immunopathology and available diagnostics. WHO headquarters organized a Technical Advisory Committee Meeting on DHF, from 4 to 6 October 1990. It was attended by participants from SEAR countries. Reviews of DHF in the WHO regions were made and discussions were held concerning the revision of technical guidelines on the prevention of DHF. Through a technical services agreement, Sri Lanka was provided with assistance to conduct, from March to June 1991, interim studies on the isolation of the virus responsible for the present DHF cases in the country. Viral Hepatitis Hepatitis AVims (HAV) infection is common in Bangladesh, India, Mongolia, and Nepal, and 85-95 per cent of children in the age-group of 6-10 years are immune to HAV. In these countries, HAV cases in adults are very few. In recent years, it has been observed that the morbidity of HAV infection in adults has increased in Indonesia andThailand. Studies conducted inThailand during 1990 showed that only 30-35 per cent of children in the age-group of 7-12 years are immune to HAV. The prevalence of Hepatitis B (HBV) infection and related diseases, such as chronic hepatitis, cirrhosis and hepatocellular carcinoma, differ widely and continue to be major public health problems in the Region. Every year, approximately 10-12 million people are infected with HBV. It is estimated that about 6 per cent of the total population of South-East Asia are HBV carriers. WHO continued collaboration with respect to epidemiological studies, situation assessment and production of local HBV diagnostic reagents, particularly in India, Mongolia and Myanmar. Model immunization programmes aimed at exploring how best to organize Hepatitis B vaccine programmes before eventual integration into EPI, to improve overall EPI efficiency, are now under way in Indonesia, Myanmar, Mongolia and Thailand. WHO supported laboratory research for the production of Hepatitis B vaccine, which is in process in DPR Korea, Mongolia and Myanmar. The prevalence of Hepatitis C Virus (HCV) infection in the Region is still not known and WHO has prepared a protocol to study the prevalence of HCV in selected countries. Delta Virus (DV) is not common in the South-East Asia Region. India, Myanmar and Thailand reported some cases of mixed infections (DV and HBV). Only Mongolia has reported a high prevalence of DV infection markers in healthy populations and in HBV cases. 13? THE WORK OF WHO IN S!3 Hepatitis E Virus (HEV) infection is an emerging problem in the Region. Several outbreaks - large and small - due to HEV have been reported from Bangladesh, India, Indonesia, Myanmar and Nepal. In India and Myanmar, HEV has been serially passaged in non-human primates. WHO continued to support epidemiological research in Nepal. Japanese Encephalitis (JE) In this Region, JE outbreaks have occurred in many countries but at present India, Nepal and Sri Lanka are the countries where outbreaks of JE continue. To mention some country specific support during the reporting period, lndia received support through a technical services agreement for a study on the impact of selective insecticidal spraying on JE vectors in Burdwan District, West Bengal, for a one-year period starting from December 1W. Five regional fellowship nominations of one month each, to study various aspects of JE control, have been processed during the reporting period. A workshop on JE was held in Varanasi, in August 1990, with the support of a WHO subsidy. Another workshop on disease surveillance was held in November 1990. Assistance was extended to Nepal for the procurement of JE vaccines. Thailand is being supported in a study of the stability of JE vaccine produced in the country. Meningwoccal Meningitis Meningococcal meningitis continues to affect Bhutan, lndia and Nepal in low endemicity outside the Kathmandu valley. WHO assistance is mainly through the provision of technical cooperation to help organize control measures and through the supply ofvaccines(biva1ent A + C) in some countries. InDecember 1990, the National Institute of Communicable Diseases, Delhi, was provided with a subsidy for conducting a workshop on surveillance of meningilis. Integration of Communicable Diseases In Indonesia, the integrated approach for the prevention and control of communicable diseases through primary health care was reviewed from 15 October to 8 November 1990 by a WHO consultant. The review results indicated that the project is feasible, beneficial, sustainable and effective. Significant progress by cadres was noted in the first stage of development of the control programme on selected communicable diseases. Case reports of ARI, TB, malaria and diarrhoea1 diseases increased considerably. The results of the review were presented at a workshop held in November 1990. A consultant was recruited in March 1991 for two weeks in the Regional Office, followed by two months as a national consultant to work on the documentation and preparation of a framework for the project. DISUSE PREVENnON AND COMOL 133 13.15 BLINDNESS AND DEAFNESS The latest epidemiological studies carried out in India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand, amongst others, report a prevalence rate of 0.5 per cent to 2 per cent blindness, with higher prevalence rates in undersewed areas of these countries. Cataract, as a rule, accounts for more than 50 per cent of blindness in most of the countriesof the Region which, in turn, accounts for more than half ofthe world's blind population. Various categories of health personnel in Nepal, Sri Lanka and Thailand were provided with training, both in the principlesof primary eye care and in the screening and referral of patients from outreach services. Efforts have also been made to 5trcngthen the physical infr.tstructurr. for c)c carc delivery at the district lcvel as part the development of district health systems in support of PIl(J. Efforts ro meet ihc cataract backlog have been intensified in nearly all the countries, particularly in Indonesia, India, Nepal, Sri Lanka and Thailand. Various important activities in relation to the setting up of mobile units in Myanmar, training of personnel in public health ophthalmology in Bangladesh, Sri Lanka, Mongolia and Myanmar, studying of the feasibility of establishing low-cost spectacles manufacturing and small-scale production units for eye medication in Nepal and Sri Lanka, training in eye care of community health workers and primary health care personnel in Myanmar and Sri Lanka, etc., were carried out with financial support from different international organizations such as UNDP, Christoffel Blinden- Mission, Helen Keller International, AGFUND, etc. Funds from the Japanese Shipbuilding Industry Foundation (JSIF) have been provided to all Member Countries, particularly DPR Korea, India, Myanmar, Nepal and Mongolia, to help strengthen the eye care infrastructure, support outreach activities, provide training in eye care and for epidemiological surveys. As far as deafness is concerned, in spite of the expected high prevalence rate in SEAR, no reliable statistical data are available in most of the countries. Most of the data available are outdated and could not serve as a reliable base for important policy decision and elaboration of strategies for, and approach to, the problem. The report of the national survey conducted between 1973 and 1974 revealed that India had 0.83 deaf and 0.61 dumb per 1(MO population. A survey of school children in Yangon, Myanmar, indicated that 5.6 per cent of the children surveyed had hearing impairment. A sample survey conducted in Nepal in 1980, revealed the total disability rate to be as much as 3 per cent. Of these, 33 per cent were found to have hearing impairment, of which 9.78 per cent were deaf, 12.09 per cent were hearing handicapped, and 11.38 per ccntwere deaf-mute. In Sri Lanka, there are an estimated 2.3 totally deaf people per 10 000 population. 134 UIL- WORK OF WHO IN SFA In collaboration with the international Federation of Otorhinolaryngological Society (IFOS), efforts have been made to conduct a general overall renew of the deafness problem by a WHO consultant in Indonesia, Myanmar, Nepal and Thailand. Thc general assessment of the situation was submitted to the eighty-seventh session of Executive Board and modalities for further collaboration with IFOS in the prevention of deafness in SEAR are being further studied. The WHO Collaborating Centre for Prevention of Hearing Impairment and Deafness, Bangkok, conducted a training course to upgrade the knowledge and skills of public health otologists. A consultant was assigned to Myanmar to assess the hearing impairment problem and assist in the preparation of a national plan for the prevention and control of deafness. Fellowships and supplies and equipment were provided to most the countries 13.16 CANCER Comprehensive national cancer cc~ntrol programmes have been formulated in Indonesia,SriLanka, andThailand. In India, such aprogramme hasbeen inexistence for several years and is being implemented in four states. Three WHO collaborating centres assist in its implementation. Four districts, each covering populations of several million and connected with a regional cancer centre, have been selected for full implementation of all activities as outlined in the national programme, with WHO support. Operational research will accompany the implementation of these district models in order to draw conclusions regarding operational and resource rcquire- mcnts for later expansion. The model activities will include campaigns for early dctcction, efforts at clinical downstaging, treatment, pain relicf, and palliative care. Thc availability of oral morphine for pain relief for out-patients will also bc assured. Furthermore, counselling services through volunteers, who arc operational in only a few cities, will be made available and their impact on the quality of life of cancer patients and their families assessed. During a WHO-supported national workshop a plan of action for the implementation of the National Canccr Control Programme was developed in Indonesia. In Sri Lanka, WHO continued 111 assist in thc postgraduate training of radiotherapists through a consultant. Public education for early detection of oral precancerous and cancerous lesions has begun in Maldives and continued in some parts of India and Sri Lanka. However, the rcferral ratc through basic health workers has not been as high as expected since health workers tend to feel the task of examining the oral cavity to be socially difficult. The promotion of self-examination is probably a more effective alternative. Audiovisual material for this purpose has been developed and field-tested by the WHO Collaborating Centre for Prevention of Oral Cancer in Bombay, India. DISEASE PREVENTION ANDCONTROL I35 Consultants have assisted in reviewing and recommending improvements to the existing cancer registries in India. They have also commented on the relative paucity of epidemiological studies which emanate from these registries. Cancer control activities in DPR Korea were supported through a number of fellowships for specialized lields of training. 13.17 CARDIOVASCULAR DISEASES Whereas the incidence of cardiovascular diseases (CVD) has shown a substantial decrease in some of the industrialized countries, there appears to be an increasing trend in many developing countries. The prevalence of cardiovascular diseases in India is estimated to be 40 million cases in 1991, according to the Indian Council of Medical Research, and is likely to increase to over 52 million by the year 2001. Hypertension and coronary heart disease affect about 9 per cent of people over 30 years of age in India. In DPR Korea, Mongolia and Thailand, where the average life expectancy is close to or above 65 years, cardiovascular diseases are already the leading cause of death. Accordingly, countries in the Region are giving increased importance to the control of cardiovascular diseases. In Myanmar, the national CVD Control Programme has gained further momentum with the in-service training of large numbers of physicians and paramedical health staff. Training courses have also been held with WHO assistance in Bangladesh, Indonesia, Sri Lanka and Thailand. Rheumatic heart disease (RHD) continues to bc highly prevalent in some of the countries in the Region. WHO continues to support, through AGFUND, integrated RHD control programmes in India, Sri Lanka, and Thailand. In Bangladesh, such a programme is being implemented with bilateral assistance from Japan. RHD control forms an important component of school health programmes. WHO continues to support different innovative approaches being undertaken by Member Countries, such as the development of vascular surgery in DPR Korea and rhc education of students and their peers in the identification of cardiac murmurs. 13.18 OTHER NONCOMMUNICABLE DISEASES PREVENTION AND CONTROL ACTIVITIES With increasingly effective control of communicable diseases, the concern with noncommunicable diseases is increasing in all countries of the Region. Activities towards the control of some of these require relatively heavy investments in capital 136 THE WORKOP WHO IN SEA and running costs sometimes putting difficult choices before countries. On the other hand, some countries are concerned about the expenses incurred when sending affected individuals abroad for specialized treatment. Such costs can offset some of the investments required for the establishment of the same treatment facility in the country concerned. WHO support to DPR Korea, where basic facilities of primary health care are available, has continued to focus on the development of skills and facilities of a higher degree of specialization. In the area of NCD, consultants have been supplied in various subspecialities of surgery, oncology, endocrinology and internal medicine. This has been complemented by a number of fellowships for related specialist training. In India loo, WHO support in this subprogramme area has mainly consisled of fellowship training in various aspects of NCD conlrol programmes. In Maldives, facilities to identify individuals who are heterozygote for thalassemia arc now available. This testingispresently offered on a limited scaleas a first step towards a full-fledged thalassemia control programme which will include surveys, genetic counselling, and blood transfusion services.

Chupter 12 DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY 12.1 CLINICAL, LABORATORY AND RADIOLOGICAL TECHNOLOGY FOR HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE Health laboratory services play an important role in supporting programmes for health care systems. As such, the strengthening of health laboratories is vital in national health care systems. WHO continued to support Member Countries in strengthening hwlth laboratory services hy improving the existing infrastruclure, including peripheral areas, introduction of appropriate laboratory technology, continuing training programmes, supplies, reagents, kits and equipment, and sustenance of quality assurance programmes. Laboratory Sewices and Technology The strengthening of laboratory services, particularly at district and provincial lcvels, is stressed through [he provision of supplies and equipment and national training programmes. A UNDP-funded intercountry project is under way to strengthen health laboratories for effective delivery of primary health care so as to achieve HFN2000 in six countries of the Region viz., Bhutan, India, Indonesia, Maldives, Mongolia and Myanmar. The project activities support national workshops on policies for health laboratory services, laying down of qualitystandards, andintroduction of appropriate lechnoloby 88 'IIIE WOKK01' WHO IN SFA and quality assessment schemes in the whole network of health laboratory services. During the period under review, national workshops on the development of national policies for health laboratory services were held in all the six countries. An intcrcountry workshop will be held in early 1W2 to consolidate the recommendations of the national workshops and to develop a regional policy for health laboratory serviccs. National workshops for the introduction of appropriate technoloby at the PHC level havc been initiated. WHO is committed to supporting the Member Countries in achieving regional self-reliance inimmunodiagnostic reagents. Through UNDPprojects, the production of modern immunological and biological reagents is being supported in Bangladesh, India, Myanmar and Sri Lanka. Regional capabilities in the production of rcagcnts for rapid diagnostic techniques and survcillance of priority communicable diseases, such as dengue haemorrhagic fcvcr, Japanese encephalitis, hepatitis, shigellosis and acute respiratory infection were supported. The National Institute of Virology, Punc. India, supplicd test kits for the surveillance of Japanese encephalitis to the countrich of the Region. The WHO Collaborating Ccntrc for Referencc and Training in Strcptococc:~l ~i~~. . ~SLS . . . ,I[ thc Lady Hardinge Medical College, New Dclhi, continued to supply rcagcnts for the diagnosis of streptococcal infection to other institutions in thc Region. Shigcllosis continues to hc a hcalth problem in the countries of the Region. 111 particular, epidemics due to Sltigcllu dyse~tferioe 1 continue to occur periodically. In collaboration with the Diarrhoea1 Disease Control Programme, laboratories in scveral countries are bcing strengthened for the detection and control of shigcllosis. Thc National Institute of Health, Thailand, continued to provide diagnostic antiscr;~ for Shi~llo dyse~tteriae to other countries of the Region. In thc field of quality control of hcalth care technology, WHO is assisting India. Indonesia, Maldives, Nepal, Sri Lanka and Thailand to takc part in global extcrn:~l quality assessment programmes in clinical chemistry, microbiology and hacn~atology. WHO provided technical support through a consultant for conducting a national workshop for the development of external quality assessment in immunology in Indonesia. Undcr the global programme on AIDS and the global blood safety initiative, WHO organii.ed an intcrcountry workshop on the transfer of technology for thc manufacture of silfe blood nroducts in Bombav in December 1990. Nationals were ~ ~~~ trained in tllc rnoilcrn meth~idoloby of productiun of safe blood component\ .an.! plasmafractionc. WHO i<st~ppt,r~ingcountrics in Iahoratory diagno\isof HI\' AID> - ~ WHO is also supporting an external assessment scheme for HIV testing in Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. In line with WHO'S commitment to global eradication of poliomyelitis by DIAENOSIlC. THERAPEUTIC AND REHABlL~ATlVETECHNOLOGY 89 the year 2000, a regional plan of action for the establishment of a regional network of polio testing laboratories has been developed. As a part of the global programme for rickettsia1 disease epidemiology, India, Bangladesh, Nepal and Thailand were supported through the distribution of rickettsia1 antigen, for indirect immunofluorescence tests. Information on the incidencc and prevalence of rickettsioses at the global level is meagre. It is expected that in the near future a realistic epidemiological picture of rickettsioses will emerge. With the aim of expediting disease control activities, a programme for the promotion of new techniques in the diagnosis of diseases has been launched in the Region. The first workshop on the promotion of the polymerase chain reaction (PCR) in the diagnosis of communicable diseases, and genetic and metabolic disorders was held at Pune (India), in May 1991. The remarkable progress in the diagnosis of infectious diseases, cancers and metabolic diseases using electron microscopy, due to advanced computer technology and ultra high resolution analytical technology, was recognized, and a bi-regional workshop (South-East Asia and Western Pacific Regions) on the application of electron microscopy is being planned to be held at Bangkok in October 1991. WHO continued to support the concept of basic radiological units in thc countries of the Region. WHO is also endeavouring to monitor the exposure to X-rays in radiology departments and the safety of cobalt irradiation units in several countries. Bangladesh, Maldives and Nepal are taking part in a personal dosimetry monitoring programme being conductcd by the International Atomic Energy Agency, Vienna. Sufficient facilities to establish appropriate imaging technology need to be developed in most countries of the Region. Efforts are being made to promote regional self-sufficiency in monitoring radiation effects. 12.2 ESSENTIAL DRUGS AND VACCINES WHO's collaboration with the Member Countries in the strengthening of thc Essential Drugs Programme continued. In the development of the Programme, special attention was paid to manpower development, quality assurance and rational use of essential drugs. Apart from the support to countries under WHO's regular budget, funds from extrabudgetary sources were being mobilized for strengthening country essential drugs programmes. In addition, two countries, viz., Indonesia and Thailand, along with other ASEAN countries, are implementing an Essential Drugs project as a WHO-executed UNDP project, besides receiving technical inputs from WHO in the field of essential drugs. 90 'fflE WORKOF WHO IN SFA 1. Drug Policies and Programmes Since the Alma-Ata Conference on Primary Health Care, countries have restructured their health development programmes with emphasis on primary health care (PHC) as the strategy for achieving health for all by the year 2020. Several essential drugs programmes have been actively developing in the countries of the South-East Asia Region. Bhutan's programme, supported by DANIDA and FINNIDA, lays emphasis on the procurement, storage and distribution of essential drugs. In order to improve the procurement of drugs, computcrization of the process is being promoted in addition to ensuring that the WHO Certification Scheme is adopted in the purchase of drugs. Training of doctors in rational prescribing and quality control of drugs is being promoted. With a view to strengthening the drugs programme, financial and technical supporc is being provided in Thailand in the areas of drug information, evaluation, registration, re-evaluation, pricing policy, quality control, good manufaduring practices, drug management and rational use of drugs. FINNIDA continued to provide financial support for the essential drugs project in Myanmar. The project was developed with technical assistance from WHO. Thc Myanmar project aims at strengthening drug policy, quality assurance, procuremcnl and distribution systems. The project plans include, in the first phase, the provision of essential drugs to nine townships over a period of threeand a halfyears, up to 1992. Sri Lanka held a workshop on drug policy and quality assurance in August 1%. Thc workshop provided further impetus to the development of drug management and policy. An action plan on drug quality assurance and measures to minimize drug shortage were formulated in the context of the national requirements. 2. TCDC in Pharmaceuticals Technicalcooperation amongst countries of the South-East Asia Region iscontinuing in several areas. The UNDP-funded ASEANiWHO project in the field of pharmaceuticals is a successful example of such a collaborative activity. In Phases I and I1 of the project, from 1982 to 1986, the six ASEAN countries developed centres of excellence in the field of quality control, drug management, reference substances, GMP, drug information and drug evaluation. In Phase 111, covering the period 1987 to 1991, these centres are being used for manpower training, not only by the ASEAN countries, but also by other countries of the Region. The tenth ASEAN Working Group met in Singapore in February 1991 to plan Phase IV of the project, from 1992 to 1996. The project aims at further strengthening national capabilities in drug quality assurance and at achieving self-reliance in the training of human resources for GMP inspection and auditing, quality assurance, drug evaluation, productionand utilizationofregional standardsand referencesubstances, clinical pharmacy, standardization, quality control, utilization of herbal medicines and exchange of information on drug regulatory matters. India, Indonesia and Thailand have developed capabilities in the areas of production, quality assurance, training of human resources and other aspects in the development of essential drugs and biologicals programmes. This has facilitated the process of cooperation both for regional as well as extra-regional Member Countries of WHO. 3. Rational Use of Drugs Rational prescribing and use of essential drugs and biologicals have been promoted by WHO in collaboration with countries, including Bhutan, India, Indonesia, Myanmar and Thailand. Drug procurement, storage, distribution and management are being developed in Bhutan to improve rational use. In India, a technical committee was constituted and charged with the responsibility of evaluating drug combinations and removing from the market those combinations which are irrational in the light of current knowledge in clinical pharmacology. With a view to improving rational use of drugs, standard treatment regimens have bcen established in Bhutan, Myanmar and Thailand. These treatment regimens will be used to improve rational prescribing as well as quantification of essential drugs needed for primary health care programmes. The quantification of drugs, based on standard treatment regimens, was successfully implemented in Myanmar. In order to facilitate drug management, computer technology is being adapted in Bhutan and Indonesia using the SWEDIS system developed in Sweden. Myanmar is also developing computerization of the Essential Drugs project for inventory control and logistics of drug supply and distribution. 4. Riologicals WHO continues to collaborate with the countries of the Region in the development of their vaccine programmes. WHO has been strengthening production capabilities of bacterial and some of the viralvaccines in Bangladesh, India, Indonesia, Mongolia, Myanmar and Thailand. In India, the production of DPT, rabies and poliomyelitis vaccines has been strengthened through the training of nationals. In Indonesia and Thailand, there is self-reliance in the production of bacterial vaccines while bilateral assistance has been provided for the production ofviralvaccines against poliomyelitis and measles. A network of WHO wllaboratingcentres for the training and testing of vaccines used in EPI, located in India, Indonesia and Thailand, continues to provide services and training for quality control and quality assurance of vaccines. 92 THE WORK OF WHO IN SEA WHO will concentrate on the transfer of technologyfor the production of bacterial and viral vaccines, including hepatitis and rabies vaccines, and will assist the training programmes in production and quality control. Technical and financial collaboration will need to be provided for attaining self-sufficiency in EPI vaccines in the countries of the Region. 12.3 DRUGS AND VACCINES QUALITY, SAFETY AND EFFICACY The major thrust of WHO has been to strengthen quality assurance programmes in the Region so as to ensure the quality, safety and eficacy of essential drugs and vaccines. Towards this end, training in the development of technical manpower for drug analysis and good laboratory practices, as well asgood manufacturing practices, in the production of essential drugs and vaccines, has been provided. In Myanmar, a quality control laboratory has been developed and nationals were trained in the analysis of pharmaceutical products. Bangladesh received technical support for strengthening the quality control laboratory through the provision of consultants, fellowships and supplies and equipment. India, Indonesia and Thailand have been supported in the acquisition of reference standards, substances and equipment as well as through group educational activities. In Bhutan, the establishment of a quality control laboratory is envisaged while in Nepal, the quality control programme was strengthened with technical and financial inputs from WHO. In Sri Lanka, the quality assurance laboratory was further supported by developing a programme at a workshop held in August 1990 with technical and funding support from WHO. 1. Quality Assurance WHO actively promotcd the WHO Certification Scheme for the quality 01' pharmaceutical products moving in international commerce as well as for good practices in the manufacture and quality control of drugs (GMP). The WHO Certification Scheme helps to ensure the quality of pharmaceutical products for countries that have not yet developed an adequate quality control system. Additionally, WHO assisted in the testing of pharmaceutical products at the WHO collaborating centres in India and Thailand for any country of the Region that has not yet developed its own quality control laboratory. 2. Drug Information and Adverse Drug Reactions WHO'S activitieswere aimed at improving drug information programmes in countries of the Region. Drug information is needed by various health professionals as well as the general public. In view of this, support was provided for the establishment of a DIAGNOSIlC,'MERAPELmC AND REHABILKATIVETECHNOLCGY 93 data base on several aspects of pharmaceuticals, including drug utilization, registration status and adverse drug reactions. Bhutan has revisedits StandardTreatment Guide and distributedit to the basic health units. In Myanmar, standard treatment schedules as well as diagnostic flow charts for different levels of health care were distributed. Health education materials were also used for community awareness of the Essential Drugs Programme. The ASEAN countries decided to exchange information on drug regulatory matters at the Tenth Meeting of the ASEAN Working Group on Technical Cooperation in Pharmaceuticals, held in February 1991. This mechanism will enable individual Member Countries to take such pre-emptive action as may be necessary. It will also promote awareness of activities amongst ASEAN countries, thus leading to an improvement in the implementation of the national programmes. Indonesia and Thailand have developed adverse drug reaction reporting systems. In addition to the national monitoring of adverse drug reactions (ADR), the two countries participated in international collaboration in ADR reporting and dissemination of the information. The drug information system needs to be further developed in several countries of the Region. 12.4 TRADITIONAL MEDICINE Countries of the Region have a rich inheritance of traditional medicines. Hence, training programmes, such as in Sri Lanka and Myanmar, were developed and strengthened with experts from within the Region. Study tours and fellowships were arranged for the nationals of DPR Korea, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand, both intra-regionally as well as extra-regionally. In the promotion of the integration of traditional medicine in the health care system, the identification of popular traditional medicines used for common ailments, training of traditional medical practitioners, standardization and quality control of traditionaldrugs, development of herbalgardens, introduction of modern production facilities and research in agro-techniques and pharmacological testing are areas where WHO has collaborated at the country level. Indonesia andThailand are the focal points for the coordination of activities in herbal medicine. The work involves standardization, quality control and utilization of herbal remedies in ASEAN countries. A manual on cultivation, production and utilization of herbal medicines was published and training programmes were convened in the coordinating countries. 94 THE WORKOF WHO IN SEA With UNDP funds, Myanmar and Sri Lanka further developed traditional medicine programmes. Myanmar's programme dealt with the development of the traditional medicine manpower required in planning and management, curriculum development in traditional medicine education and development of the library at the School of Indigenous Medicine, Mandalay. The Sri Lankan programme concentrated on institution building in regard to the development of the proposed National Institute of Traditional Medicine. Training courses and seminars were held for traditional medicine practitioners and local health workers in agro-techniques of medicinal plants, modern techniques in the production oltraditional medicine and in research. Even though traditional medicine has a long history in the countries of the Region, it needs to be further strengthened, inter alia, in the standardization of ingredients, - - quality assurance, scientific authentication of therapeutic efficacy, untoward and toxicological effects of products and improvements in manufacturing techniques based on good manufacturing practices. 12.5 REHABILITATION Though the magnitude of the disahilily problem cannot bc asccrlained accuratcly, most countries of the Region have at present either a national programme on disability preventionor a firmly-established disability prevention and rehabilitation component in the general health services as a part and parcel of the PHC package. The hospital for the disabled in Dhaka, Bangladesh, has been providing referral services for the rehabilitation of the physically handicapped through orthopaedic reconstructive surgery and production and supply of artificial limbs using local materials. Low-cost functional prosthetic-orthotic appliances and other rehabilitation aids, manufactured from indigenous materials, have been made available in Myanmar. Technical assessment of the disability situation was carried out by a consultant while the basic needs for community-based rehabilitation services were appraised in Mongolia. Two patients were provided with treatment and orthopaedic aids, and an orthopaedic surgeon and an orthopaedic technician were trained at the Nevedac Prosthetic Centre, Chandigarh, India, on the basis of TCDC, free olcharge. A seminar on evaluation of the camp approach for the rehabilitation of polio paticnts in rural areas was conducted in December 1990. Study tours for national experts from India, Indonesia and DPR Korea, in the fields of community-based rehabilitation, physical medicine and orthopaedic surgery, were processed. RHB programmes are still seen, in most cases, as orthopaedic rehabilitation services in the first instance, and do not have a strong linkage with other rehabilitation services such as leprosy, mental health, blindness, deafness, etc., which are run under different special programmes. WHO collaboration was, therefore, mainly focused on the training of national manpower, creation of awareness of the problcm and strcngthening of PHC approaches as a part of dcvclopmcnt of institutional capacity at thc lowcst level ofhealth administration and the strengthcning of intra- and intersectoral cooperation in the countries.

Chapter 5 DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH 5.1 MANAGERIAL PROCESS FOR THE DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH It is now clearly recognized that the largest cost of any health system is the cost of thc human resources that operationalize the system. In the light of the aim of achieving health for all through the primary health care approach, efficient planning, production, placement, utilization and management of health personnel assume paramount importance, particularly in the context of the current slow economic down-growth afflicting thc world. Towards this end, WHO continued to support national efforts aimed at improving health personnelplanning, production, utilization and management. WHO'S fellowships programme provided the much-needcd support to national efforts in the development of human resources for health. Support was also provided to strengthen the planning of human resources for health in all the countries of the Region. In Bhutan, technical support was provided for the development of a master plan for human resources for health in relation to the Scveuth Five-Year Plan (1992-l(W7). In India, a study was undertaken to take stock or health manpower and rcquiremcnts by the year 2000. In Indonesia, the Second Workshop on Manpower Planning and Evaluation was conducted in October 1990. In Myanmar, astudy on the problemof attrition among doctors in government service was undertaken. In Nepal, support was provided for a review of the health manpower situation in the context of the health care system, while in Thailand, support was provided for developing long-term manpower plans for various categories of health personnel. Information on human resources for health is generally inadequate in most countries of the Region. Following the meeting of the WHO Study Group on the Role of Research and Information Systems in Decision-Making for the Development of Human Resources for Health, convcncd in Geneva in November 1989, a Consultativc Mecting on a Minimum Set of Information in Support of Policy, Planning and Managcmcnt of Human Rcsourccs for Hcalth was convened in Bangkok in October 1000. Efforts will now be made to support the development of information systems on human resources for hcdlih in a number of countries by applying the conccpt of the minimum set. The management of health personnel is a vital part of the development of human rc- sources for health. Support continues to bc provided for this vital activity, particularly in indoncsia, Sri Lanka and Thailand, covering various aspccts ofmanagcment. Efforts wcrc made to strengthen nursingand midwifcry human rcsourcc planningand managen1cnt. Assistance in thc upgrading or nurse managers and othcr nursing and midwifcry personnel continued through fellowships for advanced study, training and study visits in nursing management and clinical nursing in Bangladesh, India, Indonesia, Myanmar, Ncp;il and Sri Lanka. 5.2 RESEARC11 IN THE DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH Efforts to increasc the capabilities of the countries in carrying out research into the dcvelopment of human resources for health continued. Towards this end, a Consultative Meeting on Management Research for Development of Human Rcsourccs for Hcalth was hcld in Bangkok in September 1990. The Consultativc Meeting rccommcnded that governments take necessary steps to create research cells in ministries of health or in existing national me~lical research councils to promote, coordin:~lc and conduct rcscarch into thc managcmcnt of hcalth pcrsonncl. It also rccommcndcd that the importance of rcscarch into the managcmcnl of health pcrsonncl be brought to the attention of the meetings of the Advisory Committee on Health Research and of the Directors of Research Councils. The meeting of Directors of Rcsearch Councils, held in November 19W, included rcsearch into human resources for health as an item on its agenda for technical discussions at the next meeting scheduled for 1992. In addition, national workshops on rc?.arch into the dcvclopmcnt of human resources for health were hcld in Y;~ngon, in July I'N0, in Chiaogmai, Thailand, in August l'm), and in Jakarta, in October 1W. The promotion of rcsearch in nursing was further strengthened. An Intercountry Consultation on Rcsearch in Nursing was hcld in Thailand from 24 to 28 June 1991 to follow up the recommendations of the fifteenth session of the South-East Asia Advisory Committee on Health Research relating to the development of rcsearch in nursing. This consultation aimed at identifying priority research areas and appropriate methodological approaches for research in nursing in the Region and also proposed strategies, mechanisms and plans for follow-up for promoting rescarch in nursing at country and regional levels. In spite of the increascd effort to promote the use of rescarch into the development of human resources for health as a means of rationalizing decision-making in the planning, production and utilin~ti~in of hcalth personnel, much rcmains to hc donc. Rational decision-making, hascd on faas rather than on intuition, remains elusive. Sincc the bulk of the health hudgcl is dcvotcd to thc cost of human resoi~rccs f~ir health, a small increase in productivity or cfficicncy in the use of human resources for health would result in substantial increascs in cost-effectiveness. The importancc ol decision-linked research into the development of human resources for hcalth will continue to be actively pursued in the Region. There is still a need lo rectigni;.c I hc importancc ofrescarch in nursingand lo dcvcl~,(i an explicit policy and plans for thc dcvelopmcnt ofrescarch in nursing in the Mcmhcr Countries, and to provide fin:mcial support to undertake those necessary rcscarch activilies. WHO will continuc to collaborate with Mcmber Countries in thc development of research in nursing in order to improve the quality of care. 5.3 MEDICAL EDUCATION Further progress WZIS ohscrvcd in ~hc efforts of the Mcmber C'ountrics to strcngthcn and reorient thc medical education systcms tit achicvc closer quantitative baklnce and political relevance lo their medical manpowcr development programmes. At the undergraduate level, the trcnds that were initiated in the past decade were furthcr reinforced with grcatcr community orientation of curricula, introduction of innovative education stratcgy, such as problcm-based learning, strengthening of educational management processes, cxpcrimcntingwith objective structured clinical and practical examinations and introduction of enquiry-driven stratcgy for acccleraling changes in medic:il cducati~in. The consortium of four medical schools in India whose activities arc coordinated hy the All India Institute of Medical Sciences, New Delhi, completed the first phase of its project, started in 1989, to reorienl medical education using health systcms research as the strategy. It is now entering the more ambitious second stage that will not only increase the magnitude and pace of change but is also expected to bring 20 other leading medical schools undcr the ambit oI the consortium. In Andhra Pradcsh, the University of Hcalth Scicnccs has, with WHO collaboration, cstahlishcd a Medical Education Unit, and is developing the infrastructure and personnel to coordinate health personnel dcvelopmcnt in the institutions undcr its charge. With WHO'S collaboration, the network of community-oriented educational institutions organized the second International Conference at Yogjakarta, Indonesia, under the theme of Prohlcm-hased Learning. This was attended by a large numhcr of representatives of medical schcx~ls of thc Region and the follow-up is expected to 1)I~VIII.OPMI:NI'OP IIUMAN RFSOIJRCIS FOR Illj\I.'l'l1 41 accelerate the introduction of problem-based learning in a number of conventional mcdical schools. Problem-based learning programmes have already been introduced on an cxperimcntal scale in a fcw schools in India, Indonesia, Nepal and Thailand. Myanmar, in collaboration with WHO, has completed the development of its ncw curriculum wherein problcm-based learning units have been introduced throughout the undcrgraduale education programme. They have also produced most of the relevant learning resource material and trained a group of core staff in implementing this innovative programme from the beginning of the new academic year. The experience that will be gained through this initiativewill no doubt be ofimmensevalue to other institutions planning to incorporate problem-based learning into conventional medical curricula. An intercountry workshop was organized in Thailand to develop a nucleus of medical educational leaders in the Member Countries who will be able to prepare medical undergraduates to meet the challenges posed by the emerging problem of AIDS in the Region. As a direct output of this workshop a number of innovative prototype curriculum segments havc been formulated and thesc will form the basis of the specific country and institutional level curriculum development activities that will be promotcd. This workshop al.co identified possihle mechanisms for using HIVIAIDS educational activities as an entry point in the overall strategics for the widcr goal of rcorienling mcdical educakion as a wholc. Specific curricular reforms or1 the lines recommended in the technical documents on the reorientation of medical cducation, published by the WHO Regional Office, are also being undertaken in Bangladesh, Indonesia, Sri Lanka and some of the leading institutions in India. On the basis of a review of WHO support to medical education programmes in Indonesia during the last decade, thc focus of the collaboration has bccn redirected with thc aim ofaccelcrating the diffusion of thc technical guidelincs dcvelopcd by the Consortiunl of Health Sciences down to the level of the medical schools themselves. Medical schools in Thailand havc further consolidated the innovativc medical education programmes that were launched in the past decade to bring about greatcr relevance to priority national needs and to improve community orientation in the training of basic doctors. The Institute of Medicine in Kathmandu is conducting a comprehensive review of the student assessment system with a view to dctcrmining its consistency with the actual health care needs ofthe community. There has bccn further progress in the devclopment of postgrad~iatc mcdical education programmes too. Technical support by way of consultancies and subsidics was provided to Bangladesh, Myanmar, Indonesia, and Sri Lanka for improving the competence of teachers, the quality of training programmes and the standard of examinations. The Regional Office, at the behest of a number of Member Countries and with the twin objectives of achieving greater relevance and efficiency as well as regional self-reliance, is exploring the possibility of expanding the avenues for further regional cooperation in postgraduate medical education. 42 THE WOKKOF WHO IN SFA The momentum of change generated in the last decade in reorienting medical education systems to produce physicians with competence and compassion who can serve the needs of whole populations, continues to be maintained in the Member Countries. Yet, the level of technical and financial support that will be needed by Member Countries to achieve the targets that they have set for themselves will remain high for a few years morc. Similarly, the Centres of Medical Education in Bangladesh and India have also been regularly conducting programmes for deans, principals and htaff of medical schools as well as for decision makcrs in ministries of health with the ot~rall eoal olimon~vinu ~ ~~~ --~~ -~~ r-- ~a the relevance of educational programmes. In addition, the Centre of Medical Education, Bangladesh, developed a task-oriented curriculum which is now being introduced in the medical schools in the country. However, the progress of development towards the establishment of active functional medical education units or cells in the medical schools has fallen short of the initial expectations. While it is true that most medical schools do possess core groups of teachers with competence in educational processes, the actual improvement of edu- cation practices to achieve greater relevance and efficiencyleaves much to be desired. 5.4 NURSING EDUCATION WHO continued to provide technical support for strengthening basic nursing education. Efforts were made to strengthen institutional frameworks, educational policies and teaching-learning resources for the implementation of community-oriented nursing curricula. Assistance in the upgrading of nurse teachers was continued through fellowships for advanced studies or speciality training in educational methodology or clinical nursing speciality. Efforts to ensure the quality of nursing education in preparing nurses for national needs were further promoted in the Region. In Myanmar, basic and post-basic nursing curricula were in the process of revision and a proposal for the establishment of the Bachelor of Science in Nursing programme was also being taken up. In Maldives, initial steps have been taken towards the first basic nursing education programme in the country. Efforts were also made to improve continuing education for nursing and midwifery personnel. In response to the increasing demand for better qualified personnel for the delivery of health services, especially for the upgrading of knowledge and skills of nursing and other health personnel in remote areas, a critical appraisal of the use of distance education to meet such challenges was carried out through an Intercountry Workshop on Distance Education for Nursing Personnel and other Health Workers, which was held in Thailand in October 1990. One of the recommendations arising from the Workshop was that Member Countries and WHO should lay emphasis on distance education as a means of meeting post-basic and continuing education needs of health personnel, particularly at the district health system level, and in rural and remote areas. India, Sri Lanka and Nepal plan to develop distance education programmes for their nursing personnel. Special attention was being paid to the improvement of the nursing and midwifery curriculum to better prepare graduates to comprehend the seriousness of AIDSIHIV infection, which is one of the major health problems and a threat to the world community as wcll as the Region. Multicentre field tests of "Teaching Modules for Basic Nursing and Midwifery Education in the Prevention and Control of AIDS", dcveloped by the Western Pacific Regional Olfice, were conducted in Myanmar, Nepal and Sri Lanka. In collaboration with WHO headquarters, studies on national activitics and needs in nursingimidwifcry education and in services for AIDSIHIV prevention and control in the Mcmbcr Countries of the Region have been conducted. The results will primarily be used to strengthen thc nursing component of national and regional AIDS programmes, especially in countries with the least nursing activitics and the grcatcs( nccds. In spite of the cfforts that have gone into the strengthening of nursing education in the countries of the Region, much remains to be done. Special efforts have to be promoted to further strengthen field practice areas of nursing education programmes so as to provide cffcctivc lcarning experiences for students. Special efforts arc also needed to coordinate the dcvclopmcnt of nursing services and education, so as to facilitate congrucncc between nursing services being practised and nursingcduwtion being taught in the educational programmes. Furthermore, although it is evident that the upgrading of nurse teachers, managers and clinicians is of crucial importance for the strcngthening of nursing services and education, institutional resources for post-basic and graduate nursing education programmes in the Rcgion remain limitcd. Even though consideration has been given to the strengthening of graduate nursing programmes in India and Thailand, greater support needs to be providrd in this area for the overall development of both nursing services and nursing education systems of the Region. 5.5 TEACHER TRAINING WHO continued its collaboration with the Member Countrics in consolidating the programme for thc development of the expertise of teachers of health professionals in their subjects as well as in the basics of educational science and technology. Although distinct improvements are perceptible, the resistance to change generated by adherence to traditionalvalues and practices and the lack of motivation still hinder the reorientation of the educational programmes in meeting the challenges inherent in the production of health workers with the competence and commitmcnt to supprt the goal of Health for All. 44 -. nIE WORKOP WHO IN SEA In DPR Korea, the training of academic staff was institutionalized and all the eleven medical and pharmaceutical universities now have their own education units for training teachers. It is now mandatory for all staff recruited to these universities to obtain a Diploma in Educational Technology of a year's duration from one of these units before they are confirmed as teachers. The Regional Teacher Training Centre at Chulalongkorn University Medical School, Thailand, has continued to provide training in different aspects of educational science and technology to many teachers from the countries of the Region. In response to increasing demand, this Centre has also started a Master's level programme in Educational Science and Health Manpower Research, which is gaining in popularity. The Regional Teacher Training Centre in Sri Lanka, which, at the moment, is rebuilding its capacity, has also conducted short-term training courses for teachers of health professionals in the country. WHO also supported the strengthening of research and educational capabilities of the academic staff of the State Medical Institute and the Medical Technicum in Mongolia. In Myanmar, staff were trained in the development of problem-based learning units for implementing the newly-designed PHC-oriented curriculum. Collaboration with the Consortium of Health Sciences in Indonesia included the continuation of programmes for staff development in problem-based learning and educational measurement and evaluation. In Sri Lanka, a consultant reviewed the educational technology being used at the National Institute of Health Sciences for the training of teachers of primary health care workers, and also revised the curricula and field training programmes. Another consultant assisted the Institute in streamlining the continuing education programmes for all non-medical health workers which come under its range of responsibilities. In Bangladesh, WHO support by way of consultants, fellowships and subsidies was extended to the de;elopment ofcducarional capabilities of teachers of medical schools as well asdo the Bangladesh College of Physicians and Surgeons. In Nepal, the Education Support Unit of the Instilure of Medicine continued regular trainingactivities for teachers and undertook a fewresearch studies to identify the strengths and weaknesses of some of the educational processes of the Institute. 5.6 HEALTH LEARNING MATERIALS Four countries, participating in thc UNDP-funded WHO-executed regional project, formulated national work plans and conducted 'needs and resources'surveyswith the assistance of consultants from the successful Health Learning Materials project of the Institute of Medicine, Kathmandu, which is a WHO Collaborating Centre in this field. An Intercountry Workshop on Distance Education for Nursing Personnel and Other Health Workers was held in Thailand in October 1990. Also, an Intercountry Workshop on Health Learning Materials Development was organized in Jakarta in DLVEL.OPMFNTOP HUMAN RFSOIJRC'ES FOR HFAl.111 45 February 1991. Training in the skills needed in the production of health learning materials is seen as an essential first step in the development of locally-specific health learning materials and in ensuring their use. Support was provided to the national health learning materials programme in Myanmar, while external financial assistance has been sought in support of the national programmes in Indonesia and Sri Lanka. It is estimated that, by the end of the first phase of the project, each of the four new countries participating in the network will be able to lay the foundation for a sustainable national health learning materials programme. 5.7 FELLOWSHIPS At the eighty-seventh session of the Executive Board, hcld in January 1991, the Director-General presented a report on the implementation of WHO'S policy on fellowships. The South-East Asia Region's contribution to the Director-General's report was based on country reports and used indicators and guidelines developed at the Third South-East Asia Regional Conference on WHO Fellowships, held in 1988. The Executive Board, in welcoming the report of the Director-General, urged Member Countries to take demonstrable steps to ensure the relevance of WHO fellowships to their health resource needs and national health development, to introduce or strengthen mechanisms to establish policies for planning, production and management of their human resources for health, and to evaluate their use of fellowships resources in order to ensure that their selection mechanisms are effective and that returning fellows are utilized in the best interests of the national health systems (EB87.R23). In this connection, the Regional Committee, at its forty-third scssion, held in September 1990, while reviewing the recommendations of the eighteenth meeting of the CCPDM, endorsed the view that the objectives of fellows should be clear to allow early nomination of suitable candidates, that submission of application forms should occur by September of the preceding biennium, and that it should be ensured that candidates meet the host institution requirements as well as the sponsoring government' s own requirements. Nevertheless, many countries still find it difficult to comply with the above recommendations. Of 2 176 fellowships budgeted for implemenlation during the current biennium, the Regional Office had received 1 212 FAFs at the end of the eighteenth month (June 1Y)l). WHO, on its part, is continuing to expendmuch effort in overcoming the difficulties and smoothing out the processing of fellowships. A review of the Fellowships Unit by a management expert was completed in December 1990 and the feasible recommendations arebeingimplemented, including greater use of the computerized fellowships information and monitoring system. Implementation Tuition fees for courses in institutions of some developed countries have increased enormously, resulting in high costs of fellowships. This underlines the need to explore more fellowshipslplacements within the Region, wherever appropriate. At the samc time, efforts should be made lo develop more centres of excellence within the Region so that the need to place fcllows in institutions abroad is reduced to the minimum. Another constraint being faced includes the insistence on English language capability by thevarious institutionssince, of late, it has been found that the standard of language $oficiency of candidates from the Region is not up to the requirement. There is an increasing trend to go in for more short-term study tours than long-term fellowships. While there may be certain advantages in this, it is an instrument which has to be used judiciously. Short-tcrm study tours are best suited to professionals with mature experience who can benefit from short, unstructured visits to other institutions and countries. Even so, squeezing too many visits into too short a period is likely to be unrewarding. Such factors do not seem to have been considered in a fair number of instances. Host institutions in some countries are also experiencing much difficulty in accommodating the increasing number of such ad ltoc study tours. As part of the efforts to improve the submission of fellowship application forms, the existing WHO application form is being reviewed to include up-to-date and clear instructions so that candidates are able to complete them without difficulty. This should lead to the arranging of placements sooner than at present. The tmplementat~on of rhc ~cllou.shtp\ programme requirts considerdble impru\c- men1 tmthe part of allconcerncd. In spile ofthe best efforrs ofthe RegiunalOfficudnd the countries, the implementation his bcen far from satisfactory. Table 1. Disrribiilimt oJfillowslri/~r intdcrllte WHO%@Iarbtr&,by mgicit oJstlrdy (1 Ill& 1990- 30Jllll~ 1991) Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Mongolia Nepal Sri lanka Thailand Total Percentage Mom lhon onc rtgion 05 02 - 36 18 - IS - - 10 02 88 16.33 52 10 43 IS2 62 13 511 44 35 59 19 539 1W.W Wtpien olsludy Amerles 06 01 - 23 08 - I I - 02 07 07 65 12.06 Wlslern Paetlle 05 - 11 09 15 - 05 08 - M 05 62 11.50 E,,n,Iw 09 01 30 L'J N - 0') 30 05 11 05 ------ 139 25.79 South-bsl Asla 27 06 02 55 17 13 10 - 28 27 - 185 34.32 For the 1W0-91 biennium, a budget of US$ 14 226 660 has been approved, out of which only 68.27 per cent has been utilized for the fellowships component up to June 191. This highlights the need to overcome the various problems and constraints in order to further improvc the management of the fellowships programme in the Rcgion. During thc period under review, 539 fellowships were awarded (Table I) under the regular budget at an estimated cost of US$4970 997. In addition, 87 fellowships from other sources, at an estimated cost of US$ 628 440, were also awarded. The mechanism of contractual services agreement was utilized to cover 64 fellowships (US$174 421). Placements were arranged for 327 fellows from othcr regions in the countries of the South-East Asia Region. WHO continues to promote and support the strengthening of institutional capabilities within the countries for training programmes, the emphasis being on "in-country" training. WHO provided assistance to countries for upgrading and further strengthening resource personnel to carry uui not only in-country training of nationals, but also, simultaneously, the upgradation of regional institutions into centres of excellence. The response to efforts to encourage more women to seek fellowships so that greater responsibility for them in their national health services can become a reality has not been adequate. The countries will thcrcforc hi$\? !GI cxcrt grcater cffort 111 cnccrur:jgr. marc womcn to tskc ;iJ\antagc of thc WI10 fcll~~u~liip$ programme. Thc di<lrihuti~ln oi fcll\~w<hip< I)) ex. ;lgc and duration, is given in Table 2, Table 2. Disfribrlfior~ offellowsl~ips, by sex, age and d~rratiort (1 July 1990 - 30 Jlole 1991) Over 55 21 3.90 'Total 539 i0C.30 I I Sex Male Fc'emalc Total 401 138 539 Duration Up to 1 (months) 1-3 4-6 7-12 Over 12 Total 74.40 3.68 1W.W 186 213 69 46 2( 539 3.51 39.52 12.80 8.53 4.M 100.W 48 '1'111 WOKKOF WIIO INSEA The distribution of fellowships, by professional category, is given in Table 3. Table 3. Distribrrtion offellowships, bvprofessiorl, under the regrlur brrdger (I J~rly 1990 - 30Jrrrre 1991) Table 4 gives delails of fellowship\ awardcd under various subjccrs of study and the country of origin of fellows. Dwlors Engineers Nurses Others Table 4. Disrribrrtiorr oJJ(:ll~~wships rr~rder the regrrlur brrdget, by subject ofshrdy u~rd corrrrly of origin offcllow (I Jlrly 1989 - 30 Jrrly 1990) 314 52 30 143 58.?6 9.M 5.57 26.53 I)l:Vlil.Ol'MliNTOP IlUMAN RISOIJR(:F3 I'OR 11PAI:l'11 19 In line with the fellowships policy, the Regional Office is also promoting the establishment of an adequate information base to improve the monitoring and evaluation of fellowships, since this area is considered to be in need of attention. Oirectory of Training institations in SEAR Coilntries With a view to assisting Mcmber Countries, the Directory ofTraining Institutions was rcviscd in 1990, and copies have been forwarded to the counlries. Efforts are being made to update the information so that the Directory is more comprehensive and informative. For this purpose, a short-term consultant was recruited. The consultant has already visitcd two Member Countries of chc Region, namely, Indonesia and Thailand. 1ni1)rniation has also been collected from other Member Cotlntries so that further updating can bc made to the respective chapters. Thc new Directory is cxpcctcd to he widcly distributed to Mcmbcr Countries shortly. (;roep Educational Activities During the period under rcview, 40 meetingslgroup educational activities were held, of which 33 were regional. There were also 7 policy and advisory meetings. A review showed that justifications for the meetings were clearly spelt out, that the objectives in respect of most of the meetings were achieved, and that the mcthodt adopted appeared appropriate for achieving these ohjcctivcs. In most cascs, follow-up activities have bccn initiatcd. These group educational activities, excluding policy and advisory meetings, consisted mainly of regional meetings, workshops, consultative meetings and 5hort training courses covering different subjects, such as self-care, wastewater and nightsoil reuse, MCHIFP programmes, LBW and infant morbidity and morlality, solid waste management, AIDS, health economics, PHC, HFA, polio eradication, diarrhoea1 diseases, nutrition, acute re5piratory infections, lcprosy, Corcst-relatcd malaria, EDV, EPI, etc. Table 5 shows the distribution of participants in intercountry activities, by type of activity. Table 5. Di.sfribufior~ of panicipor~is bt irltrrcolrr~fry ocli~ifies, by r)jz ofactiviy (I J~rly 1990 - 30 Jtrrle 1991) h'anlbrr orl,nrliclpnn~r - 90 204 218 43 555 Ilegional meetings Workshops Consultative meetings 'Total h'anlhrr 7 9 14 3 33 50 I'IIR WOKKOF WIIO IN SEA The participation of countries and the numbcr of participants in thcsc group educational activities are given in Table 6. Table 6. Panicipafior~ ofconr~mnes orld rll~rilber ofporfic~par~fs 61 ir~/crcol~r~m~y ofid i~~/eneoria/o~p ed~lcafiorlal acrivifics (I Jlrly 1990 - -30 Jlrrle 1991) Country h'an~hrr ornclivilics 1 Numbcrorpo~p~ Bangladesh Bhutan DPR Korea India Indonesia Maldives Mongolia Myanmar Nepal Sri Lanka Thailand Total 17 17 Y 33 34 17 14 30 31 31 37 270

The Work of WHO in the South-East Asia Region 1 July 1990 to 30 June 1991 Forty-third A nnual Report of the Regional Director The Work of WHO in the South-East Asia Region 1990-91 ISRN 92 '1022 203 4 0 World Hcalth Organi~ation 1991 Publications of the World Hcalth Organization enjoy copyright protection in accordance with the provisions of Protocol2 of the UnivcrsalCopyright Convention. For rights of reproduction or translalion, in part or in lolo, of publications issued by the WHO Regional Oflicc for South-East Asia, application should be made to the Rcgional Officc for South-East Asia, World Hcalth Housc, lndrapraslha Esta~c, New Dclhi 110202, India. The designations employcd ;~nd the prcscntation of thc matcrial in this puhlicatir~n do not imply the cxprcssion of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Printed in India CONTENTS FOREWORD EXECUTIVE SUMMARY Section I DIRECTION, COORDINATIONAND MANAGEMENT Chapter 1: GOVERNING BODIES 1.1 World Hcalth A. , 1.2 Exccutivc Board 1.3 Regional Committee Chapter 2: WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT 2.1 Regional Director's Dcvelopmcnt Programm , 2.2 General Programme Ilcvclopment 2.3 Extcrnal Q)ordinalion cvc opmcn .... . 2.4 Health Emergcncy Prep 2.5 Health for All Strategy Coordination 2.6 Informatics Management Section I1 HEALTH SYSTEM INFRASTRUCTURE Chapter 3: HEALTH SYSTEM DEVELOPMENT 3.1 Hcalth Situation and Trend Assessment 3.2 Managerial Process for National Health Development 3.3 Health Systems Research and Development 1.4 Hcalth Legislation Chapter 4: ORGANIZATION OE' HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE.. ..... ... .... . . ........ .. .. ..... .. Chapter 5: DEVELOPMENT OF HIJMAN RESOIJRCES FOR HEALTH Managerial Process for thc Dcvelopment of Human Resources Chapter 6: PURLIC INFORMATION AND EDUCATION FOR HEALTH .. ............. , Seclion I11 HEALTH SCIENCE AND TECHNOLOGY Chapter 7: RESEARCH PROMOTION AND DEVELOPMENT INCLUDING RESEARCH ON HEALTH-PROMOTING BEHAVIOUR .......... ....... . . . . . . . . . . . . ., . . . . . . . . . . . .. . . . . . , . , . . . . . .. . . . . . . . . . Chapter 8: GENERAL HEALTH PROTECTION AND PROMOTION 8.2 Oral Health 8.3 Accident PC Chapter 9: PROTECTION AND PROMOTION OF HEALTH OF SPECIFIC POPULATION GROUPS 9.1 Maternal and Child Health, Including Family Planning ...................................... 9.2 Adolescent Healt 9.3 Human Repro 9.4 Workers' Healt 9.5 Health of the E SEAIRC44, The Work of WHO in the South-East Asia Region 1 July 1990 to 30 June 1991 Forty-third Annual Report ,f the Regional Director

V Page Chapter 10: PROTECTION AND PROMOTION OF MENTAL HEALTH 10.1 Psychosocial and Behavioural Factors in thc Promotion of Health and Human Development .... ............................. .......,.. ., .. . ............. . .... .... .. . . .. .. .. ... ... 10.2 Prevention and Control of Alcohol and Drug Abuse . . . ......... . ... . 10.3 Prevention and Control of Mental and Neurological Disorders ... .......... Chapter 11: PROMOTION OF ENVIRONMENTAL HEALTH 11.1 Community Waler Supply and Sanitatic . . . . . . . . . . . . . . . . . . . . .. . . . . . . . 11.4 Control of Environmental Health Hazards 11.5 Food Safety Chapter 12: DIAGNOSTIC, THERAPEUTIC AND REHAHILITATWE TECHNOLOGY 12.1 Clinical, Laboratory and Radiological Technology for 12.5 Rehabilitation Chapter 13: DISEASE PREVENTION AND CONTROL 13.1 lmmunizalion 13.2 Disease Vecto Page 13.15 Blindness and Deafnes Control Activities Section IV PROGRAMME SUPPORT Chapter 14: HEALTH INFORMATION SUPPORT 14.1 Hcalth Literature and Library Services (including HELLJS) ............. ... ~. 14.2 Publications and Documents .......... . . Chapter 15: SUPPORT SERVICES 15.2 Personne 15.4 Budget and Financc 15.5 Supplies and Equipm ANNEXES 1. Organizational Structure . . . . .................................................. ........ . . 149 2. Projects in Operation During 1m-91 ....................................................................................... 151 FORE WORD Another eventful year has gone by. This was a year which witnessed two major disasters, first a man-made one in the Middle-East, and another of unprecedented proportions in our Region, caused by nature. The regional conflict in the Middle-East was brought to a halt through the efforts of the intemationalcommunlty, thus kindlingonce again an etemalhope in the hearts of mankind for a better tomorrow. The severe repercussions of this conflict will be felt by the economies, particularly of the developing world, for a long time. It has also severely hampered the overall developmental efforts of the countries of the Region, including that of the health sector. A devastatingcyclone stnick Bangladesh inApril 1991, leaving in its trail rintold miseries of death, destruction and despair. WHO rose to the occasion and responded quickly by giving support in the form of drugs and emergency kits. WHO also coordinated relief efforts with UN agencies, such as UNDRO, and other donor countries in rushingaid to the country. The important lesson to be learnt from our experience in handling nat~iral disasters is that, even though resources rrre limited in our Region, comprised as it is of developing cormfries, a lot more could be achieved by adequnte preparation of the health sector, especially to meet such d~sasasters, ttrrorigh greatercoordina tion and cooper(rtion amongMember Countrit*~ in a spin't of "live and let live': WHO will, therefore, be emphasizing not only the promotion but also the enhancement of the capacity of Member Co~intries for health sectorpreparedness and response in meetingsuch natural disasters, in line with thisyear's World Health Day slogan "Should Dkasfer Strike - Be Prepared". It iv against this scenario that we must attempt to measure ourprogress in the achievement of thegoal of HFAl2000 through primary health care. Plimarily, progress and development depend on the inherent strength of a nation and its people, their ability, their resilience to absorb and adapt to new and appropriate patterns of behaviour, the amount of economic, social and other forms of freedom they enjoy, and the dent of happiness which they wish to pursue. No nation can be half unhealthy, half poor, half fettered and yet strive for rapid and meaningful development. Addressing the recent World Health Assembly, the Director-General of WHO warned the Member Countries of the likelihood of dwindling economic resources, political upheavals, war and civil strife, the threat ofAIDS, cholera epidemics and, last but not the least, natural disasters, all of which placed a heavy burden on Member Countries and the O'ganization, and threatened to dirncpt the march towards our goal. In order to meet this challenge, the Director-General advocated the concept of "a new paradigm for health" for realizing the social goal of HFA. The paradigm recognizes health as being central to development and to the quality of life. To translate this philosophy into action, it may be necessary for us to give a new orientation, a new dimension, and a new thrust to our strategies and approaches. We are just less than a decade away from our goal of HFA. The time is short and the task ahead is stupendous. It is not possible for an individual, an organization, 0r.a Member Country alone to accomplish this task in isolation. It calls for n cooperative effort, an unqualified commitment, involvement, and, above all, sustained and devoted action. lam optimistic that the "newparadigm for health" willclanfi many basic hues in the HFA movement, particular(yin operational matters, and will be instrumental in ushering in a new era of hope summoning us to move on towards sustainable development in the Region. Wdh these few thoughts, which I wish to share with you, I have great pleasure inpresentingthe Forty-third Annual Report on the Work of WHO in South-East Asia. Dr U KO KO Regional Director WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT The Regional Committce's decision to adopt a single biennial programmc budget document and annual dclailed plans of action closc to the actual implementation period has introduced additional flexibility and realistic programming of resources in WHO'S programme development. The Country Support Teams provided the needed support to the WHO representatives and national health administrations in this undertaking. The satisfactory result of the first round of joint government-WHO evaluation of priority national health programmes, carried out in 1984-1986, was noted by the Regional Committee, which recommended a second round of such joint evaluation to be completed during 1W1-1993. The Regional Office undertook a fresh initiative to strengthen the established joint government-WHO programme development mechanism and process, along with strengthening of the resources of the WHO representatives in this regard. It also contributed to the initial thoughts on the preparation of the WHO Ninth General Programme of Work for the period 1996-2001. The Consultative Committee on Programme Development and Management (CCPDM) deliberated upon several important issues, such as implications of the UN General Assembly resolution 441211, besides undertaking a biannual programme management review. There were several significant developments in external coordination for health development. The CCPDM and the Regional Committee examined in detail UN THE WORK OP WHO 1N SEA General Assembly resolution 441211 and welcomed it in principle. Whie recognizing the need for better coordiiation among UNagencies, it was felt that there were many operational constraints and inappropriateness. It was also strongly felt that the existing close working relationship between WHO and ministries of health, the technical advisory and leadership role of WHO in health, and the direct technical cooperation by WHO through its regular budget should be maintained and further strengthened. WHO remained committed to supporting ministries of health in securing a greater share of national as well as international resources for the health sector in the context of development. It also endeavoured to improve the quality of health sector reviews, programme identification and project formulation. The UNDP strategy and methodology for theSth cycle programmeshifted from the project to the programme approach under a few pre-determined priority themes, which posed new challenges to the dovetailing of health protective and promotive programmes into the execution of UNDP-funded projects which, in WHO'S perception, was best applied keeping national governments' capacities and interests in view. WHO consistently supported increased flow of international resources to health development, irrespective of WHO executingthe projects funded by other agencies. WHO provided technical cooperation to Member Countries in health sector reviews, health programme formulation and project execution during the year under review. As regards the common WHO-UNICEF goals in child survival and development, maternal health and control of deficiency disorders, close cooperation was sustained at all levels. The role of NGOs has been highlighted in all community-based health activities that are consistent and complementary to national health programme objectives. More recently, WHO has enhanced collaboration with NGOswith respect to the control of HIV infection, especially in Thailand and India. Similarly, there was collaboration with Rotary International in the control of poliomyelitis. In other areas, such as leprosy, prevention of blindness, drug deaddiction and mental rehabilitation, the working relationships were maintained. Consultationswith the World Bank and the Asian Development Bank were improved through technical collaboration in World Bank-supported population and health projects in Nepal, Bangladesh and Indonesia, and generally in other countries. Considering the frequency and severity of consequences of disasters with significant health effects, WHO was collaborating in the implementation of the International Decade for Natural Disaster Reduction in the 1990s. Asexpected, WHO'smainfocus was on improving the national capacities for preparedness through training, planning and integration of health components into the total national disaster preparedness and response plan. The 1990s is the International Decade for Natural Disaster Reduction (IDNDR). Bangladesh, India, Mongolia, Myanmar and Nepal have initiated steps for IDNDR. April 1991 witnessed the worst ever cyclone disaster in Bangladesh. While the people EXFXUTIVE SUMMARY d and the Government of Bangladesh bravely battled to provide succour and mitigate hardship, WHO on its own and in partnership with the UN Disaster Relief team, provided immediate relief to avert large-scale ill health, and, at the same time, vigorously pursued the disaster preparedness programme being formulated. A pragmatic approach to health development, taking into account not only the constraints of the health system but also its weaknesses, and utilizing opportunities and resources as and when they arise or become available, with due concern for human lie, is the hallmark of a coordinated and cogent effort in health development. This has become evident in most Member Countries of the Region who are now adoptingsagacious and health-oriented approaches for human development, keeping in mind the principles of equality and social justice. Attention is also being sought for those pockets of population whose health parameters are far below the national averages. Thus in line with the recommendations of the technical discussions held during the forty-third session of the Regional Committee in 1990, the focus of special attention in the last decade of the century should be on the health of the underprivileged. The second evaluation of the implementation of the Strategies for Health for All by the Year 2000 has been completed by all the Member Countries. The country reports were comprehensive and dwelt on developments of health systems, international cooperation, health and socioeconomic status, research, technology, monitoring and evaluation processes, and plans for future action. Efforts to develop a critical mass of people capable of assuming leadership in the HFN2000 movement have been pursued vigorously in almost all Member Countries. In order to have a strong political commitment in taking decisions to further the cause of HFN2000, attempts should be made to increase the awareness of the existing leaders rather than to create new or potential leaders. Intensified actions should be carried out to make use of, and involve, communication forums in the introduclion of HFA leadership philosophy and concepts at all levels. The fast changing information technology has to be harnessed fully and taken advantage of. The informatic management programme has supported programme development and management in this area. Most of the health programmes, both in WHO and the Member Countries, have introduced information technologies both for financial and technical management. HEALTH SYSTEM DEVELOPMENT WHO continued to collaborate with Member Countries in strengthening epidemiological surveillance. Notably, during the reporting period, two external evaluations of the Field Epidemiological Training Programme were undertaken, one xii THE WORK OP WHO IN SEA in Indonesia and the other inThailand. Both the countries conductedevaluations for the second time since the initiation of FETP. In Indonesia, the evaluation team recommended the improvement of administrative and financial problems to attain self-sustainability after external assistance is withdrawn. In Thailand, the evaluation team found evidence of substantial achievements of FETP since the previous evaluation. It was found that FETP has contributed considerably to the improvement of public health. Health information in manv countries is still maintained in a vertical and - compartmentalized manner. There is also not enough system review at different levels to identify the information required at those levels. Poor quality of data and the lack of disaggregated information continues to make it difficult for information to be used as a tool to identify priority managerial action. Thus, even though health information systems have been strengthened and decentralization introduced, more efforts are needed not only in thc collection of information but also in the generation and use of disaggregated information. WHO has supported the development of district-oriented health information systems. WHO supported Member Countries in the strengthening of management of national health development with emphasis upon health policy formulation and health care financing. WHO technical collaboration was provided for the formulation of medium-term health plans in Bhutan, Thailand, Indonesia, Bangladesh and Myanmar. Cognizant of the urgency and importance of health economics, WHO convened a regional expert consultation which produced a regional programme of action in support of countries to improve their capacities in health economics and health care financing. WHO launched yet another initiative lor intensified cooperation with countries and people in the greatest need, which included Nepal, Bhutan and Myanmar. This initiative was aimed at concerted and coordinated cooperation by WHO and other partners to support countries whose needs are the most and who have been adversely affected by economic difficulties. Intensified WHO cooperation was an umbrella for bringing about the coherence of programme activities to meet priority needs and achieve a greater impact on primary health care in a short time. In view of the impact of socioeconomic and environmental conditions, conventional mechanisms and methods of health plan formulation proved inadequate. Taking this into consideration, WHO, in cooperation with national health administrations, conducted a review of health planning mechanisms and methods and identified, within a programme of action, ways and means of improving health planningwith new skills in health policy analysis in the changing economic context, and with new approaches to resource mobilization and utilization. In accordance with the recommendations of several WHO regional bodies as well as World Health Assembly resolution WHA43.19, greater emphasis is now laid on the promotion and development of health systems research in the Region. The scheme of providing institutional strengthening grants has been implemented in four countries but progress is slower than anticipated due to delays in responses and insufficient interest in some Member Countries. In order to establish HSR within a more institutionalized framework, the Regional Office is promoting consultative meetings attended by senior administrators and scientists for the assessment of priority HSR needs and also to identify multi-disciplinary research teams which will include personnel from ministries of health. A consultative meeting to develop criteria for the appraisal of HSR project proposals was held from 2 to 4 April 1991. A conceptual framework for the appraisal of HSR (in contrast to biomedical and clinical research) was constructed, based on which criteria for the appraisal of HSR project proposals were developed. HSR projects supported from intercountry funds cover areas such as ageing, health manpower development, community participation, health care delivery and health economics. Three countries in the Region have made specific provision for health systems research in their country budgets. ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE All the Member Countries are committed to the attainment of the goal of HFN2000 with primary health care (PHC) as the key approach. Considerable resources have been allocated for increasing the coverage, reorienting the health system infrastructure and for providing efficient and universal PHC. An evaluation of the HFNPHC strategies in l(W0 providedfurther impetus to the attainment of the HFA goals. Many developmental activities have taken place, such as reorienting health policies, restructuring and reorganization of ministries of health and lower level structures, establishment or strengthening of mechanisms for coordination within the health sectors as well as among health-related sectors, and expansion and reorientation of the health system infrastructure. The organization and management of district health systems have been strengthened with appropriate technical support in all Member Countries. Overall, there has been perceptible progress in the implementation of primary health care as well as improvement in the performance ofthe health infrastructure. More than90 per cent of pregnant mothers are provided with appropriate care and the same per cent are attended to at the time of delivery by trained personnel. A little more than one-third of the families have access to basic sanitary facilities in their homes or immediate vicinity, compared to merely one-tenth of the families in 1985. At least one-half of the infants are now protected from immunizable diseases in most of the countries, whereas some countries have an even better coverage of more than 80 per cent. dv TIlE WORK OP WHO IN SEA The challenge to the health sector lies not only in meeting the increasing demands from rural areas in the spirit of equity, by providing better access to services, but also in catering to the increasing urban health loads that are being placed on it by the process of urbanization. To meet the needs of the growing urban population, a number of important programmes are being implemented in urban areas. These essentially consist of sample surveys, case studies, workshops and seminars to identify issues and implications of policies and strategies and areas in need of improvement in urban health care delivery systems. WHO has continued to support efforts to develop and apply innovative approaches to community involvement in primary health care, micro-planning, and self-managed health care programmes, to promote and support intersectoral actions for health and to strengthen the information system so that it can support decentralized planning and management. The main thrust of the health development programme relies upon the extent of community involvement. Many of the WHO collaborative programmes for PHC are geared towards community involvement and such an activity has been built into the implementation plan. Community participation in terms of volunteers for health activities is progressively expanding and, in some cases, the contribution of community resources has also been a welcome feature. DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH Support was provided for strengthening the planning of human resources for health in all countries of the Region. Following the meeting of the WHO Study Group on the Role of Research and information Systems in Decision-Making for the Development of Human Resources for Health, held in Geneva in November 1989, a Consultative Meeting on a Minimum Set of InformationinSupport ofPolicy, Planning and Management of Human Resources for Health was convened in Bangkok in October 1990. Efforts will now bc made to support the development of information systems on human resources for health in a number of countries by the application of the concept of the minimum set. Efforts have also been made to strengthen nursing and midwifery human resource planning and management. Assistance in the upgradingof nurse-managers and other nursing and midwifery personnel continued through fellowships for advanced study, training and study visits in nursing management and clinical nursing. WHO hascontinued its efforts to increase the capabilities ofthe countries for carrying out research into the development of human resources for health. Towards this end, the Consultative Meeting on Management Research for Development of Human Resources for Health was held in Bangkok in September 1990. National workshops on research into thedevelopment of human resources for health were held in Yangon, EXECUTIVE SUMMARY xv Myanmar, in July 1990, in Chiangmai, Thailand, in August 1990, and in Jakarta, Indonesia, in October 1990. The promotion of research in nursing was further strengthened. An intercountry Consultation on Research in Nursing was held in Thailand from 24 to28 June 1991 to follow up on the recommendationsofthe fifteenth session of the South-East Asia Advisory Committee on Health Research regarding the development of research in nursing. Further progress was observed in the efforts of the Member Countries in strengthening and reorienting the medical education systems to achieve a closer quantitative balance and systemic relevance to their medical manpower development programmes. At the level of undergraduate education, the trends that were initiated in the past decade were further reinforced with greater community orientation of curricula, introduction of innovative education strategy such as problem-based learning, strengthening of educational management processes, experimenting with objectively structured clinical and practical examinations and the introduction of enquiry-driven strategy for accelerating changes in medical education. With WHO'S collaboration the Network of Community-oriented Educational Institutions organized the Second International Conference at Yogjakarta, Indonesia, under the theme of problem-based learning. Problem-based learning programmes have already been introduced on an experimental scale in a few schools in India, Indonesia, Myanmar, Nepal and Thailand. An intercountry workshop was organized to develop a nucleus of medical educational leadersin the Member Countries who will be able to prepare medical undergraduates for meeting the challenges posed by the emerging problem of AIDS in the Region. Specific curricular reforms on the lines recommended in the technical documents on the reorientation of medical education, published by the WHO Regional Office, arc also being undertaken. The momentum of change generated in the last decade in reorienting medical educalion systcms to produce physicians with competence and compassion, who can serve the needs of whole populations, continues to be maintained in the Member Countries. WHO continued to provide technical support to strengthen basic nursing education. Efforts have been made to strengthen institutional frameworks and educational policies as well as teaching-learning resources for the implementation of community-orientcd nursing curricula. Assistance in the upgradingof nursc-teachers was continued through fellowships for advanced studies or speciality training in educational methodology or clinical nursing speciality. Concern for ensuring the quality of nursing education in preparing nurses for national needs was further promoted in the Region. A critical appraisal of the use of distance education to meet such challenges was carried through an Intercountry Workshop on Distance Education for Nursing Personnel and other Health Workers, held in Thailand in October 1990. Particular attcntion was being devoted to the improvement of thc nursing and midwifery curriculum to better prepare graduates to comprehend the seriousness of AIDS/HIV infection. WHO continued its collaboration with Member Countries in consolidating the programme for the development of expertise of teachers of health professionals in their subject matter as well as in the basics of educational science and technology. The UNDP-funded, WHO-executed regional project to establish an intercountry network of institutions for the development of health learning materials started in January 1990. Since then, four more countries participating in the project have formulated national work plans and conducted a 'needs and resources' survey. An intercountry Workshop on Health Learning Materials Development was organized in Jakarta in February IWl. At thc eighty-seventh session of the Executive Board, held in January 1991, the Director-General presented a report on the implementation of WHO'S policy on fellowships. The report contained inputs from the South-East Asia Region. Thesc were based on the reports, using indicators and guidelines developed at the Third South-East Asia Regional Conference on WHO Fellowships, held in 1988, of eight countries that had submitted their self-evaluations. The Executive Board, in wcla,rningthc rcport, urgcd Mcrnhcr Countries to take demonstrable steps 111 cnsurc thc rclcvancc of WHO fellowships to thcir hcalth rcsourcc nccds and national health development, to introduce or strengthen mechanisms to establish policies for thc planning, production and management of their human resources for health and to evaluate their use of fellowships resources in order to ensure that their selection mechanisms are effective and that returning fellows are utilized in the best interests of the national health systems (EB87.RZ3). In order to assist the Member Countries, a revised Directory of Training Institutions was completed in 1W0 and copies sent to countries. Efforts arc being made ro updarc the information so that the Directory is more comprehensive and informative. PUBLIC INFORMATION AND EDUCATION FOR HEALTH Strategies to make health education more effective in addressing existing and emerging needs in Member Countries were the focus of information and education for health activities during the period under review. Emphasis was laid on advocacy efforts to lead to social mobilization for health and school health education. The development and dissemination of IEH materials on "World Days" continued both in the Regional Office and in Member Countries in collaboration with other technical units, media and headquarters. More can be achieved with necessary attention being paid to increasing training of human resources, including in the media, for more appropriate health education approaches at decentralized levels. RESEARCH PROMOTION AND DEVELOPMENT The programme of Research Promotion and Development encompasses several activities. These range from the promotion of research through scientific meetings to research capability strengthening by awarding visitingscientist grants and research training grants, and include the establishment of WHO collaborating centres, promotion of mechanisms for research promotion and development at the national level and provision of direct support to research projects. These activities should be considered together with the research programmes initiated and monitored by the various technical units of the Regional Office. In this endeavour, the WHO South-East Asia Advisory Committee on Health Research (SEAIACHR) serves as the main advisory body to the Regional Director on mattcrs of policy. At the seventeenth session of SENACHR, held in Yangon, Myanmar, from 21 to 27 April 1W1, apart from reviewing the regional research programme, the Committee discussed and made recommendations on research issucs pertaining to health care delivery in villages and slums, control of cancer in developing countries and youth (and adolescent) behaviour as related to health. The ACHR drew up a strategic plan for its own activities for the next five years. The seventh meeting of Directors ofMedical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries (MRCs) was held in Kathmandu, Nepal, from 4 to 9 November 1990. The need to generate a climate conducive to the development of a research culture at the national level was stressed. The importance of establishing both an infrastructure for implementation of the recommendations of the n~eetings of MRCs and also a national mechanism for the coordination of research activities was pointed out. Regular joint meetings of the research community and health care managers would subserve the achievement of these objectives. A South-East Asia Nutrition Research-cum-Action Network was established with thc main objectives of identifying major nutritional problems in the South-East Asia Region, strengthening nutrition research-cum-action capabilities, and promoting selected priority research-cum-action nutrition projects and training schemes. Among the several priority operational issues identified as being amenable to research-cum-action projects are weaning foods, to overcome protein-energy malnutrition in young children, and anaemia in pregnant women. The Regional Office will support some of the network activities. ~(VIII 'SIIE WORK OF WHO IN SEA The Eighth WHO Peer Review Meeting on Dengue Vaccine Development was held in September 1990. It was reported that 90 per cent of the human subjects who received one or more of the candidate attenuated vaccines showed seroconversion without any disabling untoward effects and maintained neutralizing antibodies for a period of years. Anolher trial of trivalenl vaccine (dengue 1, 2 and 4) in different dilutions was recommended, and as soon as an acceptable combination is found for adults, a study in children may be initiated. The vaccine programme is gaining international recognition. Further collaboration is under discussion. At a meeting of the Task Force on Research in Tuberculosis in December 1'240, lacunae in the research programme in relation to the problem of tuberculosis in the Region were analysed and research protocols were developed on: the identification of risk factors for disease; risk factors for infection; operational research for improving cure rate; programme monitoring and disease surveillance; assessmenl of the protective effect of BCG revaccination; the role of X-ray examination of the chest; centralizedsputum examination toimprove the quality of coverage; use of a combined tablet for the treatment of tuberculosis; and operations research for the attainment of a high cure rate in district TB control programmes. The protocols will be used for promoting research on tuberculosis in Member Countries. The Regional Office continues lo support investigator-originated as well as collaborative research projects. Of the 67 projects currently being supported, 38 are concerned with communicable diseases. As part of the research capability strengtheningefforts, 14 VisitingScientist Grants and ResearchTraining Grants werc awarded during 1990-91. GENERAL HEALTH PROTECTION AND PROMOTION Nutrition in the Region is in transition in response to demographic, environmental and socioeconomic changes. In an effort to prepare for the next century an in-depth assessment of priority nutrition issues in regional countries over the next few years is being carried out. National programmes for the control of IDD are developing rapidly; a regional meeting was held, concentrating on the managerial aspects. There was a useful sharing of experiences. A Regional Nutrition Research-cum-Action Network has been set up. Priority projects are starting and a Newsletter has been published. The Network brings together centres of excellence in nutrition research and training in the Region with national focal points in nutrition. The aim is to bring operational research to bear on priority problems in nutrition programming. Accidents and injuries, issues related to safety and healthy working environments, emerging socioeconomic and health problems of ageing, and diseases and conditions causing disabilities and handicaps, including blindness and deafness, continue to receive inadequate attention as compared to their effects on the social, economic and health statuses of the people. Fragmented, conventional type approaches to these problems have not yielded the results that could be expected from jointly planned and eflcctivcly coordinated efforts, using thc same financial, human and material rcsourccs available in the Member Countries. Much greater efforts are, thercfore, needed in this regard as well as towards cducation and creation of awarencss among populations and decision makers. Tobacco or Health has bcen introduced as a sub-programme area into the WHO programme classification only in the Eighth General Programme of Work, beginning in 1990. Already two countrics of the Region, viz., Indonesia and Thailand, have responded by making spccific budgetary provisions for Tobacco or Health (TOH) country programmes. In other countries, activities related to TOH arc fundcd from other country programmes, mainly related to cancer control, to noncommunicable diseases, or to research. As far as legislative and administrativc measures for the control of tobacco use are concerned, some of these have been implemcnted with surprising speed in several countrics of the Region, and full-fledged national tobacco control programmes are under preparation in some. These control measures focus on tobacco smoking since campaigns against this are facilitated by the knowledge about thc ill-effects of passive smoking. In addition to legislation and administrativc interventions, several districts in Bhutan have declared themselves tobacco-frcc in a spirit of community involvement. PROTECTION AND PROMOTION OF THE HEALTH OF SPECIFIC POPULATION GROUPS WHO collaborated with Member Countrics, together with UNFPA and UNICEF, in the dclivery of integrated MCH/FP programmes, including adolescent health. All the countries laid emphasis on maternal health by promoting safe mothcrhood programmes, by intensifying training of human resources in safe delivery, by making services available at the grassroots and by improving the quality of services. Dissemination of information on safe motherhood, family planning and child survival and dcvelopmcnt was done by holding national seminars and formulating national strategies for the attainment of national goals on maternal and child health. Support was provided for the conduct of various research projects and operational rcscarch in safe motherhood as well as on low birth-weight. Technical support was provided for the development of the MCH/FP manual in Bhutan. Human Reproduction Research (HRP) has concentrated on long-term institutional development (LID) grants for research. In regard to countries where research facilities are limited, a new approach of strengthening research capabilities at the ia ?HE WORK OF WHO IN SEA country rather than at the individual institution level has been adopted. This implies close collaboration with national policy-makers. In line with these needs, two workshops have been held, in Sri Lanka and Myanmar. The programme also concentrates on support for research finding and developing new, safe, and effective methods of fertility regulation as also for improving the performance of the existing methods. The South-East Asia Region has received a number of rcsearch grants for the abovc. The issues of 'Women, Health and Development' were discussed in September 1990 at the forty-third session of the Regional Committee, which urged Member Countries to further pursue policies for increased participation of women in health decision-making, to allocate adequate resources for relevant activities and to further involve nongovernmental and private organizations. In collaboration with HQ, 'Leadership and Participation of Women in MCHFP Programme'has been initiated in India, Indonesia and Nepal. These countries have developed programmes as a follow-up of the interregional meeting held in Mauritius and Brazzaville. Self-care activities in homesetting are also being promoted as the mother is the key person in self-care. The document on 'Women, Health and Development' in South-East Asia has heen updated. Unregulated work, lack of education among workers and absence of facilitics arc thc major issues of workers' health in the countries of the Region, with low priority being given to health of the working people, particularly those employed in small-scalc industries and the agricultural sector. Consequently, there has not been enough or adequate development of occupational health policies. The rapid pace of increasc in the number of ageing people in populations in somc countries is affecting social and health care services. Apart from the need to furthcr study biomedical and psychosocial factors of health and of ageing, it is necessary to havc a better understanding of, and, if possible, a family and community apprcsach to, the solution of this problem. WHO has collaborated in the training of pcrsonnel through fellowships and group educational activities PROMOTION AND PROTECTION OF MENTAL HEALTH The special focus of WHO collaboration in this sub-programme area continued to be on the identification of families most in need of assistance for health protection and promotion, and on the development of interventions within the PHC infrastructure to reduce the impact of these risk factors on the well-being of mothers and on the healthy development of children. A manual on special psychosocial skills which may help to achieve an improvement in coping capabilities and well-being of mothers has been prepared. The impact of such counselling support on cognitive development and nutritional status of children in risk families is being evaluated in a multicentric study. In related work, the same psychosocial skills are being evaluated in families where childhood malnutrition has occurred and in families where, according to the results of a previous multiccnlric study coordinated by the Regional Office, undernourishment in children is likely to occur. It is hoped that, through these intervention trials effective psychosocial interventions to reduce childhood malnutrition will be developed, in addition to gaining more insights into the behavioural causation of childhood undernourishment. In a further study, the impact of similar psychosocial interventions is being evaluated in risk families where one of the home risks is alcohoVdrug abuse in the father. In this set of multicentric studies, previous Regional Office-coordinated work on subjective well-being, on home risk for healthy child development, and on psychosocial factors in childhood malnutrition, have now converged to the development of interventions which hold promise of effectively reaching the hith~rto unreached or unreachable. The UNFDAC-supported and WHO-executed drug abuse control programmes in Myanmar and Sri Lanka have continued with satisfactory rates of implementation. A second phase of the Sri Lankan project has been initiated, and the UNDP-funded project to establish a monitoring system of drug use in Sri Lanka has been caendcd for one more year. With the signing of an agreemcnt between WHO and UNFDAC regarding WHO'S role in thc execution of demand reduction programmes, supported by UNFDAC - recently merged into the new United Nations International Drug Control Programme (UNIDCP) - more WHO-executed country activities can be expected. Thc high risk of HIV infection through the sharingof injection cquipmcnt in injecting druguscrs, in addition to the incrcasedrisk through drugusingsex workers, has addcd a new dimension to the is.cuc of drug abuse. A vdricty of special behavioural interventions for risk minimization have been developed and are being promoted. Countries have reacted dil'fercntly to this new concern, and, in several public health concerns in relation to the AIDS epidemic, have begun to successfully compete with political and moral concerns related to drug use and other high-risk behaviours. Several countries uf the Region have established formal national mental health programmes. In these countries, WHO activities are geared towards facilitating the implementation of these programmes. They all contain the important component of training of non-specialist staff in basic mental health skills, thereby fostering integration. WHO support has also aimed at the promotion of health systemsresearch into the integrated delivery of basic mental health care. Variables studied and monitored in some countries or districts include not only coverage but also outcome measures and process indicators such as an appropriate flow of information. ~753 THE WORKOF WHO IN SEA PROMOTION OF ENVIRONMENTAL HEALTH While most countries continue to accord high priority to community water supply and sanitation, there is in the Region agrowing awareness of environmental problems and their close links to health and sustainable development. In countries experiencing rapid urbanization there is concern for: pollution of drinking water resources from toxic chemicals; prevention and control of health hazards stemming from air, land and water pollution; chemical safety and control of poisons; health risk assessment and risk management; and environmental epidemiology and food safety issues, particularly related to adulteration and contamination by chemicals. Notwithstanding the end of the International Drinking Water Supply and Sanitation Decade (1981-19!W), which was marked by the Safe Water 2000 UNDP Global Consultation in New Dclhi in lYM, countries are vigorously pursuing the Dccadt: goals of safe water supply and adequate sanitation, and are currently engaged, with WHO support, in a comprehensive review and evaluation of their Decadc achievements and shortfalls. In thc light of lessons learnt from Decade experiences, national agencies are formulating strategies for renewed efforts to enable people to attain safe water and sanitation in the 1990s and beyond taking - into consideration the principles of environmental protection, strengthening institutions for sustainable development, community management and sound financial management. In addition to fellowships and observation tours, WHO assisted manpower development for in-country training activities for professional as well as subprofessional staff in Bangladesh, India, Indonesia, Myanmar and Nepal on such aspects as design of facilities using microcomputer techniques, environmental health education for community water uses, rehabilitation as well as operation and maintenance of watcr systems, latrine programme development processes, etc. Strengthening of water supply and sanitation sector agencies' institutional capability was provided for by technical assistance in the areas of organizational development, managcment information systems for monitoring and planning, improved operation and maintenance approaches as well as the planning and development of national watcr quality surveillance infrastructure. Most SEAR countries are faced with environmental health problems associated with rapid urbanization that have resulted in mushrooming squatter settlements and unplanned population growth, creating enormous demands on such basic services as water supply, sanitation, waste and storm water drainage and solid wastc management. The increasing deterioration of environmental conditions in urban and peri-urban areas poses a major challenge to countries. WHO has continued to support, among others, institutional development, promotion of intersectoral cooperation with community involvement and the application of appropriate technology to address solid waste management and drainage problems and issues identified by the countries. Low-cost sanitation programmes were launched in a number of countries and a Healthy Cities project proposal for five major urban EXECUTIVESUMMARY dii centres of the Region was prepared jointly with ESCAP in an effort to improve the cities' environmental services, especially in slum areas. WHO'sefforts in the newsub-programme area of health riskassessment of potentially toxic chemicals focused on intersectoral manpower training on risk assessment, emergency preparedness and response, health monitoring and environmental epidemiology. Assistance was provided for establishing national poison control centres in India, Indonesia and Thailand as well as for the preparation of projects for UNDP assistance in the areas of chemical safety and poison control. WHO supported institutional development for the effective management of chemical safety programmes and chemical emergencies in countries experiencing rapid industrialization. WHO collaborative efforts in respect of control of environmental health hazards have been directed at strengthening national institutional and manpower capabilities. The UNDP-assisted intercountry project on Safety and Control of Pollutants and Chemicals continued to address priority problems of chemical safety and industrial pollution in five countries with training in managerial approaches to reduce health risks from hazardous wastes and chemicals and in developing environmental control programmes for indoor air pollution from toxic chemicals. WHO has supported institutional development for national agencies involved in the monitoringand control of environmental health ha7.ards in DPR Korea, India, Indonesia and Thailand. Information management related to chemicals was supported through technical assistance in setting up programmes and providing computer hardware and software in India, Indonesia and Thailand. Activities of the Global Environmental Monitoring System (GEMS) involved water quality monitoring in Bangladesh, India, Indonesia and Thailandwhile air quality monitoring continued in India, IndonesiaandThailand. WHO' s support to national food safety programmes covered such aspects as food legislation for monitoringand inspection of food contamination, development oflabo- ratory capabilities for microbiological and chemical examination, and food standards control measures. Training courses for food safety administrators and public health inspectors were held in India, Indonesia and Sri Lanka. A review of state food safety laboratories was made and a manual and a training course on good manufacturing practices were developed in India. An assessment of national food safety programmes is under way to identify further areas of WHO assistance to countries. DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY Strengthening of health laboratories is essential in health care delivery, particularly at the peripheral level. WHO has continued to support Member Countries in the mv 'ME WORKOF WHO IN SEA strengthening of health laboratory services through continuing training programmes, supplies and equipment and sustenance of qualiwassurance programmes. Re~ional . . . - - self-reliance iimbdern immunological and biological reagents, particularly for the development of rapid diagnostic tests for priority communicable diseases, has been supported through UNDP-funded projects. Under intercountry technical cooperation, the National Institute of Health, Thailand, provided diagnostic antisera; the WHO Collaborating Centre for Reference and Training in Streptococcal Diseases at the Lady Hardinge Medical College, New Delhi, supplied diagnostic reagents for streptococcal infections; and the WHO Collaborating Centre for Rapid Viral Diagnostics at the National Institute of Virology, Pune, India, distributed kits for the diagnosis of Japanese encephalitis to other countries of the Region. WHO continued to support proficiency testing and development of national capabilities in the sero-surveillance of AIDS. A workshop held in December 1W trained nationals for improving the safety of blood and blood products utilizing modern technology. Under the UNDP project for strengthening health laboratories in primary health care, covering six countries of the Region, national workshops were held for drawing up national policies for networking of health laboratory services. Under the same programme, national workshops for the introduction of appropriate technology at the peripheral level are in progress. WHO has initiated a programme for the promotion of novel techniques in the diagnosis of diseases. WHO has strengthened the essential drugs programme to improve drug availability at the primary health care level, quality assurance, rational use of drugs and manpower development. Capabilities in drug procurement, storage and distribution were further promoted. Essential drugs programmes, supported by voluntary funds, continued in Bhutan, Myanmar and Thailand. The ASEAN pharmaceutical project is progressing satisfactorily and plans are under way to continue the project up to 1996. Proper utilization of essential drugs has been promoted through the establishment of the standard treatment regimens in several countries of the Region. Additionally, rational use of drugs has been further promoted through national and intercounlry training programmes. Several essential drug programmes have adopted computer technologyfor drug management, drug information and adverse drug reactions. With the introduction of newer technologies the production of EPI vaccines has been promoted. Quality control, proper storage and distribution of vaccines have been supported. The WHO Certification Scheme on the quality of pharmaceutical products moving in international commerce has been promoted. The scheme helps to ensure the quality of pharmaceutical products for the importing country. Drug registration and regulatory control were strengthened to ensure drug quality, efficacy and safety. Training workshops were held to improve drug evaluation. Good manufacturing practice was promoted in the production of pharmaceuticals, particularly in regard to the improvement of manufacturing equipment, quality control and training of human resources. Traditional medicine was supported in several aspects. Institutional strengthcniny and human resources development continued with funding from UNDP. Standardization, quality control and utilization of herbal medicines are being promoted as a component of the ASEAN technical cooperation in pharmaceuticals. Standards and quality control procedures for selected medicinal plants were established. The manufacturing of traditional medicines is improved through the introduction of modern manufacturing equipment and technology. Research activities wcre supported for the integration and utilization of traditional medicines in primary health care. DISEASE PREVENTION AND CONTROL Remarkable progress in improving immunization coverage has been obscrvcd in Member Countries. By February 191, seven out of the eleven countries (Bhutan, DPR Korea, India, Indonesia, Maldives, Mongolia, Sri Lanka) declared the percentage of fully immunized children under one year of age as 80 per cent or more. EPI reviews conducted in Nepal, Mongolia, Thailand, Bhutan and Bangladesh confirmed impressive progress in the programme. The impact of immuni~ation coverage on the reduction ofpolio and neonatal tetanus is being witnessed. However, disease surveillance, epidemiological measures/disease control, supervision and monitoring of the cold chain, training of manpower, integration with MCHIPHC, quality assurance of vaccines, as well as immunization coverage, etc., require further improvements. Sustainability of EPI has become essential for continuingEP1 during the last decade of the century. An integrated approach and long-term plans for the development of HSI and mobilization of national resources as well as strengthening of national capabilities for self-reliance in vaccine production are necessary to assure the sustainability of the programme. Some progress has been madcin the control ofvector-bornediseases in the countries of the Region, but infections such as malaria, dengueldengue haemorrhagic fever, filariasis, Japanese encephalitis and leishmaniasis still continue to be leading public health problems. As of today, vector control remains the major operation to control these diseases. Although chemical pesticides continue to be used for disease vector control, it is recognked that there is great scope for the development of comprehensive strategies with a view to judiciously using alternative methods, mi THE WORKOF WHO INSEA including pragmatic bioenvironmental measures, in a cost-effective manner at community and national levels. The overall malaria situation in the countries of the Region has remained unchanged for the past few years thoughsome improvement has been observed in afew countries. However, the malariogenic potential has remained high in practically all endemic countries. The high incidence of falciparum malaria, including its resistant strains, continued to pose a major problem, compounded by widespread vector resistance to different insecticides and development of exophilic and exophagic behaviour by the principal malaria vectors. Epidemiological approaches through the primary health care system continued to be employed by all malaria control programmes of the Region in order to tackle the problems. To facilitate cost-effective implementation of malaria control programmes in the Region and strengthen the health infrastructures, WHO has been collaborating with the countries in conducting training and planning, implementation, monitoring and evaluation of malaria control activities, particularly in the studies on drug resistance, insecticide resistance. bioenvironmental methods, personal protection methods and the like. Special attention was paid to the development of methods of malaria stratification, mechanisms of monitoring large-scale population movements and establishment of epidemiological early warning systems to predict malaria outbreaksiepidemics. Support was provided to malaria control programmes in staff collaboration, development of manpower through fellowships, study tours, workshops and seminars and in the procurement of essential supplies and equipment. Visceral Leishmaniasis still continues to be a health problem in India, Bangladesh and Nepal, particularly in India where 56 971 cases and 607 deaths were reported in 1990. Chemotherapy trials with different doses of ivermectin in microfilaria carriers and patients were continued. Research studies in schistosomiasis under TDR were carried out in the Region. India, the only country infested with guineaworm disease in this region, continued to strive towards achieving the goal of zero incidence. To supplement their efforts, two more surveillance teams were deployed in the state of Rajasthan. The UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) has supported the Region in the achievement of good progress in the ongoing field trials of new drugs against malaria, filariasis and leprosy. As several countries in the Region have been identified as least developed (in tropical diseases research), research capability strengthening activities are being initialed in some of them, including the FIELDLINCS programme. Progress has also been achieved in the development of newer immunological test kits and DNA probes for the diagnosis and field trials of biological control agents in malaria. A constant follow-upon studies of transmission-blocking antigens ofP.vivar has been continuing in the field trials of the armadillo-derived WHO vaccine. The development of these products is being emphasized in the developing countries. Diarrhoea1 diseases continue to be a major health problem in the Region. National CDD programmes have been implemented in all Member Countries as part of the primary health care services. In addition to case management strategy to reduce mortality, the CDD programme is now also layingemphasis on selected interventions to reduce diarrhoea morbidity. Plans of operation are periodically heing revised in almost all SEAR countries, mostly in formal planning exercises or following comprehensive programme reviews, always in keepingwithprogramme achievements and progress. Training activities in programme management, supervisory skills and clinical management continue to receive high priority. Acute respiratory infections (ARI), especially pneumonia, together with diarrhoeal diseases and malnutrition, are still the leading causes of death among children, and result in the largest number of attendances at out-patients departments of all the health services. Since tl~c beginning of thc programme, various types of national committees or advisory groups on ARI havc been constituted in almost all the countries, for promoting prevention and control activities. The increased awareness ofthe problem has stimulated the countries to include in their health plansthe control of ARI in children as one of the most important components. Long-term plans of action have been prepared or revised for nine out of the eleven countries of the Region. The ncw suyervisory skills module "Management of a Child with ARI" and the training video, and thc new programme managers' course have given a ncw input and created interest in the programme. The manual on ARI for doctors is considcrcd to be technically very good and ausefulreferenccdocument for all thedoctors dealing with children. In all Member Countries, the reduction of mortality from pneumonia has bcen considered the main objective and the most important priority of their national programmes. For this reason some countries, such as India, Indonesia, Myanmar, Nepal and Sri Lanka, have decided to have a new policy which will focus on thc training of pneumonia only. Accordingly, the WHO modules have also been modified. In all countries, the ncw classification of ARI has been well accepted. Tuberculosis continues to be a major public health problem in the countries of the Region. The spread of HIV infection in countries like India, Myanmar and Thailand is likely to cause a resurgence in infection with tuberculosis bacilli. WHO has formulated a draft medium-term plan for implementing new strategies for thc control of tuberculosis. A mccting of the task force, formed at the Regional Office, was hcld in Deccmbcr 1994 to ident~fy areas of research on tuberculosis. In the South-East Asia Region, a major revolution is taking place in the attitude towards, and perception of, leprosy by communities on the whole and patients individually. The increase in awareness about leprosy and confidence in MDT is gaining momentum. Governments no longer see leprosy as an insurmountable problem likely to take up a large proportion of the meagre available resources while miii THE WORK OF WHO IN SFA not being able to produce any tangible results. As a result of these factors, most leprosy endemic countries of the Region have witnessed rapid expansion of MDT coverage. The WHO-recommended multidrug regimen has been firmly accepted as the drug regimen of choice, both by national programmesas well asmost programmes run by NGOs. As rapid decline in the case-load continues, individual programmes that were formerly hesitant to accept the integrated approach have now started to adopt the approach, fully realizing its cost-effectiveness. Early detection of cases through active and passive means and treatment with MDT are being seen as the most effective way of preventing disabilities. This is being achieved through the intensification of programme activities, including social mobilization and health education campaigns. At a recent intercountry Consultative Meeting of Leprosy Programme Managers from Member Countries, the participants expressed their confidence that the elimination of leprosy as a public health problem by the year 2000 is a feasible goal in this region. Zoonotic and food-borne diseases pose serious risks both to human and animal health. They affect national economies, especially in the countries of the South-East Asia Region where agriculture and animal products form the basic and primary means of economic development. The major zoonotic diseases occurring in the countries are rabies and brucellosis. Nepal received assistance from a nongovernmental organization of Francc, Veterinarians Sans Frontiers (VSF), in implementing a WHO-assisted project for thc control and elimination of rabies in thc country. Similarly, Sri Lanka received extrabudgetary assistance from AGFUND for the control of rabies in the country. Sexually-transmitted diseases continue to persist in several countries of the Region, with serious sequelae to individuals and the community as a whole. All countries of the Region have clinical and laboratory facilities to treat persons affected by thcsc diseases, and preventive steps, such as promotion of sex education, have been taken by them. However, inadequate reporting and recording systems are an obstacle in estimating the exact magnitude and dimensions of the problem. Thc major emphasis in vaccinology is on the attainment of self-sufficiency in EPI vaccines. WHO supported the production, quality control, and storage of EPI vaccines. Technologies in the production of viral and bacterial vaccines are being introduced where necessary. Transfer of technology for the production of hepatitis B vaccine is under way in Mongolia and Myanmar. Plans for clinical trials of denguc vaccine in Thailand and snake venom vaccine in Myanmar are now at various stages of implementation. The present dimension of AIDS, if not contained with appropriate measures, poses a threat to the achievement of Health for All by the Year 2000. It has assumed the status of a serious public health problem in Thailand, India and Myanmar. In India, where hitherto HIV infection was prevalent only amongst female prostitutes, the trend has changed to that where heterosexual transmission of HIV is prevalent. The number of injecting drug users (IDUs) positive for HIV infection has also increased, particularly in Manipur. Recent serological studies on riskwise and sexwise distribution of HIV-positive percentages for two different periods in respect of Myanmar indicate a sequential infection starting with lDUs and then spreading to other groups with high-risk hehaviour. In Thailand, the magnitude of the epidemic has changed over the past few years. Whereas the problem during 1984-1986 was mainly related to homosexual men, in 1987 the epidemic among IDUs rose sharply to 89 per cent in 1988. It has reached a plateau. Although the present group of IDUs continues to make up the vast majority of reported HIV infection, the trend in transmission related to sexual practices is increasing at an alarming rate amongst female sex workers. There is evidence of a sharp increase in the transmission related to heterosexual behaviour, both male and female. The experience so far in other parts of the world indicate that SEAR countries, where HIV infection is in a stage of low prevalence, should not be complacent in taking appropriate steps for the prevention and control ofAIDS, as otherwise they will miss the advantages now available for containing the disease. Most of the countries have completed short-term pl:~ns of action and have undertaken the implementation of mcdium-term plans of :~ction for the control of HIVIAIDS with emphasis on education, information and communication, and provision of safe blood and blood products. Viral hepatitis continues to he a public health problem inSEAR countries. Hepatitis A virus (HAV) infection amongst adults has increased in Indonesia and Thailand in recent years. The prevalence of Hepatitis B virus (HBV) continues to be a major public health problem in the Region. Hepatitis E virus (HEV) infection is an emerging problem in the Region. WHO continues its support for training, research and attainment of self-sufficiency in the production of reagents. Immunization against HBV is receiving greater attention by Member Countries. The training of health personnel in various aspects of eye care has been a major activity in the area of blindness. In most countries, though the reported break-up of prevalance of blindness varies from 0.5 to 2 per cent, with cataract accounting for more than 50 pcr cent, the underserved areas fare worse. Studies on the feasibility of setting up low-cost spectacle manufacturing units, setting up mobile units, and training personnel in public health ophthalmology have been carried out in different countries. As regards deafness, no reliable statistical data are available. An effort has been made to make a general overview of the national deafness programme by fielding a consultant in Indonesia, Myanmar, Nepal and Thailand. XU I HL WOKK 01' WllO IN SFA The increase in the recognition of cancer as one of the major causes of morbidity, particularly mortality, has led to the establishment of specific national cancer control programmes in more countries of the Region besides India, Indonesia, Sri Lanka, and Thailand. Unlike the more industrialized countries, in this region about 33 per cent of patients suffering from cancer come to the attention of health services in the late and incurable stages. Palliative carc and pain relief are therefore of great importance. As a consequence, several countries have facilitated access to potent pain killcrs, including oral morphine. WHO has therefore continued to support public education campaigns to reduce tobacco consumption and for self-examination ofthe oral cavity. With an increase in life expectancy, but probably also due to changes in lifestyles, the incidence of cardiovascular diseases in most countries of the Region seems to bc increasing. This is in sharp conlrast to their marked decline in most industrialized countries. WHO'S support in thcse arcas of emerging conccrn is mainly focused on the training and transfer of expertise through fellowships, consultants, and training programmes for medical officers. Large-scale control programmes like those for hypertension and diabetes arc still hampered by the substantial resources they require. However, the secondary prevention of rheumatic heart disease, still a scrious problem in most countries of the Region, has been shown to be feasible at low cost. SUPPORT SERVICES Support services with four main units - Administrative Services, Personnel, Budget and Finance and Medical Supplies - contributed successfully towards effective programme planning, management and evaluation. World Health House, seat of the Regional Office was maintained in the usual manner andcertainimprovements were made to theoftice by commissioninga standby powcr generator, installing a new fire alarm system and improving the lift in the annex to the building. Of the 135 established professional posts, 110 have been filled as of 30 Junc 1991. There has been an increase in the number of professional posts from 133 to 135, due to new posts funded by extrabudgetary resources and voluntary funds. A total number of 183 consultants were fielded during the year to provide valuable technical support. Steady progress has also been made in office automation, with more staff mcmbcrs given training and the Administration and Finance Information (AFI) complcting one year of successful operation. The planned programme budget for the 1990-1991 biennium from regular budget was US$80,7million. The total obligation for the first 18months of the biennium amounts to USB53.9 million and it is estimated that planned programme in countries will bc implemented by the end ofthis biennium even though there has been some financial stringencies due to currency fluctuations and tremendous cost cscalation. In rcg~rd to supplies and equipment, local purchase, whcrcvcr relevant, was encouraged. Further, care has hecn taken while proccssing requests for sophislicatcd equipment not only to rcduce delivery lime, but alsu to ensure after-sales services such as installalion, maintcnancc and spare parts. Emergcncy supplies to meet epidemics and disasters were arrangcd for Bangladesh, Maldives, Mongolia, Myanmar and Sri Lanka. Ministers and other important dignitaries visitcd the Regional Office during the year. Thesc visits enabled such persons in policy-making positions to hcttcr appreciate WHO'S support to the health development proccss. The Director-(kneral, Dr H. Nakajima, visitcd Thailand and Indonesia. During his visit to Thailand and Indoncsia, the Director-General honourcd Her Royal Highness Somdcch Phra Srinagarindra Boromarajonani, Princess Mother of Thailand, and H.E.Mr Soeharto, President of Indoncsiarespcctively, with the presentation of newly-minted prcstigious HFA gold medals. The Regional Director, in addition to attending meetings of thc Executive Board, Programme Committee and the World Health Assembly, also ettcndcd the International Confercncc on HIVIAIDS in Canhcrra, Australia, in August1000, and thcThird International Seminar on Primary HcalthCarein Huvana, Cuba, in March 1991. Hc also made a number of visits lo Member Countrics 10 discuss the progress of WHO collaborativc programmes. Thc ahovc is a brief dcscriplion of the aciividcs of WHO in the South-East Asia Rcgion, complcte details of which arc available in thc following pages. Section I 1 DIRECTION, COORDINATION AND MANAGEMENT Chapter 1 GOVERNING BODIES 1.1 WORLD HEALTH ASSEMBLY Thc Forty-fourth World Health Assembly was held in Geneva from6 to 16May 1991. The Minister of Health of the Mongolian People's Republic, H.E. Dr Pagbajabyn Nymadawa, was elected as its President. The Assembly considered a wide range of health matters and adopted 43 resolutions. The Assembly called for the elimination of leprosy as a public health problem by thc year 2000, and urged that efforts be stepped up against tuberculosis, acute respiratory infections, dracunculiasis and cholera, and for thc dcvelopmcnt of ncw children's vaccines, emergency relief, health of refugees, alleviation of the urban crisis, and women, health and development, besides considering various other issues such as health promotion of the least developed countries, human organ transplantation, smoking, and international programmes to mitigate the health effects of the Chcrnobyl accident, etc. The Assembly was informed that 36 per cent of the disease-specilic budget of the World BanklUNDPiWHO Special Programme for Research and Training in Tropical Diseases is being spent on malaria, in the development of new tools for the control and treatment of malaria, which is by far the largest disease-specific effort of the Programme. Among the prizes awarded during the Forty-fourth World Health Assembly, the Child Health Foundation Prize was awarded to Professor Namjimyn Gcndenjamts of Mongolia for his outstanding service in the field of child health. The Assembly urged countries, WHO and UNICEF to work to maintain interest and activities for the health of children and their mothers generated by the WorldSummir for Children, held in New York on 30 September 1990. This year's Technical Discussions at the Assembly were on the subject of "Strategies for Health for All in the Face of Rapid Urbanization". The Assembly urged Member States to prevent excessive urban population growth by developing national policies that maintain a balance between urban population and infrastructure and services. It called upon various agencies to assess the impact of health on their policies in order to better adjust them to promoting healthy communities and a healthy environment in cities. 1.2 EXECUTIVE BOARD The three Member Countries from the South-East Asia Region entitled to designate a person each to serve on the Executive Board are India (1989-lWl), DPR Korea (1990-1'992) and Myanmar (1991-1993). India was replaced by Maldives in May 1991 at the Forty-fourth World Health Assembly. The Programme Committee of the Executive Board mct in Geneva from 27 to 31 August I990 and reviewed the presentation of programme orjentarion by thc Director-General and the Regional Directors, as also proposals for global and interregional activities for the period 1992-1993. The Executive Board, in 1987, had requested the Programme Committee to review a number of issues including the management of technical cooperation activities. In 1988, the Director-General submitted to the eighty-fifth session of the Executive Board a note on the formulation of programme priorities describing the policy bases, processes and mechanisms followed over the years in determining programme priorities. At the requesl of thc Board, the Programme Committee again reviewed the matter in the light of the preparation of the Proposed Programme Budget for 1W-1991. Later, the Board considered the report submitted by a working group of the Programme Committee on the criteria used at different levels of the Organization with a view to identifying those which could bc used for the determination of priorities, including possible utilization of cost-benefit analysis. The report dealt with the evolution of criteria for priority setting in WHO in the light of its constitutional functions, the process of priority setting by the Regional Office in its programme budgeting, potential critcria for testingin the preparation of theNinth General Programme of Work, and a serics of operations concerning priority setting at country, regional and global levels with a view to improving the criteria for priority setting in WHO. Aftcr considering the report, the eighty-seventh session of the Executive Board, in a resolution, requested the Director-General to ensurc that adequate resources arc GOVERNING BODIES 3 allocated according to priorities identified and that support be reduced or discontinued for projects and programmes that have outlived their usefulness. The eighty-seventh session of the Board took place from 14 to 25 January 1991 under the chairmanship of Mr R. Srinivasan. The Board considered the Director-General's reports on the meetings of the WHO Expert Committees on the Control of Leishmaniases, Cancer Pain Relief and Active Supportive Care, Vector Biology and Control, Systems of Continuing Education, Biological Standardization, Educational Imperatives for Oral Health Personnel, Use of Essential Drugs, and the FAOiWHO Expert Committee on Food Additives, as also the reports of Study Groups on Diet, Nutrition and Prevention of Noncommuni- cable Diseases, Implementation of Integrated Health Systems and Health Personnel Development, and the Role of Research and InformationSystemsin Decision-making for the Development of Human Resources for Health. It also passed 26 resolutions on diverse subjects, such as eradication of dracunculiasis, leprosy, tuberculosis control, smoking and travel, health promotion for the development of the least developed countries and research and development in the field of children's vaccines. The Board also appointed Dr U KO KO as Director of the WHO Regional Office for South-East Asia for a further period of three years from 1 March 1991. Thc eighty-eighth session of the Executive Board took place on 20-21 May 1991. Among the items dealt with were the report on meetings of the expert committees and the report of the UNICEFIWHO Joint Committee on Health Policy at ils twenty-eighth session. The Executive Board agreed that a special session of the Joint Committee be convened in January 1992 to discuss follow-up activities to the World Declaration on the Survival, Protection and Development of Children, and the Plan of Action for implementing it, adopted by the World Summit for Children on 30 Septcmber 1990, as well as improvement of the management of the peripheral health system based on primary health carc. The Board decided to hold its eighty-ninth session in Geneva from 20 to 29 January 1992. It also decided that the Forty-fifth World Health Assembly would open in Geneva on 4 May 1992. 1.3 REGIONAL COMMITTEE The forty-third session of the Regional Committee for South-East Asia was held in the WHO Regional Office for South-East Asia, New Delhi, from 18 to 24 September 1990. It was attended by representatives from all the eleven Member Countries of the Region, five United Nations agencies, one intergovernmental and twenty-nine nongovernmental organizations having official relations with WHO. 4 THE WORKOF WHO IN SFA The session was declared open by Dr S.L. Leimena, Chairman of the forty-second session, and inaugurated by His Excellency, Air Chief Marshal (Retd.) Arjan Singh, Lt. Governor of Delhi. Mr M.S Dayal (India) was elected Chairman and Dr J. Norbhu (Bhutan) as Vice-Chairman. Dr U Tin U (Myanmar) was elected Chairman of the Technical Discussions, and Dr S.P. Bhattarai (Nepal) as Chairman of the Sub-committee on Programme Budget. The Regional Committee, in a private session, nominated Dr U KO KO as Regional Director for a further period of three years. While reviewing the Regional Director's Annual Report, the Committee expressed its views on several issues and emphasized continued collaboration in diversc important matters linked with health development and promotion activities. A resolution was adopted on the subject of Technical discussions (Health of the Underprivileged), urging Member States to assess the extent and distribution of underprivileged populations and the magnitude of their health problems, and to undertake integrated intersectoral activities to meet the essential needs of thc underprivileged in the context of health for all. The Committee deliberated on the implications of the United Nations General Assembly resolution 441211 relating to operational activities of the UN system. Whilc appreciating the objectives and principles underlying the resolution and recognizing the need for better coordination among UN agencies, the Committee expressed strong reservations on the practicability of several of its operative provisions. In particular, it felt that the move for central pooling of operations and technical cooperation funds of the UN system under a single agency would not only jeopardize but also disturb the established effective tcchnical cooperation arrangement that had continued satisfactorily for so many years. Besides, WHO, as a specialized agency, was a technical organization, unlike thc UN agencies. It had a technical and coordinating role, as mandated by its Constitution, involving technical work, which included advisory collaboration as well as operational activities in the countries. Noting that the involvement of women at decision- and policy-making levels was still very low and needed more attention, the Committee urged Member States to further pursue their policies for increased participation of women in decision-making in health systems. Expressing its concern that AIDS had shown increased prevalence in two morc countries of the Region, the Committee urged Member States to strengthen AIDS prevention and control activities, universalize sterilization of all injecting and skin-piercingequipment, and intensify surveillance measures for a correct assessment of the prevalence of HIV infection. Regional Committee Meeting The forty-thlrd session of the Regional Committee for South-East Asia was held in New Delhi. India, from 18-24 September 1990. Theinaugural address was del~vered by the Lt. Governor of Delhi, Air Chief Marshal [Retd) Arjan Singh. Meeting of Directors of Medical Research Councils The seventh meetlng of the Directors of Med~cal Research Counc~ls or Analogous and concerned Research FOCI in the relevant mlnlstrles of the South-East Asia Reg~on was held in Kathmandu. Ne~al from 4 to 9 November lssn World Health Assembly H.E. Dr. P. Nymadawa, Mnster of Health. Mongolia Health Assembly in May 1991 vas elected President ofthe 44th World Executive Board Mr. R ~f India (left) served as Chairman 1 Executive 1991 May 1990- GOVERNING nODlFS 5 Discussions were also held on technical subjects, including the evaluation of health-for-all strategies using the common framework for the second evaluation, and the control of tobacco use, besides the usual business of nominations to the various global-level coordination aimmittces, etc. While noting the programme budget pn)posals for 1992-1993 for the Region to be $87 million for the biennium, the Committee observcd that these had taken into account national health-for-all strategies and kept within zero-level growth of the Organization's regular budget. The Committee requested the Regional Director to transmit the Proposed Programme Budget, as contained in document SEARC4313 and Add. 1, to the Director-General for inclusion in his Proposed Programme Budget for 1992-1993. On the question of reporting by the Regional Director, the Committee decidcd to refer the suggestion to adopt a system for a long report in odd-numbered years covering a biennial period, and a short report in even-numbered years covering one year only, for study by the Consultative Committee for Programme Development and Management at its next meeting. The Regional Committee decided to hold its forty-fourth session in Maldives in Scptemlier 1Yj1, and its forty-fifth session in 1992 in Nepal. The topic chosen for the tcchnical discussions in 1991 was "Disaster Preparedness". Chapter 2 WHO'S GENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT 2.1 REGIONAL DIRECTOR'S DEVELOPMENT PROGRAMME The Programme continues to meet the special and emergent nceds or Member Countries in areas not covered by specific project activities. Several emergem situations arose during the year necessitating urgent and priority assistance under the Programme in resolving unpredictable health problems. The cyclone which lashed Bangladesh was the most devastating, causing extensive damage to life and property. WHO rushed emergency kits, drugs and other materials to the country. Resources under the Programme being meagre, and the magnilude of assistance nccdcd being large, WHO successfully coordinated the mobililation of international assistance for providing relief to Bangladesh. In the case of Maldives, which was affected by storm waterlsurges, emergency kits were provided to the country, and WHO coordinated relief efforts with UNDP, UNICEF, WFP and FAO. Assistance was also provided to Myanmar and Bhutan to mcct emergent needs (for details sec Section 2.4). 2.2 GENERAL PROGRAMME DEVELOPMENT The flexibility of programme management in WHO has been further streamlined to improve the responsiveness to national health programmes. WHO representatives, with WHO country-based staff, and with support from staff in the Regional Office and WHO headquarters, prondcd technical cooperation at the country level. The WHOSGENERAL PROORAMME DEVELOPMENT AND MANAGEMENT 7 joint government/WHO coordination mechanism, the Consultative Committee for Programme Development and Management (CCPDM) and the Country Support Teams (CST) continued to play important roles in the above process. Besides six-monthly review of the implementation of WHO'S collaborative programmes in the Member States, the CCPDM examined and endorsed an outline and frame for the preparation of annual detailed plans of action to be agreed between WHO and individual Member Countries, and addressed the issue of joint governmentiWHO evaluation of selected national health programmes. The CCPDM also reviewed the implications of the operational activities of the United Nations System at the country level, as provided in the UN General Assembly resolution 441211, and the likely inlplication of the financial situation of WHO upon the 1~-1Y~1 rcgional programme. The Regional Committee, at its forty-third session in 19!M, approved the outline and frame for the annual detailed plan of action to implement the programme budget for the 1992-1993 biennium. The two annual detailed plans of action in a biennial period replaced the erstwhile detailed biennial programme budget. This provided flexibility in the use of WHO'S resources, particularly at the country level, and allowed the specification of specific collaborative activities nearer the implementation period, taking into account thc actual rcquircmcnts. The Country Support Teams provided support to these activities. Realizing that the joint government/WHO evaluation of priority national health programmes carried out during 1984-1986 had been useful, the CCPDM, at its meeting in September lYM, recommended the continuation of the exercise during 1991-1993. The existing framework for the evaluation, with some modifications, was also endorsed by the Committee. The second round of joint programme evaluation commenced. The evaluation is intended also to cover the economic aspects of health programmes in terms of their utility and cost-effectiveness. The Regional Office for South-East Asia participated in the WHO initiative for intensified cooperation with countries and peoples in the greatest need. A joint HQ and Regional Office mission held extensive discussions in three countries and identified several country-specific priority actions to accelerate national health development plans. Preparations are afoot to mobilize and coordinate WHO'S own and external resources in support of the participating countries. The mission visited Myanmar and identified priority actions within the frame of intensified WHO cooperation. In Nepal, support was provided to complete a health resource priority study and the updating of an earlier country resource utilization (CRU) review. WHO support was provided for the preparation of proposals for a study on human resource development, financing of health services and accelerated development of health information systems. In Indonesia, a National Health Conference was organized by the Ministry of Health in February 1991 with a view to reviewing the 8 THE WORKOF WHO IN SEA implementation of Repelita V and to identify actions required to improve the quality and efficiency of services. The Conference was opened by H.E. Mr Soeharto, President of Indonesia. Assistance was also provided to Bhutan in the formulation of a national health manpower policy and strategy and in the preparation of the health sector component of the Seventh Five-Year National Development Plan as an input to the country's presentation in the Round Table Meeting to be held in 1992. The possibility of extending similar support to a few other countries in need is being studied. The preparation of WHO'S Ninth General Programme of Work for the period 1996-2001 has commenced. The Regional Office contributed to its preparatory consultation phase on the subject of the utility, use, programme classification and content of the WHO General Programme ofwork. The Regional Office emphasized, ir~rcr alia, the need to undertake meaningful consultation with Member Countries in order to contribute substantively to the natureand content of the ensuing NinthGPW. The Regional Office contributed ideas to the formulation of the conceptual and operational framework of a new health paradigm initiated by the Director-General of WHO, with a view to achieving the health-for-all goal in the rapidly changing political, economic and environmental conditions. 2.3 EXTERNAL COORDINATION FOR HEALTH AND SOCIAL DEVELOPMENT Extensive and effective United Nations interagency coordination and cooperation continued to influence development cooperation with Member Countrics, particularly in areas of major concern such as the deteriorating environment, the growing populations, and urban migration, persisting illiteracy etc. In 1990, WHO established a technical expert commission to prepare a comprehensive assessment of the consequences to human health of the current and anticipated environmental changes resulting from agro-industrial and socioeconomic development. This will be a contribution to the United Nations Conference on Environment and Development (UNCED) in 1992. The Regional Office participated in the global Consultation on Safe Water and Sanitation, marking the end of the Decade, to delineate the future strategies. WHO made technical contributions to the Ministerial Conference on Environment and Development, convened by ESCAP, to ensure a place for health concerns in the Conference Declaration. WHO worked closely with the UN Disaster Relief Organization and others in supporting the activities within the International Decade of National Disaster Reduction (INDNR), both at country and regional levels. WIIO'S GENEKAI. Pl<O(iRAMME DEVELOPMENT AND MANAGEMENT V The views expressed by the Regional Committee at its forty-third session on the implications of the UnitedNationsGeneral Assembly resolution 441211 were brought to the attention of the WHO Executive Board at its eighty-seventh session, held in January 1991. The Executive Board reviewed the regional committees' recommendations and urged WHO tocontinue its constitutional role in actingas the directing and coordinating authority in international health and to maintain its direct and privileged access to national health authorities. The Executive Board recognized that the Organization's existing mechanisms for the development andimplementation of its collaborative programmes were in consonance with national aspirations and their involvement, which the UN General Assembly resolution 441211, in essence, intended to promote. 1. Collaboration with the United Nations System United Nations Development Progrnrnme (UNDP) WHO maintained collaboration with UNDP in support ofhealth sector development within the broad areas of human resource development, transfer of technology, and institutional strengthening through UNDP-funded country and intcrcountry projects. Duringthe year,the RegionalOfficeexecuted 11 intercountryand36country projects with a total UNDP input of about US$5.6 million. Additionally, the Regional Office continued to participate in UNDP-funded interregional projects, namely, 'Technical Cooperation among ASEAN countries in Pharmaceuticals', 'Control of Diarrhoea1 ~is~ases' and reven en ti on and Control of AIDS in Asia and the Pacific' The WHOIUNDP alliance to combat AIDS provided the policy and operational basis for joint collaborative work at all levels. AlDS has emerged as a major public health concern. WHO gave extensive support to national medium-term plans (MTP) for the prevention and control of AlDS in collaboration with UNDP. WHO was involved in the interregional project to study development implications of HIVIAIDS in Asia and the Pacific funded by UNDP. WHO provided technical support for the health sector in the UNDP country programming excrcises in Indonesia, Nepal, Bangladesh and Myanmar leading to the determination of priorities and formulation of health sector projects. A comprehensive review conducted by a WHO team in Indonesia during 1990 resulted, i~lfer alia, in projects for safe motherhood and primary health care in Irian Jaya and Maluku. Other projects, in nursing education, environmental health and food safety, were in the pipeline. In DPR Korea, WHO collaborated in a UNDP project on Control of Environmental Health Hazard, as the cooperating agency. WHO also collaborated in the UNDP country programming excrcise in Maldives, Sri Lanka and Thailand. 10 THE WORKOF WHO IN SEA UNDP's new strategies aim at a sM from the project to the programme-oriented approach, concentrating on a few selected themes of development which could result in large programmes in the cooperation package. Under its changed programming process for the Fifth Intercountry Programme, UNDP started consultations with governments. These consultations are the entry points for the eventual inclusion of health programmes and projects in UNDP intercountry programmes. WHO has urged the national health authorities and the WHO representatives to articulate health concerns and priorities adequately in these consultations, with a view to mobilizing UNDP resources for the health sector. United Nations Population Fund (UNWA) WHO'S collaborative programmewith UNFPA continued to support national efforts in developing and strengthening the infrastructure for the integrated delivery of maternal and child care and family planning services. The Regional Advisory Team on MCHIFP and other technical units in the Regional Office provided technical back-up to UNFPA-funded projects in the countries. WHO participated in the UNFPA programme review and strategy development mission in Sri Lanka and also in the formulation, joint monitoring and evaluation of programmes and projects in response to requests from the governments and UNFPA. During the period under review, the Regional Office executed one intercountry and seven country projects funded by UNFPA, with a total budget of about USS1.4 million. UNFPA started significant changes in its programming and operational strategies for the programme cycle commencing in 1992. These include the setting up of Country Programme Technical Support Teams under the control and supervision of UNFPA which will replace the edsting Regional MCH/FP Advisory ~eam in the Regional Office. WHO is at present examining this proposal critically. United Nations Children's Fund (UNICEF) WHO and UNICEF worked closely together towards the common goals of child survival and development, maternal and child health, safe drinking water and sanitation. As a follow-up to the declaration bythe World Summit for Children, held inSeptember 1990, WHO has been collaboratingin the preparationof plans of actions for child survival and development in the framework of HFA strategies. Specific WHO-UNICEF collaborative actintiesin the Region during the periodwere the Joint Nutrition Support Programme (JNSP) in Myanmar and Nepal, the programme for accelerating the implementation of primary health care and the expanded programme on immunization. WIIO'SGENERAL PKCXjRAMME DEVELOPMENT AND MANAGEMENT I I WHO and UNICEF are participating in the 'Rural Cohort Study on Child Survival' in Maharashtra, India. The study is of four years' duration and will be completed in 1994. Collaboration was maintained through programme-specific informal meetings, joint reviews and exchange of information on issues of common interest. Economic and Social Commission forAsia and the Pacific (ESCAP) WHO collaborated with ESCAP in the fields of human resources development, integrated rural development, population, environment, drug abuse, and rehabilitation and in prcparing plans toameliorate the health problemsof Cambodian refugees. WHO identified institutions for providing the necessary technical support for the management of disaster-related emergency preparedness and response. WHO participated in a meeting with senior officials on Drug Abuse Issues in Asia and the Pacific, organized by ESCAP in Tokyo from 13 to 15 February 1991. WHO strongly supported the in~plementation of the Jakarta plan of action on human resources development, adopted in 1988. A new project proposal on drug abuse information system, with special reference to intravenous transmission of AIDS, was being formulated. WHO and ESCAP earlier implemented a joint project on the control of drug abuse. United Nations Ed~icntionnl, Scientific and Cult~~rnl Orgnnizntion (UNESCO) The Regional AIDS Education and Health Promotion Centre was set up jointly by WHO and UNESCO in Bangkok through an agreement. United Nations Fund for DrugAb~ise Control (UNFDAC) WHO continued to execute the health components of the UNFDAC-funded Drug Abuse Control Programme in Sri Lanka and the Drug Abuse Control Programme in Myanmar. WHO cooperated with the World Food Programme (WFP) in promoting health and nutrition components of WFP assistance and maintained close relations with other UN agencies, including the International Labour Organisation (ILO) and the Food and Agricultural Organization (FAO). 12 THE WORKOP WHO IN SEA 2. Collaboration with Development Banks and Funds WHO participated in the World Bank appraisal mission and collaborated in the formulation of its fourth population and health project in Bangladesh. In Nepal, WHO collaborated with the World Bank and UNDP in formulating a project on 'Strengthening Resources Allocation, Planning, Formulation and Implementation in Health Sector'. WHO also provided technical support to the World Bank in preparing the population and health project for Nepal, particularly in such components as MCH, malaria control and prevention of communicable diseases. In addition, the Organization collaborated with the World Bank in Indonesia and Thailand on health and health-related projects. The Arab Gulf Fund (AGFUND) has continued to support the WHO-executed programme for prevention of blindness and deafness. 3. Collaboration with Bilateral Agencies A number of health and health-related development projects in the Region werc supported by bilateral agencies. WHO-executed projects funded by these agencies were in the fields of epidemiology, leprosy, malaria, TB, biomedical research, etc. The malaria, tuberculosis and leprosy control programmcs in India, funded by thc Swedish International Development Authority (SIDA) and executed by WHO, terminated in June 1990. However, SIDA remained in further support for innovative activities in malaria and leprosy control programmes in India. Projects were being developed by the Government of India for the next phase of SIDA assistance. In Bangladesh, the 'Family Planning and Clinical Supervision Team' project, executed by WHO with support from the Norwegian Agency in International Development (NORAD), will terminate by the end of 1991. The Organi7ation will participate in implementing the fourth population and health project in the areas of WHO'S competence. WHO collaborated with DANIDAISIDA in the essential drugs project in Bangladesh, which ended on 30 May 1990. The winding-up operation is expected to continue until 15 September 1'9'91. Thc Finland International Developmcnt Agency (FINNIDA) support to a work plan on vaccines and drugs in Bhutan will continue for the period 1'81-1997. FINNIDA continued lo fund the essential drugs and vaccine programme in Myanmar. These programmes were implemented in collaboration with WHO. WHO maintained close contacts with various donor agencies for Bangladesh, such as ODA, SIDA, Belgian, Dutch, DANIDA, JlCA and USAID, on priority health components of the Fourth Five-Year Plan of the Government of Bangladesh, for WIIOSGENERAL PROGRAMME DEVELOPMENT AND MANAGEMENT 13 which a resource mobilization meeting will be organized by the Government of Bangladesh. The Canadian International Development Agency supported the AIDS Control and Prevention programme in Thailand and continued to fund the WHO-executed vector-borne disease control programme in Myanmar. The biomedical research programme in Sri Lanka continued with assistance from CIDA. 4. Collaboration with Nongovernmental Oqanizations (NGOs) The Japanese ship-building Industries Foundation, the Christoffel Blinden Mission and Helen Keller International assisted in the prevention of blindness in SEAR countries. WHO made efforts to enhance the participation of NGOs in the prevention and control of HIV infection and AIDS. A meeting of NGOs was organized by the Regional Office in October 1990 to promote the participation of NGOs in AIDS control and prevention activities. Collaboration with Rotary International was strengthened in the fields of poliomyelitis control and 13PI. WHO also collaborated in the Eye Sight Programrnc of the International Association of Lions Club, particularly in the organization and conduct of eye camps, training of ophthalmic auxiliaries and educational campaigns on prevention of blindness. WHO pioneered the integratedapproach to prevention ofdisabilitiesin collaboration with the IMPACT Foundations of India and the UK. Theorganization collaborated in the Karigiri Disability Prevention and Limitation Programme in Leprosy (DISLEP) project, fundcd by the IMPACT Foundation, UK. The Regional Office collaborated with 21 NGOs in India in the fields of leprosy, traditional medicine, immunization, MCH, drug de-addiction, mental rehabilitation, prevention of blindness, and other areas. 2.4 HEALTH EMERGENCY PREPAREDNESS AND RESPONSE Disaster Vulnerability and Risk Disaster due to natural and other causes continued to afflict several countries of the Region, including Bangladesh, India, Indonesia and Nepal where cyclones, floods, landslides, volcanic eruptions and earthquakes created emergency situations of 14 711E WOHKOP WHO IN SEA varying degrees. Such situations need appropriate measures to tackle the massive health problems generated in the wake of disasters. WHO provided both technical and material support to Member Countries in their efforts to meet the immediate requirements following disasters as well as to build up long-term preparedness and health sector capabilities to respond to future challenges. The cyclone which hit Bangladesh in April this year was the most devastating natural disaster in the Region in the last two decades. It caused extensive damage to life and property in the coastal areas and the offshore islands. WHO provided emergency kits, drugs and equipment for immediate relief work undertaken by the Government. WHO also provided technical support for the assessment of the short- and long-term healthneeds ofthe affected areas, and participated in the UNlnteragency TaskForce set up by the Secretary-General of the United Nations for the preparation of a consolidated and comprehensive report on short- and medium-term needs. A joint WHOIltaly mission visited Bangladesh for appraisal of the situation and to explore possible Italian assistance for short-term and long-term emergency relief and re pa redness programmes. Another important initiative of the Organization was the mobilization of resources in support of the Bangladesh cyclone emergency relief and rehabilitation programme in the health sector. Up to 31 May 1991, pledges of over US$300 000 had been confirmed by donors. Prior to this, during 1990, Bangladesh was provided with necessary support in the health sector for formulating policy/guidelincs for disasters, assessing health sector capabilities, and preparing a working manual and training programme. WHO also provided support for the training of 12 000 health workers. In India, WHO provided financial and technical support for a national meeting on disaster preparedness with the long-term objective of involving national institutions in regular training programmes in health impacts of disasters for personnel of health and other scctors. WHO is also providing technical input, in terms of consultants, for thcpreparationofa health sector national disasterplan with the aim ofintroducing it in regular five-year national plans. WHO acquired technical capacity in the Regional Office for providing assistance to Member Countries in formulating plans, policies, and training programmes, and for promoting the International Decade for Natural Disaster Reduction (IDNDR) as well as other activities related to disasteriemergeney situations. In response to the United Nations General Assembly launching thc 1YNs as the International Decade for Natural Disaster Reduction (IDNDR), Sri Lanka has developed a draft plan for disaster management in the health sector. Bangladesh, Indonesia, India, Mongolia, Ncpal and Myanmar initiated steps for IDNDR by formulating national committees and national action plans. With the aim of generating awareness about the health impacts of disasters in policy makers of countries of the ESCAP region, WHO actively participated in a meeting organized jointly by ESCAP, IDNDR secretariat and UNDRO in February 1991. In order lo WllOS GENEML PRCGRAMME DEVELOPMENT AND MANAGEMENT IS meet the interests of various Member Countries, the necessary education material, slides and videos on health aspects of disasters were sent to them. During IW, mini kits containing medical supplies and life-saving equipment worth US$25 000 were supplied to Sri Lanka to meet emergency situations. WHO laid emphasis on emergency preparedness so that Member Countries can face the challenges of disaster situations through their own infrastructure and resources using international support and collaboration. However, the necessary material support has been provided in cases of need to meet emergencies. 2.5 HEALTH FOR ALL STRATEGY COORDINATION Health For All Strategy Coordination encompasses the whole health sector and also intertwines with development in other sectors. Consequently, advantage is taken of inputs in other programme areas such as the Managerial Process in National Health Development, Inlormalion and Education for Health, Health Systems Development, etc. Many of the activities undertaken in diverse programme areas constitute valuablc inputs into the main streani of health policy and strategy development. WHO provided active support to all Member Countries in their evaluation exercises using the Common Framework for Evaluation (CFEl2). Most countries have also started using the results of the evaluation for taking a fresh look at their health development process. The recommendations arising out of the technical discussions on Health of the Underprivileged, as endorsed by the forty-third session of the Regional Committee, have also been taken serious note of by all Member Countries. A pragmatic approach to health development, taking into account not only the strengths of the health system but also its weaknesses, and utilizing opportunities and resources as and when they arise or become available, with due concern for all human life, should be the hallmark of a coordinated and cogent effort in health development. This has in fact become evident in most Member Countries, who are now adopting a sagacious and down-to-earth approach for health development, keeping in mind the principle of equity and social justice in the process of development. There are still pockets of population in all developing countries whose health parameters are far below the national averages. These populations constituting the 'health underprivileged' should now become the focus of special attention, so that not only their health status is improved in the next ten years, but also the social and human potential of such populations is enhanced in order to contribute in a greater measure to overall progress. Thus, following the technical discussions during the forty-third session of the Regional Committee, WHO is working with Member Countries in the identification of underprivileged populations and their health problems, in carrying I6 .I'liE WORKOP WHO IN SEA out country-level studies on constraints and strategic options for achieving the health of the underprivileged, and in organizing nationaland sub-nationalgroupeducational -. activities fo; and strate& development. This effort will be strengthened and will continue in the Ninth General Programme of Work. It will be complementary to many of the other activities supported by WHO, particularly the new initiative of the Director-General to support people and countries in the most need. Efforts in the last ten years to follow a cogent and orchestrated policy of health development by developing coherent national strategies, keeping in new the goal of Health For All by the Year 2000 and the basic premise of the PHC approach, have brought about both quantitative and qualitative improvements in the health of the peoples of the Member Countries. This is evident from the reports on the second evaluation undertaken by Member Countries, which will be consolidated as ihc Eighth World Health Situation Report. In Bangladesh, a draft national health policy, a comprehensive national health referral system, and a draft medical education policy were developed. These, however, have been kept in abeyance due to the changing political situation. They are expected to be reviewed and adopted with necessary modifications. Bangladesh has also developed a training module for intersectoral action, with emphasis on equity, based on data collections of major health and social indicators. This underlines the need for an analysis of vulnerability and formulation of intervention, giving particular attention to undersewed and wlnerable areas. The dificulties and constraints faced in the implementation of the national health plan at different levels, particularly in the contexts of decentralization of executive power and resources for Upazillas, are being analysed with a view to overcoming them. Bhutan aims at providing equitable distribution of senices to all segments of the population by preferentially allocating resources for PHC to inaccessible groups of population. Here again, decentralization is a key concept in the process of development. Powers and funds are being decentralized to districts and blocks so as to pursue the national goals of development in consonance with the local requirements. In India, the emphasis in the Eighth Five-Year Plan will be on consolidating the gains already achieved and on improving the quality of services with minimal expansion. Efforts are also beingmade by the health sector to avoid waste and to ensure optimal utilization of the available resources. There is also a new emphasis on expansion of the health management information system to cover all states. In Indonesia, major developments have taken place in regard to policies for health services, health manpower, health financing and community participation. The priorities focus on the development of basic infrastructure to sustain economic activities and development. There is a stress on quality and equitable distribution of WIIO'S GENEHA1 PK(KiKAMMF I)EVl<l.OPMENTANI) MANAGEMIIn' 17 health resources, decentralized management, improvement of health manpower, efficient use of funds and greater reliance on community health financing. Preparations for the nea long-term health development plan are already under way with the formation of various working groups to review the situation from the beginning of the First Five-Year Plan. It is also expected that projections for the next 25-year period, based on the development so far, will be made. Indonesia has also published, for public use, bookson Challenges towards Attainment of Health For All by the Year UXX) in Bahasa Indonesia. It has also taken steps for active dissemination of its national health policy. The Ministry of Health in Maldives has been entrusted with the responsibility of welfare services. The budgetary allocation has more than doubled, from 6 per cent in 1989 to 13 per cent in 1991. Recognizing that there are still significant differences between the morbidity and mortality rates of the urban and rural populations, specific programmes for addressing these differences have been incorporated in the national plan for 1992-1W3, resulting in the development of specific island development programmes. In Mongolia, the whole processofhealth development is under active revicw following the large-scale change in the political order,which has ushered in democratic proccsscs. The Fourlh Congress of Health Workers, held in November 1990, approved the Principal Dircclions of Health Development for improving the health of the population. The basic tenet is to make health and sanitary services available to all by the expansion of coverage. It also emphasizes expanding the use of Mongolian lraditional medicine in combination with the modern allopathic system. The whole system is in a state of flux and the new policies, which are in tune with democratic aspirations, take into account the sparsely distributed population living in far-flung areas. In Myanmar, the Third People's Health Plan was completed in 1989-90. For the period 1991-92, a National Health Plan has been developed following a series of meetings at all levels. A significant shift in this Plan is that it involves all health-related sectors and is not centred on a departmental structure. The Plan also provides a set of 15 indicators in which changes are expected to be meaningful and substantial. Further, emphasis is laid on border area development, including health development of the population living there. This is being supported by the allocation of adequate financial resources and deployment of medical and health personnel. WHO has supported the development of the National Plan, particularly its revicw and formulation. Nepal has undergone a political transformation from monarchy to parliamentary democracy. The new constitution, promulgated in November 1990, has provision for strengthening the rights of citizens, incliding the right to health. ~t~givcs added strength to the existing national hcalth policy which, ir~ferolia, aims at improving the IS THE WORK OF WHO IN SFA physical and mental health of the people, increasing their life expectancy, reducing mortality, and controlling population growth. Nepal has also adopted a national conservation strategy which has a long-term perspective for natural resources management and is based on a recognition of the effects of environmental factors on health and quality of human life. A new Five-Year Plan is under formulation, which is expected, among other things, to extend health services coverage, strengthen the district health system, and provide for the transfer of knowledge and skills to the population, etc. Nepal has alsoutilized the results ofthe study on information support for HFA strategy management, undertaken in two districts, and proposes to extend the same to other districts so as to generate more reliable data for better plan and policy formulation. In Sri Lanka, despite three years of disruption of normalcy and economic constraints, the health situation has continued to remain satisfactory. Sri Lanka gives pride of placc to full countrywide coverage for the community-based preventive health system with the primary emphasis on preventive health. The radical new programme of poverty alleviation (Janasaviya) covering 58 AGA divisions and which has been in implementation since 1988, now benefits 310 000 families. Its expansion to cover 7 million people will take place gradually over a period of ten years. The health component of this programme, Suvasaviya, ensures that the economic and social benefits obtainedby the population under the Janasaviya Programme are not frittered away due to adverse conditions of ill health. Research on the impact of the Janasaviya Programme on the health and nutrition of thc beneficiaries has been supported by WHO. Sri Lanka has formulated the National Health Plan for 1990-1991. WHO provided support for a workshop to develop the medium-term health development plan for the period 1990-1595. TheGovernment ofThailand hassuccessfully adopted a series of innovative measures to reduce disparities in health status among different population groups as part of its overall policy of health development. The new government, which assumed office in February 1991, is currently engaged in drafting policies to be pursued by it, which, infer alia, include policies on health development. The thrust of the new policies is likely to be towards reaching the underserved, unserved, vulnerable and underprivileged groups of population with stress on equity and social justice. The vibrant economic development that has taken place in the last five years has contributed both directly and indirectly to an increasing emphasis on betterment of health status, and to greater attention on social aspects of health development. Thailand increased the health budget from 11 787 million bahts in 1989 to 20 180 million bahts in 1591. A number of measures have been undertaken in the Seventh Five-Year Plan to provide free medical care for the poor, reduce disparities in health status among different population groups, increase the use of Thai traditional medicine, improve cooperation with private and other nongovernmental organizations and to obtain the involvement of people in improving their own health. The Seventh Five-Year Plan, covering the period 1W2-1997, takes note of the deficiencies and attempts to prioritize them in the light of the analysis of social, economic, demographic and technological changes, keeping in view the changes in health and health-related resources as well as the participation of communities in health development. The Plan, expected to be finalized by March 1992, will attempt to build on the progress already achieved. Health-for-All Leadership Development Ever since WHO launched the 'HFA Leadership Development Initiative' in 1985, activities to further strengthen HFA leadership at intermediate and lower levels have been pursued vigorously, both at regional and country levels. An Intercountry ConsultationiWorkshop on HFA Leadership Nctworking and Resource Development was held in Jakarta, Indonesia, from30July to7 August 1W0. The Consultation was organized with the aim of stimulating the crcation and strengthening of a regional network of institutional resources to promote and implement HFA leadership development. The participants, being in leadership positions, reviewed country, intercountry and global situations in relation to leadership development, and endorsed the need to further strengthen leadership training programmes with active support for potential institutions. There was a need to continuously create awareness of HFA leadership, review and monitor progress, improve HFA leadership activities, and share expcricnccs, information and expertise. In India, Indonesia, Myanmar and Thailand, HFA leadership development activities were initiated as specific country programmes, whereas in other Member Countries leadership development activities form part of the overall health development programme. Meetings, dialogues, training courses and workshops, using the adapted vcrsions of HFA leadership training modules, have been held in Member Countries. Learning and information materials adapted to local situations were also prcparcd and produced for utilization at various training activities in Bangladesh, India, Indonesia, Myanmar and Thailand, which were held in order to develop a critical mass of people capable of assuming leadership of the HFAI2000 movement within their own countries. In Bangladesh, Bhutan, Maldives, Myanmar and Nepal, meetings at the district lcvcl were organized to en;~hle exchanges among decision-makers of thcir experiences of successful district programmes, to create awareness of HFAIPHC concepts, and to offer approaches of how their concepts and stratcgies can he operationalized at the local level. Most Member Countries have identified potential national centres for arranging networks and formulating strategies for the development of future leaders. The Faculty of Public Health of Mahidol University in Thailand has been nominated as a WHO Collaborating Centre in HFA Leadership Development. This Faculty is 20 - rllE WOKKOb WHO IN SFA developing a common framework for country case studies which will be used to conduct case studies in all Member Countries of the Region. The case studies will highlight issues related to HFA leadership development which link with both successful and unsuccessful experiences of health development programmes. These case studies can be utilized as learning materials for HFA leadership training and also used as advocacy for social and political action. It is expected that, during the next few years, some institutions in the countries will be undertaking similar responsibilities. The review and development of tools for setting criteria for the monitoring and evaluation of leadership development initiatives have been initiated in India, Indonesia, Myanmar, Sri Lanka and Thailand through the WHO collaborating ccntres and national focal points for HFA leadership development. Whilc progress in HFA leadership development is evident in many countries, it is too carly to mention the impact of the activities because of the many influencing factors. There is a great need for intensified support for the large unreached or underserved populations still living in conditions of poverty and suffering from the lack of education and nutrition, leading to high morbidity and mortality. In ordcr to havc a strong political commitment for HFAi2000, attempts will havc to be made to incrcasc the awareness ofthe existing leaders. 'l'echnicnl Cooperation among Developing Cunntries There have been a large number of direct bilateral exchanges. Male, the capital of Maldives, hosted the Fifth Summit Meeting of the South Asian Association for Regional Cooperation (SAARC) which was attended by the heads of the Statcs/Governments of SAARC comprising Bangladesh, Bhutan, India, Maldives, Ncpal, Pakistan and Sri Lanka. Thc 'Male Declaration', emanating from this Summit Meeting, has a special portion on health dcvclopment. Indonesia undertook a TCDC multisectoral programming excrcisc in July 1990 with support from UNDP, both to make known its potential and also for seeking support in regard to improving some capacities. India, Sri Lanka and Thailand responded to this exercise. At the fourteenth meeting of Ministers of Health of the Non-aligncd and other Developing Countries, held in Gencva in May 1990, the Medium-term Programme for TCDC was adopted. This had been developed earlicr by a meeting of experts from non-aligned and other developing countries. The progress in the implementation of this Medium-Term Programme has recently been reviewed and submitted tothe fifteenth meetingofMinistersof Health ofthe Non-aligned and other Developing Countries, held in Geneva in May 1991 WHO5 GENERAL. I'KOGRAMMI DEVIIOPMENI'ANI) MANAOBMENI ?I 2.6 INFORMATICS MANAGEMENT The Informatics Management Programme aims at supporting programme development and management of WHO and Member States through the use of informatics technologies and training of users at regional and country levels. Most of the health programmes have introduced information technologies, and financial and technical management. The degree and level of sophistication in their use vary from one programme to the other. A few corporate data bases and computeri7ed programme monitoring systems are heing developed. These may become available to the WHO Sccrctariat andMcmber States in the near future Whilein the initialstages ministries of health acquired informatics and telematics technology for the central level only, thc same technology is today spreading to provincial and district levels. In the Rcgional Office, the new Administrative and Financial System (AFI) became fully operational at the end of 1990, and technical aswell as administrative proccdurcs arc being devclopcd in the Regional Office to link AFI with the ensuing Local Area Network of the Regional Office, providing programme managers easy access to financial and technical information. The Informatics Support Committee dealt with policy issues regarding informatics support dcvelopmcnt, as well as with technical, administrative and operational issues, in order to ensure standard proccdurcs and optimum use of WHO'S resources. Section II HEALTH SYSTEM INFRASTRUCTURE Chapter 3 HEALTH SYSTEM DEVELOPMENT 3.1 HEALTH SITUATION AND TREND ASSESSMENT The second evaluation of the implementation of strategies for Health for All by the Year 2000 was completed by all Member Countries before the target date of 31 January 1991. Country reports have been prepared in the countries by multisectoral working groups guided by coordinating committees, with ministries of health playing a leading role. These reports contain extensive analyses of the achievements and constraints in accordance with the reporting structure of the WHO Common Framework for the Second Evaluation (CFEI2). Comprehensive information on the monitoring and evaluation process and mechanisms, development of health systems, availability of primary health care, international cooperation, health and socioeconomic status as well as on research, technology, plans for future action and other developments and activities, show that the evaluation process is indeed becoming an integral function of national health management processes, and the findingsof this exercise are pointers to further action. TheRegional Office has prepared the Regional Report on Evaluation of the Strateby for Health for All by the Year 2000 (Eighth Report on the World Health Situation), based on country reports. The report consists of two parts - regional evaluation, and country reports. The latter part includes significant achievements of Member Countries in the implementation of HFN2000 strategies, as also the weaknesses of health information systems in supporting the decision-making process for health management. 24 YHL: WOKKOF WHO IN SEA It may be stressed that in some countries health programme managers still maintain health information in a vertical and compartmentalized manner. It also seems that not enough systematic renew is done by decision-makers, programme managers and operational health personnel at different levels to identify the information they need. These factors, as well as the poor quality of data and the lack of disaggregated information, often make it difficult to use the information at district and lower levels to identify priority managerial actions for underserved groups of population. Member Countries continued their efforts to strengthen their health information systems. The decentralization process taking place in some countries made it possible to make the existing health information systems less vertical and to improve the utilization of data at operational levels. More stress was laid on the generation and use of disaggregated information. Further steps have been taken in India and Nepal to extend the areas of operation of the new district-oriented health information systems which were pretested during 1988-1990. Collaborative efforts to improve the quality of mortality statistics are continuing in India, Mongolia, Sri Lanka and Thailand. The introduction of the 10th Revision of the International Classification of Diseases, which will come into use in 1993, should help to improve the quality of mortality and morbidity statistics. It seems that thc three-character version of ICD-10 will be the most suitable for the South-East Asia Region. Preliminary steps have been taken by Indonesia, Mongolia, Myanmar and Thailand to involve themselves in the application and strengthening of future trend assessment approaches and methodologies. Tentative methodologies to identify the underprivileged in health have been outlined. Epidemiological Surveillance WHO continued to collaborate with Member Countries in developing and strengthening epidemiological surveillance and services for the effective prevention and control of communicable diseases. The immediate requirement of this region is to meet the training needs of managerial, mid level and lower level health personnel in epidemiological surveillance in order to promote better use of epidemiology for health development. Activities during the reporting period were directed at making use of epidemiology as a management tool for disease surveillance and control, setting of priorities, and for programme evaluation. Most of the SEAR countries benefited through fellowship awards and provision of supplies and equipment for strengthening the existing epidemiological units at the national level. HIALTH SYSTEM DEVELOPMENT ?.5 Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand have specific programmes for promoting epidemiological surveillance activities. WHO supported external evaluations of the Field Epidemiological Training Programme (FETP) in Indonesia and Thailand. The first external evaluation of FETP in Indonesia was conducted from 25 August lo 7 September 1986, and in Thailand the first evaluation was held from 9 to 20 December 1985. In Indonesia, the second external evaluation was conducted from 16 July to 3 August 1990. The main recommendation of the second evaluation team was the institutionalization of FETP within the Ministry of Health. Because FETP represents long-term training, the administrative needs of FETP are best met by placing the programme within the Centre for Health Manpower Education. According to the evaluation team, the operational aspects of FETP should remain closely linked with the Directorate General for Communicable Diseases Control and Environmental Health (CDC and EH), in ordcr to make FETP an institution that is recognized as a structural entity and is accessible to all within the Ministry of Health. The evaluation team recommended the establishment of an ad hoc task force to facilitate follow-up of the evaluation recommendations and efforts to improve administrative and financial problems in order to attain self-sustainability after external assistance is withdrawn. The second external evaluation of FETP in Thailand was held from 29 October to I0 Novcmbcr 1YX1. The evaluation tcam found evidence of substantial achievements by FETP since the previous evaluation. Even though FETP in Thailand is a self-sufficient and sustainable programme, WHO continues to support it through country regular budget resources. The evaluation results showed that FETP has made distinct contributions in Thailand to improving public health. Examples include the establishment of the national HIVIAIDS weekly surveillance report, the epidemiological annual summary and the annual national epidemiology seminar (1990 was its eighth ycar). The Bangladesh Field Epidemiological Surveillance and Disease Control Project is supported by UNDP. his project includes the establishment of sentinel surveillance in 20 selected districts and various training activities for district epidemiological unit - - members and laboratory technicians of sentinel districts, with the assistance of an eleven-month consultant. In Bhutan, the epidemiological unit was strengthened through subsidy support to increase the outputs of epidemiological and information staff. In India, the National Institute of Communicable Diseases conducted a workshop on epidemiology training for district health offices, and a national official was included in the delegation to China in connection with an epidemiology workshop. In Indonesia, epidemiological surveillance training for all chiefs of district health offices was conducted from July to October 1W. Technical assistance was provided 26 THE WORKOF WHO IN SEA in the designing, conduct and analysis of epidemiological studies and/or workshops and curricula in epidemiology. A number of Indonesian officers received training through the fellowships programme and attended international meetings such as the FETP-INCLEN-IEA Meeting in Mexico. A long-term staff member assisted the Surveillance and Immunization Sub-Directorate in the translation of WHO training materials for sentinel surveillance. Project assistance has been directed towards the development of epidemiological studies for the prevention and control of AIDS through the establishment of a computerized data base. A series of five training courses for a total of about 400 district-level chiefs of surveillance and disease control were held between 30 July and 31 October 1990. In Myanmar, technical assistance was provided to the Epidemiological Unit in the strengthening of epidemiological surveillance and control of communicable diseases and in conducting in-service training of medical officers, through a consultant in October 1990. In Nepal, study tours and fellowships were supported with a view to strengthening training. In Sri Lanka, training programmes for senior officials on epidemiological surveillance were conducted during June-September 1990. Assistance was also provided for computerizing epidemiological information. In Thailand, support was extended for conducting a four-week introductory course in epidemiology for field epidemiologists. A national epidemiological conference was organized in August 1990. Through a technical services agreement the FETP project was supported in training field epidemiologists, strengthening epidemiological services and utilizing epidemiological information. 3.2 MANAGERIAL PROCESS FOR NATIONAL HEALTH DEVELOPMENT 1. Overview WHO collaborated in all aspects of the Managerial Process for National Health Devclopment. In most countries, review and formulation of national health policy, formulation of medium-term health plans in the context of economic realities, and a shift towards improving the management of health care at operational levels were noted. Keepinginview the constraints of the health sector and in pursuance of World Health Assembly andRegionalCommittee discussions and resolutionson the subject, WHO initiative on intensified technical cooperation was undertaken in Bhutan, Myanmar and Nepal. Support was provided for the formulation of medium-term IltAL'lH SYSTEM DEVELOPMENT 27 health plans in Bhutan, Indonesia and Thailand and an overall review of the present capacity of health planning units in the countries was undertaken. A number of activities to improve training and skills in health economics of staff in the ministries of health were supportcd. Studies to identify organizational and managerial constraints that limit the effectiveness of health care institutions were also undertaken. Spccific support to review the enactment of new health legislation was offered in two countries, while efforts to promote review and updating of old laws in support of health development were continued. 2. National IIealth Policies Most countrics reviewed t heir health policy, formulating and updating as necessary, and prepared guidelines for the implementation of their national health politics. There was new emphasis on equity of services, with particular concern for the health problems of the underprivileged. In Bangladesh, a national health and population policy was drafted and subjected to public debate. In Myanmar, WHO assistance was provided for a review of the national health policy and People's Health Plan in the context of changes in the hocio-political and economic situation. 3. National Ilealth 1)evelopment Plans All countrics continued lo formulate, implement and review their medium-term national health plans as instruments for implementing national health policies and strategies. WHO collaborated in the preparation of the health sector component of thc Seventh Five-Year Development Plan in Bhutan. In Bangladesh, support was provided for thc assessment of the rclcvance, progress and achievements of the health infrastructure and health services with a vicw to determining the nceds for thc Fourth Five-year plan pcriod (lW-1995). WHO also collaborated in the preparations for the formulation of the Second Long-Term Development Plan (1993-2018) and the Sixth Five-Year Plan in Indonesia. A number of working groups reviewed past experiences and made future projections for the next 25 years. WHO collaboration was provided for the development of an interim two-year National Health Plan (1991-92) in Myanmar. In Thailand, support was provided for the preparation of the Seventh Five-Year Health Plan (1992-97), following a review of the output of the Sixth Plan. In Nepal, a study on country health resources and priorities was completed, and support was provided for a comprehensive study for the reorganization and restructuring of the national health system to meet the Basic Minimum Needs and HFAi2000 goals. A Regional Consultation on Health Planning was organized in Bangkok from 3 to 10 June 1991 with the objectives of reviewing the current situation in health policy formulation and national health planning in Member Countries and formulating a 2R THE WORK OF WHO IN SEA regional plan of action for further development and strengthening of health planning mechanisms. The main components of the regional action plan included human resource development, research and development, institutional strengthening, information support and networking. There was a consensus on the restructuring of human and material resources and on the methodology of health planning in the changing context of economic, political and social conditions. The need to establish a regional institution on training in health planning was underscored. 4. Strengthening of Health Economics As a matter of high priority for Member Countries and WHO, alternative approaches to health care financing and mobilization of resources to build and sustain health infrastructures are being studied. At the same time, there has been a serious effort to improve efficiency and effectiveness of service with the available resources. The Regional Consultation in Health Economics, held in the Regional Office in October 1990 and attended by senior health economists and administrators of the Region, identified five main areas for action, viz. research and development, human resource developmcnt in health economics, information support, institutional strengthening and networking. Indonesia made significant progress in health financing by simplifying procedures in financial administration and instituting alternative financing such as compulsory health insurance for civil servants, workers'health care, and maintenance, etc. WHO has been collaborating in these efforts, and in the development of management audit methodology. An organization and management study, a detailed manual for recovering financial shortfalls, and training in auditing techniques and procedures were also~upported.~echnical assistance was providedto strengthen the information system for the coordination and monitoring of foreign assistance. Thailand commenced the training of Provincial Chief Medical Officers and Directors of community hospitals in health economics with WHO support. A cost analysis oE training of paramedical personnel in Khon Kaen, Thailand, is in progress. Research studies on different aspects of health economics have been developed and are being reviewed for funding by WHO. Myanmar developed proposals for alternative financing of health care in the course of preparation of the National Health Plan. WHO support has been provided to India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand in the field of training and research. Countries have utilized WHO resources in the development of manpower in health economics through fellowships, study abroad and in-country training activities. HEAL711 SYSTEM DEVELOPMENT 29 5. Intensified WHO Cooperation with Countries in Greatest Need In view of the serious economic problems faced by many developing countries, WHO took the initiative on intensified technical cooperation with countries in the greatest need. WHO headquarters and the RegionalOffice staff supported Bhutan, Myanmar and Nepal, who expressed interest in this new WHO initiative. In Nepal, with the completion of the study on country health resources and priorities, 1990.1995, with WHO support, draft proposals on human resource development and on health financing to increase the capacity of the Ministry of Health in economic analysis of health policies, including alternative approaches to health financing and accelerated development of the health information system, were prepared for WHO support. In Myanmar, health policy analysis, a country resource utilization review, and health care financing were the identified activities for WHO'S initial support. A framework For national hcalth development was the broad overall aim of these collaborative activities. The initiative on intensified WHO cooperation with countries in the greatest need is expected to act as an umbrella under which diverse programme activities will be integrated to support national health development. 6. Strengthening of Operational Management In most countries, extension and expansion of the health system infrastructure was so rapid that the management capacity came under strain. As a component of improved management of operations in the health services, the preparation and printing of a manual of office procedures on operational management and supervisory system was supported in Bangladcsh. Support was provided for job analysis ofvarious categories of hcalth personnel as well as development of job descriptions and introduction of the 'contract' systcm to encourage equitablc distribution and increased pr(iductivity of health worker5 in Indonesia. Also, astudy to identify organizational and managerial constraints limiting effectiveness of health centres was supported. A personnel administration data base was designed to support health manpower information systems. Support was also provided for the implementation of a uniform record system. Overall improvement in managcment has been accomplished with these activitieb. In Myanmar, management training modules have been developed and management lrainingcoursesorganized. In India, support wasprovidedforimparting hcalth managcment training to health workers at various levels, and to include managerial aspects in postgraduate training in preventive and social medicine. Workshops in planning and management and hcalth team building at the primary health care level were also conducted. Nepal received support for training in supervision, and for monitoring and evaluation in various districts; and Sri Lanka received support to review ongoing national and district-level monitoring processes andactivities. There was anencouraging trend ofimprovingoperational management 30 THE WORKOF WHO IN SEA in most countries though some countries have accomplished their objectives better than others. In the area of decentralization of decision-making, Member Countries have been engaged in the development and strengthening of district-based health systems. WHO support has been made available for detailed programming at regional, district and more peripheral levels and for the development of management information systems. Fellowships support has been provided to DPR Korea for training in computer applications for developing automated information systems. Assistance has also been provided for the translation of relevant MPNHD documents for use in the country. However, most countries need to make sustained efforts to strengthen district health management and undertake health services research in management for improving efficiency and effectiveness. 3.3 HEALTH SYSTEMS RESEARCH AND DEVELOPMENT In accordance with the recommendations made by the Regional Committec, the South-East Asia Advisory Committee on Health Research, the meetings of the Medical Research Councils and Analogous Bodies, the Global Advisory Committec on Hcalth Research and the Forty-third World Health Assembly, greater emphasis is now being laid on the promotion and development of health systems research in the Region. As part of this greater effort, a separate budgetary provision has been made for the strengthening of research capability of institutions in the Region, especially for undertaking health systems research. The scheme for institutional strengthening has now been implemented in Bangladesh, DPR Korea, Myanmar and Thailand, while consultations are being held with Ncpal. A more expeditious response and active collaboration to this initiative would result in more rapid and better implementation of the scheme, which, at present, has not taken off well. Another step in line with the ideaof strengtheninginstitutions for HSR is that of ajoint effort between the Regional Office and WHO headquarters with the objective of strengthening an institution in thesouth-East Asia Region so that it can bensed asa model for replicationelsewhere. An institutional strengthening grant has been provided to the ASEAN Training Centre for Primary Health Care Development at Mahidol University, Salaya, jointly funded by the Regional Office, WHO headquarters and other agencies, including Mahidol University itself. In order to establish health systems research within a more institutionalized framework, the Regional Office is promoting consultative meetings attended by senior administrators and scientists not only for the assessment of priority health systems research needs in Member Countries but also to identify multi-disciplinary HEALTH SYSI'EM DEVELOPMENT 31 research teams which will include personnel from ministries of health as well. Such national health systems research needs assessment meetings have been held in two countries of the Region. The WHO Collaborating Centre for Health Services Development (located at the Health Services Research and Development Centre in Surabaya, Indonesia) is engaged in the preparation of a detailed work plan for the next two years. The Centre will convene a more limited consultative meeting to asses health systems research needs in Surabaya province. As a further step towards institutionalizing health systems research, a consultative meeting to develop criteria for the appraisal of HSR project proposals was convened from 2 to 4 April 1991. At this meeting it was possible to construct a conceptual framework for the appraisal of health systems research (in contradistinction to biomedical and clinical research). Based on this conceptual framework, criteria for the appraisal of health systems research project proposals were developed. It was accepted by the consultative meeting that these criteria would be applicable globally at least as a general framework, and hence would be useful to various bodies concernedwith healthsystems research, both at national andinternational levels. The development of appropriate criteria and peer review mechanisms for the evaluation of HSR projects and results was one of the means suggested for its institutionalization by the panel on health systems research at the Technical Discussions held during the Forty-third World Health Assembly in May 1990, and this product is one example of Regional Office efforts to follow up on the resolution of the Forty-third World Health Assembly on health research. In fact, the Regional Office had already taken the initiative and presented draft criteria for discussion at the Interregional Workshop on Health Systems Research, held at Arusha, Tanzania, from 4 to 13 July 1W. Hcalth systems rcscarch projects supported from intercountry funds, during the period under review, covcr areas such as ageing, health manpower development, community participation, health care delivery and health economics. An attempt has been made within the Regional Office to incorporate health systems research in the research activities promoted by the technical units. Expert assistance was provided to Member Countries for research pertaining to health policy formulation and health planning, health management and utilization of health services, economic analysis of expenditure for health and family welfare services at the district level, and self-care. Three countries of the Region (India, Indonesia and Myanmar) have made specific provision for health systems research amounting to a total of US$260 000 for 1990 and US$196 700 for 1991 in their country budgets. The Regional Office actively collaborates with WHO headquarters as well as other bodies in promoting HSR, including the training of research workers. One Member Country and the Regional Office were represented at the Interregional Workshop on Health Systems Research ;it Arusha, Tanzania, where learning modules for research 32 THE WORKOF WHO IN SEA managers were tested. The Regional Office also co-sponsored, with the International Development Research Centre, a Symposium on Essential National Health Research on 4-5 March 1991 in New Delhi. Collaboration with other WHO programmes, such as the Special Programmes on Tropical Diseases and Human Reproduction, continues as before and has resulted in several health systems research projects, including field studies, being supported in the Member Countries. 3.4 HEALTH LEGISLATION The role of legislative support in the improvement of health policy formulation to provide guidance to national health development and plans of action is of great importance. Most countries are aware of this need for support. However, promotional efforts are still necessary. India and Indonesia had intensive collaboration with WHO. Support was provided to India for organizing workshops on health legislation, organ transplantation and brain death, which underscored the need for the enactment of law in the area of human organ transplantation. The meeting of an expert committee to review the Dentist Act and a workshop to update it also received support. A national consultant was assigned to suggest and draft amendments to existing acts and formulate proposals for ncw legislation. In Indonesia, support was provided for organizing a workshop on medical records and formulating draft legislation on informal consent. WHO support was provided to Mongolia for drafting a Tobacco Law which will be used to establish a tobacco control programme, prohibit advertisementsin tobacco and its products and establish non-smoking areas. In Nepal, the preparation of a document on health-related laws and by-laws has been supported. In its endeavours against discrimination to HIVIAIDS cases, WHO provided consultancy support to Thailand to review draft legislation on AIDS. The negative impact and futility of highly discriminatory legal measures in respect of HIVIAIDS was underscored during discussions with senior policy-makers, academicians, legal experts and nongovernmental organizations. Therc has been close collaboration with WHO headquarters in the promotion and support for renewing and introducting health legislation. Relevant documents and working materials have been distributed to Member Countries. There has been close collaboration with WHO headquarters, which has beenprovidingrelevant documents and working materials for distribution to Member Countries. Chapter 4 ORGANIZATION OF HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE Since thc concept ofacomprehensive healthcare system based on the primary health care approach has become the main thrust for total health development, all the Member Countries of the Region have madc great efforts in reorienting and restructuring their health system infrastructure, which is an essential element of national strategies for attaining the universal goal of HFN2000. Further efforts have been made to promote appropriate organization and effective operation of the comprehensive health systems, so as to provide efficient health care to the entire population. Special efforts have been made to improve health infrastructure and increase health care coverage in the unserved and undersewed areas. WHO has continued to collaborate in these national efforts to achieve the goal of HFN2000, and considerable resources have been allocated from donor agencies in this endeavour. All countries of the Region had adopted strategies that call for social and political action, such as leadership development, restructuring health organization, including decentralization, empowering people, alternative health care financing, reaching the unreachcd, strcngthening planning and management capabilities at (he district level and below, adoption of appropriate technology, etc. Greater emphasis had been placed on the transformation of these strategies into reality. 1. Reorientation of Health Systems Infrastructure In the era of the worldwide economic crisis, the countries of the Region, especially thc five least developed ones, are reviewing their current patterns of resource 34 THE WORKOF WHO IN SEA allocation in the health sector and reorienting their spending priorities, including the allocation of any additional resources in support of primary health care giving preferential attention to the underprivileged. As the target of HFAI2000 is moving closer, it is necessary to achieve total population coverage by health infrastructure based on primary health care. However, budgetary and infrastructure constraints and the lack of adequate and suitably trained human resources hinder programme implementation. Efforts are being made to identify practical problems and constraints being encountered in the implementation of HFA strategies as well as ways to overcome them. WHO'S efforts are aimed at initiating, developing and strengthening district health systems based on primary health care, through technical and policy meetings, seminars, conferences, training workshops, reports, guidelines and manuals. The intensification of health development, focusing on the district level, has been pursued with commendable results. Efforts are being made to achieve greater equity in the distribution of health facilities, especially in rural and urban populations. Health care coverage through the health infrastructure has increased in almost all countries as a result of improvement of the planning and management process, especially at the district level. In Indonesia, Myanmar, Nepal and Thailand, WHO has not only used the standard conventional approach of providing tailor-made planning and management training for improving specific services, but also used the 'learning-by-doing' approach wherein the national core group of staff are involved in planning, management, monitoring and evaluation, with the technical support and collaboration of experts. The product of the latter approach is a firm understanding of management methods, and a realistic programme plan or project proposal which can be used for funding and management. The experience gained thus far indicates that health development programmes aimed at serving the most seriously undersewed and vulnerable sections of the population - should receive priority. It is, therefore, necessary to give greater attention to social relevance as also to the management of the health care revolution by combining high technology with the primary hcalth care approach and using the existing health infrastructure with an integrated approach to optimize the use of available resources. Due attention has been paid to thc development of human resources for health through training and retraining of health workers, includingvolunteers. It is also being stressed, in the planning and implementation of health programmes, that greater involvement of sectors other than health should be secured, as well as much more involvement of the community. ORCiAN17A'l'lON OF 1IEAI.TH SYSTEMS EASED ON PtiC 35 WHO collaborated with all Member Countries of the Region in enhancing their capabilities to plan, manage, and evaluate health development programmes at the district level and below, particularly through micro-planning and middle-level management training, and transferring knowledge and practices through practical manuals, so as to help district managers play a leading role. WHO support in Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand also involved a review of district health development, promotion of research-cum-action- oriented programmes for strengthening community involvement and intersectoral coordination. In order to improve understanding of the scope of self-care and current practices in the home, an operational framework for the promotion of self-care at home, in the context of primary health care, was developed, and critical obstacles as well as strategies to be undertaken by countries were identified. The Regional Office has plans to initiate field research in Member Countries. In Thailand, WHO is supporting further expansion of local initiatives for self-managed primary health care by local communities dealing with various health problems. WHO also supported Myanmar, Bangladesh and Thailand in the development of a proper referral system at various levels, primarily at the first referral level. Planning and evaluation workshops were held in Bangladesh, Myanmar, Nepal, Sri Lanka and Thailand to re-examine the health care systems. Fellowships in hospital planning and administration, medical stores management, nursing and medical care, including specialized medical care, were awarded to nationals from Bangladesh, Bhutan, India, Indonesia, Sri Lanka and Myanmar. Support was also provided to national authorities for the preparation, revision and production of hospital procedure manuals in Bangladesh and Myanmar. A Hospital Sanitation Manual was finalized and printed in Indonesia for distribution to district hospitals. In-country training on advanced biomedicaVclinica1 engineering and practical maintenance of modern electromcdical equipment was supported through consultants in Bangladesh and Myanmar. 2. Strengthening ot1)istrict Health Systems Countries of the Region are being supported in reviews of their health system infrastructures, especially in the development of district health systems and in finding measures which lead to better planning and management. The focus of improvement has been on the integration of programme delivery, coordination within the sector as well as with other related sectors, and increasing population coverage aimed at reaching the underserved and unreached populations. Activities carried out in the first year of the biennium contributed to health development at the community and health centre levels and aimed at improving the capability of local-level health staff 3h THE WORKOF WHO IN SEA in respect of planning and management and also at improving the quality of health services. WHO continued to support the development of district health systems in Member Countries. Assistance was provided to Bangladesh for improving operational management at the Upazilla level, and the country is now expanding its activities to eight districts. Technical support was given to Sri Lanka for strengthening the three-tier health care delivery system at the district level. A consultant was assigned for the development of the district health system in Nepal. Model district health projects, such as the Mongar project in Bhutan and PHC strengthening in the Huvsgul Aimak of Mongolia, were getting into their evaluation stages, and wereshowing their success in achieving the targets. A modeldistrict health system was being developed in the Regional Office to assist the countries in reviewing district health development and in accelerating the developmental process. Mechanisms for the self-assessment of district health development were progressing in Indonesia through the stratification of performance of health centres, and in Thailand through the Basic Minimum Needs movement. Research capability of the WHO Collaborating Centre in District Health Systems in DPR Korea has been strengthened through the provision of some equipment, study tours for staff and research grants. Under the UNDP project 'Intensification of Action Programme for Primary Health Care', baseline surveys have been completed and national and district health development work plans developed in all the countries. An integrated learning module, prepared by the Regional Office, was used in training health managers, supervisors and workers in the project districts. Workshops for health managers were held in all the participating countries. In-service training of health workers and health supervisors has also been conducted using integrated learning modules. Training in laboratory diagnosis for the control of diarrhoea1 diseases and acute respiratory infections has been completed in Bangladesh, Bhutan, DPR Korea, India, Indonesia, Mongolia, Nepal, Sri Lanka and Thailand. Nongovernmental organizations, especially women's organizations, are closely involved in project implementation in Bangladesh, Bhutan, India, Indonesia, Mongolia, Myanmar, Sri Lanka and Thailand. An evaluation of the project showed that significant advances have been made, resulting in the strengthening of primary health care, and concluded that this was an extremely ambitious project with high objectives, and that important results had been obtained. It was also seen that chances of real success and sustainability are much higher with efficient management at the country level. Some countries, e.g. Bangladesh, DPR Korea, Indonesia, and Thailand, appreciative of the favourable outcome of this project, are considering plans for sustaining the efforts and action as well as replication to additional districts. Health System Infrastructure Member Countries are organizing effective health systems strengthening their health infrastuctures and increasing coverage, especially in underselved and unsewed areas. numan Resources for Health Member Countries are givlng due attention to the appropriate training of all categories of health personnel. The effective utll~ratlon of different types nf health learning materials is also recognired as being crucial for the successful implementation of health development programmes. ORGANIUTION OF HFALTH SYSTEMS BASEDON PHC 37 Indonesia and Thailand have been implementing health development activities with the support of community participation and intersectoral action. They are now embarking on policy formulation in other sectors with a view to reducing the negative impact on health. Thailand is now stressing environmental issues, drug abuse and AIDS, while Indonesia is dealing more with urban slum issues and how to reach the unreached. In Sri Lanka, the Janasaviya movement, with its health component, the Suvasaviya programme, is being supported. 3. Community Participation The main thrust of the health development programme relies upon the extent of community involvement. Many of the WHO collaborative programmes in primary health care are geared towards it. The Posyandu approach in lndonesia is an extension of health care delivery organized by combining the services of health centres. Community participation in terms of volunteers for health activities under primary health care is progressively expanding. WHO support continued for the training of ten-household health workers and their trainers in Myanmar, while in Bangladesh the training of community health volunteers, selected on a neighbourhood basis, was initiated. Nearly two-thirds of the health volunteers were women, reflecting a social change at the village level. Fellowships to nationals from India, Sri Lanka, and Bangladesh were arranged for studying community involvement in health development, with emphasis on community health financing and basic minimum needs, in Thailand. 4. Urban Primary llealth Care WHO supported a nation~~l workshop in Indonesia in March 1W to discuss the development of urban health care delivery system. This was followed by a country case study of three selected big urban areas to study the issues and implications of public policies and urbanization, the results of which were submitted to a national meeting held in May 1991. WHO also continues to support Thailand in its application of the PHC development model in low-income urban communities and in the community financing scheme in two urban areas of the country. Support was provided to Bangladesh for a rapid assessment of urban health needs, designing of the health se~ces, and formulation and implementation of an action plan for the population of an urban slum area of Dhaka municipality. Chapter 5 DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH 5.1 MANAGERIAL PROCESS FOR THE DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH It is now clearly recognized that the largest cost of any health system is the cost of thc human resources that operationalize the system. In the light of the aim of achieving health for all through the primary health care approach, efficient planning, production, placement, utilization and management of health personnel assume paramount importance, particularly in the context of the current slow economic down-growth afflicting thc world. Towards this end, WHO continued to support national efforts aimed at improving health personnelplanning, production, utilization and management. WHO'S fellowships programme provided the much-needcd support to national efforts in the development of human resources for health. Support was also provided to strengthen the planning of human resources for health in all the countries of the Region. In Bhutan, technical support was provided for the development of a master plan for human resources for health in relation to the Scveuth Five-Year Plan (1992-l(W7). In India, a study was undertaken to take stock or health manpower and rcquiremcnts by the year 2000. In Indonesia, the Second Workshop on Manpower Planning and Evaluation was conducted in October 1990. In Myanmar, astudy on the problemof attrition among doctors in government service was undertaken. In Nepal, support was provided for a review of the health manpower situation in the context of the health care system, while in Thailand, support was provided for developing long-term manpower plans for various categories of health personnel. Information on human resources for health is generally inadequate in most countries of the Region. Following the meeting of the WHO Study Group on the Role of Research and Information Systems in Decision-Making for the Development of Human Resources for Health, convcncd in Geneva in November 1989, a Consultativc Mecting on a Minimum Set of Information in Support of Policy, Planning and Managcmcnt of Human Rcsourccs for Hcalth was convened in Bangkok in October 1000. Efforts will now be made to support the development of information systems on human resources for hcdlih in a number of countries by applying the conccpt of the minimum set. The management of health personnel is a vital part of the development of human rc- sources for health. Support continues to bc provided for this vital activity, particularly in indoncsia, Sri Lanka and Thailand, covering various aspccts ofmanagcment. Efforts wcrc made to strengthen nursingand midwifcry human rcsourcc planningand managen1cnt. Assistance in thc upgrading or nurse managers and othcr nursing and midwifcry personnel continued through fellowships for advanced study, training and study visits in nursing management and clinical nursing in Bangladesh, India, Indonesia, Myanmar, Ncp;il and Sri Lanka. 5.2 RESEARC11 IN THE DEVELOPMENT OF HUMAN RESOURCES FOR HEALTH Efforts to increasc the capabilities of the countries in carrying out research into the dcvelopment of human resources for health continued. Towards this end, a Consultative Meeting on Management Research for Development of Human Rcsourccs for Hcalth was hcld in Bangkok in September 1990. The Consultativc Meeting rccommcnded that governments take necessary steps to create research cells in ministries of health or in existing national me~lical research councils to promote, coordin:~lc and conduct rcscarch into thc managcmcnt of hcalth pcrsonncl. It also rccommcndcd that the importance of rcscarch into the managcmcnl of health pcrsonncl be brought to the attention of the meetings of the Advisory Committee on Health Research and of the Directors of Research Councils. The meeting of Directors of Rcsearch Councils, held in November 19W, included rcsearch into human resources for health as an item on its agenda for technical discussions at the next meeting scheduled for 1992. In addition, national workshops on rc?.arch into the dcvclopmcnt of human resources for health were hcld in Y;~ngon, in July I'N0, in Chiaogmai, Thailand, in August l'm), and in Jakarta, in October 1W. The promotion of rcsearch in nursing was further strengthened. An Intercountry Consultation on Rcsearch in Nursing was hcld in Thailand from 24 to 28 June 1991 to follow up the recommendations of the fifteenth session of the South-East Asia Advisory Committee on Health Research relating to the development of rcsearch in nursing. This consultation aimed at identifying priority research areas and appropriate methodological approaches for research in nursing in the Region and also proposed strategies, mechanisms and plans for follow-up for promoting rescarch in nursing at country and regional levels. In spite of the increascd effort to promote the use of rescarch into the development of human resources for health as a means of rationalizing decision-making in the planning, production and utilin~ti~in of hcalth personnel, much rcmains to hc donc. Rational decision-making, hascd on faas rather than on intuition, remains elusive. Sincc the bulk of the health hudgcl is dcvotcd to thc cost of human resoi~rccs f~ir health, a small increase in productivity or cfficicncy in the use of human resources for health would result in substantial increascs in cost-effectiveness. The importancc ol decision-linked research into the development of human resources for hcalth will continue to be actively pursued in the Region. There is still a need lo rectigni;.c I hc importancc ofrescarch in nursingand lo dcvcl~,(i an explicit policy and plans for thc dcvelopmcnt ofrescarch in nursing in the Mcmhcr Countries, and to provide fin:mcial support to undertake those necessary rcscarch activilies. WHO will continuc to collaborate with Mcmber Countries in thc development of research in nursing in order to improve the quality of care. 5.3 MEDICAL EDUCATION Further progress WZIS ohscrvcd in ~hc efforts of the Mcmber C'ountrics to strcngthcn and reorient thc medical education systcms tit achicvc closer quantitative baklnce and political relevance lo their medical manpowcr development programmes. At the undergraduate level, the trcnds that were initiated in the past decade were furthcr reinforced with grcatcr community orientation of curricula, introduction of innovative education stratcgy, such as problcm-based learning, strengthening of educational management processes, cxpcrimcntingwith objective structured clinical and practical examinations and introduction of enquiry-driven stratcgy for acccleraling changes in medic:il cducati~in. The consortium of four medical schools in India whose activities arc coordinated hy the All India Institute of Medical Sciences, New Delhi, completed the first phase of its project, started in 1989, to reorienl medical education using health systcms research as the strategy. It is now entering the more ambitious second stage that will not only increase the magnitude and pace of change but is also expected to bring 20 other leading medical schools undcr the ambit oI the consortium. In Andhra Pradcsh, the University of Hcalth Scicnccs has, with WHO collaboration, cstahlishcd a Medical Education Unit, and is developing the infrastructure and personnel to coordinate health personnel dcvelopmcnt in the institutions undcr its charge. With WHO'S collaboration, the network of community-oriented educational institutions organized the second International Conference at Yogjakarta, Indonesia, under the theme of Prohlcm-hased Learning. This was attended by a large numhcr of representatives of medical schcx~ls of thc Region and the follow-up is expected to 1)I~VIII.OPMI:NI'OP IIUMAN RFSOIJRCIS FOR Illj\I.'l'l1 41 accelerate the introduction of problem-based learning in a number of conventional mcdical schools. Problem-based learning programmes have already been introduced on an cxperimcntal scale in a fcw schools in India, Indonesia, Nepal and Thailand. Myanmar, in collaboration with WHO, has completed the development of its ncw curriculum wherein problcm-based learning units have been introduced throughout the undcrgraduale education programme. They have also produced most of the relevant learning resource material and trained a group of core staff in implementing this innovative programme from the beginning of the new academic year. The experience that will be gained through this initiativewill no doubt be ofimmensevalue to other institutions planning to incorporate problem-based learning into conventional medical curricula. An intercountry workshop was organized in Thailand to develop a nucleus of medical educational leaders in the Member Countries who will be able to prepare medical undergraduates to meet the challenges posed by the emerging problem of AIDS in the Region. As a direct output of this workshop a number of innovative prototype curriculum segments havc been formulated and thesc will form the basis of the specific country and institutional level curriculum development activities that will be promotcd. This workshop al.co identified possihle mechanisms for using HIVIAIDS educational activities as an entry point in the overall strategics for the widcr goal of rcorienling mcdical educakion as a wholc. Specific curricular reforms or1 the lines recommended in the technical documents on the reorientation of medical cducation, published by the WHO Regional Office, are also being undertaken in Bangladesh, Indonesia, Sri Lanka and some of the leading institutions in India. On the basis of a review of WHO support to medical education programmes in Indonesia during the last decade, thc focus of the collaboration has bccn redirected with thc aim ofaccelcrating the diffusion of thc technical guidelincs dcvelopcd by the Consortiunl of Health Sciences down to the level of the medical schools themselves. Medical schools in Thailand havc further consolidated the innovativc medical education programmes that were launched in the past decade to bring about greatcr relevance to priority national needs and to improve community orientation in the training of basic doctors. The Institute of Medicine in Kathmandu is conducting a comprehensive review of the student assessment system with a view to dctcrmining its consistency with the actual health care needs ofthe community. There has bccn further progress in the devclopment of postgrad~iatc mcdical education programmes too. Technical support by way of consultancies and subsidics was provided to Bangladesh, Myanmar, Indonesia, and Sri Lanka for improving the competence of teachers, the quality of training programmes and the standard of examinations. The Regional Office, at the behest of a number of Member Countries and with the twin objectives of achieving greater relevance and efficiency as well as regional self-reliance, is exploring the possibility of expanding the avenues for further regional cooperation in postgraduate medical education. 42 THE WOKKOF WHO IN SFA The momentum of change generated in the last decade in reorienting medical education systems to produce physicians with competence and compassion who can serve the needs of whole populations, continues to be maintained in the Member Countries. Yet, the level of technical and financial support that will be needed by Member Countries to achieve the targets that they have set for themselves will remain high for a few years morc. Similarly, the Centres of Medical Education in Bangladesh and India have also been regularly conducting programmes for deans, principals and htaff of medical schools as well as for decision makcrs in ministries of health with the ot~rall eoal olimon~vinu ~ ~~~ --~~ -~~ r-- ~a the relevance of educational programmes. In addition, the Centre of Medical Education, Bangladesh, developed a task-oriented curriculum which is now being introduced in the medical schools in the country. However, the progress of development towards the establishment of active functional medical education units or cells in the medical schools has fallen short of the initial expectations. While it is true that most medical schools do possess core groups of teachers with competence in educational processes, the actual improvement of edu- cation practices to achieve greater relevance and efficiencyleaves much to be desired. 5.4 NURSING EDUCATION WHO continued to provide technical support for strengthening basic nursing education. Efforts were made to strengthen institutional frameworks, educational policies and teaching-learning resources for the implementation of community-oriented nursing curricula. Assistance in the upgrading of nurse teachers was continued through fellowships for advanced studies or speciality training in educational methodology or clinical nursing speciality. Efforts to ensure the quality of nursing education in preparing nurses for national needs were further promoted in the Region. In Myanmar, basic and post-basic nursing curricula were in the process of revision and a proposal for the establishment of the Bachelor of Science in Nursing programme was also being taken up. In Maldives, initial steps have been taken towards the first basic nursing education programme in the country. Efforts were also made to improve continuing education for nursing and midwifery personnel. In response to the increasing demand for better qualified personnel for the delivery of health services, especially for the upgrading of knowledge and skills of nursing and other health personnel in remote areas, a critical appraisal of the use of distance education to meet such challenges was carried out through an Intercountry Workshop on Distance Education for Nursing Personnel and other Health Workers, which was held in Thailand in October 1990. One of the recommendations arising from the Workshop was that Member Countries and WHO should lay emphasis on distance education as a means of meeting post-basic and continuing education needs of health personnel, particularly at the district health system level, and in rural and remote areas. India, Sri Lanka and Nepal plan to develop distance education programmes for their nursing personnel. Special attention was being paid to the improvement of the nursing and midwifery curriculum to better prepare graduates to comprehend the seriousness of AIDSIHIV infection, which is one of the major health problems and a threat to the world community as wcll as the Region. Multicentre field tests of "Teaching Modules for Basic Nursing and Midwifery Education in the Prevention and Control of AIDS", dcveloped by the Western Pacific Regional Olfice, were conducted in Myanmar, Nepal and Sri Lanka. In collaboration with WHO headquarters, studies on national activitics and needs in nursingimidwifcry education and in services for AIDSIHIV prevention and control in the Mcmbcr Countries of the Region have been conducted. The results will primarily be used to strengthen thc nursing component of national and regional AIDS programmes, especially in countries with the least nursing activitics and the grcatcs( nccds. In spite of the cfforts that have gone into the strengthening of nursing education in the countries of the Region, much remains to be done. Special efforts have to be promoted to further strengthen field practice areas of nursing education programmes so as to provide cffcctivc lcarning experiences for students. Special efforts arc also needed to coordinate the dcvclopmcnt of nursing services and education, so as to facilitate congrucncc between nursing services being practised and nursingcduwtion being taught in the educational programmes. Furthermore, although it is evident that the upgrading of nurse teachers, managers and clinicians is of crucial importance for the strcngthening of nursing services and education, institutional resources for post-basic and graduate nursing education programmes in the Rcgion remain limitcd. Even though consideration has been given to the strengthening of graduate nursing programmes in India and Thailand, greater support needs to be providrd in this area for the overall development of both nursing services and nursing education systems of the Region. 5.5 TEACHER TRAINING WHO continued its collaboration with the Member Countrics in consolidating the programme for thc development of the expertise of teachers of health professionals in their subjects as well as in the basics of educational science and technology. Although distinct improvements are perceptible, the resistance to change generated by adherence to traditionalvalues and practices and the lack of motivation still hinder the reorientation of the educational programmes in meeting the challenges inherent in the production of health workers with the competence and commitmcnt to supprt the goal of Health for All. 44 -. nIE WORKOP WHO IN SEA In DPR Korea, the training of academic staff was institutionalized and all the eleven medical and pharmaceutical universities now have their own education units for training teachers. It is now mandatory for all staff recruited to these universities to obtain a Diploma in Educational Technology of a year's duration from one of these units before they are confirmed as teachers. The Regional Teacher Training Centre at Chulalongkorn University Medical School, Thailand, has continued to provide training in different aspects of educational science and technology to many teachers from the countries of the Region. In response to increasing demand, this Centre has also started a Master's level programme in Educational Science and Health Manpower Research, which is gaining in popularity. The Regional Teacher Training Centre in Sri Lanka, which, at the moment, is rebuilding its capacity, has also conducted short-term training courses for teachers of health professionals in the country. WHO also supported the strengthening of research and educational capabilities of the academic staff of the State Medical Institute and the Medical Technicum in Mongolia. In Myanmar, staff were trained in the development of problem-based learning units for implementing the newly-designed PHC-oriented curriculum. Collaboration with the Consortium of Health Sciences in Indonesia included the continuation of programmes for staff development in problem-based learning and educational measurement and evaluation. In Sri Lanka, a consultant reviewed the educational technology being used at the National Institute of Health Sciences for the training of teachers of primary health care workers, and also revised the curricula and field training programmes. Another consultant assisted the Institute in streamlining the continuing education programmes for all non-medical health workers which come under its range of responsibilities. In Bangladesh, WHO support by way of consultants, fellowships and subsidies was extended to the de;elopment ofcducarional capabilities of teachers of medical schools as well asdo the Bangladesh College of Physicians and Surgeons. In Nepal, the Education Support Unit of the Instilure of Medicine continued regular trainingactivities for teachers and undertook a fewresearch studies to identify the strengths and weaknesses of some of the educational processes of the Institute. 5.6 HEALTH LEARNING MATERIALS Four countries, participating in thc UNDP-funded WHO-executed regional project, formulated national work plans and conducted 'needs and resources'surveyswith the assistance of consultants from the successful Health Learning Materials project of the Institute of Medicine, Kathmandu, which is a WHO Collaborating Centre in this field. An Intercountry Workshop on Distance Education for Nursing Personnel and Other Health Workers was held in Thailand in October 1990. Also, an Intercountry Workshop on Health Learning Materials Development was organized in Jakarta in DLVEL.OPMFNTOP HUMAN RFSOIJRC'ES FOR HFAl.111 45 February 1991. Training in the skills needed in the production of health learning materials is seen as an essential first step in the development of locally-specific health learning materials and in ensuring their use. Support was provided to the national health learning materials programme in Myanmar, while external financial assistance has been sought in support of the national programmes in Indonesia and Sri Lanka. It is estimated that, by the end of the first phase of the project, each of the four new countries participating in the network will be able to lay the foundation for a sustainable national health learning materials programme. 5.7 FELLOWSHIPS At the eighty-seventh session of the Executive Board, hcld in January 1991, the Director-General presented a report on the implementation of WHO'S policy on fellowships. The South-East Asia Region's contribution to the Director-General's report was based on country reports and used indicators and guidelines developed at the Third South-East Asia Regional Conference on WHO Fellowships, held in 1988. The Executive Board, in welcoming the report of the Director-General, urged Member Countries to take demonstrable steps to ensure the relevance of WHO fellowships to their health resource needs and national health development, to introduce or strengthen mechanisms to establish policies for planning, production and management of their human resources for health, and to evaluate their use of fellowships resources in order to ensure that their selection mechanisms are effective and that returning fellows are utilized in the best interests of the national health systems (EB87.R23). In this connection, the Regional Committee, at its forty-third scssion, held in September 1990, while reviewing the recommendations of the eighteenth meeting of the CCPDM, endorsed the view that the objectives of fellows should be clear to allow early nomination of suitable candidates, that submission of application forms should occur by September of the preceding biennium, and that it should be ensured that candidates meet the host institution requirements as well as the sponsoring government' s own requirements. Nevertheless, many countries still find it difficult to comply with the above recommendations. Of 2 176 fellowships budgeted for implemenlation during the current biennium, the Regional Office had received 1 212 FAFs at the end of the eighteenth month (June 1Y)l). WHO, on its part, is continuing to expendmuch effort in overcoming the difficulties and smoothing out the processing of fellowships. A review of the Fellowships Unit by a management expert was completed in December 1990 and the feasible recommendations arebeingimplemented, including greater use of the computerized fellowships information and monitoring system. Implementation Tuition fees for courses in institutions of some developed countries have increased enormously, resulting in high costs of fellowships. This underlines the need to explore more fellowshipslplacements within the Region, wherever appropriate. At the samc time, efforts should be made lo develop more centres of excellence within the Region so that the need to place fcllows in institutions abroad is reduced to the minimum. Another constraint being faced includes the insistence on English language capability by thevarious institutionssince, of late, it has been found that the standard of language $oficiency of candidates from the Region is not up to the requirement. There is an increasing trend to go in for more short-term study tours than long-term fellowships. While there may be certain advantages in this, it is an instrument which has to be used judiciously. Short-tcrm study tours are best suited to professionals with mature experience who can benefit from short, unstructured visits to other institutions and countries. Even so, squeezing too many visits into too short a period is likely to be unrewarding. Such factors do not seem to have been considered in a fair number of instances. Host institutions in some countries are also experiencing much difficulty in accommodating the increasing number of such ad ltoc study tours. As part of the efforts to improve the submission of fellowship application forms, the existing WHO application form is being reviewed to include up-to-date and clear instructions so that candidates are able to complete them without difficulty. This should lead to the arranging of placements sooner than at present. The tmplementat~on of rhc ~cllou.shtp\ programme requirts considerdble impru\c- men1 tmthe part of allconcerncd. In spile ofthe best efforrs ofthe RegiunalOfficudnd the countries, the implementation his bcen far from satisfactory. Table 1. Disrribiilimt oJfillowslri/~r intdcrllte WHO%@Iarbtr&,by mgicit oJstlrdy (1 Ill& 1990- 30Jllll~ 1991) Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Mongolia Nepal Sri lanka Thailand Total Percentage Mom lhon onc rtgion 05 02 - 36 18 - IS - - 10 02 88 16.33 52 10 43 IS2 62 13 511 44 35 59 19 539 1W.W Wtpien olsludy Amerles 06 01 - 23 08 - I I - 02 07 07 65 12.06 Wlslern Paetlle 05 - 11 09 15 - 05 08 - M 05 62 11.50 E,,n,Iw 09 01 30 L'J N - 0') 30 05 11 05 ------ 139 25.79 South-bsl Asla 27 06 02 55 17 13 10 - 28 27 - 185 34.32 For the 1W0-91 biennium, a budget of US$ 14 226 660 has been approved, out of which only 68.27 per cent has been utilized for the fellowships component up to June 191. This highlights the need to overcome the various problems and constraints in order to further improvc the management of the fellowships programme in the Rcgion. During thc period under review, 539 fellowships were awarded (Table I) under the regular budget at an estimated cost of US$4970 997. In addition, 87 fellowships from other sources, at an estimated cost of US$ 628 440, were also awarded. The mechanism of contractual services agreement was utilized to cover 64 fellowships (US$174 421). Placements were arranged for 327 fellows from othcr regions in the countries of the South-East Asia Region. WHO continues to promote and support the strengthening of institutional capabilities within the countries for training programmes, the emphasis being on "in-country" training. WHO provided assistance to countries for upgrading and further strengthening resource personnel to carry uui not only in-country training of nationals, but also, simultaneously, the upgradation of regional institutions into centres of excellence. The response to efforts to encourage more women to seek fellowships so that greater responsibility for them in their national health services can become a reality has not been adequate. The countries will thcrcforc hi$\? !GI cxcrt grcater cffort 111 cnccrur:jgr. marc womcn to tskc ;iJ\antagc of thc WI10 fcll~~u~liip$ programme. Thc di<lrihuti~ln oi fcll\~w<hip< I)) ex. ;lgc and duration, is given in Table 2, Table 2. Disfribrlfior~ offellowsl~ips, by sex, age and d~rratiort (1 July 1990 - 30 Jlole 1991) Over 55 21 3.90 'Total 539 i0C.30 I I Sex Male Fc'emalc Total 401 138 539 Duration Up to 1 (months) 1-3 4-6 7-12 Over 12 Total 74.40 3.68 1W.W 186 213 69 46 2( 539 3.51 39.52 12.80 8.53 4.M 100.W 48 '1'111 WOKKOF WIIO INSEA The distribution of fellowships, by professional category, is given in Table 3. Table 3. Distribrrtion offellowships, bvprofessiorl, under the regrlur brrdger (I J~rly 1990 - 30Jrrrre 1991) Table 4 gives delails of fellowship\ awardcd under various subjccrs of study and the country of origin of fellows. Dwlors Engineers Nurses Others Table 4. Disrribrrtiorr oJJ(:ll~~wships rr~rder the regrrlur brrdget, by subject ofshrdy u~rd corrrrly of origin offcllow (I Jlrly 1989 - 30 Jrrly 1990) 314 52 30 143 58.?6 9.M 5.57 26.53 I)l:Vlil.Ol'MliNTOP IlUMAN RISOIJR(:F3 I'OR 11PAI:l'11 19 In line with the fellowships policy, the Regional Office is also promoting the establishment of an adequate information base to improve the monitoring and evaluation of fellowships, since this area is considered to be in need of attention. Oirectory of Training institations in SEAR Coilntries With a view to assisting Mcmber Countries, the Directory ofTraining Institutions was rcviscd in 1990, and copies have been forwarded to the counlries. Efforts are being made to update the information so that the Directory is more comprehensive and informative. For this purpose, a short-term consultant was recruited. The consultant has already visitcd two Member Countries of chc Region, namely, Indonesia and Thailand. 1ni1)rniation has also been collected from other Member Cotlntries so that further updating can bc made to the respective chapters. Thc new Directory is cxpcctcd to he widcly distributed to Mcmbcr Countries shortly. (;roep Educational Activities During the period under rcview, 40 meetingslgroup educational activities were held, of which 33 were regional. There were also 7 policy and advisory meetings. A review showed that justifications for the meetings were clearly spelt out, that the objectives in respect of most of the meetings were achieved, and that the mcthodt adopted appeared appropriate for achieving these ohjcctivcs. In most cascs, follow-up activities have bccn initiatcd. These group educational activities, excluding policy and advisory meetings, consisted mainly of regional meetings, workshops, consultative meetings and 5hort training courses covering different subjects, such as self-care, wastewater and nightsoil reuse, MCHIFP programmes, LBW and infant morbidity and morlality, solid waste management, AIDS, health economics, PHC, HFA, polio eradication, diarrhoea1 diseases, nutrition, acute re5piratory infections, lcprosy, Corcst-relatcd malaria, EDV, EPI, etc. Table 5 shows the distribution of participants in intercountry activities, by type of activity. Table 5. Di.sfribufior~ of panicipor~is bt irltrrcolrr~fry ocli~ifies, by r)jz ofactiviy (I J~rly 1990 - 30 Jtrrle 1991) h'anlbrr orl,nrliclpnn~r - 90 204 218 43 555 Ilegional meetings Workshops Consultative meetings 'Total h'anlhrr 7 9 14 3 33 50 I'IIR WOKKOF WIIO IN SEA The participation of countries and the numbcr of participants in thcsc group educational activities are given in Table 6. Table 6. Panicipafior~ ofconr~mnes orld rll~rilber ofporfic~par~fs 61 ir~/crcol~r~m~y ofid i~~/eneoria/o~p ed~lcafiorlal acrivifics (I Jlrly 1990 - -30 Jlrrle 1991) Country h'an~hrr ornclivilics 1 Numbcrorpo~p~ Bangladesh Bhutan DPR Korea India Indonesia Maldives Mongolia Myanmar Nepal Sri Lanka Thailand Total 17 17 Y 33 34 17 14 30 31 31 37 270 Chapter 6 PUBLIC INFORMATION AND EDUCATION FOR HEALTH Information and Education for Hcalth, recognized as an integral component of thc hcalth care systcm, was further strengthened through various collaborative projects with Member Countries. The recommendations made at the lntercountry Consultation on Health Education Strategies in South-East Asia in the Context of HFA/2OlW, with spccial reference to the Prevention and Control of AIDS, held in the Regional Office in Dccembcr 19W, should providc the necessary impetus to the programme. The recommendations covcred, among other aspects, thc functions and roles of hcalth educators and the strategies to bc adopted to make hcalth education more cffccctive in the current decade. Senior health education officials from all the Member Countries of the Region participated in this important Consultation. At the country level, WHO'S collaborative activilies were aimed at strengthening the hcalth education infrastructure, training, production and use of health education materials and involvement of the media. To facilitate IEH activities in thc Rcgion, countries were providcd with necessary audiovisual equipment, public address systems, vehicles, teaching books and journals. There is however a strong need to make health communications more effective in the Region by improving interpersonal communication techniques, and with more appropriate use of the media. Local broadcasting and audience research are particularly needed. New directions include building alliances with other 52 THE WORK OF WllO IN SEA development sectors, including nongovernmental organizations, women and youth groups. In Bangladesh, steps are beingtakcn by the Ministry of Health to integrate thc Bureau of Health Education with the Family Planning Unit, while in Bhutan, an IECH (Information, Education, Communication for Health) Bureau will be established shortly. Toexpand the availability of trained human resourcesin health education, fellowships to provide short-term training, master's certificates and diplomas in health education were availed of by Bangladesh, India, Indonesia, Myanmar, and Sri Lanka. Activities are also taking place to rcvicw training programmes and health education curricula, as in Thailand, and provide in-service orientation courses to sanitary and health inspectors, as in Bangladesh. Hospital health education is also gaining attention; various programmes in hospital health education were conducted in Sri Lanka and technical guidance was provided in Maldives. In keeping with the growing awareness of the need to strengthen school hcalth education in the Region, a case report on school health education in Nepal has been added to the list of reports received earlier from four other countries - India, Indonesia, Sri Lanka and Thailand. InSri Lanka, trainingwas imparted to300teacher trainers from the Education Department. Intersectoral collaboration for school health education is conceptually accepted but there is an urgent need for strong advocacy to further strengthen joint involvement of the health and education sectors. With WHO collaboration, health education organizations in the Region continue to produce a wide range of prototype health education materials, including video films, as in India and Thailand. In Thailand, efforts are also being made through training workshops to mobilize folk artistes to carry health messages. Health hehaviour research is being planned in Myanmar while other research activities include conducting studies on the utilization of health education materials and the compilation of an annotated bibliography on health and health education in India. Field tests of tools developed in Bangladesh for undertaking evaluative studies in health education are also being undertaken. In Thailand, research into the country's history of medicine and public health is being undertaken with the production of a pictorial document which will contribute to future public health policy and development. To optimize material production and use, there is an urgent need for intrasectorai collaboration between the health education bureaux and other health programmes. Thisis alsonecessary for more planned efforts in reaching messages out to the people. PIJIII.IC INFORMATION AND EDUCATION I'OR HFAL.TH 53 As in previous years, specific activities were carried out on HIVIAIDS education and counselling. An intercountry Workshop on Developing Counselling Procedures and Materials for Prevention of AIDS was held in New Delhi in November 19%l and was attended by counsellor traincrs and health personnel from nine countries. This was followed by a national workshop on counselling skills in Maldivcs for health workcrs, tcachcrs, the mcdia, national security service personnel, NGOs, etc. Tcchnical guidance was also provided for the establishment of a national cancer control programme in Maldives. Incollaboration with the World Assembly ofYouth (WAY), it is planned to further involve youth in health through an intercountry workshop focusing this time on their mobilization for the prevention and control of AIDS. With the health education bureauxlunits in Member Countries as focal points for the production and dissemination of information and education materials in the national AlDS prevention and control programmes, a wide range of both public information and education materials, as well as training materials for health and other workers have been produced. In addition, seminars for women's groups, teachers, etc., have been organized. A campaign against AIDS through the trade unions is being organized in Thailand in collaboration with ILO. The Sri Lanka AlDS Health Education Programrnc was reviewed and assessed in June 1991. Anti-smoking cducation programmes were particularly significant during the period under rcvicw. Thc World No-Tobacco Day was observed across the Region on 31 May 1991 In Bangladesh, India, Indonesia and Thailand, anti-smoking activities were specially reported in the areas of surveys conducted on various aspects of smoking, awareness raising programmes in schools, exhibitions, media competitions and national conferences. In Bangladesh, the Health Education Bureau provided leadership in a number of action areas including a ban on advertising of cigarettcs ovcr thc mcdia and a ban on sponsorship of sports activities by tobaccomanufacturing firms. Nominations for the 'Tobacco or Health' medals were received from Bangladesh, Bhutan, Indonesia, Myanmar and Thailand. Involvement of the media for IEH in Member Countries has accelerated with the increasing use of radio, TV and newspapers in disseminating health information. Journalists and media persons in Indonesia and Sri Lanka were provided orientation on important health issues through regular media seminars. World Health Day, No-Tobacco Day and World AIDS Day generated extensive media interest in the Member Countries with wide coverage of important health-related issues in newspapers, and by radio and television. These days were observed equally enthusiastically by nongovernmental organizations and academic institutions involved in health and health-related work through exhibitions, talks, seminars, rallies, essay and painting competitions, etc. Information kits on the themes pertaining to the days were distributed throughout the Region by the Regional Office. Two additional kits on 'Safe Motherhood' and 'Drug Dependence - The Dead End', prepared by the Regional Office, were also distributed. A special issue of World Health magazine dcvotcd to thc South-East Asia RL~' ' 71on and with contributions from nationals was published. The folio containing a sample of health education materials developed in the Region for the Prevention and Control ofAIDS, published earlier, was reprinted to meet country requests as was the briefing booklet, Essence of Cooperation. World Health Day this year focused on Disaster Preparedness and evoked widespread interest in the Region, by the governments, media, academic institutions and nongovernmental organi/ations. To mark the day, activities reported from thc countries included exhibitions, seminars, health talks, poster and painting competitions, panel discussions, etc. Information kits on the theme were widely distributed and adapted in the Member Countries. The Regional Director's World Health Day broadcast was beamed by All lndia Radio tomany countries in thc Region and tapes of the broadcast as well as the Director-General's message, both for radio and television, were sent to Member Counlries for their use. Information on WHO'S activities was provided to an increasing number of pcoplc through briefings in the Regional Office as well as through the provision of materials, includingvideo tapes, to various government and nongovernmental groups. A source book of health education materials for drinking water supply and sanitation projects is being prepared. Collaboration with other agencies continued. Together with UNICEF and UNFPA, WHO is part of the resource group responsible for the design and display of an exhibition based on the small family norm and age at marriage lo be pul up at thc India International Trade Fair in New Dclhi in November 1991. In Octoher I'Ml, WHO contributed to ESCAP for their Regional Plan of Action in support of Education For All. The WHOIUNESCO AIDS Education and Health Promotion Materials Exchange Centre for Asia and the Pacific, established at UNESCO PROAP in Bangkok, issued, in January 1991, the first edition of a resource directory containing organizational profiles and an inventory of materials received from India, Mongolia, Nepal and Thailand. The Region participated in the Pacific Rim Youth Conference organized by the Students Initiatives in Community Hcalth in Sydney, Australia, in August 19%. Health administration and health education specialists from countries and the Regional Office participated in the 3rd International Conference on Health Promotion, Sundsvall, and in the XIV World Conference on Health Education, Helsinki, held in June 1991. . - Health Education The emphasis of health education and information activities is on helping people to protect and promote their health. Involvement of women and children in IEH activities is increasingly beina strenothened in the Region. Nutrition Promoting theuseofappropriateand available weaningfoods is a major emphasisof health workers in the~r interaction with mothers to tackle the severe problems of undernutrition in the Reg PIJIII.IC INFORMATION AND EDUCATION FOR 11EALTIX 55 Health promotion for the staff of the Regional Office received special attention. Beginning with a panel discussion on an integrated approach to health promotion activities, including creating staff awareness on lifestyle diseases and their prcvention are being carried out. Even though health education has contributed to a significant cxlenr to the health litcra~y of the populations in the Region, new directions and strategies must be considered to mobilize communities for health action. Advocacy roles for health educators and efforts towards social mobilization for health must receive special attention. I I Section Ill i HEALTH SCIENCE AND TECHNOLOGY Chapter 7 RESEARCH PROMOTION AND DEVELOPMENT INCLUDING RESEARCH ON HEALTH- PROMOTING BEHAVIOUR The objcctives of the regional research programme are to strengthen national research capabilities and to promote and coordinate research activities on regional priority health problems, including those on socio-behavioural and economic aspects pertaining to health. In this endeavour, the WHO South-East Asia Advisory Committce on Health Research (SENACHR) serves as the main advisory body to the Regional Director on matters of policy. The Regional Office also receives technical advice from the subcommittees oISEA1ACHR as well as scientific working groups convened by the Regional Director from time to time. The biennial mcetings of Directors of Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relcvant Ministries (MRCs) serve as an important means of obtaining the views of Member Countries on the strategies for research promotion and development in general as well as information on the implementation status of specific research programmes. The scventccnth session of SENACHR was held in Yangon, Myanmar, from 21 to 27 April 1091. It reviewed the regional research programme as well as the report of thc Regional Office on the broad range of activities being undertaken to provide information support for research, especially the functioning of the HELLIS system, as well as the efforts of the Special Programmes. The Regional Office identified weaknesses in the HELLIS system, especially in the linkages within the countries, and SENACHR made a number of recommendations to further strengthen information support for research. SEAIACHR was also informed of the consultative meeting to 58 THE WORKOP WHO IN SEA .- develop criteria for the appraisal of HSR project proposals. Three sets of attributes for the appraisal of projects were described: the scientific, utility and contextual. Based on this framework, criteria pertaining to each one of these attributes were developed. SENACHR appreciated the importance of this consultative meeting for the development of health systems research in the Region. The framework and criteria for the appraisal of HSR will help in identifying HSR projects which are scientifically sound and relevant to user needs, and will be useful for promoters, supporters and evaluators of HSR as well as researchers themselves. The technical subjects discussed at SEAIACHR covered areas of research in health care delivery in villages and slums, research in the control of cancer in developing countries, and research into youth (and adolescent) behaviour as related to health. In discussing the follow-up actions to the WHO Technical Discussions at thc Forty-third World Health Assembly on the role of health research in the strategies for HFNW, and the World Health Assembly resolution on the subject, it called upon institutions andscientists in thecountries to respondeffectively to the challenges contained in the Assembly resolution and recommended that WHO cooperate with countries in developing national plans of actions in response to the resolution. ACHR also discussed the need to identify a strategic plan for its own activities for a period of five years and agreed on the need for greater emphasis in providing advice for research capability strengthening, especially with respect to overcoming the difficulties of translating the aims and objectives into practical programmes. This strategic plan would be linked to the operational paragraphs of the Assembly resolution. Theseventh meeting of Directorsof Medical Research Councils or Analogous Bodies and Concerned Research Foci in the Relevant Ministries (MRCs) was held in Kathmandu, Nepal, from 4 to 9 November 1W. It reviewed the collaboration between WHO and medical research councils in the South-East Asia Region, and affirmed that the present practice of conveningregular periodicmeetingsof Directors of National Medical Research Councils is useful and should be continued. Participants at the meeting were of the opinion that efforts should be made at the national level togenerate a climate conducive to the development of research culture. It was important to develop the infrastructure necessary for implementation of the recommendations of the meetings of Directors of Medical Research Councils while nationalmechanisms should be established for the coordination of research activities. Regular meetings at which the research community and health care managers arc fully represented would further the achievement of these objectives. In discussing the role of health research in the strategies for HFNUXW, the MRCs meeting endorsed the call for action embodied in the World Health Assembly resolution and the viewpoints expressed in the preamble. The meeting further called upon medical research councils and analogous bodies to respond effectively to the challenges contained therein, and agreed that health systems research is essential for every country irrespective of the level of economic development and is not a luxury. Participants called for the formulation of a plan for national action to respond to the Assembly resolution. They alsodiscussed mechanisms to promote national capability for self-sustained research and the role of traditional systems of medicine in health care delivery. In response to the importance of nutrition in Health for All strategies, the Regional Office supported a meeting of concerned scientists inThailand. The first Consultative meeting of the South-East Asia Nutrition Research-cum-Action Network took place in Thailand in August 1990 One of the major objectives of this Network was to help bridge the gap between rcsearch scientists and health managers. The former often felt that decision-makers could make better use of their results in planning nutrition programmes; the latter, on the other hand, feel that more research to help solve operational nutrilional problems should be undertaken. The other objectives of the Network include the identification of major nutritional problems in the South-East Asia Region; strengthening of nutrition research- cum-actioncapabilities; promotion of selected priority research-cum-action nutrition projects; promotion of training programmes; and cxchange of experts, scientists and programme managers to facilitate realization of the above objcctives and to share information on priority nutrition research-cum-action matters of mutual interest and concern to the countries of the Region. Several priority operational issues in nutrition at the primary health care level, and amenable to research-cum-action projects, have been identified jointly by Member Countries and collaborating centres. Four important areas identified are: weaning foods to overcome protein-energy malnutrition in young children, anaemia in pregnant women, reduction of the prevalence of vitamin A deficiency and nutritional monitoring. The Regional Office will support some of the Network activities. The dengue haemorrhagicfever (DHF) vaccine development programme, supported by the Regional Office, has been progressingsatisfactorily at the WHO Collaborating Centre for Dengue Haemorrhagic Fever (DHF), at the Department of Pathology, Mahidol University in Bangkok, Thailand, where work is in progress on the development of dengue vaccine and immunological reagents. Since vaccine development is a major project being supported by the Regional Office, a peer review mechanism has been set up to provide direction in this research effort. The Eighth WHO Peer Review meeting was held at the WHO Collaborating Centre for Research on the Immunopathology of Dengue Haemorrhagic Fever, Mahidol University, Bangkok, Thailand, on 29-30 September 1990. One hundred and fifty-nine human subjects have received one or more of the candidate attenuated vaccines. There have been no disabling untoward effects, and up to 90 per cent of subjects have 60 - THE WORKOP WHO IN SEA seroconverted and maintained neutralizing antibody for a period of years. After a review of the datapresented, it was recommended that another trial of the trivalent vaccine be conducted in flavivirus nonimmune adults using the dilutions of vaccine in a total volume of 1.0 ml. The members also recommended that once an acceptable combination of Dengue 1,2 and 4 vaccines is found for adults, a study may proceed in children. The dengue vaccine development programme is now receiving international recognition. The sixteenth session of SEAJACHR, held in April 1990, reviewed the research programme in tuberculosis and recommended renewed thrust and intensification of research. Based on this recommendation, the Regional Office convened a meeting of a Task Force on Research in Tuberculosis in December 1M. At this meeting, lacunae in the research programme in relation to the problem of tuberculosis in the Region were analysed and research protocols dealing with nine important areas were developed. These included the identification of risk factors for diseases; the risk factor for infection; operational research for improving the cure rate; programme monitoring and disease surveillance; assessment of the protective effect of BCG revaccination; the role of X-ray examination of the chest; centralized sputum examination to improve the quality of coverage; the use of combined drug tablets for the treatment of tuberculosis; and operations research for the attainment of a high cure rate in district TB control programmes. These protocolswill be circulated to the countries for their consideration and use in promoting research on tuberculosis. The Regional Office continues to support investigator-originated as well as collaborative research projects. A total of 34 new research proposals were received in 1990 and, up to March 1991, eleven had been funded. Seventeen projects are still awaiting revision by the Principal Investigators and further review. Sixty-seven research projects are currently being supported; of these, 38 are concerned with communicable diseases (acute respiratory infections, dengue haemorrhagic fever, diarrhoea1 diseases, Japanese encephalitis, liver diseases and malaria), 3 with environmental health, 4 with health of the elderly, 6 with health manpower development, 7 with maternal and child health, one eachwith mental health, nutrition, operational research and primary health care, and 5 with other things. Research capability strengthening has been an inherent part of the RPD programme from its inception. Fourteen awards were made for Visiting Scientist Grants and Research Training Grants during the period 1990-1991. The fields of research of these grants were tuberculosis, hepatitis, diabetes and statistical methods, among others. There are a total of 66 active WHO collaborating centres with a wide scope of functions ranging from health programme development to cardiovascular diseases. Some 20centres are related to the programme areas of disease prevention and control as compared to 16 centres concerned with diagnostic and therapeutic technology. A KLSMKCH PROMOTION AN11 DI.VFI.OPMF.NT 61 -- Directory of WHO Collaborating Centres in South-East Asia, giving the terms of reference, institutional profileand information on thegeneral activities of the Centres as well as on the specific activities undertaken as a WHO Collaborating Centre was published in 19!M. Thc South-East Asia Regional Office now lays grcatcr emphasis on thc promotion and development of hci~lth systcms research. A separate budgcl line has been provided for l!M-1991 for the strengthening of rcscarch capability of institutions in the Region, especially for undertaking hcalth systems research through a system of providing institutional strengthening grants (see Section 3.3 for details). The Research Promotion and Development programme of the Regional Office thus encompasses activities ranging from promotion of research through scientific meetings to research capability strengthening through the provision of visiting scientist grants and research training grants; establishment of WHO collaborating centres; promoting mechanisms for rcscarch promotion and development at the national level; and providing direct support to research projects, including projects initiated and monitored by the various technical units in the Regional Office (details of which arc provided in the respective reports of these units). However, this is only one facet of thc total rcsedrch effort of WHO. These activities have to he considered together with sevcral other inputs. Substantial contributions arc also made by the various WHO Special Programmes such as the Programme for Research, Dcvclopment and Training in Human Reproduction (HRP), the Programme for Research and Training in Tropical Diseases (TDR), and the Global Programme on AIDS (GPA). In addition, some Member Countries utilize the WHO country budget to promote and support research activities. It is clear that the total of all efforts for research promotion and development is considerable. Chapter 8 GENERAL HEALTH PROTECTION AND PROMOTION 8.1 NUTRITION WHO has continued to support national activities and programmes to strengthen the sharing of the considerable experience that is available on nutrition programme implementation, promotion of relevant effective strategies against the major deficiencies, human resource development and appropriate research-cum-action. All the countries of the Region have programmes against the main nutritional deficiencies to which their people are prone: protein-energy malnutrition, iodine deficiency disorder (IDD), Vitamin A deficiency (VAD), and anaemia. The achievement of the nutrition goals of the Region demand, in largc part, action on behalf of families supported by service providers. Well-trained peripheral health workers can be important and effective change agents in achieving such family-level action. They complement the broader developmental policy actions needed to deal with the economic and agronomic causes of malnutrition. The importance of a cohcrent and problem-oricnted training programme in support of such family action has been clearly demonstrated by the Joint WHWUNICEF Nuttilion Supprl Programme (JNSP) in Myanmar. The report of this programme is being processed as a SEAR0 Regional Health Paper. The lessons demonstrated are replicable in other countries. It is now fully integrated with regular government services. The programme has proved sustainable as well as technically sound. Posts previously supported by JNSP are now included within the normal structure. Support was given to further streamline the nutritional (iENF.K/\I. lIEALl?l PROTF1710N AND PROMOllON 63 - monitoring and surveillance system to ensure that it serves both local-level needs and those for central planning, rapidly and effectively. WHO supported the strong emphasis on appropriate performance-based training in relevant nutrition through JNSP in Nepal so as to ensure that appropriate nutrition is included in the training of community workers (based on their newly-defined job descriptions) and of thcir supervisors. Nutrition was integrated within the existing training system a1 all levels. There is a renewed confidence that iodine deficiency disorders (IDD) as a major public health problem can be eliminated in all countries by the year 2000, as resolved by the Forty-third World Health Assembly in 1990. Countries in the Region have already made rcccnt studies in this respect. In October 1W, a workshop was held in Delhi at which progrcss was assessed and practical managerial issues discussed, new techniques for monitoring iodine in salt at the community level demonstrated, and conclusions drawn for national activities and regional support. Much research in nutrition has been undertaken over the decades by a number of renowned institutions in the Region. The results of some of this research have been utilized for improving programmes so as to achieve a better nutrition status for thc people of thc Region. But scientists are often frustrated that, in their view, decision-makersdo not use thcir results in planningprogrammeswhile plannersolten complain that thc research they need to help them solve their operational nutrition problems is not bcing undertaken. Partly to resolve this issue the South-East Asia Nutrition Research-cum-Action Network has been started. The first consultative meeting on the Network took place in Thailand in August 1990 with WHO support. The Network has six aims and objectives for the benefit of the Region, namely: (1) to identify major nutritional problems; (2) to strengthen nutrition rescarch-cum-action capabilities; (3) to promote selected priority research-cum-action projects; (4) to promote training programmes in the Region for nutrition research-cum-action; (5) to exchange experts, scientists and- programmemanagers, and (6) to share information on priority nutrition research-cum-action matters of mutual interest and concern to Member Countries of the Region. A mechanism for the Network consisting of focal points in each Member Country, and four collaborating centres in nutrition with the Regional Oflice acting as a clearing house, was devised. Research-cum-action projects have been designed to deal with priority operational issues in nutrition in primary health care decided on jointly by Member Countries and the collaboratingcentres. The first issue of a Newsletter was distributed in March 191. 61 lliE WORKOF WHOIN SEA The countries of the Region are all, to some extent, in a period of transition with regard to priority nutrition problems. While protein-energy malnutrition remains a serious impediment to human development, its epidemiology is changing. Urban migration means that millions of poor people are moving to a cash economy and have to adapt to new potential food ways. As female employment increases, there will be potential changes in the pattern of breastfeeding and weaning. Both these lactors influence the prevalence of protein-energy malnutrition. Data from various sources analysed in the Regional Office indicate that currently about half of the infants and under fireyear old children in the Region are stunted. Environmental destruction and degradation are expanding exponentially. This has, as yet unchecked, effects on the availability of food and water as well as on their quality, and, consequently, on the epidemiology of malnutrition. Some regional countries appear to be in a transition between a rural-based and an industrialized economy. Their increasing populations are becoming subject to lifestyle-related diseases now common in the already industrialized countries. A major lifestyle factor is diet. TheRegional Office isstudyingin depth issues pertaining to such a transition, and expects to report its findings next year. 8.2 ORAL HEALTH The lack of oral health manpower, inappropriate training of health personnel working at the different levels of the health service infrastructure in the prevention of oral diseases involving caries, poor oral hygiene and ineffective health education of the masses, coupled with the relatively low priority given to oral health are the major factors contributing to the deteriorating oral health status in the Region. Studies in Myanmar show that 80 lo '90 per cent of children between 6 and 12 years have gingivitis. In the 35-44 year age-group, oral hygiene was found to be poor and 25 per cent is estimated to have advanced periodontal destruction. A national epidemiological study carried out in India revealed that, in children of5 years of age, the number of DFT and DFMT varied from 5.3 in Assam to 6.4 in Meghalaya and Nagaland. InThailand, in children aged3 and6 years, the percentages of dental caries have been found to be as high as 67.2 and 81 respectively, with the average number of affected teeth being 4 and 5.5 respectively. The situation, which is similar in other countries, demonstrates the need for increased epidemiological and other fundamental research aimed at determining the most important socioeconomic, health, dietary and other factors contributing to the deteriorating oral health in the Region. The wide gap between the needs of the people and the availability of dental health care continues to be a concern for health authorities in the Member Countries. GENEKAI. HEALTH PROTE(TI0N AND PROMO'TITION 65 Epidemiological assessment and critical reviews of the existing health service infrastructures for oral health are essential for improving prevention, treatment and rehabilitation, reduction of incidence of periodontal diseases, and for improving the existing status of oral health. With this in view, WHO collaboration has mainly been focused on the training of national oral health personnel, enhancing the services through- better utilization of existing health service infrastructures and providing logistic support to improve institutional capacities. 8.3 ACCIDENT PREVENTION Rapid urbanization, industrial expansion and unprecedented increase of vchiclcs coupled with high traffic congestion, poor road condilions, inadequate enforcement of traffic rules and the lack of proper safety in industrialization and mechanization of labour in all spheres of life have contributed to increasing rates of accidents. For example, the fatality rate of 5.9 per 1000 vehicles in India, where the accident rate is more than 30 per 1 MYJ population, is found to be much higher compared to some highly industrialized countries. Existing knowledge and available technologies are still not utilizcd effectively for the prevention of accidcnts and injuries, which have emerged as one of the five leading causes of death in most of the countries of the Region. The Eighth International Congress on Burn Injury was held in New Delhi in November 1WO and the International Conference on Traffic Safety (ICOTS 91), sponsored by WHO, was also held in New Dclhi, in January 1W1. The latter adopted the "Delhi Dcclaration on Road Safety" with particular emphasis on"vulnerable road users". Based on the Dcclaration at ICOTS 91, a series of recommendations were made for implementation in the near future in India. Among othcr things, the establishment of a special intersectoral Road Safety Research Coordination Standing Committee, under the auspices of the National Road Safety Council, was recommcnded. In Indonesia, a national seminar on childhood injury prevention was conducted in November 1!Wl with a view to creating awareness in regard to childhood accidents and injuries. 8.4 TOBACCO OR HEALTH Though Tobacco as a health problem has been recognized by WHO for about two decades,this subprogramme area,withits ownidentity,wasintroduced intothe WHO programme classification only in the Eighth Gcnerdl Programme of Work, beginning M THE WORKOF WHO IN SEA in 1990. Twocountries of the Region,viz., Indonesiaand Thailand, have made specific budgetary provisions for Tobacco or Health (TOH) programmes. In other countries, activities related to TOH are funded from other country programmes, mainly those related to cancer control, noncommunicable diseases, or research. But even where specific TOH programmes have been initiated, it has become clear that they have to stay well integrated within general programmes for health promotion and disease control. As far as legislative and administrative measures for the control of tobacco use are concerned, these have been implemented with commendable speed in several countries of the Region. Smoking has been prohibited in all airconditioned public places, includingdomestic nights and buses, in Thailand. Indian airlines have decreed all domestic flights smoke free, beyond the previous limit of 1''~ hours flying time, while smoking in all government offices and health facilities is prohibited in a number of countries. The movement for a 'smoke-free Bangladesh' has continued in Bangladesh through NGOs, with the highest government support. The movement towards tobacco-free districts in Bhutan has proven to be a community-based rather than a centrally imposed activity, thereby considerably improving the chances of its sustainability. Three regional symposia on tobacco or health, to be followed by a national conference, will pave the way towards a National Tobacco Control Programme in India. With WHO assistance, Mongolia has taken preparatory measures for legislative and administrative action to reduce smoking in the country. A stepwise reduction in the import of tobacco has so far not led to any untoward reaction by the country's population. In a unique pecr-to-peer youth programme in Sri Lanka, a youth group in Ciampaha district has motivated hundreds of smoking youths to quit and to join activilies for a drug-free life. The fourth World No-Tobacco Day, 31 May 1991, was observed in all countries of the Region. The theme 'PublicPlaces - Better Be Tobacco Free'proved to be ofgreat gcneral appeal and received wide press coverage. It has become obvious that the right of non-smokers to clean air is a powerful component of the anti-tobacco movement. Chapter 9 PROTECTION AND PROMOTION OF HEALTH OF SPECIFIC POPULATION GROUPS 9.1 MATERNAL AND CHILD HEALTH, INCLUDING FAMILY PLANNING WHO'S collaboration with Member Countries in the delivery of an integrated MCHJFP component of primary health care continued in close liaison with UNICEF, UNFPA and professional and nongovernmental organizations. An emphasis on maternal care, initiated after the International Conference on Safe Motherhood, was evidenced by all countries of the Region during the reporting period. Increased efforts, including the encouragement of meetings at the country level, are being made by the Regional Officc to work out appropriate strategies and plans of action for functional integration of associated child health programmes, such as EPI, CDD and ARI, into MCH. Efforts now being directed at improving maternal health have focused on the need to adopt a holistic approach in the delivery of MCH services. While more emphasis is being laid on perinatal care as a whole, some specific problems in the early neonatal period, namely birth asphyxia and hypothermia of the newborn, are receiving closer attention. Both conditions have specific adverse effects on low birthweight infants and, given the high incidence of low birthweight in the South-East Asia Region (the average is approximately 25 per cent), these conditions assume great importance. Though accurate data are not available, estimates suggest that about 1.2 million infants die and an equal number suffer from brain damage each year in developing countries due to birth asphyxia. Interventions being promoted commence during pregnancy and delivery with the detection of risk factors, followed by proper management of birth asphyxia and prevention of hypothermia, strengthening of 68 THE WORK OF WHO IN SEA referral systems, training and operational research. Specific reference needs to be made to two studies supported by WHO, namely, a hospital-based study on thermal control of the newborn in Nepal, and a community-based KAP study of delivery practices related to the management of birth asphyxia and hypothermia in Indonesia. An extensive a$sessment oC maternal care was launched by Indonesia in the last quarter of 19% The one-year WHO-executed project titled "Development of a National Strategy and Plan of Action for Safe Motherhood is the first step in the assessment process. Expected outputs include a systematic assessment of midwife training curricula, facilities and development; an analysis of existing constraints (socio-cultural and other) impeding the effective delivery and utilization of services; specific provincial strategies for reducing maternal mortality in high-risk groups; and a five-year plan of action with resource estimates for achieving set targets. Both national and international consultants have been fieldcd for the review and assessment activities. After the August 1990 National Seminar on Safe Motherhoodin Maldives, plans havc been drawn up to train medical officers and senior community health workers in essential obstetric functions. In addition, recognizing that child-spacing is an important factor in the reduction ofboth maternal and infant mortality, senior family health workers have been upgraded with three months' intensive training in order to supply contraceptives a1 the island level and to supervise and assist foolhumas (traditional birth attendants) in safe delivery practices. To further reduce maternal mortality in Mongolia, emphasis is being laid on child spacing, with senior medical officers visiting China and the Republic of Korea to exchange information and gain experience. The objectives of a newly-formulated UNFPA project "Strengthening of Family Health Services" in Mongolia (1992-1995) include increased use of modern contraceptive methods, training of doctors at the Aimak and inter-Somon levels in modern contraception and evaluation of thc impacl of population-related activities. A national conference on family planning and safe motherhood is being planned for the third quarter of 1991. The family planning programme in Bhutan has been expanded with the use of long-acting injectables after successful clinical trials in three areas, and medical officers will be trained in non-scalpel vasectomy. Under a special project in maternal health care, Bangladesh plans to train 62 doctors in essential obstetric functions. The project "Family Planning Clinical Supervision Team" continucs to assist the Government of Bangladesh in the maintenancc of quality of voluntary sterilization and clinical contraceptive se~ces. The project had its final four-partite review in March 1991. A reduction of infant mortality has been seen in most countries of the Region as a result of the collaborative child health activities that have been undertaken. During this reporting period related activities have included postpartum care and

ealth It i~~ell-~~cogrnred that the foundations of good health arelald early inlite. Uue empnasls 1s oclny ywt.b~ I school health in the Region and to child-to-child programmes so that the lnessageof good health is carrir to all homes counselling; combating acute respiratory infections and diarrhoea1 diseases; training of traditional birth attendants in safe delivery; and dissemination of knowledge through such mediaas the "Handbook for Delivery ofcare to Mothers and Children". Support has been provided for the training of midwives in neonatal care in Sri Lanka and for developing a model for the detection of congenital hypothyroidism in neonates to prevent mc~~tal retardation in Thailand. Management continues to be recognized as an important component in the service delivery of any programme. An Intercountry Meeting on Strengthening of Management in MCHIFP Programmes was held from 27 to 31 August 1990 in the Regional Office with ten countries participating. An ove~ew of past WHO efforts to support management development in health was presented along with descriptions of some ol the specific methods currently being used in the Family Health Division. Limitations of trained human rcsources in MCHIFP programmes arc still a problem insomeSEARcountries and WHO has continued tosupport the trainingofMCH1FP personnel through study tours and fellowships. Five medical officers from Nepal visited Thailand for two-weeks' training in minilap; six visited Indonesia for two weeks' training in Norplant; five went on study tours of four weeks' duration and one for two weeks to review MCHIFP programmes in Indonesia and Thailand, and one was awarded a fellowship of two months for training in the use of computers in Thailand. Eleven medical officers from Mongolia were awarded fellowships of three months' duration for training in dilferent advanced fields of medicine in Czechoslovakia, Germany and Poland. Under the Thailand UNFPA project, one fellow is studying for an MPH in the USA and one fellow from Maldives went to Thailand for studies in population and family pliinning. A manualon MCHlFPfor hcalth workers in Bhutan has been published with technical assistance from the Regional Olficc. Curriculum development for training doctors from Bangladesh in essential obstetric functions is under way. Support was provided for the conduct of various research projects, including those under the Safe Motherhood Operational Research Programme in Bhutan, Indonesia and Nepal, and a multicentre study of low birthweight and infant morbidity and mortality (India, Ncpal and Sri Lanka). The study of "Knowledge, Attitudes and Praclicesof Mothers-in-law" in Nepal was completed in September I990 with lindings presented in a national seminar in early 1581. The results indicate that the training of mothers-in-law in safe delivery has provided positive inputs to change the practices of their daughters-in-law and is a viable strategy to reduce maternal morbidity and mortality. This study design will be extended to other parts of Nepal, India and Bangladesh, where mothers-in-law play an important role in decisions concerning the health practices of their daughters-in-law, especially during pregnancy. 70 - THE WORKOF WHO IN SEA WHO is continuing to support research in child development, including child development indicators. In this context, a multicentre study on the development and testing of techniques for monitoring physical growth and psychosocial development was initiated by WHO, with study centres in Thailand and India. The study on low birthweight and infant morbidity and mortality in India, Nepal and Sri Lanka has been completed and the individual study centre reports are being prepared. Multicentre data analyses and reporting of findings will be carried out by the Regional Office. The study in Pune (India), initiated with full support from WHO for the last three years, has been extended for an additional four years with UNICEF funding and WHO technical support in order to follow the development and survival of the cohort of over 3 000 infants. The Sri Lanka centre will continue to follow up its cohort of infants up to the age of three years, studying growth and developmcnt and child survival. Myanmar has undertaken a prospective study of thc influence of socioeconomic, cultural and environmental Factors on the growth and developmcnt of a cohort of 500 children. A national seminar was held in Bhutan in September 1990 to present the results of the pilot project for the maternal morbidity and mortality surveillance system and to review the results of clinical trials of Depo-Provera from three centres. The surveillancesystem proved successful in trackingmatcrnal adverse eventsand is being expanded to the cntire country in early 1991. On the basisof clinicaltrials, nation-wide use of Depo-Provera is being initiated in 1'991. To strengthen maternal health care, inchding self-care components, support is being provided to adapt and field-test the Home-Based Mother's Record (HBMR) in Maldives and Nepal. Women, Health and Development Issues related to Women, Health and Development, such as policies for increased participation of women in decision-making, allocation of adequate resources for activities such as safe motherhood, promotion of self-care in the family, preventive measures against AIDS for women, reproductive health of women and further involvement ofnongovernmental and private organizations in implementing activities for raising women's socioeconomic and health statuses, were highlighted during the forty-third session of the Regional Committee in September 1990, and resulted in the adoption of a resolution. India and Indonesia were represented at the Interregional Workshop on Leadership and Participation of Women in MCHIFP, held in Brazzaville in Octobcr 1990. As a follow-up to the Workshop, Indonesia is pursuing activities including a national workshop on the same topic, a study on indicators to assess the performance and impact of leadership and participation of women in MCHIFP, and development of an information kit for women in leadership positions. India and Nepal are also pursuing follow-up activities related to leadership and participation of women. HEALTH OF SPECIFIC POPIIIATION GKOUPS 71 In order to strengthen self-care activities in the home setting, a consultative meeting was convened in July 1990 with the objectives of differentiating between non-harmful and harmful home practices and promoting research for knowledge of still unknoun useful practices. This meeting recommended the strengthening of health education as related toself-care within the existing health programmesoftheMember Countries at all levels by curriculum development, training of health and health-related personnel and effective health communication. The involvement of women leaders and women's groups was strongly advocated in self-care activities through meetings and seminars. For coordinating and reviewing self-care activities in the Region, WHO was requested to designate a primary health care unit in the Regional Office. The role of the mother as a key person in self-care in the family was highlighted. 9.2 ADOLESCENT HEALTH With the commencement of the Eighth General Programme of Work the subject of Adolescent Health, included earlier under Maternal and Child Health, has been designated as a separate suh-programme. This has been reflected accordingly in the Medium-Term Programme for 1990-1995. With the exception of Indonesia and Myanmar, no other country of the Rcgion has made provision For a separatc Adolescent Health sub-programme for the 1W-1991 biennium. Some countries, such as Sri Lanka, have made modest budgetary provisions under the sub-programme of Maternal and Child Health. 9.3 HUMAN REPRODUCTION RESEARCH Close collaboration continued with the WHO Special Programme of Research, Development and Research Training in Human Reproduction. Currently there are four members from the Region on the Programme's Policy and Coordination Committee (PCC), vb., Bangladesh, India, Nepal and Thailand. In addition, the Committee on Resources for Research (CRR), which deals with research strengthening activities, met in a sub-committee meeting for Asia in April 191 and approved, among others, long-term institutional development (LID) grants for institutions in the Region, to be submitted to the main CRR meeting to be held in July 1991 lor funding support. A total of 12 LID grant project5 continued to be supported in the countries of the Region, which represented one new grant for Myanmar over 1990. Of thesc 12 projects, one was completed, seven are ongoing and four were initiated. These projects are listed as DPR Korea (1), India (I), Indonesia (4), Myanmar (I), Nepal (I), Sri Lanka (1) and Thailand (3). There are currently five WHO collaboratingcentres in human reproduction in the Region - three in India and two in Thailand. For countries where contacts with HRP have either been non-existent or limited, the Special Programme's new approach is to strengthen research capabilities at the country level rather than individual institutions. This implies that an assessment of the reproductive health strategy of the country would be made in consultation with national policy-makers and development programme implementors. In linc with the recommendations, needs assessment workshops were held in Sri Lanka and Myanmar. These workshops were a necessary prelude to further consideration for an LID grant This is particularly significant for Myanmar as there had been no activity at all in relation to HRP. A Workshop on Critical Appraisal of Research Protocols on Prioritized Topics in Reproductive Health was held in Myanmar. On the basis of thesc research protocols, an LID grant proposal was submitted to HRP. A research group at Pyonbyang Maternity Hospital had been identified as good potential for institutional strcngfhcning support. A grant application had been submitted to UNFPA for consideration and WHO headquarters had provided an initial small grant to complement UNFPA support. Arrangements were also initiated for HRP to act as the executing agcncy and the Regional Office to provide technical back-up. An international master's dcgrec course was initiated at the lnstitutc for Population and Social Research in Thailand with the focus on population and family planning. This course was developed with a long term institutional development grant from HRP in 1989. The Special Programme concentrates on two major activities, namely, (a) support for rcscarch aimed at finding and developing new, safe and effective methods of fertility regulation, and (b) support for rcscarch aimed at improving the performance of existing mcthods of fertility regulation. To undertake research on these aspects, a numher of research grants werc awarded to various institutions in the Region. Up lo the end of 1990,21 RTG and 21 task force research grants had been awarded to six Member Countries of the Region. An external impact evaluation of HRP was carried out by an independent team of scientists. The team took into consideration the 'optimal role of the Special Programme in the 1990s'. The future direction of the Programme would be towards maintainingcurrent activities at an effective level to ensure continued impact,placing increased emphasis on behavioural and social research, promoting and expanding the country approach for research capability strengthening, promoting international effort to enhance the involvement of scientists and research institutions of developing countries, broadening the scope of activities to focus on other appropriate areas of reproductive health with unmet research needs, and giving attention to the dissemination of information generated by the Programme to services and to the publicat large. It was alsonoted that the Programmeshould developstronger linkages with WHO regionaloffices and other programmes and divisionsin researchcapability strengthening. 9.4 WORKERS' HEALTH In most of the countries of the Region, due to economic reasons, emphasis has been placed on productivity both in industry and agriculture, with little attention to the control of work environment or workers' health. Unregulated work, the lack of education among workers, and virtual absence of health, welfare and proper hygienic facilities continued to he the most important issues ofworkers'health in the countries. Continuing low priority given by all the concerned sectors to the health of working people, particularly those employed in small-scale industries and agricultural enterprises, continues to hc the main constraint for the development of adequate occupational health policies and resource mobilization in almost all Member Countries. In India alone, it was estimated that 316000 agricultural workers are killed and 25 million injured in accidents each year. Efforts have been made to assess workers' hcalth in small-scale, unorganized work industries in lndia and Indonesia. A seminar on occupational hcalth problems of agricultural and plantation workers was hcld in lndia. A field-level evaluation of training programmes in occupational health was carried out for public health inspectors in Sri Lanka to appraise the technical knowledge and skills in practical terms. Efforts arc being made to develop a modcl for preventing hcaring loss and ensuring safety in textile factories on the basis of an assessment of the magnitude of hcaring loss and injurics among textile workers in Thailand. Support was provided for the training of national OCH personnel, promotion of situation analysis in the countries and dissemination of information to create more awareness. 9.5 HEALTH OF THE ELDERLY The impact of substantial demographic transition and the accompanying epidemiological consequences are being felt in some countries in the economic, social, health and development fields. The rapid pace ofageingin populations insome countries, which affects social and health care services, i.e. housing, food, income, family status, etc., demands further comprehensive study of the biomedical and psychosocial factors involved in healthy ageing. An increasing understanding of the 70 'nlE WORKOF WllO IN SEA need for family and community approaches to the problem has been evidenced in the countries of the Region. A multicountry study on ageing aimed, among others, at providing a baseline for simple demographic projections of health needs, has been completed in DPR Korea, Indonesia, Myanmar, Sri Lanka and Thailand. The results are being analysed. The WHO Collaborating Centre for Gerontology and Geriatrics, Red Cross Gcneral Hospital, Pyongyang, DPR Korea, is actively carrying out numerous research studies on different fundamental factors of the ageing process, and is preparing scientific films for mass education. A Seminar on the Role of Nongovernmental Organizations in Health of the Elderly was organized in India in October 1990, to assess the social and health problems of the elderly, and promote bcttcr collaboration with NGOs in the priority areas of ageing. The formulation of a manual on care of the elderly is being supported in Indonesia. WHO collaboration mainly focused on the training of personnel through fellowships and group educational activities, creation of awareness and logistic support. Chapter 10 PROTECTION AND PROMOTION OF MENTAL HEALTH 10.1 PSYCHOSOCIAL AND BEHAVIOURAL FACTORS IN THE PROMOTION OF HEALTH AND HUMAN DEVELOPMENT Collaborative efforts continued to focus on the identification of families most in need of assistance for health protection and promotion, and on the development of interventions within the PHC infrastructure to reduce the impact of these risk factors on the well-being of mothers and on the healthy development of children. A draft manual on special psychosocial skills which may help to improve coping capabilities and well-being of mothers has been prepared. The impact of such counselling support on cognitive development and nutritional status of children in risk families is being evaluated in a multicentric study, with the support of the Indian Council of Medical Research (ICMR) and UNICEF. In related work, the same psychosocial skills are being evaluated in families where malnutrition in a child has occurred and in families which, according to the results of a previous Regional Office coordinated multicentric study on psychosocial factors in malnutrition, are likely to generate malnourished children. It was considered appropriate to add this complementary study because the predictive value of the Home Risk Card for childhood malnutrition was found not to be sufficiently high since only about 20 per cent of the variance was found to be shared between HRC scores and the nutritional status of children. It is hoped that through these intervention trials in families at risk of generating childhood malnutrition and in families where malnutrition has already occurred, effective psychosocial interventions to reduce childhood malnutrition will be developed, in addition to 76 I'Hli WOKK OF WtiO IN SEA gaining more insights into the behavioural causation of childhood undernourishment. So far, groups/centres in India, Indonesia, Sri Lanka and Thailand have committed themselves to implement these studies. These study protocols were developed during an intercountry meeting of investigators in Jakarta in November 1990. In a further study, the impact of similar psychosocial interventions is bcing evaluated in risk families where one of thc home risks is alcohoVdrug abuse in the father. This complementary study to the two related studies above was considered appropriate because it is felt that some additional specific interventions can be developed for such families. They include simple harm reduction efforts as far as the alcohoVdrug abuse of the father is concerned. The outcome measures for evaluation are again scores on the subjective well-bring inventory (SUBI) of mothers, and cognitive dcvclopmcnt and nutritional status of children, in addition to a measure of thc severity of the alcohol/drug-related family problems. In this set of multicentric studies, previous Regional Office coordinated work on subjective well-being, on home risk for healthy child development, and on psychosocial factors in childhood malnutrition, havc now converged on the development of interventions which hold promise to effectively reach the hithcrto unreachcd or unreachablc. A second lntcrcountry Workshop on Social and Bchavioural Research lor the containmcnt of AIDS was hcld in Madras, India, in October 19'H). Spccilic intervention trials for female and male sex workers and for prison inmatcs wcrc developed and are bcing implemented in some parts of India, Indonesia, and Sri Lanka. It still seems very difficult to find investigators or 'strcet-corner- epidemiologists' willing to collect related qualitative, intervention-linked data on homosexual men, another high-risk group which has been, in many industrialized countries, the first in which HIV infection took roots. To date, no country in thc Region includes this group in sentinel surveillance for reasons of lack of access to, and collaboration with, this community. 10.2 PREVENTION AND CONTROL OF ALCOHOL AND DRUG ABUSE The UNFDAC-supported and WHO-executed drug abuse control programmes in Myanmar and Sri Lanka havc continued with satisfactory rates of implementation. A project document for a second phase of the Sri Lankan project has been prepared and additional funds have been provided by UNFDAC on an ad hoc basis to bridge the time until the beginning of the second phase, without interruption of the activities. Equally, the project activities in Myanmar, which, according to the projcct document, arc to end in June 1991 will continue with unspent project funds. The project may continuc into a fourth phasc, its importance havingincreased with the spread of HIV PI<OIWIION AND PROMOTION OF MENTAL HEALTII 77 infection in injecting drug users. The UNDP-funded project to establish a monitoring system of drug use in Sri Lanka has been extended for one more year with substantial additional funds. This project will then merge with the UNFDAC-supported project for demand reduction. The latter was favourably reviewed on the occasion of a tripartite review, and considerable expertise in drug use and dependence has now accumulated in Sri Lanka. Also, innovative ways of community involvement and the use of volunteers have successfully been explored. An agreement to WHO execution of demand reduction programmes has been signed between the new Division of the Programme of Substance Abuse (PSA) in WHO headquarters and UNFDAC, now merged into the new and comprehensive United Nations International Drug Control Programme (UNIDCP). It is hoped that, following thisgeneral agreement, WHO-coordinated demand reduction programmes can start in other countries of the Region, especially in Bangladcsh and Nepal, where preliminary explorations of thc possibilities for collaborative programmes have takcn place for several years. The HIV epidemic has led to the acceptance of the new approach of harm minimization instead of the insistence of full abstinence from drugs in some affected countries. Thailand has takcn the lead in this direction by evaluatingthe effectiveness of methadone mi~intenancc as a means of protecting drug users and their sexual partners against AIDS, and tcsting out programmcs of bleach decontamination of injection cquipmcnt and ofcducational programmes to reconvcrt injecting drug uscrs to inhaling. Thcsc approachcs arc all the morc important because drug users have bccn shown to havc an esjiecially high transmission capability to other population groups by virtue of their often high sexual promiscuity in the early phases of drug use, and their frequent involvement in sex work. Alcohol abusc lcads to substantial hcalth problems in a numbcr of countries of the Region. Howcvcr, thesc problems tcnd to have a low visibility in vicw of the high polilical visibility of thc abuse of illicit drugs and of lohacco. Some innovative approachcs towards a reduction of harm due to cxcessivc alcohol use havc bccn initiated in India, partially supported by WHO, in Sri Lanka, and in Thailand. Such activities need more attention. In Sri Lanka, amodulc on substance abusc is hcingdevcloped and tested for inclusion into the curricula of mcdici~l schools, with WHO support. 10.3 PREVENTION AND CONTROL OF MENTAL AND NEUROLOGICAL DISORDERS Recognizing the importance in terms of lasting morbidity and family burden due to mental disorders, and aware of the need to share experiences and expertise in this field, six countries of the Region have specific country programmes within the WHO country budgets, and a further three have explicitly included mental health in their umbrella PHC programmes. WHO continues to focus its collaborative activities on the development oi national mental health programmes. WHO-supported workshops in India and Sri Lanka have reviewed and updated their national mental health programmes. However, as in thc past, such programme reviews have not always avoided the pitfalls of recommending to others what they should be doing rather than focusing on a detailed formulation of what should be done in the actual situation and with the existing resources. Also, the participation of mental hospitals in provincial or district mental health programmes is still limited or non-existent in some parts of the Region. A reorientation of postgraduate training in psychiatry towards public mental health is under serious consideration in Indonesia and in Sri Lanka. Chapter 11 PROMOTION OF ENVIRONMENTAL HEALTH Countries of the Region continue to accord high priority to community water supply and sanitation in the contea of primary health care. There is, at the same time, in many countries, agrowing awareness of environmental problems and their close links with health and socioeconomic development, particularly in those countries experiencing rapid urbanization and industrialization. Concern for pollution of drinking water resources from toxic chemicals and solid and hazardous wastes is receiving increased attention in the Region. Many countries, while continuing to pursue the goal of safe water and sanitation as part of HFN2000, have also initiated activities related to the improvcment of environmental health in rural and urban development and housing, prevention and control of health hazards from environmental pollution, chemical safety and control of poisoning, health risk assessment and risk management, environmental epidemiology and food safety. To assess current scientific knowledge on the consequences to human health of environmental factors linked to socioeconomic development, the Director-General of WHO established a high-level technical expert Commission on Health and Environment. The Commission has focused its attention on environmental determinants affecting hcalth in the areas of energy, industry, urbanization, food and agriculture. The report of the Commission, likely to be available later this year, is expected to suggest general strategies to prevent or mitigate adverse effects of the changing environment on health. The Commission's report will not only form thc basis for WHO'S newglobalstrategy for environmental health, but will also be WHO'S input to the 1992 UN Conference on Environment and Development. WHO participated in the ESCAP Ministerial-level Conference on Environment and Sustainable Development, held in Bangkok in October 1990. The Conference reviewed the state of the environment and policies in Asia and the Pacific, and 80 THE WORK OF WHO IN SEA endorsed the broad framework for regional strategy for environmentally sound and sustainable development in Asia and the Pacific region, issuing a ministerial declaration to that effect. 11.1 COMMUNITY WATER SUPPLY AND SANITATION A Global Consultation on Safe Water and Sanitation, held in New Delhi inSeptember 1990, reviewed the International Drinking Water Supply and Sanitation Decade (1981-1990) and issued the New Delhi Statement that appealed to countries for concerted action to enable people to obtain the basic needs of safe drinking water and environmental sanitation. The New Delhi Statement's challenge was "Some for all, rather than more for some", and it recommended four guiding principles for countries in formulating strategies for the 1990s. These strategies were: environmental protection to safeguard health by integrated management of water resources and wastes; strengthened institutions for sustainable development; community management empowering people to own and control their systems; and sound financial practices for better management. Following up on the Global Consultation, countries of the Region are engaged, with WHO support, in a comprehensive review and evaluation of Decade achievements and shortfalls to be addressed in preparing their sector strategies for the 1990s and beyond. This information will be an input to the new WHO global strategy on community water supply and sanitation, which is a component of the new global environmental health strategy that is being developed. Countries and external support agencies have been urged to collaborate to formulate and implement action plans to incorporate the guiding principles of the New Delhi Statement. Consequently, WHO collaborated closely with the UNDPtWorld Bank Decade programme on water supply and sanitation by assisting in the preparation of sector review and development documents, development of MIS and an information management system to strengthen national planning and coordination in the sector, and in areas of environmental sanitation and drainage. As a result of the agreement between WHO and UNICEF to jointly support country-level water supply and sanitation monitoring for improved sector management, WHO is supportibg the development of national sector information management within the framework of thc CESI micro-computer data base system. 1. Manpower Development WHO continued to support manpower development relevant to countries' needs through fellowships, special courses, observation tours within and outside the Region and through other group educational activities. PROMOTION OF ENWRONMEKTAL HEALTH 81 Training in the country of subprofessionals and professionals in low-cost sanitation, network design, handpump operation and maintenance and communily participation in the management of water supply and sanitation systems was organized in Bangladesh, India, Indonesia, Myanmar and Nepal. A workshop for planning in environmental health, based on the national five-year plan, and a seminar on health education aspects for community water users were held in Indonesia. A national-level workshop on the use of micro-computers for planning and design of water supply and sanitation facilities was organized in Bangladesh with the participation of engineers from Indonesia and Thailand. Training activities to strengthen village-level institutional development as part of the ongoing water supply and sanitation projects continued in Indonesia on handpump installation, rehabilitation of water supply systems, operation and maintenance as well as other aspects of health improvements. On-the-job training was provided in Mongolia in the operation and maintenance of wastewater treatment plants and in water quality laboratory testing. In Myanmar, evaluation workshops on latrine construction and on water supply and sanitation programmes at state and division levels were planned, and an orientation workshop on construction of latrines at the township level was held. A source bookof health education and communication support materialsfor drinking water supply and sanitation in India has been finalized. 2. Institutional Development Support was provided for thc strengthening of institutional capabilities in the areas of manpower development, management information systems, improvement of operation and maintenance, water quality surveillance and monitoring, etc. The institutionalstructure of the Department of PublicHealth Engineeringin Bangladesh was studied for improving its capability, especially in coordinating with other sector agencies. A water supply and sanitation sector review was carried out in Nepal and preliminary plans and programmes up to 2000 A.D. were formulated. The development of national water supply and sanitation management information systems was undertaken in Bangladesh and Nepal. Manuals for basic health workers for the operation and maintenance of sanitary latrines were being prepared in Myanmar. 3. Water Quality S~~weillance National standards and codes of practice for drinkingwater quality were revised and formalized in a ministerial decree in Indonesia. District laboratories in Bengkulu and Lampung provinces of Indonesia are being strengthened as part of the development of a model system for water quality monitoring and surveillance to be replicated in other Water quality laboratory equipment installation and training were provided in Mongolia as part of the development of the Central Reference Laboratory. 82 THE WORKOF WHOIN SFA 4. Research Research studies for the improvement of performance in the various aspects of water supply and sanitation were being carried out in India, Indonesia, Myanmar, Sri Lanka and Thailand. 11.2 ENVIRONMENTAL HEALTH IN RURAL AND URBAN DEVELOPMENT AND HOUSING Most SEAR countries are faced with the problems associated with rapid population growth and urbanization, resulting in squatter settlements, overcrowding in existing settlements and unplanned growth in urban peripheral and fringe areas with deteriorating environmental conditions and senices such as water, excreta disposal, waste water and solid waste collection as well as disposal facilities. A healthy city project proposal to improve environmental conditions and senices in slums and squatter settlements in five cities of SEAR was therefore prepared jointly with ESCAP for donor funding. The Regional Office has collected and reviewed solid waste management status reports from Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand and prepared an overvicw to be used as a background paper at the Regional Consultation on Solid Waste Management, planned for October 191. The Consultation will enable exchange of experience on solid waste management and formulation of a national agenda for action. In addition, a workshop on the same subject has already been organized in Kathmandu, Nepal, in collaboration with GTZ, in which officials from Bangladesh, Bhutan, India, Indonesia, Myanmar, Sri Lanka and Thailand participated. Waste water drainage is another common problem faced by most SEAR countries. A regional workshop on drainage is planned to be held jointly with the UNDPNorld Bank Water Supply and Sanitation Group in South Asia in late 1991 to discuss issucs and problems of drainage and evolve a regional drainage strategy. Country status reports and regional overview papers have been prepared. 11.3 HEALTH RISK ASSESSMENT OF POTENTIALLY TOXIC CHEMICALS WHO'S efforts in this sub-programme area were focused on technical cooperation for manpower training on riskassessment, dissemination of information on potentially toxicchemicals being used inSEAR countries, and oncontrolof environmental health hazards, food safety and workers' health. PROMOTION OF ENVIRONMWI'AL HEALTH 83 1. Manpower Training Anlntercountry Course on Risk Assessment/RiskManagement was held in the WHO Regional Office for South-East Asia, New Delhi, in October 1990, with participants from India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. The course included the IPCS teachingilearning module for risk assessment, emergency preparednesslemcrgency response, survey techniques, health monitoring and environmental epidemiology. A National Course on Health Risk Assessment in Chemical Safety, supported by IPCS, was also organized by the Directorate General of Drug and Food from 26 November to 1 December 1990 in Indonesia. A national Course on Environmental Epidemiology, sponsored by IPCS, was held at the Industrial Toxicology Research Centre, Lucknow, India, in October 1990. Participants of this course included medical inspectors of factories and people from medical colleges and statc pollution control boards. 2. Institr~tional Development Under the UNDP-assisted project "Safety and Control of Pollutants and Toxic Chemicals", the establishment of poison control centres supported by a data base on toxic chemicals was being implemented in India, Indonesia and Thailand. Hardware and software equipment were provided. Project formulation framework documents for UNDP assistance were prepared for Bangladesh and India. 11.4 CONTROL OF ENVIRONMENTAL HEALTH HAZARDS WHO'S collalx~ralion with Member Countries was mainly directed ar strengrhening institutional and manpowcr capabilities through technical cooperation and other support. The UNDP-funded intercountry project "Safety and Control of Pollutants and Toxic Chemicals" enteredits third year of operation and addressed the countries' respective priority problems of chemical safety and pollution. The second phase ofthe UNDP-fundedproject on "ControlofEnvironmenral Health Hazards" became operational in DPR Korea in April. The project is expccted to further upgrade the capability of the Central Hygienic and Anti-Epidemic Station in controlling pollution by toxic organic compounds or heavy metals from industrial and agricultural sectors. The municipality of Delhi, India, is pursuing the recommendations made by WHO in respect of the city's environmental pollution problems. 84 THE WORKOF WHO IN SEA 1. Manpower Training Management approaches for reducing health risks, hazardous wastes and chemicals were covered in the Intercountry Course on Health Risk Assessment and Risk Management, held in the Regional Office in October 1990. A second national workshopon intersectoral cooperation was held in Thailandin April 1991 with aview to strengtheningenvironmental control programmes related to indoor pollution from toxic chemicals. A course developed by the Regional Office for training trainers of community health workers in India in the diagnosis and treatment of pesticides poisoning was held in April-May 1990. Similar courses will be presented in Indonesia and Thailand later this year. A hvo-month special course on water and air pollution control aspects was organized in the Netherlands for ten officials of the Indian Central Pollution Control Board. 2. Institutional Development WHO assistance in water, air and soil pollution monitoring and control was provided to the Central Hygiene and Anti-epidemic Station Laboratory in DPR Korea. Computer hardware and software were provided for information management related to toxic chemicals and hazardous substances as well as other essential laboratory and field monitoring equipment for national programmes in India, Indonesia and Thailand. A data base on chemicals in use in Indonesia is being established in Indonesia with the assistance of a consultant. Another consultant assisted India, Indonesia and Thailand in preparing strategies on chemical emergency preparedness and emergency response. A third consultant reviewed hai-ardous waste management practiccs and recommended improvements in implementing waste management procedures in the industrial regions in India. 3. Global Environmental Monitoring Under the Global Environmental Monitoring System (GEMS), water quality monitoring activities continued in Bangladesh, India, Indonesia and Thailand. Air quality monitoring activities continued in India, Indonesia and Thailand. In connection with the preparations for the United NationsConference on Environmenf and Development in 1W2, the Regional Office assisted WHO headquarters in compiling information on air quality, and motor vehicle and energy-related air pollution in five megacities ofthe Region. Food contamination monitoring continued in Thailand. Health effects monitoring continued in Central Bombay, India, under the Human Exposure Assessment Location (HEAL) project. Bangladesh, India, Indonesia, Nepal, Sri Lanka and Thailand are participating in the Global Environmental Health A new global community water supply and sanitation strategy veloped for better planning and implementation of sustainable sectoral activities to ensure safe adequate sanitation facilities for all. is being de water and Expanded Programme on Immunization Sign~fcant progress has becn madr in the Reglor1 towards ach~evinq the main object~ves of €PI and the goal of iln~versal Child lmniun17ation through an integratcd approach. Environmental Radiation Monitoring Network (GERMON) on monitoring levels of radioactivity in the environment. 4. Research In Thailand, various national studies are being carried out on such aspects as agricultural chemical use and effects, motor vehicle emissions, plant extract insecticides, environmcnt;~l problems in newly industrialized areas, and guidelines development for sca food-related wastes from households. 1 1.5 FOOD SAFETY WHO assistance to MembcrCountries in the field of foodsafcty covered aspcctssuch as strengthening of food legislation for monitoring and inspection of food contaminants, strengthening of laboratory facilities for microbiological and chemical examination, training of manpower on various aspects of food safety control pr~igrammcs, training of analystsichcmists and food inspectors, food standardization and control scrviccs, and dcvclopmcnt of information material for cducaling food manufacturers and user communities in food s;~fcty measures. The est;~hlishmcnt of intcrscctoral coll;~horation for effcctivc implcmcntation ofthc monitoringsyslcm and dcvcloprnent or harmonization of national food standards using the Codex Alimentarius standards wits emphasized. With a vicw to identifying possible arcas of WHO assistance to countries, the Rcgional Office initiated a study to assess national food safety programmes and prepare a regional overview with thc assislance of a consultant. Officials from Myanmar and Thailand participated in thc Codex mccting held in Rome in March 1991, while officials from India, Indoncsia and Thailand attended thc First Asian Conference on Food Safcty in Malaysia in September 1990, during which issues and stratcgics for the 1990s were dealt with. Nationals from Indonesia were awardcd fellowships to htudy food laws, standards and an;~lytical monitoring techniques. In Indoncsia, :I training course on food hygicnc was organized for food inspectors from provinces and another training course on quality control of manufactured food com~nodities was held for provincial food inspectors and administrative officers. Support was given to the preparation of training modules and health education in the subject. In India, food analystsichemists from seven state food laboratories were trained in the analysis of food additives and contaminants. In Sri Lanka, public health officials were trained in food inspection and sampling techniques and on lcgal procedures related to food safety. R(, 111E WOKKOF WHO IN SEA In Indonesia, an interministerial workshop on food standardization and control services was held in October 1990 with a view to strengthening inter-agency coordination. A revision of the national food sanitation programme was completed. The revised decree on the inspection and classification of eating establishments and food catering services was reviewed. The translation of the Codex Alimentarius and other relevant literature was completed. A consultant assisted in the strengthening of food inspection in low-acid canned food. In India, a review of food safety laboratories was completed and a chapter on the food laboratory was prepared for incorporation into the statutory provision of the national food laws. A training course on good manufacturing practices was developed and a manual preparcd for harmonizing national standards with Codex standards. Electronic laboratory equipment for the ccntral food laboratory was provided. 3. Information Support In response to various queries from governments, the Regional Office provided health-related information on such substances as the use of hexane as a cleaning solvent used in edible oil, brominated vegetable oil for soft drinks, food colouring for ice creams, sanitary practices for mineral water production and lactoperoxidasc for milk preservation. Chupter 12 DIAGNOSTIC, THERAPEUTIC AND REHABILITATIVE TECHNOLOGY 12.1 CLINICAL, LABORATORY AND RADIOLOGICAL TECHNOLOGY FOR HEALTH SYSTEMS BASED ON PRIMARY HEALTH CARE Health laboratory services play an important role in supporting programmes for health care systems. As such, the strengthening of health laboratories is vital in national health care systems. WHO continued to support Member Countries in strengthening hwlth laboratory services hy improving the existing infrastruclure, including peripheral areas, introduction of appropriate laboratory technology, continuing training programmes, supplies, reagents, kits and equipment, and sustenance of quality assurance programmes. Laboratory Sewices and Technology The strengthening of laboratory services, particularly at district and provincial lcvels, is stressed through [he provision of supplies and equipment and national training programmes. A UNDP-funded intercountry project is under way to strengthen health laboratories for effective delivery of primary health care so as to achieve HFN2000 in six countries of the Region viz., Bhutan, India, Indonesia, Maldives, Mongolia and Myanmar. The project activities support national workshops on policies for health laboratory services, laying down of qualitystandards, andintroduction of appropriate lechnoloby 88 'IIIE WOKK01' WHO IN SFA and quality assessment schemes in the whole network of health laboratory services. During the period under review, national workshops on the development of national policies for health laboratory services were held in all the six countries. An intcrcountry workshop will be held in early 1W2 to consolidate the recommendations of the national workshops and to develop a regional policy for health laboratory serviccs. National workshops for the introduction of appropriate technoloby at the PHC level havc been initiated. WHO is committed to supporting the Member Countries in achieving regional self-reliance inimmunodiagnostic reagents. Through UNDPprojects, the production of modern immunological and biological reagents is being supported in Bangladesh, India, Myanmar and Sri Lanka. Regional capabilities in the production of rcagcnts for rapid diagnostic techniques and survcillance of priority communicable diseases, such as dengue haemorrhagic fcvcr, Japanese encephalitis, hepatitis, shigellosis and acute respiratory infection were supported. The National Institute of Virology, Punc. India, supplicd test kits for the surveillance of Japanese encephalitis to the countrich of the Region. The WHO Collaborating Ccntrc for Referencc and Training in Strcptococc:~l ~i~~. . ~SLS . . . ,I[ thc Lady Hardinge Medical College, New Dclhi, continued to supply rcagcnts for the diagnosis of streptococcal infection to other institutions in thc Region. Shigcllosis continues to hc a hcalth problem in the countries of the Region. 111 particular, epidemics due to Sltigcllu dyse~tferioe 1 continue to occur periodically. In collaboration with the Diarrhoea1 Disease Control Programme, laboratories in scveral countries are bcing strengthened for the detection and control of shigcllosis. Thc National Institute of Health, Thailand, continued to provide diagnostic antiscr;~ for Shi~llo dyse~tteriae to other countries of the Region. In thc field of quality control of hcalth care technology, WHO is assisting India. Indonesia, Maldives, Nepal, Sri Lanka and Thailand to takc part in global extcrn:~l quality assessment programmes in clinical chemistry, microbiology and hacn~atology. WHO provided technical support through a consultant for conducting a national workshop for the development of external quality assessment in immunology in Indonesia. Undcr the global programme on AIDS and the global blood safety initiative, WHO organii.ed an intcrcountry workshop on the transfer of technology for thc manufacture of silfe blood nroducts in Bombav in December 1990. Nationals were ~ ~~~ trained in tllc rnoilcrn meth~idoloby of productiun of safe blood component\ .an.! plasmafractionc. WHO i<st~ppt,r~ingcountrics in Iahoratory diagno\isof HI\' AID> - ~ WHO is also supporting an external assessment scheme for HIV testing in Bangladesh, Bhutan, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. In line with WHO'S commitment to global eradication of poliomyelitis by DIAENOSIlC. THERAPEUTIC AND REHABlL~ATlVETECHNOLOGY 89 the year 2000, a regional plan of action for the establishment of a regional network of polio testing laboratories has been developed. As a part of the global programme for rickettsia1 disease epidemiology, India, Bangladesh, Nepal and Thailand were supported through the distribution of rickettsia1 antigen, for indirect immunofluorescence tests. Information on the incidencc and prevalence of rickettsioses at the global level is meagre. It is expected that in the near future a realistic epidemiological picture of rickettsioses will emerge. With the aim of expediting disease control activities, a programme for the promotion of new techniques in the diagnosis of diseases has been launched in the Region. The first workshop on the promotion of the polymerase chain reaction (PCR) in the diagnosis of communicable diseases, and genetic and metabolic disorders was held at Pune (India), in May 1991. The remarkable progress in the diagnosis of infectious diseases, cancers and metabolic diseases using electron microscopy, due to advanced computer technology and ultra high resolution analytical technology, was recognized, and a bi-regional workshop (South-East Asia and Western Pacific Regions) on the application of electron microscopy is being planned to be held at Bangkok in October 1991. WHO continued to support the concept of basic radiological units in thc countries of the Region. WHO is also endeavouring to monitor the exposure to X-rays in radiology departments and the safety of cobalt irradiation units in several countries. Bangladesh, Maldives and Nepal are taking part in a personal dosimetry monitoring programme being conductcd by the International Atomic Energy Agency, Vienna. Sufficient facilities to establish appropriate imaging technology need to be developed in most countries of the Region. Efforts are being made to promote regional self-sufficiency in monitoring radiation effects. 12.2 ESSENTIAL DRUGS AND VACCINES WHO's collaboration with the Member Countries in the strengthening of thc Essential Drugs Programme continued. In the development of the Programme, special attention was paid to manpower development, quality assurance and rational use of essential drugs. Apart from the support to countries under WHO's regular budget, funds from extrabudgetary sources were being mobilized for strengthening country essential drugs programmes. In addition, two countries, viz., Indonesia and Thailand, along with other ASEAN countries, are implementing an Essential Drugs project as a WHO-executed UNDP project, besides receiving technical inputs from WHO in the field of essential drugs. 90 'fflE WORKOF WHO IN SFA 1. Drug Policies and Programmes Since the Alma-Ata Conference on Primary Health Care, countries have restructured their health development programmes with emphasis on primary health care (PHC) as the strategy for achieving health for all by the year 2020. Several essential drugs programmes have been actively developing in the countries of the South-East Asia Region. Bhutan's programme, supported by DANIDA and FINNIDA, lays emphasis on the procurement, storage and distribution of essential drugs. In order to improve the procurement of drugs, computcrization of the process is being promoted in addition to ensuring that the WHO Certification Scheme is adopted in the purchase of drugs. Training of doctors in rational prescribing and quality control of drugs is being promoted. With a view to strengthening the drugs programme, financial and technical supporc is being provided in Thailand in the areas of drug information, evaluation, registration, re-evaluation, pricing policy, quality control, good manufaduring practices, drug management and rational use of drugs. FINNIDA continued to provide financial support for the essential drugs project in Myanmar. The project was developed with technical assistance from WHO. Thc Myanmar project aims at strengthening drug policy, quality assurance, procuremcnl and distribution systems. The project plans include, in the first phase, the provision of essential drugs to nine townships over a period of threeand a halfyears, up to 1992. Sri Lanka held a workshop on drug policy and quality assurance in August 1%. Thc workshop provided further impetus to the development of drug management and policy. An action plan on drug quality assurance and measures to minimize drug shortage were formulated in the context of the national requirements. 2. TCDC in Pharmaceuticals Technicalcooperation amongst countries of the South-East Asia Region iscontinuing in several areas. The UNDP-funded ASEANiWHO project in the field of pharmaceuticals is a successful example of such a collaborative activity. In Phases I and I1 of the project, from 1982 to 1986, the six ASEAN countries developed centres of excellence in the field of quality control, drug management, reference substances, GMP, drug information and drug evaluation. In Phase 111, covering the period 1987 to 1991, these centres are being used for manpower training, not only by the ASEAN countries, but also by other countries of the Region. The tenth ASEAN Working Group met in Singapore in February 1991 to plan Phase IV of the project, from 1992 to 1996. The project aims at further strengthening national capabilities in drug quality assurance and at achieving self-reliance in the training of human resources for GMP inspection and auditing, quality assurance, drug evaluation, productionand utilizationofregional standardsand referencesubstances, clinical pharmacy, standardization, quality control, utilization of herbal medicines and exchange of information on drug regulatory matters. India, Indonesia and Thailand have developed capabilities in the areas of production, quality assurance, training of human resources and other aspects in the development of essential drugs and biologicals programmes. This has facilitated the process of cooperation both for regional as well as extra-regional Member Countries of WHO. 3. Rational Use of Drugs Rational prescribing and use of essential drugs and biologicals have been promoted by WHO in collaboration with countries, including Bhutan, India, Indonesia, Myanmar and Thailand. Drug procurement, storage, distribution and management are being developed in Bhutan to improve rational use. In India, a technical committee was constituted and charged with the responsibility of evaluating drug combinations and removing from the market those combinations which are irrational in the light of current knowledge in clinical pharmacology. With a view to improving rational use of drugs, standard treatment regimens have bcen established in Bhutan, Myanmar and Thailand. These treatment regimens will be used to improve rational prescribing as well as quantification of essential drugs needed for primary health care programmes. The quantification of drugs, based on standard treatment regimens, was successfully implemented in Myanmar. In order to facilitate drug management, computer technology is being adapted in Bhutan and Indonesia using the SWEDIS system developed in Sweden. Myanmar is also developing computerization of the Essential Drugs project for inventory control and logistics of drug supply and distribution. 4. Riologicals WHO continues to collaborate with the countries of the Region in the development of their vaccine programmes. WHO has been strengthening production capabilities of bacterial and some of the viralvaccines in Bangladesh, India, Indonesia, Mongolia, Myanmar and Thailand. In India, the production of DPT, rabies and poliomyelitis vaccines has been strengthened through the training of nationals. In Indonesia and Thailand, there is self-reliance in the production of bacterial vaccines while bilateral assistance has been provided for the production ofviralvaccines against poliomyelitis and measles. A network of WHO wllaboratingcentres for the training and testing of vaccines used in EPI, located in India, Indonesia and Thailand, continues to provide services and training for quality control and quality assurance of vaccines. 92 THE WORK OF WHO IN SEA WHO will concentrate on the transfer of technologyfor the production of bacterial and viral vaccines, including hepatitis and rabies vaccines, and will assist the training programmes in production and quality control. Technical and financial collaboration will need to be provided for attaining self-sufficiency in EPI vaccines in the countries of the Region. 12.3 DRUGS AND VACCINES QUALITY, SAFETY AND EFFICACY The major thrust of WHO has been to strengthen quality assurance programmes in the Region so as to ensure the quality, safety and eficacy of essential drugs and vaccines. Towards this end, training in the development of technical manpower for drug analysis and good laboratory practices, as well asgood manufacturing practices, in the production of essential drugs and vaccines, has been provided. In Myanmar, a quality control laboratory has been developed and nationals were trained in the analysis of pharmaceutical products. Bangladesh received technical support for strengthening the quality control laboratory through the provision of consultants, fellowships and supplies and equipment. India, Indonesia and Thailand have been supported in the acquisition of reference standards, substances and equipment as well as through group educational activities. In Bhutan, the establishment of a quality control laboratory is envisaged while in Nepal, the quality control programme was strengthened with technical and financial inputs from WHO. In Sri Lanka, the quality assurance laboratory was further supported by developing a programme at a workshop held in August 1990 with technical and funding support from WHO. 1. Quality Assurance WHO actively promotcd the WHO Certification Scheme for the quality 01' pharmaceutical products moving in international commerce as well as for good practices in the manufacture and quality control of drugs (GMP). The WHO Certification Scheme helps to ensure the quality of pharmaceutical products for countries that have not yet developed an adequate quality control system. Additionally, WHO assisted in the testing of pharmaceutical products at the WHO collaborating centres in India and Thailand for any country of the Region that has not yet developed its own quality control laboratory. 2. Drug Information and Adverse Drug Reactions WHO'S activitieswere aimed at improving drug information programmes in countries of the Region. Drug information is needed by various health professionals as well as the general public. In view of this, support was provided for the establishment of a DIAGNOSIlC,'MERAPELmC AND REHABILKATIVETECHNOLCGY 93 data base on several aspects of pharmaceuticals, including drug utilization, registration status and adverse drug reactions. Bhutan has revisedits StandardTreatment Guide and distributedit to the basic health units. In Myanmar, standard treatment schedules as well as diagnostic flow charts for different levels of health care were distributed. Health education materials were also used for community awareness of the Essential Drugs Programme. The ASEAN countries decided to exchange information on drug regulatory matters at the Tenth Meeting of the ASEAN Working Group on Technical Cooperation in Pharmaceuticals, held in February 1991. This mechanism will enable individual Member Countries to take such pre-emptive action as may be necessary. It will also promote awareness of activities amongst ASEAN countries, thus leading to an improvement in the implementation of the national programmes. Indonesia and Thailand have developed adverse drug reaction reporting systems. In addition to the national monitoring of adverse drug reactions (ADR), the two countries participated in international collaboration in ADR reporting and dissemination of the information. The drug information system needs to be further developed in several countries of the Region. 12.4 TRADITIONAL MEDICINE Countries of the Region have a rich inheritance of traditional medicines. Hence, training programmes, such as in Sri Lanka and Myanmar, were developed and strengthened with experts from within the Region. Study tours and fellowships were arranged for the nationals of DPR Korea, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand, both intra-regionally as well as extra-regionally. In the promotion of the integration of traditional medicine in the health care system, the identification of popular traditional medicines used for common ailments, training of traditional medical practitioners, standardization and quality control of traditionaldrugs, development of herbalgardens, introduction of modern production facilities and research in agro-techniques and pharmacological testing are areas where WHO has collaborated at the country level. Indonesia andThailand are the focal points for the coordination of activities in herbal medicine. The work involves standardization, quality control and utilization of herbal remedies in ASEAN countries. A manual on cultivation, production and utilization of herbal medicines was published and training programmes were convened in the coordinating countries. 94 THE WORKOF WHO IN SEA With UNDP funds, Myanmar and Sri Lanka further developed traditional medicine programmes. Myanmar's programme dealt with the development of the traditional medicine manpower required in planning and management, curriculum development in traditional medicine education and development of the library at the School of Indigenous Medicine, Mandalay. The Sri Lankan programme concentrated on institution building in regard to the development of the proposed National Institute of Traditional Medicine. Training courses and seminars were held for traditional medicine practitioners and local health workers in agro-techniques of medicinal plants, modern techniques in the production oltraditional medicine and in research. Even though traditional medicine has a long history in the countries of the Region, it needs to be further strengthened, inter alia, in the standardization of ingredients, - - quality assurance, scientific authentication of therapeutic efficacy, untoward and toxicological effects of products and improvements in manufacturing techniques based on good manufacturing practices. 12.5 REHABILITATION Though the magnitude of the disahilily problem cannot bc asccrlained accuratcly, most countries of the Region have at present either a national programme on disability preventionor a firmly-established disability prevention and rehabilitation component in the general health services as a part and parcel of the PHC package. The hospital for the disabled in Dhaka, Bangladesh, has been providing referral services for the rehabilitation of the physically handicapped through orthopaedic reconstructive surgery and production and supply of artificial limbs using local materials. Low-cost functional prosthetic-orthotic appliances and other rehabilitation aids, manufactured from indigenous materials, have been made available in Myanmar. Technical assessment of the disability situation was carried out by a consultant while the basic needs for community-based rehabilitation services were appraised in Mongolia. Two patients were provided with treatment and orthopaedic aids, and an orthopaedic surgeon and an orthopaedic technician were trained at the Nevedac Prosthetic Centre, Chandigarh, India, on the basis of TCDC, free olcharge. A seminar on evaluation of the camp approach for the rehabilitation of polio paticnts in rural areas was conducted in December 1990. Study tours for national experts from India, Indonesia and DPR Korea, in the fields of community-based rehabilitation, physical medicine and orthopaedic surgery, were processed. RHB programmes are still seen, in most cases, as orthopaedic rehabilitation services in the first instance, and do not have a strong linkage with other rehabilitation services such as leprosy, mental health, blindness, deafness, etc., which are run under different special programmes. WHO collaboration was, therefore, mainly focused on the training of national manpower, creation of awareness of the problcm and strcngthening of PHC approaches as a part of dcvclopmcnt of institutional capacity at thc lowcst level ofhealth administration and the strengthcning of intra- and intersectoral cooperation in the countries. Chapter 13 DISEASE PREVENTION AND CONTROL 13.1 IMMUNIZATION Substantial progress in EPI has been made in the Region. Thc majority of thc countries achieved immunization coverage of 80 per cent or morc during the year 1990. The infant coverage in 1990 was 86 per cent for the third dose of diphtheria-pertussis-tetanus vaccine, 87 per cent for the third dose of oral polio vaccine, 80 per cent for measles vaccine and 95 per cent for BCG vaccine against tuberculosis. Tetanus toxoid coverage in pregnant women was reported as 68 per cent (Figure 1). In some countrics, the impact of immunization coverage on the reduclion of'diseascs, especially poliomyelitis, diphtheria, and pertussis, can be seen (Figure 2). In order to achieve reductions in morbidity, disability and mortality from the six EPI targrt diseases, it is important to sustain and augment activities for the control of EPI target diseases with a strong health services infrastructure and adequate financial support. An epidemiological approach for the control of EPI diseases will be stressed during thc 1990s. Much of the success of this approach is dependent upon implementation and improvement of survcillancc. The integration of thc Expanded Programme on Immunization with Matcrnal and Child Health and Primary Health Care continues to be encouraged. This will help to achieve self-reliance in the delivery of immunization services within the context of comprehensive health services. An Intercountry Consultative Meeting on Financial Management of EPI was held in New Delhi in January 1991 to strengthen EPI managers' capabilities in financial planning and management. Plans of action, country timetables and general guidelines on financial management were the outcome of the meeting. Figure I. Immunization Coverage ,IS 'Illti WOKK01. WHO IN St:,% . - F@re 2. Morbidity Rates in SEAR, 1974-19W) (pcr- IOU 000p,1p,pabrion) IlISIi4SE PKEVENI'ION AND (:ONI'ROL. V9 WHO supports self-sufficiency in EPI vaccines through indigenoub production. While viral vaccines are mostly imported, Bangladesh, DPR Korea, India, Indonesia, Mongolia and Thailand produce bacterial vaccines. Efforts are bcing made to develop national vaccine quality control systems to ensure that the indigenous production of EPI vaccines conform to the WHO standards. Efforts in measles and polio vaccine5 production are going on in India and Indonesia. The production of Edmonston-Zagreb strain (E-Z) of measles vaccine is being carried out at the Serum Institute,Pune, India, anda pilot study of LheE-Zvaccine isunderway at the National Institute of Virology, Pune. The recent results of oral polio vaccine potency testing in India are encouraging. Compared to previous results, improvement is significant with more than 90 per cent of samples meeting the minimum requirements. Similar results wcre reported by Thailand. Poliomyelitis Eradication/NeonataI Tetanus EIimination/Measles Reduction Initiatives The global targets (polio eradication by 2000, neonatal tetanus elimination by 1995 and measles reduction by 00 per cent by 1995) have becn cndorsed by all the countries of the Rcgion. However, the annual national targets and approaches differ from country to country, based on the local health infrastructure and available resources. Eradication of Poliomyelitis. Based on the annual country reports, thc regional polio incidence rate decreased significantly, even considering the factor of underreporting. In Sri Lanka, Thailand, Mongolia, DPR Korea, Bhutan and Maldives, with high sustained coverage, the trend in the incidence indicates that the targets of polio eradication could be achieved before 2000. Currently, polio-free zones are observed in parts of Indonesia, Mongolia, Sri Lanka, Thailand and Maldives. The use ~f epidemiological approachcs is nccessary to achieve results. High coverage is not enough. The concept of mopping up and special attention to high-risk arcas will be needed. The strengthening ofbasic health services management, improvemertt of surveillance and laboratory services, and enhancement of public awareness arc necessary to achicvc thc eradication of poliomyelitis. A regional polio laboratory network plan, which will be the basis for devclopinglaboratory diagnosticscrviccs for additional EPI and other infectious diseases, is being established. Elimination of Neon;tt;tl Tetanus. The target of eliminating neonatal tetanus can bc achieved by timely tetanus toxoid immunization of pregnant women and all women of child-bearing age and by aseptic delivery and post-delivery care. All countries in the Region are committed to the global elimination target. The integrated approach through MCH and PHC is considered to be essential. In 1990, tetanus toxoid immunization coverage of pregnant women increased lo a level of68 per cent. Thc IW THE WORXOF WHO IN SEA regional coverage excludes DPR Korea and Mongolia which do not at present have national policies on the use of tetanus toxoid for pregnant women. The majority of the countries in the Region follow the policy of immunizing pregnant women. The WHO immuni7ation schedule of 5 tetanus toxoid doses for all women in child-bearing age is being examined by the countries. A few countries have introduced tetanus toxoid immunization among all women of child-bearing age. Recording and reporting of neonatal tetanus cases are deficient. As a result, the true impact of tetanus Loxoid immunization and clean delivery practices on the incidence of neonatal tetanus is difficult to determine (Figure 2). Reduction of Incidence of Measles. Although EPI started in 1977, measles vaccination was introduced by some Member Countries only in 198411985, In 1990, a dramatic increase occurred in the regional measles coverage (52 per cent in 1988, 59 pcr ccnt in 1989 and 80 per cent in 1W). Some countries declared a coverage of over 80 per ccnt (Figure 1). The annual number of reported measles cases did not change during the period 1981-1990. This is duc to a number of problems, including very limited surveillance systems and inadequate routine reporting. Compnterized EI'I Information System (CEIS) Ten countries of the Rcgion havc established their vcrsion of the Computeri/ed EPI Information System (CEIS), based on national needs. The development ol CEIS software with more professional and sophislicated programmes is encouraged hy governmcntlnational programmers, REACH and other bilateral and international agencies, as well as private organizations. Software and hardware system improvements are needed for the sustainability of EPI management information systems. National and local computer programmers are needed to manage current programmes and to develop other software. For the next two years, outside programmers are needed in some Member Countries, and certain countries, such as DPR Korea and Mongolia, require hardwarc as well. Cold Chain and Logistics Adequate central cold stores arc established in most countries of the Region. Bangladesh, Nepal, India and Myanmar have established very good cold chain systems in spite of difficult geographical conditions. Reviews of the cold chain using cold chain monitors have been conducted in selected areas in India, Nepal, Mongolia, Myanmar, Bangladesh, Bhutan, DPR Korea and Sri Lanka. The Asian InstituteofTechnology (AIT), Bangkok, isaccredited as a WHOIUNICEF training centre for solar refrigerators. AIT conducted the first training course on solar refrigerator repair and maintenance in July 1990 and a second course in May 1991. SEAR countries are now making plans to use solar refrigerators in remote areas. Indonesia has already procured more than 100 solar refrigerators for use in small DISFASE PREVENTON AND CONTROL 101 islands and held its first national Solar Fridge Training Course in early 1991. Myanmar and Maldives received new Japanese-made equipment for field trials in 199011991. A solar-powered sterilizer was field-tested in India. Responding to the goal of country self-sufficiency for EPI, India, Indonesia and Thailand have produccd some of their own cold chain equipment. Two cold chain equipment testing centrcs in India and Thailand are accredited by WHO for testing the suitability of cold chain refrigerators and cold boxes for EPI. Training and Kesearch Following the Intercountry Consultative Meeting on Financial Management of EPI for National EPI Managers of SEAR countries, New Delhi, January 1991, emphasis was laid on national training workshops with coursc material suitably adapted to thc local situation. An intcgratcd approach to training was encouraged. New rcvised training modules were field-tested in Thailand in May 1991. The Eighth National EPI Managers Consultative Meeting on the main subjects of EPI sustainability and surveillance was held in Nepal in June 1991. EPI coverage surveys were organized in all the Member Countries of the Region. National EPI reviews were conducted in Nepal, Mongolia, Thailand, Bhutan and Bangladesh and it was found that impressive progress in the Programme had bccn achicvcd. 13.2 DISEASE VECTOR CONTROL Vector-borne diseases, i.c. malaria, denguclDHF, filariasis, Japanesc encephalitis and leishmaniasis, continue to be public health problems in several countries of the Region. Prolonged use of insecticides, both in agriculture and in the field of public health, together with accelerated rural economic development, rapid urbanization and other human activities, have resulted in changes to agreat extent in the ecology, bionomics and susceptibility status of many species of disease vectors. As a result, many of them arc not amenable to control with insecticides alone because of changes in their seasonal and geographical prevalence, behaviour or susceptibility to insecticidcs that have bccn commonly used in the past. Therc is undoubtedly a growing opposition to the use of insecticides by environmentalists as well as householders. The trend, thereforc, is not towards sole reliance on chemical control but towards integrated approaches for vector control. The International Irrigation Management Institute (IIMI), Sri Lanka, has been designated as a WHOIFAOIUNEP Collaborating Centre for Vector Control, to provide technical support lo the countries of this region. 102 THE WORKOF WHO IN SEA WHO confirmed its collaboration in research on the development and application of innovative and cheaper control methods in the context ofprimary health care through community participation. Malaria In spite of the long-term residual insecticide spraying of premises for malaria control, the control of malaria vectors still poses problems. The widespread resistance to the commonly-used insecticides in the vector population and refractory behaviour of some of the vectors, notably several sylvatic species in the forested hilly areas, are of concern and have resulted more often ina setback to anti-vector operations, primarily due to the decreasing coverage. Apart from vector resistance, insufficient and erratic supply of insecticides, increasing cost and unwillingness of householders to acccpt residual insecticide spraying are contributing factors for setbacks in vector control. Consequently, remedial measures supported by WHO are: stratification of the most affected areas for rational use of available resources; and promotion of cost-effective integrated bioenvironmental measures as an alternative to chemical wntrol. The use of impregnated bednetsicurtains and other personal protection methods, such as repellents and coils etc., which are useful components in integrated vector control interventions, are also being promoted. Field trials of these methods continuc to be undertaken in the countries of the Region. A WHO-supported study on the effectivencss of environmental measures against anopheline vectors in the Terai region in Nepal is in progress. A WHOIUNDP project to determine the impact of residual spraying with 75 per cent DDT wdp on malaria control in the highly malarious areas of Bangladesh, whcre A~~ol?l~eles dinrs is the principal vcctor, is in progress. WHO is continuing its support for the cylogenetic study of sibling specics,A~roplreles crilicifocies and Anopheles subpichrs, in Sri Lanka. Dengue Haemorrhagic Fever (DHF) DHF continued to persist in Indonesia, Myanmar and Thailand, where it is prevalent in endemic form and the control of its vector Aedes aegypti remains a challenge. Sporadic cases of DHF have also bcen reported from India, Maldives and Sri Lanka. The control of DHF has been far from simple. Greater community involvement is needed to prevent breeding places ofAedes aegypti in and around houses. Phase I of the multicentre project to control DHF vectors with community participation, supported by the Regional Office, was completed both in Indonesia DISEASE PREVENnON AND COKTROL 103 andThailand in 1989. The project in Myanmar was, however, interrupted and could not be implemented. A Technical Advisory Committee meeting was organized by WHO headquarters and the South-East Asia, Western Pacific and American Regions in Bangkok from 4 to 6 October 1990. Thirty members, including the WHO secretariat, participated in this meeting to update the scientific knowledge being gained in various aspects of DHF, including the vector situation and control. The WHO Dengue Newsletter (Vol. 16), brought out during the period under review, highlighted the latest information on the DHF situation and community-oriented control and prevention of the DHFvector Aedes aegvpli. Japanese Encephalitis (JE) Japanese encephalitis (JE) has become a major health problem in India, Ncpal, Sri Lanka and Thailand. Several culicine species seem to play a significant role during outhreaks of JE. The most prominent species are Cula Infaertiorliyrtchtrs.~, Culer gelidtrs, Ctrlex vishrtrii, Ctrlex psetrdovishrttri and Ct~lex fitscocephala. The virus has been recovered from approximately 30species of mosquitocs belongingto fivegenera, i.e.Clrlex,Artopheles, Aedes, Martsortia and Amtigeres. These mosquitoes generally breed in groundwater habitats, particularly in rice fields and major components of irrigation systems, groundpools and shallow ditches. The important factors governing the spillover of the disease to man arc the relative abundance of the vectors, the availability of the amplifying hosts, thc density and absolute number of infected mosquitocs, adequate man-mosquito contact and the longevity of the vector. Control measurcs in affected areas have been primarily devoted to vector control by focal spraying and fogging of outdoor tracts with insecticides. Limited insecticidal coverage achieved by ground application and space-spraying cannot be expected to achieve a significant impact on the overall mosquito population in these areas due to large-scale production of vector densities and immigration of mosquitoes. Larviciding is impracticahlc due to vast breeding habitats. Human vaccination has been triedin Sri Lanka for the control of Japanese encephalitis. Filarissis Lymphatic filariasis caused by Wtrdtereria bartcroffi is endemic in Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. India and Thailand present the diversity of filariasis in two forms, M bartcrofi and Bnlgia malayi, while Indonesia is affected by Brugia timori in addition to W. barlcrofi and B. ritalayi. I04 ME WORKOP WHO IN SEA Urban W. bartcrofli is mainly found in the slum areas of citiesltowns and transmitted by Culerqirinquefasciahrs while in rural areas it is spread by the species ofA~toplteles, in addition to C. qrrinq~refasciahis. The strains ofB. ntalayi are transmitted by Mansonia spp. and Anopheles spp. while B. ti~nori is localized in the Lesser Sunda Islands of eastern Indonesia and is transmitted byAnoplteles barbiroslris. At present, most of the programmes depend heavily on anti-larval measures for the control of filariasis. WHO-TDR continued to extend technical and financialsupport for the development of integrated approaches to the control of this disease, including various chemotherapy approaches. Research studies are in progress in India, Indonesia and Thailand. A national seminar was organized in Calicut, Kerala, India, in October 1990, with financial support from WHO, to review operational research needed to improve the efficiency ofvector control under the National Filariasis Control Programme in India. WHO provided support to the longitudinal study of filariasis in Nepal. Leishmaniasis (VL) Visceral leishmaniasis or Kala-azar continues as a public health problem in some parts of Bangladesh, India and Nepal. Although this disease virtually disappeared in the 1960s from these countries following intensive indoor spraying with DDT for malaria control, it has recently reappeared. The principal vector is Plrleboto~~i~is argentipes, but the possibility ofPlrlebotomirspapatasi as the secondary vector cannot be ignored. In India, Bihar and West Bengal states account for the highest incidence of thc cascs. A total of 56 971 cases and 607 deaths were reported in 1W. 54 000 cascs and 590 deaths were reported from Bihar and 2 917 cases and 16 deaths from West Bengal. In Bangladesh, 4 893 cases and 18 deaths were recorded. In Nepal, 327 Kala-azar cases and 14 deaths were reported during 1990 from several districts bordering Bihar state in India. The strategy for control is through DDT spraying, activelpassive detection of cases and trcatment. However, owing to administrative and financial constraints, the control of Kala-azar in these countries is not effective. Manpower in Entomology In view of the scarcity of qualified entomological expertise to deal with the complex nature of vector-borne diseases and more efficient deployment of entomology teams DISEASE PREVENTION AND CONTROL 105 in the context of primary health care, countries of this region are trying to strengthen their entomological manpower. WHO continues to promote the training of personnel in the field of vector biology and control through regular in-service training and refresher courses for various categories of entomological staff involved in vector-borne disease control programmes. The National Institute of Communicable Diseases (NICD), Delhi, India, conducts advanced courses in medical entomology for medical officers and entomologists from time to time. Assistance continues to three institutions in the Region, namely, the Vector Control Research Centre, Pondicherry, India; Mahidol University, Bangkok, Thailand; and Bogor University, Bogor, Indonesia. These institutions provide academic training in medical entomology (M.Sr. courses). 13.3 MALARIA All malaria cndemic countries of the Region continued to implement the revised malaria control strategy through the primary health care system. Special attention was given to the harmonic development of all components of malaria control programmes so as to avoid exclusive dependence on one particular measure, such as the use of residual insecticides. The malaria stratificationapproach hadbeen fostered by all malaria control programmes in the Region since it has proved to be useful, particularly in situation5 with limited resources. In the course of the malariogenic stratification exercise in the countries of the Region,various problems and constraints which were held responsil)le for the slow progress of malaria control have been identified. An analysis of these factors has resulted in the identification of malaria priority areas. Forests, forested foothills and hills, forest-fringe areas, and developmental project sites - dams, irrigation and road construction in the forest and border areas-were accorded the highest priority in almost all countries of the Region. Infants, young children and pregnant women have been identified as malaria high-risk groups, followed by mobile population groups, particularly those engaged in forcst-related economy, gem mining, fishing, industrial and road construction work and the like. Ethnic minorities, refugees, displaced persons, tourists and pilgrims constitute malaria high-risk groups in a few countries of the Region. Malaria control programmes have been fully integrated into the basic health services in Bangladesh, India, Indonesia, Maldives, Myanmar, Nepal and Sri Lanka at the intermediate and peripheral levels, while at the national level a core group of specialists is entrusted with the task of planning, technical support and supervision, training, research and coordination. In Bhutan and Thailand, malaria control 1% -- THE WOKKOF WIIO IN SEA Figure 3. Profile of Malaria in Selected Countries of WHO South-East Asia Region, 1985-90 SEA RFGION *-... " SPUY BlRl ~. ~ .-.- ~-~p-~ 'I~~~~--~~ -5 4k q4 3t ------ *. --- + 13 21 42 ,t . ,,. 0 " ! 1 oL-~ ..... .- A. BS 86 81 Rti 89 90 Yea? "C., BANGLADES14 5 r..-.....- ~~. ~ I," rllDYI.nes, ;5 I :*o n 20 30L 130 : 15 . .A- 0 ---*- *- d $0 0 0 10; 5 ,L_ 85 86 8, 88 i4 90 ' i Yea7 INDIA Y.37 5C.~ ~ -. Il" mllllonrl l5 *- "enr :NOONES14 [JAVA 6 BAL11 "em,- I," r"o"ean6.l i5 ,a0 - - ---- - n 00 ; 60 d ro I z 20 rear O 85 85 81 88 89 90 "ear DISFC(E PRWEN11ON AND CONTROL 107 MALDIVES* +--+ 0 0 - - IP"X S'PI Pral car.. ,oral rmrer li ~ - .. 1 . . , ,*. ,' " 1 _ -* dl? ,, 0 85 86 UI dtl 89 90 86 86 87 88 B9 40 "mar Yes? NEPAL ,in tnousanes, .All cases detecled since 1984 are imported. NOTE SPR = Slide Posiliviy Kate (per hundred slides) SIR =Slide falciparvm Rate (per hundred rlides) 1990 Data: Provisional -6 2, A 4 ~. .~ ~ . ii O 05 Rb 8, 88 t(4 .to ,"aP "en? " o---- ~-~-~ ~. --~~~~ 5R1 LANKA ti,, t"n"ma"6s, 32- 24- '5 0. 40 >. , . , . 112 . 1 '.+ . . .24 1 :' -16 I" ,""i Y.. . .~ 85 in, aa nr sa '" ""er "as- it" k"0"rana.l 500r.. -. --p- ~- > i t .aOOL i >3 .. . . .. - ~ . 85 iih A; an "'4 iio '-85 86 81 RB 89 90 "cap ""a" 108 THE WORKOF WHO IN SEA continues to be implementedas aspecialprogramme, although effortsare being made to involve basic health service personnel in the diagnosis and treatment of malaria cases and in referring severe and complicated caseQto the appropriate institutions. Overall, the malaria situation in the Region has remained somewhat stationary for the past 5-6 years, with the case incidence remaining between 2.5 to 2.8 million cases and the slide positivity rate (SPR) remaining at about 3 per cent. The proportion of P. falcipamrl~ continues to be about 40 per cent of the total malaria cases, the highest being in Myanmar (more than 85 per cent) and the lowest in Nepal (about 10 per cent). There has been no indigenous case of Malaria inMaldives for the last few years. The malaria profile in the countries of the Region is shown in Figure 3. P. folcipan~rn resistance to various antimalarials, vector resistance to different insecticides and the development of exophilic and exophagic habits by the principal malaria vectors constitute the main technical problems to malaria control in the countries of the Region. In addition, large-scale uncontrolled population movement, increasing economic constraints, socio-cultural barriers and the like, played a major role in the transmission of malaria in the South-East Asian countries. The foci of P. folciporunt malaria resistant to various antimalarials in the malarious countries of the Region have been gradually spreading. The resistance to Caminoquinolines is most pronounced in all the countries except Maldives. Resistance of P. falcipanrn~ to sulfa-pyrimethamine combination (SP) has also developed in vast areas of Thailand, some parts of Myanmar, Bangladesh, Bhutan and Indonesia. An increasing trend of P. falciparum resistance to the triple combination of Mefloquine-Sulfadoxine- Pyrimethamine (MSP) has been reported recently from the Thai-Cambodian border, particularly from Borai district. Somewhat reduced sensitivity to quinine has also been seen in the same areas. The problem of insecticide resistance in malaria vectors has also been increasing in some of the countries of the Region, i.e. DDT resistance among the principal vectors in India, Indonesia, Sri Lanka and Nepal. Other major administrative and operational problems and constraints encountered during the programme implementation included the shortage of trained manpower, especially at the district level, and financial constraints and difficulties in procuring insecticides from abroad. The principal components of malaria control programmes in the Region continue to be case detection, drug treatment and vector control measures along with programme-oriented field trials and development of required manpower. Residual sprayingis still the main strategyforvector control in the malaria control programmes in the Region - DDT, malathion, HCH and a few other insecticides being widely used. Focal spraying in areas of unstable malaria is practised in some countries to prevent/control epidemic outbreaks. Attempts have been made recently by some of the programmes to reduce the use of residual insecticides, and savings resulting therefrom were being earmarked for development and operational use of bioenvironmental and personal protection DISEASE PREVENTION AND WNIXOL 1W measures. The use of larvivorous fishes was operational in Indonesia but was mostly confined to trial areas in India, Myanmar, Nepal and Thailand. Mosquito nets, coils and repellents increasingly attracted the attention of the national authorities for study and research, with the hope of using them on a larger scale. There has beenincreasing emphasison the diagnosis and treatment of clinical malaria cases with the objective of shortening disease episodes and preventing deaths, especially in areas where prompt laboratory facilities were lacking. Community involvement in simple drug treatment and referring severe cases to nearby health centreslhealth institutions, as well as intersectoral collaboration have been progressing in many countries. The establishment of malaria clinics in inaccessible areas, particularly in areas with the problem of drug resistance, has facilitated quick microscopic diagnosis and treatment with appropriate drugs in Thailand. This approach is being gradually adopted in Myanmar and Nepal. III vitro and i11 vivo drug sensitivity tests are being carried out in all the countries except Maldives as no indigenous P.falcipanrrlt cases have been recorded in Maldives since 1976. These studies have proved to be helpful not only in providing a basis for early warning of reduced sensitivity of P.falcipanrm to antimalarials, but also in facilitating the development of national drug policies. The foci of resistant P. falciponrn~ have been promptly dealt with using the second or even third line of drug treatment and the monitoring of movements of malaria high-risk population groups. WHO collaboration in the smooth implementation of malaria control activities and in the solving of both technical as well as operational problems in thc Mcmbcr Countries was continued. Support was provided to the programmes in staff collaboration, manpower development, organizing study tours and workshops, procurement of essential supplies and equipment and in conducting programme-oriented field studies. Country long-term staff collaborated with the national programme authorities in the planning, implementation, supervision and evaluation of the control activities and in organizing staff training courses on malaria for mid-level staff. They also assisted in carrying out field studies. Efforts were made to improve trained manpower at all levels of the country programmes, using for this purpose either WHO country budgets or the assistance of bilateral agencies and international agencies. Fellowships were provided for regional as well as extra-regional training courses and study tours on malaria. A number of health services staff at the peripheral level in most of the countries were given training in malaria and malaria control activities. As usual, Thailandlltaly basic courscs on malaria and planning of antimalaria activities were held during January-April 1991 and were attended by middle-level staff engaged in the implementation of malaria control programmes. A series of seminars on the management of acute and complicated malaria was being conducted for both health services staff and private practitioners in India. The Regional Office published the third edition of 77le Clirticol Mo~~age~ilntl of Acufe Molaria (Regional Publication Series No. 9). Seminars were organized for architects and engineers engaged in the construction of water-resource 110 lWE WOKKOF WHO IN SEA development projects (WRDP) in India to prevent the creation of mosquitogenic potential in their respective projects. A travelling seminar, sponsored by WHOIUNDP, was organized in Thailand in December 19W for newly-appointed Directors of Malaria Control Programmes in Bangladesh, Bhutan, India and Thailand. Since drug resistance in their respectivc countries is an acute problem, they had an excellent opportunity to exchange views on epidemiological data and acquired experience on the subject. Moreover, the participants visited those areas on the Thai-Cambodia border where reports of reduced sensitivity to mefloquine had been recently reported. An informal consultative meeting on Forest-related Malaria in the countries of the SEA Region was organized in New Delhi from 18 to 22 February 1991. Participants included country representatives who were Directors of malaria control programmes andlor research institutions, epidemiologists and other senior level officials, and WHO malariologists working in the countries of the Region and in WHO headquarters, Forest-related malaria constitutes about 40 per cent of total malaria and about 60 per cent of the P. fulcipunrm cases in the countries of South-East Asia, and forests are becoming more accessible due to the exploitationof natural resources. Very often population movements result in malaria outbreaks. Malaria control in different forest settings is cxtrcmcly difficult since malaria transmission in the% arcas is intcnsc due to highly cfficicnt vectors, prolonged transmission, and drug resistance combined with large-scale uncontrolled population movement. Recognizing that the current general objectives of prevention of malaria mortality and reduction of morbidity are highly relevant in various forest settings and that the problem of forest-related malaria in the countries of the Region varies in magnitude and extent, it was recommended that the populations at risk in different forest settings be identified and stratified together with relevant information relating to malaria situations and vectors, to enable appropriate remedial measures to be adopted. In addition, studies may be taken up to investigate the impact of a changingenvironmcnt on various factors involved in malaria transmission, to identify the problems and to undertake possible control measures as suited to local situations. Programme-oriented operational research continued in the countries of the Region, particularly in the field of malaria control through the primary health care approach. Several research projects aimed at promoting biological, environmental and personal protection measures and projects on community participation in case-finding and treatment continued. New areas for operational research were identified in thc course of the meeting on forest-related malaria, and included the study of thc epidemiology of severe and complicated malaria as well as the impact and cost-effectiveness of the use of residual insecticides under different epidemiological situations, etc. International, bilateral and multilateral agencies, such as SIDA in India, CIDA in Myanmar, USAID in Sri Lanka and Nepal, ODA (UK) in Nepal and Bangladesh, IIISFASE PREVENTION AND CONTROL 111 and the World Bank and JlCA in Indonesia, are actively collaborating with the countries concerned in their malaria control activities. UNDP continued to provide funds for conducting training courses and seminars on in vitro microtechniques and for providing test materials. It also providrd support for manpower development and carrying out field studies in Bangladesh. A total of 733 supervisors and field staff were trained in malaria in 1M. Two field trials - one on the efficacy of antimalarial drugs (MSP vs Larium) and the other on the impact of DDT coverage plus chemotherapy vs chemotherapy alone - were carried out. 13.4 PARASITIC DISEASES WHO continued to providc technical cooperation to countries in thc conlrol and management of parasitic diseases, mainly intestinal parasitic infection, filariasis, leishmaniasis, schistosomiasis and guineaworm disease. Intestinal Parasitic Infections Intestinal parasitic infections continued to be a public health problem in this Region and arc closcly associated with undernutrition, poor pcrsonal hygiene and environmcntal sanitation. Many countries are engaged in research and control of these parasitic diseases through ongoing projects such as those in family planning, school health, etc. As a result of the studies carried out in India, Indonesia, Nepal, Sri Lanka and Thailand, mass treatment of children and women of child-bearing age, which are the main target groups for intestinal parasitic infections, has been rstablished in highly infected areas. In India, WHO supported a national Workshop on Intestinal Parasitic Diseases for District-Level Health Programme Managers, held in Calcutta in September 1990. Visceral Leishmaniasis (Kala-azar) Visceral Leishmaniasis continued to be a health problem of importance in the rural areas of the states of Bihar and West Bengal in India, as well as in Bangladesh and Nepal. In Bihar, almost 44 million people, covering 28 districts, and in West Bcngal 5.5 million people covering 8 districts, are at risk from Kala-azar. During 1993,54 000 cases with 590 deaths in Bihar, and 2 917 cases with 16 deaths in West Bengal, were reported. Sporadic Kala-azar cases have been detected in Uttar Pradesh, Assam and Delhi. In India, the total number of cases reported was 56 971 with 607 deaths. In Bangladesh, 4 893 cases and 18 deaths were recorded. In Nepal, 112 THE WORKOF WHO IN SEA 327 Kala-azar cases and 14 deaths were reported during 1990 from several districts bordering Bihar state in India. WHO supported a national Workshop on Visceral Leishmaniasis for Medical officers, on Efficient Management through PHC Services, which was held in Patna, Bihar, on 21 January 1991. A training course on visceral leishmaniasis, with special reference to epidemiology, diagnosis and treatment, held in Patna from 20 to 22 May 1991, was also supported by WHO. Sera-epidemiological studies, supported by WHO, were carried out in some endemic districts of Bangladesh, India and Nepal. WHO also provided laboratory equipment to ~angladeshwhile some research &dies were supported in Bangladesh and Nepal. Lymphatic filariasis continues to remain a public health problem in eight countries of the Region. In India alone, 374 million (275 million rural and '99 million urban) people are exposed to the risk of filariasis and 25 million are microfilaria carriers, whilc 19 million are suffering from filarial diseases. WHO continued to encourage integrated control strategies and facilitated TDR-sponsored operational projects in India, Thailand and Indonesia, especially those concerned with chcmotherapy trials of different doses of ivermectin in microfilaria carriers and paticnts with filarial diseases. WHO alsosupported a nationalSeminar onoperational Rebearch on Vector Control in Filariasis, held in Calicut, Kerala, India, on 9-10 October 1990. This seminar was attended by state-level National FilariaControl Programme officers, epidemiologists, entomologists and public health engineers. The seminar reviewed the problems and constraints in the implementation of filaria vector control measures, operational rescarch nccded to improve the efficiency of vector control under NFCP, and ihc feasibility of extending filaria control measures to rural endemic areas. Schistosomiasis Schistosomiasis is endemic in limited areas of lndonesia (Scltisrosorita Japo~~icrr~it) and Thailand (Scltisroso~na Mekortgi). WHO supported a national Seminar on Parasitology, held from 22 to 26 June 1990 in Surabaya, East Java. This seminar was organized by the Indonesian Parasitic Control Association. The results of filariasis and schistosomiasis research conducted by various institutions in lndonesia during the last two years were also presented in this Seminar. Control activities were continued in the endemic valleys in lndonesia and Thailand. Research studies were also supported under TDR. DISEASE PREVENTION AND CONTROL 113 Guineaworm Disease (Dracunculiasis) The problem of guineaworm disease is present only in India in the South-East Asia Region. The National Guineaworm Eradication Programme (NGWEP) was initiated in 1984 with WHO assistance. At the beginning of the programme, about 40 000 guineaworm cases were recorded in 1 284 villages of seven endemic states in India. Tamil Nadu has been frce from guineaworm disease since 1985. Andhra Pradesh, Gujarat, Karnataka, Madhya Pradesh, Maharashtra and Rajasthan continue to be endemic states. Gujarat is on the verge of being declared a 'no case' state. Major problems are faced by Rajasthan, which contributed 70 per cent of the total cases in 1990. Based on the latest evaluation report, 4 978 guineaworm cases were reported in 2 592 villages in I990 as against 7 881 cases in 3 596 villages reported in 1989. WHO supported the thirteenth Task Force Meeting on Guineaworm Eradication, held in Ncw Dclhi in January 1991. The meeting stressed the importance of active search, propcr survcillancc and community participation in the Programme. It was proposed to add twomore surveillance teams for Rajasthan to thc ten already cxibting. 13.5 TROPICAL DISEASES RESEARCH The UNDPiWorld BankiWHO Spccial Programme for Research and Training in Tropical Diseases (TDR) is a goal-oriented global programme with two main objectives: research and development to obtain new and improved tools for the control of major tropical diseases, and strengthening of research capabilities of endemic countries. The programme has identified four thrust areas for the 1990s, viz., field research; product development, including rational drug development; social and economic resci~rch; and research capability strengthening. In this context, emphasis is laid on malaria research out of thesix target diseases, while leprosy and tuberculosis are heing considered together in the search for newer drugs and other control tools and operational research. A Product Development Unit was established within TDR in order to better implement the various development activities such as determining priorities for urgently needed drugs, collaboration with industry, funding arrangements and emphasis on product development in developing countries. A fresh approach towards research capability strengthening (RCS) is heing considered and a policy paper on the Programme's RCS activities is being prepared for consideration by the Joint Coordinating Board. There is a shift in support to least developed countries in tropical diseases research. In this context too, the FIELDLINCS programme, which focuses on young researchers from developing countries, and their research project development, are emphasized. There are in effect 2 programme-based grants in Thailand, 1 TDR-Rockefeller Foundation grants in India, Sri Lanka and Thailand, and 114 THE WORK OF WHO IN SEA 4 long-term institutional strengthening grants in lndia (I), Indonesia (1) and Thailand (2). There has been good progress in the ongoing projects, and onc new ~- . grant was initiated. A new grant proposal for institutional strengthening was submitted by Nepal, which has not previously been supported. The number of training activities supported by the Special Programme has beeti substantial, i.e. 172 up to the end of 1990, with the result that institutions have benefited immensely from fully-trained personnel. Specifically, the training has had a strong local component and linkage with disease control. A total of 15 new R&D projects have been initiated in the South-East Asia Region. Malaria Among thc TDR target diseases, malaria received the highest share of its budget - almost one-third of the total research and development budget during 1YM-1YlI. Non-chemical methods of control of vector mosquitoes, including community participation and use of larvivorous fish, are being investigated, but it is too early to assess their usefulness. These ongoing antimalarial studies have been largely focuscd in India, Indonesia and Thailand. Studies to identify potentially uscful surface antigens for possiblc malaria vaccine development have been initiated in Sri Lanka. Leprosy The multicentre field trials of leprosy vaccine, including the armadillo-derived WHO vaccine recently initiated, is an important ongoing activity. Several projects with strong emphasis on the social sciences have been initiated in relation to the control of Leprosy. Most ofthe leprosy research activities are focused in India andThailand. Filariasis The evaluation of clinical trials usingivermectin in the treatment oflymphaticfilariasis has moved to the second phase where the drug is being compared to DEC in its eflicacy. The results of completed studies have indicatedgood microfilaricide activity and minimal toxicity. Five new designs for further study have been developed jointly by TDR and Indian and Sri Lankan scientists. These new projects arc both hospital-based and community-based, and emphasis is laid on the trcalrncnt and prevention of infection and disease. In Indonesia, a monkey modcl has bccn developed and is being used for screening newer antifilarial drugs. Future field trials of ivermectin will also be largely focused in India, Indonesia and Sri Lanka. A DNA probe for the detection of L.3 stage W. bancrofti has been developed in Sri Lanka. Further studies are in progress. DISEASE PREVENnON AND CONTROL 115 Leishmaniasis Leishmaniasis still continues to be a problem disease in three countries of the Region, i.e. India, Bangladesh and Nepal. So far, the support has been minimal, but greater participation is strongly encouraged, especially in the area of vector control, drug treatment and epidemiology. 13.6 CONTROL OF DIARRHOEAL DISEASES PROGRAMME Since 1979 the Control of Diarrhoea1 Diseases (CDD) has been one of the priority programmes of the countries of the South-East Asia Region with the primary objectives of reducing diarrhoea-associated deaths in children under 5 years of age and prevention of diarrhoea morbidity. The former objective is being promoted through effective case management at home and at health institutions, primarily with the use of oral rehydration therapy (ORT). The second objective is being addressed by the promotion of preventive measures such as exclusive breastfeeding, improved weaning practices, use of plenty of clean water, handwashing, use of latrines, proper disposal of babies' stools and measles immunization. WHO continues to assist the countries in achieving these objectives. In all SEAR countries, the national CDD programmes are being implemented as part of the primary health care services. National CDD programmeltraining plans were developedor revised during thisreportingperiod inThailand, Indonesia, DPR Korea and Mongolia. A comprehensive programme review was conducted jointly in Myanmar with the participation of the Government, UNICEF and WHO. Somc of thc highest priorities in the C'DD programme are training in clinical managcmcnt, programme management and supervisory skills. Intcrcountry clinical management courses were conducted in India, while an intercountry programme management course was held in Kathmandu in 1990. Training modules were translated into the local languages in Myanmar, Mongolia, Nepal and DPR Korea. Additional diarrhoea training units (DTU) were established in Bangladesh, India, Indonesia and Myanmar. During thc reporting period, national courses on different aspects of CDD werc conducted in most of the SEAR countries. Nine of the eleven SEAR countries produce ORS locally. The majority of ORS-producing countries of SEAR continue to strive towards self-reliance by improving their technical and managerial capabilities. In 1989, the most recent year for which data are available, SEAR countries produced over 106 millionlitrcs of ORS. 116 THE WORKOF WHO IN SEA National programmes are giving high priority to conducting CDD household case management surveys. Such surveys were conducted in Bangladesh, Indonesia, Maldives, Myanmar, Nepal, and Sri Lanka. In addition, a health facility survey to evaluate diarrhoea case management practices was carried out in Bangladesh. ORS acccss and ORT use rates are two common indicators used by all Membcr Countries to measure programme performance. In 1989, the ORS access ratca increased slightly to 64 per cent from 63 per cent in 1988. In six SEAR countrics (Maldives, Sri Lanka, Indonesia, Thailand, DPR Korea and Nepal) the access rate reached 80 per cent or higher. The regional ORT use rates declined in 1989 to 19 per cent from 28 per cent, largely due to more reliable estimates based on recent household case management surveys undertaken in Bangladesh, India and Indonesia. Health education, information and communication activities in the Region were further strengthened by country reviews. These were considered in detail during the programme managers meeting in 1W. CDD strongly promotes integration with primary health care and collaboration with other programmes in implementing CDD preventive strategiessuch as breastfeeding, improved weaning practices, use of clean water, handwashing, proper disposal of human excreta and measles immunization. Most diarrhoeal diseases research in the Region continues to focus on problem-solving-orientcd operational research. The WHO collaborating centres at the National Institute of Cholera and other Enteric Diseases (NICED), Calcutta, and International Centre for Diarrhoea1 Diseases Research, Bangladesh (ICDDR, B), Dhaka, continued to work closely with the Regional CDD Programme in the areas of training and research, while UNICEF, UNDP and US AID continucd their support for the implementation of CDD aclivilies at thc national level. 13.7 ACUTE RESPIRATORY INFECTIONS Acute respiratory infections (ARI), especially pneumonia, together with diarrhoeal diseases and malnutrition, arc still the leading causes of death among children and attcndancc at out-patient departments of all the health services. Sincc the beginning of the programme, national committees or advisory groups on ARI have been constituted in almost all the countries for promoting prevention and control activities. Increased awareness of the problem has stimulated the countries to include, in their health plans, the control of ARI in children as one of the most important components. In 199U and in the first months of 1991, long-term plans of action were prepared or revised, with the collaboration of the Regional Office, for DISEPSEPREVENnON ANDCONTKOL 117 nine out of the eleven countries of the Region. In all these countries, a national programme manager has been appointed. The new supervisory skills module 'Management of a Child with ARI' and the training video, field-tested in Thailand, and the new programme managers course, field-tested at a WHO interregional course in Thailand in 1989, have given a new input and created interest in the programme. The manual for doctors has been considered as a technically very good and useful reference document for doctors dealing with children. As a result of this, countries have now started sending their requests for bulk copies of this document for wide distribution. In all Member Countries, reduction of mortality from pneumonia has been considered the main immediate objective and the most important priority of their national programmes. For this reason, some countries, such as India, Indonesia, Myanmar, Nepal and Sri Lanka, have decided to focus on the training of handling pneumonia only. WHO modules have also been developed accordingly. In all countries, the new classification of ARI has been well accepted. One of the major concerns has been to have the agreement of paediatricians to the programme before starting it. In SEAR countries, national paediatric associations and professors of pacdiutrics at the university level have been involved in the programmes. Policy mattcrs have always been discussed with them to seek their agreement and support for the implementation of the programmes. In India alone, there were 40 meetings of the paediatric association, with a total number of 1 400 participants. The programme is being implemented in 15 districts in India. Though the coverage is still limited, implementation of the programme in 15 districts in a country like India means coverage of a population of more than 30 million people. Programme managers courscs were also organized in India, Indonesia, Myanmar, Sri Lanka and Thailand. Some of these were attended by participants from smaller countries such as Maldives. WHO had close collaboration with UNICEF. Some NGOs, such as CARE, DANIDA, PATH, USAID, John Snow and SWACH, were involved in planning and training activities. Thailand has been selected by UNICEF for an intensified ARI programme to which the Regional Office, along withJohn Hopkins University, hasgiven technical support. Supervisory skill courses were conducted in India, and were attended by 1 000 participants. Similar courses have also been started in Indonesia. It has taken a long time to have the modules adapted, translated, reviewed by paediatricians and finally printed. Bangladesh, India, Indonesia and Thailand have already produced their own modules and started training activities. In Myanmar, Nepal and Sri Lanka, the translation of the material into the local languages is under process. IIX THE WORKOF WHO IN SFA New training videos have been prepared in India and Thailand and in other countries (i.e., Bangladesh, Indonesia), the WHO videos are being dubbed in the local languages. Posters, leaflets and other communication material have been produced in almost all the countries. A monitoring system for training activities has also been set up in India, in collaboration with the SWACH foundation, Chandigarh, and the same methodology will also be utilized in other SEAR countries. An intercountry Meeting on Prevention and Control of Acute Respiratory Infections was held in Jakarta, Indonesia, in 1990, and was attended by programme managers of SEAR countries, UNICEF representatives and observers from NGOs. The objectives of the meeting were to review the progress of the programme; to stimulate countries that did not have a national programme to initiate activities; to ascertain the acceptability of standard case management of pneumonia at different health facilities levels; and to share experience in training, methodologies and materials utilized. In all SEAR countries, ARI will be an essential and integrated component ofthe PHC programme even if, being a relatively new programme, case management training on ARI needs more consideration. and more time has to be devoted to it. 13.8 TUBERCULOSIS Tuberculosis continues to be a major public health problem in the countries of the South-East Asia Region and yet most countries have achieved less than 50 per cent coverage in respect of case finding and consequential treatment. With the sprcad of HIV infection, countries such as India, Myanmar and Thailand, arc likely to have a surgr in infections with tubercle bacilli. WHO has recently formulated a draft Medium-Term Plan (1992-1995) for implementing new strategies for the control of tuberculosis and for promoting operation support, research and coalition building. Twomajor activities that WHO undertook during the reporting period need mention. First, a meeting on Tuberculosis Control and Research Strategy for the I1MOs was held in Geneva, on 26-27October 1990, which was attended by participants from lndia andThailand, besides a representative from the Regional Office. In this meeting, new strategies for implementing tuberculosis control, emphasizing operation support and research development were discussed. According to the new strategies, the primary objective of the tuberculosis control programme is to improve the cure rate and the second objective is to expand the coverage of tukrculosis services. Toachieve bctler DIStASE PREVENTION AND CONTROL I IY case treatment results the meeting recommended the introduction of 6-8 month short course chemotherapy (SCC). The second important activity was the Task Force Meeting on Research in Tuberculosis, held in the Regional Office from 3 to 6 December 1W to identify research priorities on tuberculosis in the countries of the Region. This meeting, held in response to the recommendations of SEAIACHR, anaiysed the problem of TB in SEAR countries and developed nine research protocols for the consideration of researchers. These protocols are in the areas of identification of risk factors for diseases, risk factors for infection, operational research for improving the cure rate, programme monitoring and disease surveillance, assessment of the protective effect of revaccination with BCG, the role of chest X-ray examination, centralized sputum examination to improve the quality of coverage, relative efficacy of different drug regimens, thc usc of combined drug tablets for the treatment of tuberculosis and operations research for the attainment of a high cure rate in district TB control programmes. In general, the countries were supported through fellowship placements, provision of supplies and equipment to strengthen projects and subsidies for holding national-level training activities. Bangladesh was assisted in the procurement of anti-TB drugs and X-ray films. Motivation units for TB patients havc bccn started in all the TB clinic to reducc thc default~.r ratc considcrably. Thcrc arc 44 static units with the facility topcrform thesputum AFB stain in the460 upazilla health complexes and 24 district hospitals. In Bhutan, tuberculosis ranks fourth among ten diseases which cause mortality. A review of the National Tuberculosis Control Programme was undertaken by the national TB Task Force members in September 1W. One of the recommendations of the review was to have short-course chemotherapy uniformly implemented throughout the country. India continued to receivc WHOISIDA assistance for improving casc finding and trcatment, including SCC and essential supplies and equipment. The second international Training Course on Tuberculosis was organized by the National Tuberculosis Institute, Bangalorc, from 14January to 22 March 1991. In this Course, six international WHO participants received training. One national was awarded a fellowship in TB and clinical epidemiology for 12 weeks in the USA. Laboratory facilities wcrc strengthened through the SKrE component of the National Tuberculosis Institute (NTI), Bangalore, and the Tuberculosis Research Centre, Madras. The national workshops for senior teachers of medical collegcs and state-level administrators were conducted by NTI, Bangalore, in November 1990, with WHO support. Inclonesi:~ usr prsnidcd tc:hnical ,upport through a consultant for onc month, in Jul) l')'/tl,tt~,~,>c>,:~n~l rc\,icu lhc Ndi<~n:tl'l'ti Pr~~gr.tn~n~c i~~tcrm~,~ithcFifth Fi\c.Y~.ir I20 THE WORKOF WHO IN SEA Development Plan of Indonesia. A national attended the WHO-Japan International TuberculosisCourse inTokyo from2July to 20 October 1990, followed by a two-week post-course study tour to South Korea. Support was extended for a participant to attend a workshop on tuberculosis treatment in adults and children in Geneva from 2 to 4 July 1990. Besides, the project was strengthened with the provision of a vehicle and an overhead projector. Mongolia received subsidies support for conducting a national Seminar on Early Diagnosis of Tuberculosis. WHO support also included supplies. The number of registered cases of active TB cases in the country as of 1 January 1990 was 10 897. Myanmar was assisted through fellowships and provision of supplies for sputum testing. During 1990,69535 persons were examined by theTB centres with a coverage rate of 35 per cent. In Nepal, reports on TB cases arc sent by health posts and other nongovernmental organizations to the National Tuberculosis Control Programme for compilation. Hospital treatment is done only in Kalimati Hospital by the Nepal Anti-TB Association located in Kathmandu. WHO support was extended for two participants to attend a Regional Seminar of the Eastern Region of IUAT, Beijing, from 16 to 20 October 1990. WHO assistance to Sri Lanka included the procurement of computers, an airconditioner and subsidy assistance for holding national-level meetings for the evaluation and monitoring of the TB Control Programme. Thailand was extended support for holding a meeting on accelerated case finding and application of short course chemotherapy in tuberculosis control in December 1990. 13.9 LEPROSY The South-East Asia Region has witnessed a steep decline in the registered cases of leprosy, from 3.7 million in 1985 to 2.7 million in 1990. Of these 2.7 million cases, 1.8 million or over 66 per cent are currently on MDT, and over 1.0 million patients havc already completed MDT. In Bangladesh, as of December 1990, about 25 000 leprosy patients were receiving treatment, out of which over 16 000 or 65 per cent were on MDT. During the past year, 21 technicians of upazilla health complexes were trained with assistance from WHO. WHO also provided an anaesthesia machine with accessories and other supplies and equipment as well as rifampicin and clofazamine. Leprosy control services are integrated with general health services, particularly with TB control activities. DISFASE PREVEKnON AND COmOL I21 Despite the constraints of communication and logistics, because of the difficult terrain, Bhutan has achieved93 per cent coverage with MDT. The prevalence, based on registered cases, has been reduced by 92 per cent over the past nine years. The incidence has also decreased by approximately 50 per cent during the same period. Political will and strong commitment at the highest level have been instrumental in achieving this. The National Leprosy Review Workshop, held recently with the participation of WHO, recommended that the strategy of the programme, which is currently based on domiciliary visiting, be reviewed with a view to integrating leprosy control senices with those of primary health care in a phased manner. In India, the estimated number of leprosy cases was 4 million in 1981. However, with intensified and effective programme implementation, this figure has been reduced to 3 million in 1990. The National Leprosy Eradication Programme aims at achieving arrest of the disease in all leprosy cases by the year 2000. To achieve this, MDT is being extended to endemic areas in a phased manner. During 1990,0.46 million new cases were detected and 0.64 million discharged as cured. At the end of December 1990,2.4 million cases were shown in the records of NLEP, of which 1.4 million were on MDT. So far, over onemillion cases have beendiicharged on completion of MDT. The relapse rate is less than one per cent of the cases who have completed MDT, and complications arc very few. The disability among new cases, especially in those districts which have been under MDT for five years or more, has declined significantly. At present, 130 endemic districts out of 1% have been brought under MDT through the vertical approach. The Programme has plans to partially integrate the leprosy control senices with the basic health system in the remaining 66 endemic districts. Field trials of several candidate vaccines for leprosy, including WHO vaccine, are being undertaken by the Indian Council of Medical Research, with WHO support. A request for conducting Oflaxine trials, with the support of WHO, from 8-9 leprosy institutes is under consideration by the Ministry of Health and Welfare, Government of India. Since 1969, the Leprosy Control Programme in Indonesia has been integrated into the general health services. All provinces are implementing MDT. As of March 1990, there were 107 271 cases receiving treatment (prevalence 0.59 per 1000 population) with an MDT coverage of 50 per cent. More than 64 000 cases have received or arc receiving MDT, of which 26 000 cases have been released after treatment. The long-term objective of the National Programme is to reduce the leprosy prevalence rate to 0.1 per 1000 population by the year 2000 in order that it wiU no longer be a public health problem. The prevalence of leprosy in Maldives has shown a steady decline from 12 per 1000 in 1979 (1 654 registered cases) to 1.24 per 1 MX) at the end of 1990 (273 registered cases). Out of202inhabited islands, 120islands were reported as havingactive leprosy 122 THE WORKOF WHO IN SEA cases in 1987. At the end of 1990, only 79 islands had leprosy cases. A unique ~ ~ programme of zero transmission~chemoprophylaxis for leprosy was launchedin Maldivesin March 1991. This programme includesthe survey of the entire population of each island and physical examination of each person. ~fi new cases detected are put on MDT and all healthy people with no contraindications are given a single dose (20lkg body weight) of rifampicin. In the first phase, the chemoprophylaxis programme will be implemented on 16 islands, and will be continued on other islands after evaluation if found feasible, given the existing constraints. In spite of some slowing down in 1990 due to unavoidable circumstances, the Leprosy Control Programme in Myanmar is progressing satisfactorily. MDT was first introduced on a mass scale in six hyperendemic divisions of the country in 1988. Out of a total of 185 townships in these 6 divisions, 150 townships are currently covered by MDT. An overall MDT coverage of registered cases (in these 6 divisions) of 55 per cent has been achieved. The Three-Year Plan, 1990-1993, has been approved by the Governmenl and envisages the integration of leprosy services with the general health services. In this connection, a number of training activities, with support from WHO, have been carried out. WHO is currently negotiating with donors with a view to obtaining the necessary drugs required for MDT in Myanmar. In Nepal, s~nce 1987, the Leprosy Control Programme has been intcgrdted in all thc 75 districts where the major responsibility lies with the District Public Health Olfice. and at the regional level with the Regional Health Directorate. The long-term objective of theProgramme is to achieve areduction in the prevalence rate of O.1/1000 by UMO. At the end of 1990, theprevalence rate was 1.36/1000 and an MDT coverage of 52 per cent (registered cases) had been achieved. In 1990, leprosy control efforts in Sri Lanka were intensified with the objective of detecting and treating at least 12 000 new cases by 1995, and reducing the active case-load to below 1000 by that time. A number of novel steps, such as a social advertising campaign launched in February 1990 using all available channels of the media, have been taken. This has led to a significant increase in self-reporting (from 10 per cent in 1989 to 42 per cent). Another step has been the training of all the basic health staff in the country and about 1000 doctorsin leprosy. As well, dermatologists and general practitioners have been provided with free MDT blister packs, in return for which they will provide anonymous patient information. In 1990 there were 3 000 patients on register, all of whom were on MDT. In Thailand, the Leprosy Control Programme has been integrated since 1972. As of 1 October 1990, an MDT coverage of 93.7 per cent has been achieved, with a total of 12 164 cases on MDT. The number of patients who have completed MDT since the beginning of MDT in March 1984 is 29 486. A reduction in the prevalence rate from 0.911 000 in 1984 to 0.24/1000 in 1990 has been achieved. The programme in future DISEASE PREVEKnON AND CONTROL 123 will concentrate on the strengthening of all aspects of leprosy control activities. A national programme of disability prevention will be launched in the near future. The development of biomedical research, especially in immunology and animal experiments, will be given emphasis. The Programme hopes to achieve the goal of a prevalence of 0.111 000 by the year 2WO. In spite of the satisfactory progress made by the leprosy control programmes in the Member Countries there are still a number of areas requiring further intensification of efforts. They are: to estimate the number of cases as accurately as possible, the urgent need to close the wide gap between the number of registered patients and the estimated number of cases, promoting more efficient use of available human resources, evolving cost-effective strategies for disability prevention and rehabilitation, improving coordination among all parties concerned with leprosy, and, above all, mobilization of adequate resources for the programme. 13.10 ZOONOSES Thecountriesof theRegion were assisted by WHO in their efforts tolaunch measures for the prevention and control of rabies and to take some steps for effective control of brucellosis. The Rabies Control Programme in India has been further strengthened. The Government constituted an intersectoral task force, including a WHO staff member, for coordinating the activities of the departments of Health and Agriculture and for providing further technical and financial inputs to activate the programme in several states. In Indonesia, preparatory activities for the rabies intcgrated reduction programme were conducted in West Java, South Kalimantan and Central Kalimantan. In August 1990, vaccinations were carried out and the coverage among the dog population ranged from 70 to 80 per cent. Plague surveillance activities were carried out in the plague foci in Central Java and East Java to detect human plague as well as Y. peslis among the rodent and flea populations. Surveillance activities were carried out in seven villages in the districts of Samarang and Boyolali in Central Java which have reported human anthrax cases. In a population of 23 000 people, 90 per cent of cutaneous type and 10 per cent of gastrointestinal human anthrax reported cases were confumed. Necessary manpower was trained in laboratory diagnosis, epidemiology and control of taxoplasmosis, and WHO provided assistance in obtaining information on the surveillance of Ebola virus in monkeys for the country. 124 DIE WOKKOF WHO IN SFA Eradication of plague and effective control of brucellosis are the main aims of the ZoonoticControl Programme in Mongolia. The services of two consultants, on vector biology and on brucellosis, were made available to the Programme. Three nationals were trained in vector biology, diagnosis and treatment of brucellosis and in epidemiological surveillance of plague. Supplies and equipment needed by the Programme were also made available to the country. A seminar on brucellosis wntrol is scheduled to be held in June 1991. In Nepal, the Control of Zoonoses and Food Safety Programme aims at strengthening the zoonotic disease control section of the Epidemiology Division, Ministry of Health, through developing and implementing a surveillance and wntrol programme of zoonotic diseases, strengthening food legislation and implementing food safetylsanitation activities. Preparatory work for the activities specified in the plan of action is in progress. Four nationals were trained in zoonotic disease control and study of meat-borne diseases in Thailand and India. WHO provided supplies and equipment to meet the requirements of the project. Surveillance, prevention and control of zoonoses and related food-borne diseases, including food safety sanitation, hygiene and sanitation of restaurants and hotels, are still in a rudimentary stage. The lack of food legislationlregulations and trained manpower in the field have been the major obstacles to the implementation of the project activities. In Sri Lanka, medical supplies, including journals and other publications, were madc available to the project. Production of a TV documentary on rabies in Sinhala, with Tamil translation, was scheduled for January-May 1991. The production of 5 000 pamphlets on rabies wntrol is also on the cards. A review of the rabies control activities with provincial staff has been in progress since January 1991. A consultant, supported by AGFUND, helped thecountry in the preparation oftheNational Rabies Control Programme. 13.11 SEXUALLY-TRANSMITTED DISEASES A high incidence of sexually-transmitted diseases continues to persist in many countries of the Region. All countries of the Region now have clinical and laboratory facilities to treat persons affected by these diseases, and preventive steps, such as promotinghealth education and banningprostitution, have been taken by them. Some countries have launched special programmes to control these diseases and have included them in the priority list. However, inadequate reporting and recording systems are an obstacle in estimating the exact magnitude and dimensions of the problems. The main problems are an increase in antibiotic resistance, the scarcity of physicians in remote areas, self-medication by patients, difficulties in case finding, poor community participation and motivation, and limited health education. WHO support was provided to assist the Government of India in organiring national workshops on clinical management of AIDS, in Delhi and Hyderabad. Laboratory equipment, reagents and chcmicalswerc supplied to Safdarjung Hospital, New Delhi, to strengthcn the Regional STD Reference L;~boratory. Two workshops werc held - one for district and peripheral level medical officers in Bangalore and one for nurses and hcalth cducators in Lucknow in August 19OOand nine fellowships werc providcd for highcr training in STI) contrnl. In Indonesia, the AIDS programme was integrated with the programme for STD control. A national Workshop on Yaws, held in 1989, resulted in the revision of strategies for the control and eradication of yaws. Surveys arc being conducted to focus on sch1111l childrcn of 6-12 years of age. During the liscal year 1989-90, 15 IM 'ISLS of yi~ws werc dctcctcd during surveys ciirricd out in all ihc pro\' c, ,. '~nccs. Assisl;~ncc w:rs provided to rcvicw the stalusof lhc STD Control Progr;tmmc in Nepal with the ol!jcctivc of dcvcloping close collahorati~m between the AIDS Conlrol Programme and the STD Control Programme. In Sri lank;^, the possibilities of intervention-linked research directed at reduction 0fHIV ir;~nsmission by STD con~rol amongst groups at greater risk of infection, wcrc supported. 13.12 RESEARCH AND DEVELOPMENT IN TIfE FIELDOF VACCINES WHO continued to support counlrics in the resc:irch and devclopmcnt of v;iccincs. Wilh technical and fin;tncial inputs, WHO has strcnglhcncd f;~cilitics for thc producl inn of hactcrial and somc of ihc viral v;~ccincs in India, ln~loncsia, illy;tnm;jr and Thailand. India has dcvcloped capabilities for the production of DPT, rabies and poliomyelitis vziccines. Several nationals wcre trained and new technology using fermentation was introduced. In Indonesia, excellent facilities have been established for the production of hactcrial v;~ccincs. In Th;~il;~nd, thcrc is scll'rcliancc in the production of bacterial vaccincs. Bi1;tlcral assist:~ncc has hcerr provided for establishing facililics for rhc produelion of viral vi~ccii~cs. Wl4O's major thrust in thc South-East Asia Region was to establish expertise in quality control of bactcrii~l and viral vaccines. Nationals from several countries of the Rcgion were trained in quality conlrol procedures and techniques. Intera~untry and national seminars wcre organized for training nalionals in qu;ilily control of DPT, poliomycliiis ;ind mcaslcs vaccincs. A nctwnrk of WHO collnhoraling ccrllrcs has been established in India, Indonesia and Thailand, where facilities are available for quality controlof DPTvaccineand training of nationafs in qualitycontrolprocedures. Dengue vaccine and snake venom vrrccine are now being developed in Thailand and Myanmar respectively. Plans for clinical trials of these vaccines are now at various ~tagcs of implementation, with support from WHO. In future, WHO will concentrate (In the transfer of technology for the development of newer vaccines, particularly viral vaccines for hepatitis and rabies, and ncw bacterial vaccines, and will develop training programmes for the production and quality control of thcse vaccines. 13.13 AlDS AlDS has now emerged as a serious problem in some countrics of the South-East Asia Region, particularly Thailand, India, and Myanmar. In Thailand, in 1987 less than one per cent (if a group of IVDUs wcre infected with HIV, hut by 1090, nearly 50 per ccnt of IVDUsseen in treatment facilities in Bangkok wercpositivc for HIVinfection. Similarly, less than oneper ccnt offemaleprostitutes in the various cities in Thailand, surveyed in 1987, were positive for HIV infection, whereas in 1990, the prevalence rate amongst female prostitutcs in at least three provinces ranged between 25 and 70 per cent in small groups in some areas. Mother-to-infant lransmission has also been recorded, both in Thailand and India. A sequential infection has been noticcd. Initially, rapid transmission among IVDUI was noted. After some lime, incrc;lscd prc\'alencc amongst fcmale prostitutcs was noted. Sobsequcntly, incrcascd prcvalcncc amongst proniiscuous persons visiting prostitutes, patients attending STD clinics and in the gcneral community was also reported. In India, in 1987, less than one per cent of fcmale prostitutes surveyed were infected, but now, in Maharashtra alone, 20 to 70 per cent of selected groups of prostitutes arc infected. The HIV serological surveys in India have not hccn comprehensive enough to allow an estimate of thc total HIV-infccted persons, but from thc trend it is clear that, with the high-risk bchavioor of pcrsons observed in a number of Indian cities, a rapid increase in HIV prevalcncc will occur. A new dimcnsion, in addition to the existing heterosexual transmission of HIV, has been noted with the rapid transmission of HIV infection amongst intravenous drug users in Manipur where, among 2 124 IVDUs, 1 Olhwere found positive for HIV infection (43.7 percent) as of 30November 1YN. Thc spread of infection to ncighhouring states from Manipur has also hccn observed. AIDS In theabsence of a cure for AIDS. attention continues to befocussed on prevention through education and information. Member Countriesarealso strengthening laboratory, surveillanceand counsellingfacilitiesfor prevention and control of AIDS. I ne nllessage of Good Health These happy triplets sing for health-health for all Myanmar, which had reported only one HIV positive belorc May 1988, started reporting large numbers of HIV positives amongst lVDUs by the end of 1989. The prevalenceof HIV attracts attcntionduring twopcriods. In the lirst phase, from 1985 [(I 1989, low heterosexual transmission occurred, while in the second phasc, from January to Augusl lOXI, si;.c;~hlc numbers of female prostitutes were round positive with an increase in hdcroscxual transmission. This was similar lo the trend observed in Thailand. The countrywisc situation of HIVIAIDS is given in Table 7 Table 7. Sitrrutio~r ofAIDS arrd HIVinfectiorl ~II SEAR cowltries (as of 4 June 1991) Ilangladeah I3hutan India Indonesia 111'11 Korea Maldtves Mongulla Myanmar Sepal Sri Lanka l'ha~land Month lilst rrporlrd WHO has heen supporting Mcmher Coonlrics in the implcrnenlation ol medium-tcrm plans, which arc now operational in India, Thailand, Nepal, Mongolia, DPR Korea and Myanmar. Bangladesh, Indonesia and Sri Lanka are being supported by WHO for implementing interim plans of action. The short-term plan of action was extended in Maldives pending the formulation of a medium-term plan. It is anticipated that MTP will bc initiated in these countries during 1991. WHO has been ;~ssisting the countries in rcsourcc mobilization for supporting medium-tcrm plans. WHO hasalso supported many interregional and intcrcountry (iEAs, not;~hlcami)ng lhcm hcing the Inlcrnalional C:onfcrcnce on AIDS in Asia and the Pacilic, held in Canberra, Australia, in August 1990, GEAs on thc involvemcnl of NGOs end women's organizations in the prevention and control of AIDS, and the Fourth International Course on Clinical Management of AIDSIHIV in Australia. Programme review is a continuing feature ol the mcdium-term plan. Table 8givcs the status of the various reviews th;~t have been conducted in diflercnt countrics. Table 8. Slulrrs ofprogmri~ri~e review urlder MTP irt differertl SEAR cor~rllrics Review Exkrnal rul~nlry MTP donon) nornlncr Myanmar lind 1991 - Tharland 1 1:;; 1 gm; Nepal Country Situation And Aciivilies WHO has intensified the rcgional activities in support of national AlDS prevention and control programmes taking guidance from discussions and resolutions of the World Health Assembly iind the Regional Committcc. The main programme activi~ics arc summarized hclow. I>one - Activities undcr thc short-term plan of action for prevention and control of AIDS in Bangladesh have bcen complclcd. The imporlant activilies included publicawareness through health educalion, sero-surveillance, blood transfusion services, and strengthening of laboratory services. At present, a work plan relating to the interim plan is being in~plementctl. A WHO c~,nsultant assis~cd thc government or Bhutan in integrating teaching of prevcntion and control ol AlDS and ST0 in the curricula for health and hcalth-rclatcd workers with thc introduc~ion of sex education in lho hcallh and population education cornponcnt of curricula. A WHO lahoratory scientist helpcd the national authorities plan lalx~ratory supplies. End 1991 - Allac~ivitiescnvisaged under the short-term plan for prevention andcontrolorAlDS in DPR Korca were completed. A medium-term plan (MTP) is now operational in the country. Done - India is the only country 111 the Region which has implcmen~cd the activiliescnvisagcd undcr the short-lcrm plan (STP) through its own resources. Activities undcr the medium-term plan (MTP) have been started. These focus on four metropolitan cities and north-castcrn states of Manipur, Nagaland and Mizoram. A WHO consulIan1 visited Indonesia in October 1990 111 carry out activitics for the prcven~ion ancl control of AlDS under an interim plan. A draft plan for HIV DISFXE PREVENTION AND CONTROL 129 surveillance was prepared by him. Another WHO consultant provided technical support in epidemiological surveillance activities, development of AIDS education and counselling and other supportive activities. Maldives is expected to formulate its medium-term plan (MTP) for prevention and control of AlDS during 1991. So far it has implemented activities under the extended short-term plan (STP). WHO assisted the country in organizing a Workshop on Counselling for Prevention and Control of AlDS in March 1991. Mongolia has signed the MTP project document. Steps have been taken to expand laboratory diagnostic facilities. Blood donors are screened regularly. The Government of Myanmar signed a project document with UNDP and WHO in early 1991 to support the implementation of the National AIDSISTD control programme through the provision of technical expertise, training and equipment. A mcdium-term plan (MTP) for the prevention and control of AIDS in Nepal has been approved by the Government. WHO consultants assisted the country in assessing the present status of epidemiological surveillance, STD diagnostic treatment, and in strengthening close links between AIDS and STD control programmes within the context of MTP. Sri Lanka is currently implementing activities for the prevention and control of AlDS under an interim plan. A medium-term plan has been formulated. Assistance of UNDPISIDA is being sought to support the medium-term plan in addition to WHO resources. Thailand is implementing activities under year 3 of MTP. A resource mobilization meeting was held on 6 March 1991. The programme was reviewed in January 1991 and a comprehensive review is planned towards the end of 1991. WHO, in consultation with the Member Countries, is promoting the concept and practice of sentinel surveillance for trend analysis. In some countries, particularly Thailand, sentinel surveillance is well established. Considering that most of the countries have implemented medium-term plans, WHO has been assisting the countries in the evaluation of the programmes. An external review by a team appointed by the Global Management Committee on AIDS, reviewed AIDS activities inThailand in April 1991 and in India in June 1991. A team from WHO headquarters visited India and Thailand in June 1991 to discuss with national authorities possible sites for the vaccine trials proposed to be conducted. Although, by and large, the programme is progressing in the anticipated direction, a sense of complacency has been noticed incountries that have low prevalences of HIV infection. his could be harmful to the programme as the three countries which now have serious problems of HIV infectionlAIDS too had low prevalences two or three years ago. I30 THE WORKOF WHO IN SEA 13.14 OTHER COMMUNICABLE DISEASES This group of diseases includes, amongst others, dengue haemorrhagic fever (DHF), Japanese encephalitis (JE), viral hepatitis and meningococcal meningitis. The reporting of thisgroup of diseases is not adequate as these are not notifiable diseases in many countries of the Region. Dengue Haemorrhagic Fever Although the case-fatality rate is on the decline, the number of cases reported during 1990 showed an upward trend in all the three endemic countries. Indonesia reported 13 043 cases and 458 deaths, Myanmar reported 5 200 cases and 178 deaths and Thailand reported 102 312 cases and 360 deaths (Table 9). Table 9. DHFcases, deaths artd case-fafalily rates (CFR) lit lr~dor~esiu, Myar~n~ar and 7Itailarzd, 1985-1990 For the control of dengue haemorrhagic fever, the Regional Office is supporting studies on the development oTan eKective vaccine against lour sero types ofdcnguc virus. The eighth Peer Review meeting was held in Bangkok on 29-30 September 1990. The results of trivalent vaccine Dl, D2 and D4 were discussed and it was felt that this vaccine is safe and its immunological response good in human beings. This is an imoortant milestone on the road to a auadrivalent vaccine. The Peer eroun . ~~ r ~ ~~ -, recommended trials again with different dilutions of each type of vaccine. The Peer group recummended a Phase 1 studv of D3 PtiMK30 passage and 3 passages in FR hl Indonesia - ~ to be conducted in adults. The Peer group approved the result of the study on the follow-up of volunteers who received monovalent Dl, and bivalent Dl-2, D2-4. A detailed report on the genetic stability ol virus isolates from Dl vaccine recipients, seed virus and stability of virus isolates from Dl vaccine recipients, and on seed virus and parental virus, showed genetic stability of the vaccine virus. The report on molecular studies, including Western Blot and Polymerase chain reaction tests, showed positive progress. No. 01 cases Myanmar Thailand I I No. 01 deaths No. of esscs CFR (%) CPR 1%) I I No. 01 deaths No. ol rases I I CFR (%) No. 01 deaths DISEASE PREVENTION AND CONIROL 131 An International Symposium on Dengue Fever and DHF was organized by Mahidol University, Bangkok, from 1 to 3 October 1990. It facilitated the obtaining of information on recent advances on immunopathology and available diagnostics. WHO headquarters organized a Technical Advisory Committee Meeting on DHF, from 4 to 6 October 1990. It was attended by participants from SEAR countries. Reviews of DHF in the WHO regions were made and discussions were held concerning the revision of technical guidelines on the prevention of DHF. Through a technical services agreement, Sri Lanka was provided with assistance to conduct, from March to June 1991, interim studies on the isolation of the virus responsible for the present DHF cases in the country. Viral Hepatitis Hepatitis AVims (HAV) infection is common in Bangladesh, India, Mongolia, and Nepal, and 85-95 per cent of children in the age-group of 6-10 years are immune to HAV. In these countries, HAV cases in adults are very few. In recent years, it has been observed that the morbidity of HAV infection in adults has increased in Indonesia andThailand. Studies conducted inThailand during 1990 showed that only 30-35 per cent of children in the age-group of 7-12 years are immune to HAV. The prevalence of Hepatitis B (HBV) infection and related diseases, such as chronic hepatitis, cirrhosis and hepatocellular carcinoma, differ widely and continue to be major public health problems in the Region. Every year, approximately 10-12 million people are infected with HBV. It is estimated that about 6 per cent of the total population of South-East Asia are HBV carriers. WHO continued collaboration with respect to epidemiological studies, situation assessment and production of local HBV diagnostic reagents, particularly in India, Mongolia and Myanmar. Model immunization programmes aimed at exploring how best to organize Hepatitis B vaccine programmes before eventual integration into EPI, to improve overall EPI efficiency, are now under way in Indonesia, Myanmar, Mongolia and Thailand. WHO supported laboratory research for the production of Hepatitis B vaccine, which is in process in DPR Korea, Mongolia and Myanmar. The prevalence of Hepatitis C Virus (HCV) infection in the Region is still not known and WHO has prepared a protocol to study the prevalence of HCV in selected countries. Delta Virus (DV) is not common in the South-East Asia Region. India, Myanmar and Thailand reported some cases of mixed infections (DV and HBV). Only Mongolia has reported a high prevalence of DV infection markers in healthy populations and in HBV cases. 13? THE WORK OF WHO IN S!3 Hepatitis E Virus (HEV) infection is an emerging problem in the Region. Several outbreaks - large and small - due to HEV have been reported from Bangladesh, India, Indonesia, Myanmar and Nepal. In India and Myanmar, HEV has been serially passaged in non-human primates. WHO continued to support epidemiological research in Nepal. Japanese Encephalitis (JE) In this Region, JE outbreaks have occurred in many countries but at present India, Nepal and Sri Lanka are the countries where outbreaks of JE continue. To mention some country specific support during the reporting period, lndia received support through a technical services agreement for a study on the impact of selective insecticidal spraying on JE vectors in Burdwan District, West Bengal, for a one-year period starting from December 1W. Five regional fellowship nominations of one month each, to study various aspects of JE control, have been processed during the reporting period. A workshop on JE was held in Varanasi, in August 1990, with the support of a WHO subsidy. Another workshop on disease surveillance was held in November 1990. Assistance was extended to Nepal for the procurement of JE vaccines. Thailand is being supported in a study of the stability of JE vaccine produced in the country. Meningwoccal Meningitis Meningococcal meningitis continues to affect Bhutan, lndia and Nepal in low endemicity outside the Kathmandu valley. WHO assistance is mainly through the provision of technical cooperation to help organize control measures and through the supply ofvaccines(biva1ent A + C) in some countries. InDecember 1990, the National Institute of Communicable Diseases, Delhi, was provided with a subsidy for conducting a workshop on surveillance of meningilis. Integration of Communicable Diseases In Indonesia, the integrated approach for the prevention and control of communicable diseases through primary health care was reviewed from 15 October to 8 November 1990 by a WHO consultant. The review results indicated that the project is feasible, beneficial, sustainable and effective. Significant progress by cadres was noted in the first stage of development of the control programme on selected communicable diseases. Case reports of ARI, TB, malaria and diarrhoea1 diseases increased considerably. The results of the review were presented at a workshop held in November 1990. A consultant was recruited in March 1991 for two weeks in the Regional Office, followed by two months as a national consultant to work on the documentation and preparation of a framework for the project. DISUSE PREVENnON AND COMOL 133 13.15 BLINDNESS AND DEAFNESS The latest epidemiological studies carried out in India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand, amongst others, report a prevalence rate of 0.5 per cent to 2 per cent blindness, with higher prevalence rates in undersewed areas of these countries. Cataract, as a rule, accounts for more than 50 per cent of blindness in most of the countriesof the Region which, in turn, accounts for more than half ofthe world's blind population. Various categories of health personnel in Nepal, Sri Lanka and Thailand were provided with training, both in the principlesof primary eye care and in the screening and referral of patients from outreach services. Efforts have also been made to 5trcngthen the physical infr.tstructurr. for c)c carc delivery at the district lcvel as part the development of district health systems in support of PIl(J. Efforts ro meet ihc cataract backlog have been intensified in nearly all the countries, particularly in Indonesia, India, Nepal, Sri Lanka and Thailand. Various important activities in relation to the setting up of mobile units in Myanmar, training of personnel in public health ophthalmology in Bangladesh, Sri Lanka, Mongolia and Myanmar, studying of the feasibility of establishing low-cost spectacles manufacturing and small-scale production units for eye medication in Nepal and Sri Lanka, training in eye care of community health workers and primary health care personnel in Myanmar and Sri Lanka, etc., were carried out with financial support from different international organizations such as UNDP, Christoffel Blinden- Mission, Helen Keller International, AGFUND, etc. Funds from the Japanese Shipbuilding Industry Foundation (JSIF) have been provided to all Member Countries, particularly DPR Korea, India, Myanmar, Nepal and Mongolia, to help strengthen the eye care infrastructure, support outreach activities, provide training in eye care and for epidemiological surveys. As far as deafness is concerned, in spite of the expected high prevalence rate in SEAR, no reliable statistical data are available in most of the countries. Most of the data available are outdated and could not serve as a reliable base for important policy decision and elaboration of strategies for, and approach to, the problem. The report of the national survey conducted between 1973 and 1974 revealed that India had 0.83 deaf and 0.61 dumb per 1(MO population. A survey of school children in Yangon, Myanmar, indicated that 5.6 per cent of the children surveyed had hearing impairment. A sample survey conducted in Nepal in 1980, revealed the total disability rate to be as much as 3 per cent. Of these, 33 per cent were found to have hearing impairment, of which 9.78 per cent were deaf, 12.09 per cent were hearing handicapped, and 11.38 per ccntwere deaf-mute. In Sri Lanka, there are an estimated 2.3 totally deaf people per 10 000 population. 134 UIL- WORK OF WHO IN SFA In collaboration with the international Federation of Otorhinolaryngological Society (IFOS), efforts have been made to conduct a general overall renew of the deafness problem by a WHO consultant in Indonesia, Myanmar, Nepal and Thailand. Thc general assessment of the situation was submitted to the eighty-seventh session of Executive Board and modalities for further collaboration with IFOS in the prevention of deafness in SEAR are being further studied. The WHO Collaborating Centre for Prevention of Hearing Impairment and Deafness, Bangkok, conducted a training course to upgrade the knowledge and skills of public health otologists. A consultant was assigned to Myanmar to assess the hearing impairment problem and assist in the preparation of a national plan for the prevention and control of deafness. Fellowships and supplies and equipment were provided to most the countries 13.16 CANCER Comprehensive national cancer cc~ntrol programmes have been formulated in Indonesia,SriLanka, andThailand. In India, such aprogramme hasbeen inexistence for several years and is being implemented in four states. Three WHO collaborating centres assist in its implementation. Four districts, each covering populations of several million and connected with a regional cancer centre, have been selected for full implementation of all activities as outlined in the national programme, with WHO support. Operational research will accompany the implementation of these district models in order to draw conclusions regarding operational and resource rcquire- mcnts for later expansion. The model activities will include campaigns for early dctcction, efforts at clinical downstaging, treatment, pain relicf, and palliative care. Thc availability of oral morphine for pain relief for out-patients will also bc assured. Furthermore, counselling services through volunteers, who arc operational in only a few cities, will be made available and their impact on the quality of life of cancer patients and their families assessed. During a WHO-supported national workshop a plan of action for the implementation of the National Canccr Control Programme was developed in Indonesia. In Sri Lanka, WHO continued 111 assist in thc postgraduate training of radiotherapists through a consultant. Public education for early detection of oral precancerous and cancerous lesions has begun in Maldives and continued in some parts of India and Sri Lanka. However, the rcferral ratc through basic health workers has not been as high as expected since health workers tend to feel the task of examining the oral cavity to be socially difficult. The promotion of self-examination is probably a more effective alternative. Audiovisual material for this purpose has been developed and field-tested by the WHO Collaborating Centre for Prevention of Oral Cancer in Bombay, India. DISEASE PREVENTION ANDCONTROL I35 Consultants have assisted in reviewing and recommending improvements to the existing cancer registries in India. They have also commented on the relative paucity of epidemiological studies which emanate from these registries. Cancer control activities in DPR Korea were supported through a number of fellowships for specialized lields of training. 13.17 CARDIOVASCULAR DISEASES Whereas the incidence of cardiovascular diseases (CVD) has shown a substantial decrease in some of the industrialized countries, there appears to be an increasing trend in many developing countries. The prevalence of cardiovascular diseases in India is estimated to be 40 million cases in 1991, according to the Indian Council of Medical Research, and is likely to increase to over 52 million by the year 2001. Hypertension and coronary heart disease affect about 9 per cent of people over 30 years of age in India. In DPR Korea, Mongolia and Thailand, where the average life expectancy is close to or above 65 years, cardiovascular diseases are already the leading cause of death. Accordingly, countries in the Region are giving increased importance to the control of cardiovascular diseases. In Myanmar, the national CVD Control Programme has gained further momentum with the in-service training of large numbers of physicians and paramedical health staff. Training courses have also been held with WHO assistance in Bangladesh, Indonesia, Sri Lanka and Thailand. Rheumatic heart disease (RHD) continues to bc highly prevalent in some of the countries in the Region. WHO continues to support, through AGFUND, integrated RHD control programmes in India, Sri Lanka, and Thailand. In Bangladesh, such a programme is being implemented with bilateral assistance from Japan. RHD control forms an important component of school health programmes. WHO continues to support different innovative approaches being undertaken by Member Countries, such as the development of vascular surgery in DPR Korea and rhc education of students and their peers in the identification of cardiac murmurs. 13.18 OTHER NONCOMMUNICABLE DISEASES PREVENTION AND CONTROL ACTIVITIES With increasingly effective control of communicable diseases, the concern with noncommunicable diseases is increasing in all countries of the Region. Activities towards the control of some of these require relatively heavy investments in capital 136 THE WORKOP WHO IN SEA and running costs sometimes putting difficult choices before countries. On the other hand, some countries are concerned about the expenses incurred when sending affected individuals abroad for specialized treatment. Such costs can offset some of the investments required for the establishment of the same treatment facility in the country concerned. WHO support to DPR Korea, where basic facilities of primary health care are available, has continued to focus on the development of skills and facilities of a higher degree of specialization. In the area of NCD, consultants have been supplied in various subspecialities of surgery, oncology, endocrinology and internal medicine. This has been complemented by a number of fellowships for related specialist training. In India loo, WHO support in this subprogramme area has mainly consisled of fellowship training in various aspects of NCD conlrol programmes. In Maldives, facilities to identify individuals who are heterozygote for thalassemia arc now available. This testingispresently offered on a limited scaleas a first step towards a full-fledged thalassemia control programme which will include surveys, genetic counselling, and blood transfusion services. Section IV PROGRAMME SUPPORT Chapter 14 HEALTH INFORMATION SUPPORT 14.1 HEALTH LITERATURE AND LIBRARY SERVICES ( INCLUDING HELLIS) IleaIth Literatare, Library and lnfnrmatinn Sewices (HELLIS) The Regional HELLIS (Health Literature, Library and Information Services) Network is now estahlished in nine Member Countries. It has continued to provide relevant health literature information to users by the provision of free photocopies of rcfcrenccs that arc not available in counLries on request, including MEDLARSI MEDLINE searches. Through this rcsourcc-sharing mechanism, it has been possiblc for users in Member Countries to have easy access to both regional and international health science literature information. A complete MEDLINE data base (1966.10 date) on CD-ROM (Compact Disc Read Only Memory) has now been made available to HELLIS National Focal Point (NFP) libraries of Bangladesh, India, Indonesia, Myanmar and Sri Lanka. Efforts are being made to provide a complete CD-ROM MEDLINE data base along with the CD-ROM drive to the HELLIS NFPs of DPR Korea, Mongolia and Nepal. A Regional HELLIS Workshop was held from 29 September to I October 1990 in the Regional Office, including a HELLIS-ESCAP Joint session on 1 October 1'40, to review the status of the HELLIS system and the relevant recommendations of the 6th International Congress on Medical Librarianship (61CML), and to determine the training needs for effective introduction of newer technologies. The seventeenth session of ACHR reviewed the situation with respect to informalion support For rescarch and made a number of recommendations lor improvcmcnt. WHO also supported participation from Member Countries in the 6ICML as well as in a Pre-Congress Seminar. Unfortunately, the rising cost of books and periodicals has restricted the sharing of resources. Besides, there are weaknesses in the links between some parts of the network. The availability of MEDLARSIMEDLINE data bases onCD-ROM system has, to some extent, cnablcd difficulties previously encountered in rapid responses to requests for MEDLINE searches to bc overcome. The Index Medicusjor WHO Sourlt-East Asia Regio11 (IMSEAR) Volume 5, covcring 139 regional health science periodicals published in English, or with abstracts in English, from seven countries - Bangladesh, India, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand - has been compiled and published with the active participation of National HELLIS Focal Points. It contains 6 752 annotated citations and covers the period January-December 1985. Although access to health literature information and its availability has improved, further concerted efforts need to be made in the areas of adoption of newer technology and strengthening of resources of participating libraries of the HELLIS network in Member Countries. Regional Omce Library The Regional Office Library continues to provide technical inform;~tion/litcr~~turc support to WHO staff, Member Countries and other researchers as required by way of photocopies, loan of publications, MEDLARSiMEDLlNE searches, rcfcrcnce and current awareness services. As a part of HELLIS activities, the compilation of the Inder Medicus for WHO Sotrtlt-east Asia Region (IMSEAR) and publication of a HELLIS Newsletter were undertaken. Further progress in the field of automalion of library services has been made. It is expected to increase efficiency in bibliographic searches and response to requests. A complete MEDLARSIMEDLINE data base on CD-ROM has been installed in the Regional Office Library. The Library staff helped to organi~c the 6th International Congress on Medic:~l Librarianship and the Prc-Congress Seminar in New Delhi from 24 to 28 Scptcmhcr 1990 and the Regional HELLIS Workshop in New Delhi from 29 September lo I October 1993. 14.2 PUBLICATIONS AND DOCUMENTS The Chief of Distribution and Sales, WHO headquarters, and the Director, Medical and Health Information, Eastern Mediterranean Regional Office, visited the Regional Office and discussed matters of mutual interest. Two new titles and revision of one publication were issued under the SEAR0 publications series, while non-priced documents, including reports of various kinds, were produced and distri\)uted (Table 10). The sale of WHO publications increased over the previous year. Table 10. Prod~rcfiori of doc~mterlls, 199lX91 'I'ranslations and l'sblicutions Support was given to India for the translation of Cancer Pain Relief, and Guidelines for Nursing Management of People Infected with Human Immunodeficiency Virus (HIV), into Hindi, and for the translation of Adolescent Reproductive Health: An Approach to Planning Health Service Research, Treatment and Prevention of Acute Di:irrhoca, and The Conimunity Health Worker and Primary Child Care, into Bengali: 10 lndoncsia for tr;~nslati~n into Bahasa Indonesia of Anacsthcsia at thc District lIospit;~l, Concepls, Issues and Country Expericncc, Rapid Assessment of Sources of Air, (;cncritl Surgery at the District Hospital, Health Systcm Decentralization: Water and Land Pollution, Manual of Epidemiology for District Hcalth Management, The Community Health Worker, Drugs Used in Anaesthesia, Early Detection of Occupational Diseases, Respiratory Infections in Children: Management in Small Hospitals, Treatment and Prevention of Acute Diarrhoea: Practical guidelines, Manual of Radiographic Interpretation for Gcncral Practitioners, Conjundivilis of the Newhorn, and The Growth Chart; to Nepal lor translati<~n inlo Ncpalesc ol(;uidclincs for Nursing Managcmcnt ofPc<iple lnfectcd with HIV, (;uidclincs forTraining Community Hcalth Workersin Nutrition, Weaning from Breast Milk to Family Food: A Goidc for Health and Community Workcrs, Protecting, Promoting and Supporting Breastfeeding, Treatment and Prc\cntion of Acute Diarrhoea: Practical Guidelines, Food, Environment and Health: A Guidc for Primary School Teachers, and Nutrition Learning Packages: Joint WHOIUNICEF Nutrition Support Progriimme; and to Thailand for translation into Thai of Cancer Pain Rclicf, Educirtion for i-lc;ilth, (;uidclincs for Counselling ahoitt tI1V Infection and Disc;lsc, Appropriate Usc of Fluorides for Human Hcalth, Sclf-asscssmcnt for ManagcrsoSHcalthCarc: Howcanl hea Bcttcr Manager, Oral HealthSurveys: Basic Methods, and Prevention of Oral Diseases. The Regional Officeissued the fourthvolume of Reorientationof McdicalEducation, (SEAR0 Regional Publication No. 18) and the third volume of Research Abstracts (Regional Publications No. 16). The third edition of Clinical Management of Acute Malaria (WHO Regional Publications No. 9) was published. llrnl -. Asslgnn~enl rcports Reports of group educat~onsl activirles Terminal reports of UNDP projects l'oe~ Nunlher 91 28 - 12 131 - I'nges rdilrd 1821 1 M>3 - 513 3 097 I'iuges prinfrd 1 '126 786 - UJ 3 156 . Documents The loose-leaf List of Technical Documents Issued since 1979 was updated in January, and again in June, as also the Handbook of Resolutions and Decisions of the WHO Regional Committee for South-East Asia. Dengue Newsletter, Vol. 16, was issued. Lists of documents received from other regions and from other UN agencicc and distributed by the Regional Office were issucd periodically. Sales A number of approaches to achieve optimal dissemination of information under the Organization's publications programme were tried. These included participation in five important medical conferences, taking over of the marketing of WHO video cassettes on hcalth, a policy dccision to stock and market publications of all thc regions, and broadcning thc base of the distribution network through commercial channels. The five conferencesicongresscs where displays of WHO publications were arrangcd included the Global Consultation on Safe Water and Sanitation, New Dclhi, 10-14 September 1990; the 6th International Congress of Medical Librarianship, New Dclhi, 24-28 September 10!)0; the Sixty-sixth All-India Medical Conference, Ahmedabt~d, 25-30 December 10YO; the lntcrnational Symposium on Prevcntivt: Cardiology and Cardiovascular Epidemiology, New Delhi, 10-14 January 1901; and the Asian Conference on Health Care Management -Challenges and Response, New Delhi, 21-23 February JWl. The number of subscriptions registered in the calendar year 1930 increased by nearly 20 per cent over the 1989 figure. A regional catalogue of WHO video cassettes on hcalth was prepared and disseminated widely to mark the beginning of the distribution and sales arrangements for video cassettes. Negotiations started with selected distributors for appointing them as distributors of WHO publications. A record number of45 agrccmcnts covcring 51 titles were signcd granting reprint righ~s to puhlishcrs in respect of low-priced local editions of WHO publications. Details of the financial turnovcr during 1989-1W are reflected in Table 11. Table 11. Sales of WHOp~rblicafio~ls, 1989-1990 July 90-June 91 11s $ 63 3'15 126 231 - I89 626 - Ilrn, . Subscriptions Other p~lblieations Tot.11 NOTE The above figures represent actual receipts alter deduction of all discounts and applications ol canrcrional mnversion rate 01 (ieneva cover prices to Indian rupees. 1989 11s S 85 124 71 095 156219 1990 US $ 7') 3UX 81 409 160 717 Chapter 15 SUPPORT SERVICES Organizational Structure The organizational structure of the Regional Office, as of 30 June 1991, is given in Annex 1. 15.1 GENERAL Seminar on Management and Administrative Procedures in WHO A Seminar on Management and Administrative Procedures in WHO, vis-a-vis country programmes, was held in Yangon, Myanmar, from 22 to 24 October IVM. Thc objcclive of thcSeminar was togive oricnlation to national health staff onvarious aspects related to management and administrative procedures of the Organization lor cffeclivc planning and management of government1WHO collaborative programmes. Participants were central-level staff of the Ministry of Health involved in the planning, implementation and evaluation of governmentiWH0 collaboralive programmes. Visitors and Visits Dr H. Nakajima, Director-Gcneral, WHO, visited the Regional Office in September 1990 in connection with the forty-third session of the Regional Committee. During his visit to Thailand, the Director-General presented the HFA gold medal lo Her Royal Highness Somdech Phra Srinagarindra Boromarajonani, Princess Mother of Thailand. During his visit to Indonesia, the Director-General presented the HFA gold medal to H.E. Mr Soeharto, President of Indonesia. Other important visitors to the Regional Office during the year included: H.E. Mr 1.K Gujral, Miter ofExternal Affairs, Government of Indii; HE. Dr M.P. Shestha, Minister of Health, His Majesty's Government of Nepal; H.E. Dr Kim Yong Ik, Vice-Minister of Public Health, DPR Korea; H.E. Dr G. Dashzeveg, First Deputy Minister of Health, Mongolian People's Republic; H.E. Mr Rasheed Mascnd, Minister of Stale for Health and Family Welfare, (;overnment of India; Dr J.R. Hanncssy, President, International Commission on Irrigation and Drainage, UK; H.E. Mr B.C. Gangopadhyay, Secretary-(kneral. Afro-Asian Rural Reconstruction Organization, New Delhi; Prof Demissie Habte, Director, International Ccntre for Diarrhoea1 Diseases Research, Bangladesh; Dr A.K.N. Sinha, President, Medical Council of India; Dr B. Ramamurti Presidcnt, National Academy of Medical Sciences; Dr Arvind M. Shah, President, Indian Medical Association; Mr R.N. Mirdha, President, lndian Federation of UN Associations; US Congressman Mr Jim McDcrmolt, accompanied by Mr Charles M. Williams, Legislative Director, and Mr Miles Lackey, Legislative Assistant; Mr S.J. Rana, Ag Secretary, Ministry of Health, His Majesty's Government of Nepal; Mr R.L. Misra, Secrelary, Ministry of Health and Family Welfare, Government of India, and Dr C. Gopalan, Presidcnt, Nutrition Foundation of India. The Regional Director attended thc International Conference on HIV/AIDS in Asia and the Pacific, held in Canberra, Australia, from2 to 8AugustIY)O. In March 1991, the Regional Dircctor visited Havana, Cuba, to attend thc Third International Seminar on Primary Heallh Care. During the year, the Regional Director visited Geneva to attend the fifteenth and sixteenth sessions of the Programme Committee of the WHO Executive Board, the thirtieth session of Global ACHR, the eighty-seventh and eighIy-eighth sessions of the WHO Executive Board, the Director-General's meetings with the Regional Directors and the Forty-fourth World Hcalth Assembly. Within the Region, the Regional DirectorvisitedPyongyangin October 1YX)loatlend the Fifth National Conference on Acupuncture and Moxibustion, and held discussions with the national authorities on the WHO collaborative programme. He also visited Thailand, Myanmar, Nepal, Sri Lanka, Maldives and Indonesia to have discussions with the national authorities on WHO collaborative programmes in the respective countries. The Regional Director also joined the Director-General on his official visits to Thailand and Indonesia. Meetings Attendedllnaugorated by the Regional Director The Regional Director inaugurated and participated in a number of important meetings, symposia and workshops - national, regional, and intercountry - as well as those organized by other agencies. He delivered a lecture on "Relevance of Research on Primary Health Care" at the Central Drug Research Institute, Lucknow (India), the Dean's Lecture at the London Schoo\ ol Hygiene and Tropical Medicine, U.K., entitled "Health Problems and Programmes in Asia, with particular reference to WHO'S activities in the South-East Asia Region", and the Public Lecture organized by the Indian Socicty on Tobacco and Hcalth, New Dclhi. 15.2 PERSONNEL As of30 June 1991, the Regional Office had 135 established professional posts in thc South-East Asia Rcgion as comparcd lo 133 on 30 June 1990. Tahlc 12shows the numhcr of postsin thc prolcssi(~nnl cntcgory in the Region, fundcd from all sources, and the number actually filled as of30 June 1991 Table 12. Nlr~ilber ofprofessiurlalposls, by localiur~, us of 30Jlllle 1991 . . I~~lablishcd Posts frozen Filled hy appointment' 61 Still to lbc lilled: A list of projccts in npcration during thc year is included as Anncx 2. ol which: (a) candldatea rclcclcd (I,) candidates yet lo he aelcrted During the period under rcview, 183 consultants were cmploycd in various projccts for periods rangingfrom one week to 11 months. This represents decrease 016.67 pcr ccnt in the number of consultants employed, compared with the previous year. Fourteen professional and 12 gcncral scrvicc slall mcmhcrs scp:rratcd from WHO scrvicc. 1 10 .I 8 5 18 Three professional and one general service staff membcrs left the SEA Region on reassignment to other regions of WHO or other UN Agencies. Three professional and two general scnice staff members died during the year. As of 30 June 1991, 57 nationals were employed on Spccial Service Agreements Staff 1)evelopment and l'raining At a meeting of the SDTCommittce, held on 27 November 1990, the SDT plans and activities of the Regional Office were reviewed with the Programme Manager of the Staff Development Programme from WHO headquarters. About 40 staff membersin the Regional Office have been trained in 'WordPcrfect'. It is hoped to continue the training so that the majority of the secretarial staff arc ahlc to handle correspondence through word processors. The computer training of selected general service staff from the WHO Representatives' offices and the Regional Office was continued. Trainingwas imparted to three general service staff in desk-top publishing and to one general service staff in stores management in August 19'90. Three WHO Representatives participated in the Interregional Seminar for WHO Representatives, held in Gencva from 22 October to 2November 1990, and one WHO Representative-designate attended a similar seminar in Geneva from 27 May to 7 June where Director, Programme Management also participated as facully member. A stalf training seminar for new professional staff was organized in the Regional Office on6 Novemhcr 199010 providc orientation into theOrgani.t.ation's procctlurcs on report writing, linancial and personnel management, etc. A Senior Staff Management Seminar was organized on 23-24 Noveml~cr 1990 a1 Surajkund, near Delhi, to promote and encourage the sharing of ideas and experiences in areas of coordinating role of WHO Representatives, external resources mobilization, and human relations in staff management. Three professional staff attended thc On-entry Group Briefing organized in WHO headquarters - two in February 1W1 and one in June 1W1. Mr R. Gieri, Secretary, United Nations Joint Staff Pension Fund, New York, visited the Regional Office in February 1991 and held discussions on pension matters with the Support Programme staff. He also addressed a meeting of staff from WHO and other UN Agencies, including UN pcnsioncrs. 15.3 GENERAL ADMlNlSTRATlVE SERVICES Kegional Oflice Ruilding The installation of a second standby generator was complelcd in carly l'Nl and it is fully operational. I1 provides full back-up for all Regional Office electrical rcquircments. The upgrading of fire prevention and safety installations is in the final stages of completion. The standby 80 KVA uninterrupted powcr supply (UPS) has been commissioned to provide power back-up to all computers functioning in the Regional Office. Old cables connecting all the power points in the main building have been replaced with new cables. Also, new distribution boards with miniature circuit breakers (MCB) have been installed to upgrade the old eleclrical powcr system. The lift in [he Annex to the main building has been upgraded by providing a micro-processor control unit. An addilional projjccl to renovate and upgrade the existing telephone system in the Regional Oifice was approved by the Forty-third World Hcalth Assembly in May l!BOandis expected to be implcmcntcd during 1991. Office Automation Efforts arc being conccntratcd on the development of computer programmes for routine activitics handled in Personnel and Medical Supplies Units, which will lead to more outpu~ and saving of staff time. A Local Area Nelwork (LAN) is proposed to be installed in the Regional Office. The initial planning for LAN has been completed and orders placed with the suppliers for the purchase of hardware. This will become operational during 1991. Training in desk-lop publishing (DTP) has been organized for staff with a view lo preparing documents such as bullains, publications, books, clc., in-house. 15.4 BUDGET AND FINANCE The planned programme budget for the biennium 1990-1991 is US$80.7million from regular hudgcv,and the total,includingearabudgetary resourcesandv<>luntary funds, US$ 112.4 million. Thc lolal obligations for the period 1 January 19W to 30 June 1991 under all sources of funds, amounted to US$81 G93 672. Even though the Organbation is facing somc financial stringencies on account of currency fluctuations and tremendous cost escalation, it is expected that the planned programmes in countries will be implemented successfully. Since extrabudgetary resources (UN or otherwise) are made available during the course of the year, thc total extrahudgefary resources for the Region will also be finally much more by the end of the biennium than that shown at present. The regional Administration, Finance and Informalion (Af'l) system completed one year of successful operation. For the first time, the Regional Office provided its annual closure, as of end-December I'H, on the AFI sydem. Wilh the training of staff and through the process of "learning by doing", initial difficulties arc bcing overcome. In this connection, support was obtained from WHO headquarters, EURO and From staff of the Western Pacific Regional Office. External Auditors External Auditors visited thc Regional Office in April 1Yll and discussed lhcir observations with the Support Programme staff. 15.5 SUPPLIES AND EQUIPMENT Medical supplies and equipment worth US$ 15 802 521 were procurcd during thc period July 1'30 - June 19'91. Figure 4 shows the procurement trends in rcccnl ycars. Apart from conventional items, such as drugs, laboratory equipment, hospital equipment, surgical instruments and office equipment, etc. , an increased number of requcsts For diagnostic kits and supplies wcrc processed during this period under lhc (ilobal Programme on AIDS. In tho area of health literature, the period a)n~inued to witness a signilicanl number of requests for CD-ROMs, particularly for projects related to medical research and environmental health. CD-ROMs, medical literalure and publications worth US$574 190 wcre procured, of which WHO publications accounted for US$30 802. In accordance with WHO'S Global Action Plan on Management, Maintenance and Repair of Health Carc Equipment, while proccssingrequests for sophisticated health care and laboratory cquipmcnl, aflcr-salcs aspccls, such ;is installation, maintcn;~ncc and availability of sparc parts to cnsurc long-term operational benefits to thc projccts wcre given full consideration. Emphasis was also laid on reducing delivery time and exploring cosl-effective alternatives for items requested. Local purchase, wherever feasible, was encouraged with a view to reducing delivery time and establishing direct contact with suppliers. As a rcsull of signilicant savings that accrued due to procurement of supplies from Figure 4. Procurement Trends Jul 88-Jun 89 = Total P, Jul 89-Jun 90 Perlod rocurement $Sf$ Lot Jul 90-Jun 91 :a1 Purchase lowl sources, available at cheaper alsts, projects could hc provided with more supplies within the budgeted amounts. Emergency Supplies To meet requests from Member Countries arising out of emergency situations such as epidcmics and calamities, supplies were arranged against rcquests from B;ingl:ladesh, Maldives, Mongolia, Myanmar and Sri Lanka. I'urchases Under the Revolving Fund and on a Reimbursable Basis Bangladesh, Bhutan, India, Myanmar, Nepal and Sri Lanka availed of the Organization's procurement services under its Revolving Fund scheme and on a rcimhursahle hiisis. ANNEXES Annex I ORGANIZATIONAL STRUCTURE , ,,,,,h . A'ulr Rnpmlori inlrilml . r"mmunr.blr Dir- . rvrnmunlli Hullh .%.",id . lhanhrra D8u.m . Dlscnr~ Iluilh SPCem . Fnlom,,l,.g ."d Y..,", Con,",, . tnxrunmmu, i*.i,h . T*",,li hug in< Ylrnn.. . e Prnylrnrn~ on ?m.,\mn . iLl"", KIvlvrrrl -"",urn . hs#v H.sICM.mb PI###wn& . lirlllh rnd &hFlnu. . ilcallh ilhlr.l"~T~hn.bw . il<.l,h rromn,,m . linlrh S,,".,,"" ."d lr.,,d I .I FIELD PROGRAMMES ....... I Annex 2 PROJECTS IN OPERATION IN MEMBER COUNTRIES In ihc lisl of projccls, the following abhrcvialions arc used undcr "Sourcc of Funds": A<iI:UNI> AS I)I. 1)M 111' I:A I'll 1'1) 1'1' I'x RI3 sr kab Gull Programme for the United Nations Uevelopment Orgao~zanons Special Account for Servicing Costs Standard Letter of Agreement Between Executing Agencies (Jnited Nations Development I'rogmmme/Spccial Measures IJnltcd Nanuns Ilevel~~pment Programme 'l'rust Fund for the Specill I'rtlgramnlc for llcscarch and 'l'r;ltntng in I'roptcal I)isc;~scs Assoc~;~lc 1:hpcrls Olhcr 'I'hi~n IINI)I1 llnltcd Nations t:und for Drug Ahusc (l,ntrc~l lin~led Nations Population Fund Voluntary Fund for AIDS Regular nudge1 Sasakawa llealth'l'rust Fund VI) V<llunlary Fund - Olhcr V(i Vr~luntary Fund for Medical Research - Other (General) VI Voluntary Fund for Fxpanded Programme on Immunizauon Vk Voluntaty I'und for Training Courses (DANIDA) VI. Voluntary Fund for Leprosy Programme VM Voluntary Fund for Malaria VV V<lluntary Fund for Disasters and Natural Calastrophes ~ ~~ ~~ ~~ ~~ ~ Plojtct No. Sourer of funds Tills HANGL4DESH RANCORWI VH BAN CORW? RB BAN ISSW1 RB BAN I<.- W1 RB BANHXW3 UP IIANMPN W2 RB I3AN MPN2W RB RAN PIICW3 RB I3AN PHCKW KB IIAN PllC 005 KB RANIlMD007 KH RAN IlMD 010 Dl' RAN HMD011 DP BAN HMD 014 KII RAN HMI) 015 KB !IAN IIMI) OIII I1B HAN IIMI) 017 HI1 IIAN 11111W1 RI1 IIAN RI'D WI KI1 ~~RYU ~2 RB BANNUTW3 RB BANORHWI RB IMN APR WI RB IIAN MCI I WS VI) HAN MCII DO(> 1111 [IAN 0(:11 Wl RII BAN l lE1'. 001 RB RANMNDWI RI1 BANCWSWI KH RAN I'OS001 RB nANCLRW2 RB I3AN lillV 001 KH'VO RAN I<I)V W3 KB l3AN DSIi001 RII IIAS TKM 003 It11 RAN Rllll Wl RH AN 'I I RBIVl 13AN MALW1 KB BANMALWZ UP IIANPDP W1 RR IIAN CDI) WI RRNC Iimergency Relief Operattans Emergenq Prrparedness and llesponse Informatics 1)evclopment Hcalth Situation and Trend Assessment Field Epidemiotogiral Suweillance and Disease (:ontml Planning and Management of Hcalth Services Managerial Process for Nauonal Ilealtlh Dwclopment Organization of lleallh Systems Rasedon Primary lleallh (:are Repair and Maintenance of L:lertm-Medical Equipment Com~nanity I'artictpatios and lleallh I'or All Iradctship I)cvelopmelll Nursing Advisoly Scrviccs and Training Training of Senior Nurscs Developmrnt of the (:entre for Mcd~cal Fduration Human Ilesoorccr 1)evclopment -Trainingof t'araa,edicsl Workers Srrcnglheningof I'orl-gr;tduale Medical FAuration Undergraduate Medical I%eration Strcngthenlng~,fNational lnatitotc of I'leventivc and Scxaal Med8rillc 1)evelopmen~ of llealth lidural8on Sclvcccs Research Promotton and 1)evelopment Slrcngthening of Selected lnstitulions Community-based Nutrition lmpmvement Programme Oral Health Accident Prevention I'am~ly Planning Clinical Supelvisiun~eam Maternal and Child lleallh, inrhlding I'amily Planning Workers' llcalth lleallh olthe Ildcrly Prevention and'l'realmcnt of Mental and Neurological Disorders Community Water Supply and Sanllalion Food Safety Clinical, Laboratory and Radiological Technology for Health Systems based on Primaly llealth Care Fssential llrugs and Varcincs Fssential 1)rugs Production 1)rug and Varrinc Quality. Safety and Efficacy 1)c~elopmenr of Manpower in'Traditional Medicine llchabilitation of the Disabled lnlmunizalion Malaria Conrrol Malaria Control Programme Parasitic Diseses 1)iarrhocal Diseases UANARI 001 BANTUR 001 nAN 1.EP 001 RAN VI)T 001 !IAN GPA 001 IlAN 1'111) 001 RAN l'nn ooz IlAN CAN Oil3 I1AN CVI) Wl l1AN NCD 001 RAN HBI 001 BHUTAN l1IIU IISl'(KI1 IlIlU MI'NMII I3IIU PIICOOI HHU HMD 001 DIlU HMD 002 111 IU HMD 003 IlllU lli11001 I1IIU MCI I (XI2 IlllU li1)V 001 1111U (iPA 001 111IU OCD 001 nllu NCD oo~ KR RR RBiVD RB I'X N11Nl) VI) 1111 KII R 13 RR 111% I< R KR DP DP RB KII FI' VO 1:s RIJ K1l Control of Acute Respiratory Infections Tuberculosis lrprosy Sexually Transmitted 1)iscases Prcvcnlion and Control of AIIX Prevenuon of lllindness l'rirna~y I':yc (:arc I'rcvcntion and Control of Canrcr Cardiovascular Diseases Other Non-Conlrnunirablc 1)isease Prevention and Control Activities Development of Heallh L.irerature and Lihraryand Information Setvices I leallh Situation and 'Trend Assessrnrnt Country lleallh Programming I'rirnaly Health Care Promotion and Ilealth Infrastructure Development Development of lluman Resources for Health Strenglhening and Development of Nursing SeMccs Development of Human Resources for Health Slrengtheningofllcalth FAucation I'mgrarnme Ileuclopmcnt and Strengthcn~ngol I'amily Ileallh Services Il\rcntial I)rub.\ I'rograrnlne I'revenlion and Contml of AII)S Prevention and Control of Specific Communitahlc Iliseascs Prevcntian and Control of Non-Communicable Diseases DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA KRI) MI'N 001 RE1 Managerial Process for National Health I)evelopment KIU) I (MI) NI? Ill1 I)eveloprnenl of lluman Resoorccs lor llcalth K111) R1'1) 001 RII I'romolion of llesearrh KIl1) 111111 001 RII Oral lfcalth KllD MCH 001 RU Maternal and Child Ilealth KRD MCll 002 FI' Suppon for the MCHiW Activities KRDOCH001 RII Workers' Ileallh KRI) Illill 001 RI1 (ierontologv KIII) C1111 001 Dl' (:ontrol of linvironmental lleallh Ila2ards KI11) CI(II 002 1<11 ('ontrol oflinvironmenlal I'ollulants and Ilealth llarards KRI) (:Ill1 003 111' ('ontrol of linviron~ncntal Ilealth Ilarards I l.1 KI1 Iahoratory Scicnrcs and 'Icchn~qaes KRD IRM 001 RB 'Tradilional Medicine KRI) RI In 001 RB Rehahilitation KRDGPA001 FX Prevenlaon and Control of AIDS KRII CAN 001 RH Cancer Control KRI) CVI) 001 RH Cardiovascular Diseases KI11) N(:l) (MI 1111 Other Non-rommunicahle Disease Prcvenli<m and Control Acrtvitics 'WE WOKKOF WHO IN SEA INDIA IKD COR WI IND HSC MI IN11 HST W3 IND llSI'W5 INI) I IST OO(, INI) MPN W1 INI) MPN 002 INI) MPN 2W IND HSR Wl IND HLE Wl IN11 I'IIC 001 IN11 I'I IC WZ INI) I'I{C 003 INI) 1IMI)OIS INI) HMI) 017 INI) IEH 001 INI) RPD W1 IND WD W? IND NUTWh INI) ORllW1 INI) APR WI IN11 MCH W3 INI) MCH 004 NI) MCII 005 INI) MCII nm IND MCH 001 IND HEE MI IND ADA 001 INn MNI) WI INI) CWS 001 1x1) <:ws 002 IN11 ('Ell Wl INI) I'OS W1 IND CI.RW1 1x1) CI.R 002 IND C1.R W3 INI) linv OOI INI) I)Sb:(K)I IN11 'TJIM 001 INI) IIIII1WI INl) l<l'l Wl INI) MAL W1 IND MAL 002 IND PDP 001 INI) CDD W1 IN11 ARI W1 1Sl) 'TUG W1 VN RB RB RH VI) KB RR RB RB RB RBND RH RB IIII RB RBND KB DP KR RB RB RH Kn KH 111 KL! RB KB RII KH Rll 101 KB KR RB DP I<B KI1 HI3 KII KB IIBlVM VM RB KB KO RWD Emergency Preparedness 'Trainingand Development of HFA Leadcnhip Epidemiological ScMces Development and Training Devclapmenl and Training of Health Information Sclvltes Field Rpidemialogy and lahoratory Support Selvirer Country Ilealth Planning Slrcngtheningoflleallh Pmgrammlngand Management Managerial Proeess for National tleallh Development Health System Research and Development Health Legislation Organization of Health Systems based on Prirnaly Hcalth Care Trihal llealth Care Strengthening of Medical Stores Orgmiration Nursing Development and Research llealth Management Assessment. Developmcnl and'l'rainlng Development of National Hcalth Education SeMees Biomedical Research Studies on Tribal llealth Nutrition including Goitrc Oral llealth Prevention of Accidents Maternal and Child llcalth Promotion of Famnly Welfare Scwiccs and Rcsearch Family WclfarelMCII Sewires in Urban Areas A Rural, Cuhorl Study on Child Sulvival Worken' Ikalth llealth of the Elderly Prevcntion and l'rcatmcnt of Problcms related to the Ahuse of Lhgs Prevention and Canlml of Mental and Neumlogical Disorders Community Water Supply and Sanitation Rural Water Supply and Sanitation Control of Enuironn,ental Pollution Qualily Control of Fssential i'ood Blood Banking laboratory Quality Control and Standardization Strengthening National Institute of Immunology using Modern Immunohiological and B~ological Approaches Fssenlial Drugs and Vaccines Quality. Safely and FJficacy of Drugs and Vaccines Traditional Medicine (inrltldingHo~t,ocopalhy and Yoga) Rehabilitation Expanded Programme on lmmuniralion Malaria Eradication Research and Training in Malaria Control Control of Parasitic Diseases Diarrhueal Disease Control Programme Prevention and Control ofAet>te Respiratory lnlertions Tuherculosia Control IND I.lil'W1 KllVl. IND 1.EP WZ DP INDVPll WZ RB ISI>VDT001 Rl3 IND (;PA 001 11lin:X IS11 0C1) 001 Kli IN11 0<:I) MI2 KIi INI) OCI) W3 KIi IND OCI) IKW R1i IND I'UU 001 KIi IND CAN 00(1 KI1 INL) CVI) (H12 Kli IND (1VI) 0113 RIi!VIl INI) NCl) Wl INI) IIIII IXII KIi INDONESIA IN0 11S1' 103 1111 IS0 IISI' IOI 1113 IS0 IISI'IOS K1i IS0 IIST I06 KIi IN0 MPS Ill? KIi IN0 MI'N 103 RB IS0 MPN IM KI? IS0 MI'N 105 RH IN0 MI'S 10(1 1<1i IN0 MPN Z00 1113 IN0 HSRWZ RB lrprosy Control Approaches lo Treatment and Prevention of Leprosy 7aonoses Control I'revcntion of Sexually l'ransmilted Diseases I'reuentcon and Cnnlrol ofAI1)S I'revention and Control of Viral Ilepaulis (iu!neaworm llradiralion Pn~grarnmc I'revenlion and ('ontrol of Jananese linrephal~t~s Other (:omrnunirahle I>iscases Prevention and (:ontrol Art~v~l8er. ~ncludcng 'Qphold Prevention of Blindness (8nrer (including Radiation Medirtne) I'revention ef tlypcrlension and lllD I'revent~on of Rheumalir l~cver/Rhcurnatic Ilcan 1)iseasc Othcr Non-mmmunirahle 1)lsease Prevent#on and Contml Artcvit~cs National Medical l.ihraryand 1)ocumentalion Cenlre Health lor All Strategy Coordination - 1)ircclorale General of Communily Health Strengtheningof llealth lnfornlalion Syslem Ccnlre for lleallh Data Stren lh~ningof llcalth Information System - 1)irerloraIc (ieneral of Commanity ~~ea~ti ' Strenglhening~,f Ilealth Inlormalion System - lnspertoratc (ienen~l StrenglheningofIlealth1nformation Systcm111rertoratc(;encralofMcdical(:are Strenglhensng of ilealth information Syslern - Directorate (icneral of C1)C N 1111 Streng1hen.cn of Health Information System - Dirertaratc ticne~al of Focd and Drug ~ontrof Strengtheningof I'Kl'l'Training in Epldemioloa- Directorate (icncral of CDC N 1111 Strcngthen~ng of 1)lsease Surveillance - I)irertorate Cjenersl of (:I)(: B Iil I Strcnglhening of lleallh Informalion Syslem - Ccotre fur Ilealth Inhorato!y Scrvices Strcngthcning of the Managertal I'mress for Natnonal llealth l)evelopmenl - llureau of Planning Strengthening of the Managerial Prmess for National Ileallh I)evelopmeat - Ilarcau ol Organiration Strenglhening of the Managerial Process for National Health Development - Bureau of Penonnel Strengthening of the Managerial Pmcess for National Ilealth Oevelopmenl - Hureau of I'inance Strengthcnin of the Managerial Prnress for National llei~lth llevelopment - Inspcrtoratc fieneral Sucngthcning of the Managerla1 I'rocess for Kational Ilenlll? 1)cvelopmesl - llurcau of (iencral Affairs Stren~lhcning (iovernrnent ollndonesiaIWll0 Collahoral~on Merhasism - . llealth Sysfclns Research at Centre of llealth Sewire llesearch and 1)evelopment. Surahaya - National lnstitutc of Health Research and Developn~ent Srrengthcningofllealth lrgislation-Bureau of Legal Affairs and Puhlir Relations l'r~mary Health Care in lrian Jaya Strenglhening of l{ealth Care Delivery and Primary lleallh (:are - 1)irectorate General ol Community llealth 'THE WORKOF WHO IN SEA INO PHC 102 IN0 PllC 103 IN0 PHC 104 IN0 HMD OIS IN0 HMI) 101 IN0 IIMI) I02 IN0 HMD 103 IN0 IlMD 104 IN0 IlMD 105 IN0 IIMI) IW, IS0 llill 101 IS0 Ilil1 102 IKO RI'D 001 IN0 XUT W5 IN0 OH4 002 IN0 APR W1 INO'1'011 W1 IN0 MCIl 003 IN0 MCH 005 IN0 ADfl W1 IN0 OCH WI IN0 HEE 101 IN0 IIEE I02 IN0 ADA001 IN0 MFI) WI IN0 ('WS WI IN0 CWS W7 IN0 CWS WY IN0 I'CS 001 INO 1'0s 101 IN0 FOS 102 IN0 C1.R 001 IN0 lil)V 001 IN0 I)SI~OUI IN0 TRM LO1 IN0.I-RM 102 IN0 RHB 001 IN0 13'1 001 RB RB RB r)P RH IIB RB RB RB RB KIi KH RB RB KB RB KB IIB 1)P KO KB RH RB ItB KB KB I)P DP RB KB KH Kli IIH K11 RH RB KB 101 Strengtheningof Referral Hospital Nuning- Directorate General of Medical Care Hospital Sanitation - Directorate General of CDC & Ell Stren thening of Cammunlty Participation - Directorate General of Communcty ~ealtf Dcvclo men1 of Nursing Hikher Fduralion System including a I'aculty of Nuning at the Qni~cnityof lndonesla Overall Development and Coordination of Human Resources for Health will> cmphasison Paramcdirals- Centre of Iiealth Manpower Fduration - Pusdiknahrs Development of Numing Penonnel - Centre of llealth Manpwcr Muration - Pusdiknakes Planning of Human Resources for Health - Bvrcau of Planning Human Resources for Health - Management Training Centre for Penonnel FAueation Training - Pusdiklat Development of Higher Education in Health Sciences - Consonivm of Health Sciences, Univenityof Indonesia Development of Puhlir IIealth FA'ducation Systems - I'acully of Puhlir Ilcalth. Univenily of Indonesia Strcnglhen~ngof llealth I!d'ducation - Centre for I leallh lidurnlion Strengthening of Puhllc Relations - Bureau of Lcgal Affaln and Puhlit Relat~o,,~ Strengtheningaf National I*ealth System Research and Dcvclopment (~apahilities - Natjonal Institute of Health Research and Dcvelopment Nutrition Improvement Programme Directorate (iencral of C<lmnlunily Health Oral Acalth - Directorate Gcneral of Medical Care Areidcnts Preventnon and Control - Directorate General of Mcdlcal Care Tobacco or Heallh Maternal and Chlld lleallh including Family lleallh - 1)irertorate (icneral <>I Community Ilealth Dcvclopment of a National Strategy and Plan of Aclion for I'romotlon of Sale Motherhood Adolescent lfealth - Dirertoratc General of Comnlunity Health Strengtheningof Orcvpational Health-Dirertaratc Generalof (lommun$ty Heall11 Hcalth of the Elderly - Directorate Gcneral of Cammunlly Health Care of the Elderly - Directoratc General of Medtral Care Prevention and Cdntrol of Alcohol and Drug Abuse - Directorate (iencral of 14md and Drug Q,ntrol Protectionand Promotionof Mental Ilealth-Dircnoralc(icner;~lof Medlcal(:src Strengthening of Iinvironmental llealth - Direelori$te (ieneral of CI)C & lill Rural Water Supply and Sanitation. lkngkulu and lnmpung Provinces Rural Water Supply and Sanitation Project, East Timor Province llealth Kisk Assessment of Potentially Toxic Chemicals - Directorate General of Food and Drug Control Food Sanitation - 1)ireclorate Gencral of CDC & EH l'wd Safety - Ilirerloratc Gencral of Fd and Drug (:onlrol lleallh Iahoratury Scrvlces Cenlre for tlealth lahoralory Sewires Fsscntial Drugs and Vaccines - Directorate General of Food and Drug Control I)rugs,VacrineOual~ly.Safctyand Iiffira~y-Direct~rrrtc(ieneraloI'1~oodnndl)ro~ Control Utilization of l'radlttonal Medicine - Directorate Gcneral of and l)ntg Conlr~l Utilization of Traditional Medicine Practitionc~s in I'IIC - Directoratc (ieneral 01 Community Health Rehahilitation - Directorate General of Medical Care rqanded Prograrnmc on lmmuni?.ation - Directorate General of (:I)(: & Ill! IN~ vnc UOI KII IN0 MAL.001 KLI IN0 PDPOOI KR IN0 CDD 1101 KH IN0 A111 001 KR ISO'l'UIlM~I I111 IN0 I.lil'001 Kl1rYl. IN0 VI'II IKII KT1 IN0 VIYT iI01 RH IN0 Gl'A 001 KI3:PS IN0 OCD 001 KB INO r'no 001 KII IN0 I'III) IlOZ VI) IN0 (:AN IlOl Kt1 INO (YO IN1 Kt1 IN0 11131 IN1 KI1 MALDIVES MAV MI'S ?Ill1 1111 MAV I'II('IIO1 I<IIVI'VI) MAV IIMIIOIII lit1 LlAV M('I1 OIII 11ll'I~'l' MAV MC'I 1002 1.1' MAV CWS 001 KT1 \lAVMALOOl RR MAV (;!'A 001 I:X MAV 1'131) Oil1 VII MAV III3I Oil1 1111 110Ci MI'N 1011 It11 0 1: 0 1111 MO(i IIM1)OOS K11 MOC; OR11 001 KII MOG MCII 002 RII MOG MCl1001 FF MOG CWS 001 RB MOG CL.RM!Z KB MO<i IIIV 002 1)1' Dtseasc Vcnor Control- Uirectorate General of CDC Er 1:ll Malaria Control - Directorate General of CDC & EH Parasitic Diseases - Directorate General of CDC & Ell Il~arrhoeal Disease Contml- Directorate General of (:I)(: & 1(11 Control of Arutc Respiratory Infections - nirectoratc General of CI)C & lill 'l'uherrulos~s - IIirertoratc iicncral of CDC & lil I I~prosy- 1)irectoratc (icneral of(:DC & lill Veterinary I'ohlic Ilealth (7~x,noses) - 1)irerlorale (icneral of (:I)(: B lill Senually'l'mnsmitted 1)iseaser and Yam -I)ireclnrate (icncral of CI>C & Ell Acquired Immuno-deficiency Syndrome - Dlrcctorate General of CIIC & lil( Communicable Disease Control with Community Participation - Directorate (ieneral of CDC & fill I'revenuon of ~lindness - Directorate (iencral of Community I leallh I'rimary llyc Care Cancer Control - 1)irectorate (ieneral ofolMed~cal ('arc Cardiovasrolar l)iseases l)ircrtorate (iencral of Medicitl (:are Se>cnttftr Information Network and lleallh Information Sup~rl to the Nal$onal l~tsritute of I leallli Research and lIcvelopn>ent Miiaager<sl I'rocess for National Ilealth 1)evelopment Strcngtheningofllealth Scrviccs l)eliverySyslum hased on 1'rim;try Ileallh ('arc Ilcvel~~pn~ent oi lluman ll~sourcea for llealth ('lilld Spar~ng 1'mgr;lnlme Strenglhen!ng 1)f I'amily Ilealth/Child Spacing Scwices \Vilter Supply and Sanitation Malaria and Other Vertor-bomc Disease Control Prcvcntion and O>otrol of AIDS Primary Iiye Carc I)evelopnlcnt ~~fllealth 1.iteralure and 1.chralyand lnfonnarion Sew~ces Development of National Health Information Sptcrn for ilnproilng the Ilealrh Planning and Management Process Managcrial I'rocess fur National lleallh l)evelopnlenl \li!niigcmenl ofllealth Servtccr Ilumi8n Resc~nrres for Ilc;llth 1)evclopmenl and Strcngllierling 01 Il~sci~r~h Capal,llxlio Ilcscarrh I'n,rnotlon and l)cvcli,pment, iacluding Resc;$rrh on llc;~ltl~ I'mmol~ng Ilchavioer 1)cvclopmenl olOral lleallll Maternal and Child Health Strengthening of MCIIIPP Sewices Strengthening of Environmental llealth Sewices I>cvelopn>ent of Clinical Laboratory Sevicea I)cvelopmcnt of llcpatilis I? Vaccine and 1)iagnostics MO(i DSE Wl RH MOGEPIWI RB MOG'IUHWI RB MOGVPH00l RB MOO Ol'A 001 FX MO(; OCIl WI RI1 MOCi NU) IN1 I<ll MYANMAR MMRRSrWI KB MMRIISI'WZ RB MMR MPNOOZ KIlND MMI< MPN W3 1))' MMRMI'N2W KR MMK IlSK Wl I<# MMRPHC001 KU MMRPHCW3 I(B MMR I'IICMJ Kt1 MMR PllC 005 I)P MMR HMD 010 RB MMR HMDOI4 1)P MMR HMD 016 I)P M,MR HMD 017 FP MMII IIMDOIX VD MMII IIMI)01'J VI) MMK IrMI) 020 KB MMII IBII 001 KII MMR RPIl Gill RHNG MMRRPD002 RB MMR RPD003 f<R MMII NU'I'002 RB MMRNlrI'003 VD MMRORH WI RB MMII AI'R WI KH MMR MCII W KR MMRMCH WS FP MMRADHWI RB MMROCH W2 KB MMRHEEWI RB MMRADAMll DP MMII MNII M)I KI1 lmprovemcnt of Drug Supply and Vaccine Control Bpanded Programme on Immunization Tuberculosis 7mnoses Prcvcnlion and Conlrol of AII)S (:ommunicahle 1)iscases Prevcntion and Conrml Non-Comnlunirahle 1)iseases Pmvention and Conlrnl Health Information Services F.pidemiologiral Suwcillance of Comn~unicable Diacases Health Selvlecs Planning and Managcnlent Stren thening of h'ational Capabilities in I'lanning, Managcmenl and I'ulancing of 11ea1ti kctor Managerial Proresa for National Health Developmcnl Health Sysren~s Rcacarch Primary Ilealth Care and Uaslc Health Services Ilospital Sclslcer Managcmenl Supply Systcm and Maintenance and Kepanr Workshop for llealth Fquiprnenr Re,nforcemcnt of the lnsrrt~mentat~on Divlsion (Workshop) of thc Departmcnl nf Medical Research Development of I'nxcdures and Stall'kaining of Medical Education Methodologies for the 'l'ralninr and Ilcalth 'l'cams, including Physicians, in support of I'eople's l\calth - Development of Human Resources for Health Strengthening of the Nurstng Services Human Resources Development for the lnstitutesof Medicineand Dental Medicine Strengthening of thc Departments of Obslctrics and Gynaecol~~y of tl?e Jnrilulc of Mcdicine Health Manpower Plsnningand Information Syslem Work Slady on i)~u!r~ons and Sections of 1)eparlment ~~flle~tltl~ HP'A I.cadenh8p I)evelopmenl Development of llcallh IMucation Ilealth Research I" Support of I'cople's Health I'rogramme Research Training I'mgramme Development of Research lnfraslructure Nutrition WHO/UNI(:BI' Nutrition Support Programme Primary Oral Health Care Accident Prevcntion I'amily llcalth Care Slrengtheningof MCH kwices Development of physical Health Workers' Ilealth Health Care for the Elderly UNIBurma Programme for Ilrug Abuse Control, Trealment and Ilcsearch Component -Phase 11 (hmntuoini-oriented Mental Ilcalth ('arc programme MMI(CWS00i RH tnwronmental liealth Plannlngand Management VMRRUD W1 KB Urban Enwronmental Health MMl1 IIlV 002 MMR lil)V 003 MMII IlSl,. [Kll MMR'I'I~M 001 MMRTRM 002 MMR KHI) W1 MMR lil'l 001 MMl1 VI3CMJI MMII CI)Il MI MMII A111 IXJZ MMII'I'UIIIYJI MMR 1.11' Mll MMl1 GPA 001 IMMR GI'A W? MMR GPA003 ,MMII I'H1l 001 MMl1 PI11) 002 MMII 1'131) OR3 MMII CAN IXJI MMll CVI) 001 MMl111111001 NEPAL Nlil' 155001 NICI' IlSl'IYJl Slil'Ml'N001 NliI' MPN 002 NEP MPN 200 NEP PIIC001 YI.:P I'IIC003 NItP IIMI)00S Nlil'11MIl 1108 Nlil'IIIIIOtII !4Iil'lll'll 001 NEI' NUI'MJ3 NIT NUT W KEl' APR 001 NEP MC11003 NI'T MCI I 005 Nlil' MNI) W1 " Ilevelopment ofl'rodurtion and Quality Control ofiliulogirals and I'harmaceut~ral Pmducts Standardization, Pharmacological and 'Ibxicolagieal Evaluation of 'Traditional Drugs and llerbal Medicine Develooment ofl'raditional Medicine Man~ower Community-oriented Programme for Disability Prevention and Rehahilitation - Phase I Expanded Programme on Inlmuniration Vector-llornc Ilisease Control Control and I'revenlion of Uiarrhoeal 1)iseaaes Aculc Respiratory Infertionr (:onlrnl ~luberculos~s Contrul liepnxy Control and Research Activities Prevention and Control of AlDS Control of AlDS and other Sexually Transmitted Diseases Support lo the National AlDS Control Programme Trachoma Ciintnll and I'revenl~on of nlindness I'rogrammc I'rcvcntion of 13eafness I'rcvenrion of Illiodaess Citnrer Contn,l (:ardiovascular Iliseases Ilevclopmenl of 1.thrary and Information SeMccs Ilcvrlopment of informatics I'aci\itics in Snppn of l\eai\h Sytem Ileveloprnent 01 Bpidenliological Su~veillanre and lnf~lrmation System Covnlry lleallh Programming Health Planniogand Programmingand Health Information System Managerial Process for National Health Devclopment Community Hcalth Development and Development of Referral System through Primary Ilealth Care Allernatwe Approaches to Primary llealth Care I>cvelopmeot of lluman I<csources krr llcalth I>evclopn,ent of Nutsing Penonnel I'lanningand M;~nagcalent I'ul,lir lnfc~rmation and Iidurat~on for llealth Kercarrh Pruniotion and Ilevelopmer~t Nutrition WHOIUNICEF Nutrition Support Programme Accident Prevention Programme Maternal and Child Health including Family Planning Centre lor Fan* Health Protectionand PromotionofMental tlealth, including Alcoholism and Drug Abusc NliP CWS WI NEP LU'S W3 NEP CLR 001 NEP IISE W2 NFPTRM WI NliP Rt11+001 NEI' I:.Pl Wl NF.P VI3C W1 NEP MA1.001 NEPCDD W1 NEP ARI WI NEP TUB MI NEP 1.W WI NHP V1'11WI %I<l' VlYI'00l Nlil' (iPA00I NI~t1' OCD 001 NEI' PUD WI NEP ran 002 NEP NCD W1 NI'I'III11 WI SKI LANKA SRI.lISl'WI SKL HSI' 002 SKI. HST 003 SKI. MPNWI SIII. MPN 002 SKI. MPN 200 SK, I'IIC 101 SKIPtlC 102 SIl1. I'IIC 103 SKI. PHC 104 SKI. PllC 105 SRl.IIMD 011 SIII. IIM1)01? SI11. IIMII014 SKI. 1IMl)OlK S111.11MIIOl'J SKI, llMD020 SKI. llMD 101 SKI. HMD 102 SIU. HMD 103 SKI. HMI) 104 SKI. IEl4 071 RB Community Water Supply and Sanitation DP Training of Manplwcr for Drinking Water and Sanitation I'rogrammc (I'hase 11) REND Developmcnl of Laboratory Senices based on PHC RBND Drug Policy. Legislation and Information RB Promotion of Traditional Medicine 1111 Cnrnmunily lbscd RchahiIital!on Kt1 Expanded I'rogramme on Immunization KB Vector 11lology O,nlrol RB Control ol Malarta KR Control of Dlarrhwal Diseascs KB I'revention and Control of Acute Respiratory Inleclions KB Control of'l'uherculosis KBND Control of l rproy I<L( Contml of 7m,n<hes and lmd Safety KI1 I'rcuention and Conlrol of jexually Transmiltcd 1)iscases. ~ncluding A11)S FX Prcvcnlinn and (:onlrol of AIDS 1111 Control of Other Communirahle IIiseases KBiVRiVD Prevention and <.'onlrol of Ulindness REND Prevenlion and Control of Deafness KB Prevention and Control of other Non-communicable Diseases RR Development of Ilealth Lilcrature and Library and Information Sewices Strengthening of llcalth Informallon System Strengthenmgol Ep8demiolugital Surveillance Nalional Health Information Syslem (buntryllcalth l'rogrammlng Srrenglhen~ngul I'lanningand Management Managerial Pmrcss for National Health Developmcnl I>evelopment of I'rimary llealth Care - PIIC Management and Inlcmectol;tl Coordinalion Devclopmenl of I'nrnary llealth Care -Traditional Med#c!ne IIevelopment of I'rimary Health Care - Referral Hospitals (Secondary) Development of Primary llealth Cart -Tertiaty llosp~lals Development of Primary Health Care - Biomedical lingineering Sewices Nursing Fducalion I'ort-graduate Medical I3ucalion 1)evelopment of Nalional l~~stitute of lleallh Sciences Ilevclopment of llun,an Kcsourrrs for llealth I)evclopment of llurnan Resources for Iorensic Medicine Dcvclopment of llcgional Training Centres in Coll;ihoralioa wllh Ihe flalional Institute of Ilealth Sciences Undergraduale Medical Education - Universityof Colombo Undergraduate Medical Education - Univenify of Ruhuna Undereraduate Medical Fdueation - Univenitv of Pcradeniva - Undergraduate Medical 1':duralion - Univcrsityof Jaffna llcallh I'duratirm SlU. RPD 001 SRL NUT 002 SRL ORH 001 SRL. APR 001 SI11. MCl l 009 SIIL. MCII 010 Sltl,O(:ll (Kll SIII. ADA MI SKI. ADA 002 SRL MND 001 SRL CWS 001 SRL FOS 001 SRL C1.11001 SKI.. EI)V 001 SIII.'l'IIM 002 SRI. RIIII WI SIII. IIPIUIll SRI. VH(:001 SRI. MA1.001 SRL CUD W1 SlIL ARI 001 SRl.'l'Un 001 SRI. I.liPiNlI S111,VPII IM2 SIII. VIYI'UOI SRI. GI'A Gill SRI. PIII) W1 SRL PBII W? SRL CAN 002 SRI. CVD 002 SRI. CVI) 003 5111. IIIII (HI1 1111 RII RII RB KII I:P KII I'l) IIP RII RB RH RII HIIIVI) I)P 1<11 RII,VI RH RD RB RBIVD RIt KII RIIVI) KII rx IIB VD RH Rn VO KIi Research Promotion and Development Nutrition Communiry Oral Health Ilevelopment oia National Programme on Accldent Prevention I)evelopmcnt of Family llcalth I'rogramme Strengthen~ng l:amlly I'lanning Services Worken' Ilratth I'revention and 'l'rcalmenl of I'roblems Related lo ihc Ahusc of Ilrugs Drug Ahvsc Monitocing System Mental Health Communily Waler Supply and Sanitation Food Safety Strcngthcning ol Laboratory *Gees I'ssential Dnlgs and Vaccines 1)evelopmcnt oi'l'radilional Mcdirinc - Phase ll (i,mmuntty-Oriented Rehabilitation Setviccs Fzpandcd I'n,gramme on ln~munizatbn I)#sease Veclor Conlrol Malaria Control Control of Diarrhwal Diseases Control of Acute Respiratory Infections Tuberculosis Contml l'eprusy Conlrol Acccleralcd Ralxes Conlrol (hmpaign Control oiScrually l'ransmilted Diseases Prcvcntion and Control of All)S I'revenlion of Blindness Primary Eye &re Prevention and Control of Cancer Prevention and Conrmt of Cardiovascular Dcseases Prcvcntion of llheumal~c FeveriRhcumaIic llcarll)iscase I)cvclopn~cnt of Ilealth 1,iterdture and 1.ihraly Network THAILAND THA HSl'W1 RB'FH Health Situatirln and Trend Assessment 'IIIA MI'S 200 '1.1 IA 1'1 I(: m2 l'l lA 1'1 IC 003 'I'IIAIIMLlOIS l'llAIEH001 IHA KPD 003 THA AIIK 001 'THA TOH 001 TlIAMC11010 Development and Strengthening of the National Derenlralired Management System - RTGIWIIO Fxecutive Committee Managerial Pnress lor National Ileatlh l)evelopmenl Support ni O,mmunity-hased Self-Managed Primary Ilealth <$re llevelopn~enl Ilealth Systems Reonenlation and llcvclopmenl in Support 01 I'IIC Ilevelopmenr oi lluman Rerourrcs for Health I'ubltc Inlormarion and Wucation for Health Research Promotion and Development, including Research on Health Promoting Whavlour Prevention of Accidents Smoking and Health hpans~on of I'umlly I'lanning SeMccs I h? IIII5 WORK0F WHO IN SEA A -- TIIA MCH011 THA OCH W1 THA HEE 001 THA PSFW1 'IHA ('EH 001 '~IIA I:OS 001 TIIA lil)V 001 'I'IIA DSE 001 THA I'RV 00 I THA VBC Wl TllA MAI. 001 TllA KDV001 'I'IIA (;I'A(~I I'l lA <;PAW? 'I'IIA 0(:1) 001 'IIIA PBI)001 '7 IA PBD 002 THA CVD W2 TI IA NCD 00? 'THA 11111 001 'I'IIA GPA 001 IUR RB RB KR KIJ 1)11 IUBNL) KB IUB KB RB KB FX 1<13 HH VD VD VD RB KR IllZ INTEKCOUNTRY OK1 l1CO 103 RB OW EXMOO1 RH ICPDGPOOI RH 000 GPD 001 RRiAS I I'M Rl1 I(:I2 COl1 001 RH IN10 ('011 1(m As ICP IISC 001 R1l OW ISS W1 KB 000 11ST001 KR 000 HST 002 RR 000 11Sl' lW RE 000 MI'N Mll RRNII O(NI MI'X 003 I)P I('PMI'N004 ST Maternal and (:h!ld Ilcalth, including I'amily Plannlng Workers' llealth I3ealth of the Elderly Psychosocial Factors ~n the Promotion of Health and lluman Development (:ontrol of Environmental Health Ha?.ards Develo mcnt of Regional Cenlrc of Food and Drug Adm~nistration for (:onsumcr 1Icalth $rr,lerlion at 'Trang l'molnrc Promotion of I'ssential Ilrugs - 1)istribution and Rstionali,ation of l)rug Uscs at the PIIClrvel I>cvelopmcnt of Pharmaceut!cals and Biologicals Traditional Medicme Disease Vector Control Malaria Control Vaccine and Research and Dcvelopmenl AIIX I'revcnt~on and Chntml Programme All)S Prevention and Control 1)isease I'revcntion and Control Activities Primary l'yc Carc I'revcntion of Lllindness Prevenlion of Rheamat~r I~everIKheumatic Heart Disease Preventton and Control of Non-cornmunieable Diseases llealth Information Support National MU' for I'revention of AIDS Regional D,m!nittees Executive Management Regiooal Director's Dcvelopmenl Programme <;enera1 Programme 1)cvelopmcnt Staff llevelopment and'l'ralning I.iaison wth ILS('AI' (;<rrrdinatioo wth other Organizations I leallh-for-A11 S~rateky C<x~rdination Informatics Management Strenglhenmg or Epiderntol~gical Sumillanre System National Health Information Systems Development I4ealth Situation and Trend Assessmenl Managerial Pmcess for Health Dcvelopmcnt Strengthening Ilcallh Managerial Capabilities Strcngthening<:;~pacilyafU'Kc'Officcsand.loint (iovernmcnl/WI 10 ('oodlnaul,n Mechanisms I ll100 I<DNUNK Promotion of Ilcalth for All with I'rimaryllealth (:arc as Kcy Approach inchldltlg Appropriate'Yechnal<,~ for fleallh WO I'HC OW I)I' Intensification of Adion Programme far Primary Health (:arc MMPIK 100 KL) Organimtion of llealth Syslcms Bascd on Primary Health Care 000 HMD 014 IlBmBND Developrncnt of Human Resources for Health I MI Oh Sr HI'A lraderrhip Devclopn,ent (KKI IlMI)OIR 1)l' 1)cvelnpmcnt of llealth I rarning Materials

'IIIE WORK OF WHO IN SM ICP VPH WI ICP VDT W1 000 GPA 1W ICP PBD 001 000 PDD WZ 000 PllD 04 OM NCD 001 ICP NCD WZ 0001lRIWI OM A81 W2 OM PER 001 OM PGS W1 000 BFIW1 000 SUP 001 VD DP FX RBND ST DP RBPH VD RRIAS RB RB RBIAS RBIASFI RBIAS Control of knoses and Food-borne Diseases Prevention and Control of AlDS in Asia and the Pacific AIDS Prevention and Control Programme Prevention of Blindness and Deafness Prevention of Blindness Contml of lllindness (Primary Eye Carc) A Communily-oricntcd Approach to the Prcvcnlion and (:ontrol of Nor comn~unicable Diseases Prevenlion and Control of Deafness llcalth Informalion Support llealth Literature, Library and Information Services Support Services - Personnel General Administration and Services Support Services - Budget and Finanrc Fipipment and Supplies lor Member Slates

Annex 2 PROJECTS IN OPERATION IN MEMBER COUNTRIES In ihc lisl of projccls, the following abhrcvialions arc used undcr "Sourcc of Funds": A<iI:UNI> AS I)I. 1)M 111' I:A I'll 1'1) 1'1' I'x RI3 sr kab Gull Programme for the United Nations Uevelopment Orgao~zanons Special Account for Servicing Costs Standard Letter of Agreement Between Executing Agencies (Jnited Nations Development I'rogmmme/Spccial Measures IJnltcd Nanuns Ilevel~~pment Programme 'l'rust Fund for the Specill I'rtlgramnlc for llcscarch and 'l'r;ltntng in I'roptcal I)isc;~scs Assoc~;~lc 1:hpcrls Olhcr 'I'hi~n IINI)I1 llnltcd Nations t:und for Drug Ahusc (l,ntrc~l lin~led Nations Population Fund Voluntary Fund for AIDS Regular nudge1 Sasakawa llealth'l'rust Fund VI) V<llunlary Fund - Olhcr V(i Vr~luntary Fund for Medical Research - Other (General) VI Voluntary Fund for Fxpanded Programme on Immunizauon Vk Voluntaty I'und for Training Courses (DANIDA) VI. Voluntary Fund for Leprosy Programme VM Voluntary Fund for Malaria VV V<lluntary Fund for Disasters and Natural Calastrophes ~ ~~ ~~ ~~ ~~ ~ Plojtct No. Sourer of funds Tills HANGL4DESH RANCORWI VH BAN CORW? RB BAN ISSW1 RB BAN I<.- W1 RB BANHXW3 UP IIANMPN W2 RB I3AN MPN2W RB RAN PIICW3 RB I3AN PHCKW KB IIAN PllC 005 KB RANIlMD007 KH RAN IlMD 010 Dl' RAN HMD011 DP BAN HMD 014 KII RAN HMI) 015 KB !IAN IIMI) OIII I1B HAN IIMI) 017 HI1 IIAN 11111W1 RI1 IIAN RI'D WI KI1 ~~RYU ~2 RB BANNUTW3 RB BANORHWI RB IMN APR WI RB IIAN MCI I WS VI) HAN MCII DO(> 1111 [IAN 0(:11 Wl RII BAN l lE1'. 001 RB RANMNDWI RI1 BANCWSWI KH RAN I'OS001 RB nANCLRW2 RB I3AN lillV 001 KH'VO RAN I<I)V W3 KB l3AN DSIi001 RII IIAS TKM 003 It11 RAN Rllll Wl RH AN 'I I RBIVl 13AN MALW1 KB BANMALWZ UP IIANPDP W1 RR IIAN CDI) WI RRNC Iimergency Relief Operattans Emergenq Prrparedness and llesponse Informatics 1)evclopment Hcalth Situation and Trend Assessment Field Epidemiotogiral Suweillance and Disease (:ontml Planning and Management of Hcalth Services Managerial Process for Nauonal Ilealtlh Dwclopment Organization of lleallh Systems Rasedon Primary lleallh (:are Repair and Maintenance of L:lertm-Medical Equipment Com~nanity I'artictpatios and lleallh I'or All Iradctship I)cvelopmelll Nursing Advisoly Scrviccs and Training Training of Senior Nurscs Developmrnt of the (:entre for Mcd~cal Fduration Human Ilesoorccr 1)evclopment -Trainingof t'araa,edicsl Workers Srrcnglheningof I'orl-gr;tduale Medical FAuration Undergraduate Medical I%eration Strcngthenlng~,fNational lnatitotc of I'leventivc and Scxaal Med8rillc 1)evelopmen~ of llealth lidural8on Sclvcccs Research Promotton and 1)evelopment Slrcngthening of Selected lnstitulions Community-based Nutrition lmpmvement Programme Oral Health Accident Prevention I'am~ly Planning Clinical Supelvisiun~eam Maternal and Child lleallh, inrhlding I'amily Planning Workers' llcalth lleallh olthe Ildcrly Prevention and'l'realmcnt of Mental and Neurological Disorders Community Water Supply and Sanllalion Food Safety Clinical, Laboratory and Radiological Technology for Health Systems based on Primaly llealth Care Fssential llrugs and Varcincs Fssential 1)rugs Production 1)rug and Varrinc Quality. Safety and Efficacy 1)c~elopmenr of Manpower in'Traditional Medicine llchabilitation of the Disabled lnlmunizalion Malaria Conrrol Malaria Control Programme Parasitic Diseses 1)iarrhocal Diseases UANARI 001 BANTUR 001 nAN 1.EP 001 RAN VI)T 001 !IAN GPA 001 IlAN 1'111) 001 RAN l'nn ooz IlAN CAN Oil3 I1AN CVI) Wl l1AN NCD 001 RAN HBI 001 BHUTAN l1IIU IISl'(KI1 IlIlU MI'NMII I3IIU PIICOOI HHU HMD 001 DIlU HMD 002 111 IU HMD 003 IlllU lli11001 I1IIU MCI I (XI2 IlllU li1)V 001 1111U (iPA 001 111IU OCD 001 nllu NCD oo~ KR RR RBiVD RB I'X N11Nl) VI) 1111 KII R 13 RR 111% I< R KR DP DP RB KII FI' VO 1:s RIJ K1l Control of Acute Respiratory Infections Tuberculosis lrprosy Sexually Transmitted 1)iscases Prcvcnlion and Control of AIIX Prevenuon of lllindness l'rirna~y I':yc (:arc I'rcvcntion and Control of Canrcr Cardiovascular Diseases Other Non-Conlrnunirablc 1)isease Prevention and Control Activities Development of Heallh L.irerature and Lihraryand Information Setvices I leallh Situation and 'Trend Assessrnrnt Country lleallh Programming I'rirnaly Health Care Promotion and Ilealth Infrastructure Development Development of lluman Resources for Health Strenglhening and Development of Nursing SeMccs Development of Human Resources for Health Slrengtheningofllcalth FAucation I'mgrarnme Ileuclopmcnt and Strengthcn~ngol I'amily Ileallh Services Il\rcntial I)rub.\ I'rograrnlne I'revenlion and Contml of AII)S Prevention and Control of Specific Communitahlc Iliseascs Prevcntian and Control of Non-Communicable Diseases DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA KRI) MI'N 001 RE1 Managerial Process for National Health I)evelopment KIU) I (MI) NI? Ill1 I)eveloprnenl of lluman Resoorccs lor llcalth K111) R1'1) 001 RII I'romolion of llesearrh KIl1) 111111 001 RII Oral lfcalth KllD MCH 001 RU Maternal and Child Ilealth KRD MCll 002 FI' Suppon for the MCHiW Activities KRDOCH001 RII Workers' Ileallh KRI) Illill 001 RI1 (ierontologv KIII) C1111 001 Dl' (:ontrol of linvironmental lleallh Ila2ards KI11) CI(II 002 1<11 ('ontrol oflinvironmenlal I'ollulants and Ilealth llarards KRI) (:Ill1 003 111' ('ontrol of linviron~ncntal Ilealth Ilarards I l.1 KI1 Iahoratory Scicnrcs and 'Icchn~qaes KRD IRM 001 RB 'Tradilional Medicine KRI) RI In 001 RB Rehahilitation KRDGPA001 FX Prevenlaon and Control of AIDS KRII CAN 001 RH Cancer Control KRI) CVI) 001 RH Cardiovascular Diseases KI11) N(:l) (MI 1111 Other Non-rommunicahle Disease Prcvenli<m and Control Acrtvitics 'WE WOKKOF WHO IN SEA INDIA IKD COR WI IND HSC MI IN11 HST W3 IND llSI'W5 INI) I IST OO(, INI) MPN W1 INI) MPN 002 INI) MPN 2W IND HSR Wl IND HLE Wl IN11 I'IIC 001 IN11 I'I IC WZ INI) I'I{C 003 INI) 1IMI)OIS INI) HMI) 017 INI) IEH 001 INI) RPD W1 IND WD W? IND NUTWh INI) ORllW1 INI) APR WI IN11 MCH W3 INI) MCH 004 NI) MCII 005 INI) MCII nm IND MCH 001 IND HEE MI IND ADA 001 INn MNI) WI INI) CWS 001 1x1) <:ws 002 IN11 ('Ell Wl INI) I'OS W1 IND CI.RW1 1x1) CI.R 002 IND C1.R W3 INI) linv OOI INI) I)Sb:(K)I IN11 'TJIM 001 INI) IIIII1WI INl) l<l'l Wl INI) MAL W1 IND MAL 002 IND PDP 001 INI) CDD W1 IN11 ARI W1 1Sl) 'TUG W1 VN RB RB RH VI) KB RR RB RB RB RBND RH RB IIII RB RBND KB DP KR RB RB RH Kn KH 111 KL! RB KB RII KH Rll 101 KB KR RB DP I<B KI1 HI3 KII KB IIBlVM VM RB KB KO RWD Emergency Preparedness 'Trainingand Development of HFA Leadcnhip Epidemiological ScMces Development and Training Devclapmenl and Training of Health Information Sclvltes Field Rpidemialogy and lahoratory Support Selvirer Country Ilealth Planning Slrcngtheningoflleallh Pmgrammlngand Management Managerial Proeess for National tleallh Development Health System Research and Development Health Legislation Organization of Health Systems based on Prirnaly Hcalth Care Trihal llealth Care Strengthening of Medical Stores Orgmiration Nursing Development and Research llealth Management Assessment. Developmcnl and'l'rainlng Development of National Hcalth Education SeMees Biomedical Research Studies on Tribal llealth Nutrition including Goitrc Oral llealth Prevention of Accidents Maternal and Child llcalth Promotion of Famnly Welfare Scwiccs and Rcsearch Family WclfarelMCII Sewires in Urban Areas A Rural, Cuhorl Study on Child Sulvival Worken' Ikalth llealth of the Elderly Prevcntion and l'rcatmcnt of Problcms related to the Ahuse of Lhgs Prevention and Canlml of Mental and Neumlogical Disorders Community Water Supply and Sanitation Rural Water Supply and Sanitation Control of Enuironn,ental Pollution Qualily Control of Fssential i'ood Blood Banking laboratory Quality Control and Standardization Strengthening National Institute of Immunology using Modern Immunohiological and B~ological Approaches Fssenlial Drugs and Vaccines Quality. Safely and FJficacy of Drugs and Vaccines Traditional Medicine (inrltldingHo~t,ocopalhy and Yoga) Rehabilitation Expanded Programme on lmmuniralion Malaria Eradication Research and Training in Malaria Control Control of Parasitic Diseases Diarrhueal Disease Control Programme Prevention and Control ofAet>te Respiratory lnlertions Tuherculosia Control IND I.lil'W1 KllVl. IND 1.EP WZ DP INDVPll WZ RB ISI>VDT001 Rl3 IND (;PA 001 11lin:X IS11 0C1) 001 Kli IN11 0<:I) MI2 KIi INI) OCI) W3 KIi IND OCI) IKW R1i IND I'UU 001 KIi IND CAN 00(1 KI1 INL) CVI) (H12 Kli IND (1VI) 0113 RIi!VIl INI) NCl) Wl INI) IIIII IXII KIi INDONESIA IN0 11S1' 103 1111 IS0 IISI' IOI 1113 IS0 IISI'IOS K1i IS0 IIST I06 KIi IN0 MPS Ill? KIi IN0 MI'N 103 RB IS0 MPN IM KI? IS0 MI'N 105 RH IN0 MI'S 10(1 1<1i IN0 MPN Z00 1113 IN0 HSRWZ RB lrprosy Control Approaches lo Treatment and Prevention of Leprosy 7aonoses Control I'revcntion of Sexually l'ransmilted Diseases I'reuentcon and Cnnlrol ofAI1)S I'revention and Control of Viral Ilepaulis (iu!neaworm llradiralion Pn~grarnmc I'revenlion and ('ontrol of Jananese linrephal~t~s Other (:omrnunirahle I>iscases Prevention and (:ontrol Art~v~l8er. ~ncludcng 'Qphold Prevention of Blindness (8nrer (including Radiation Medirtne) I'revention ef tlypcrlension and lllD I'revent~on of Rheumalir l~cver/Rhcurnatic Ilcan 1)iseasc Othcr Non-mmmunirahle 1)lsease Prevent#on and Contml Artcvit~cs National Medical l.ihraryand 1)ocumentalion Cenlre Health lor All Strategy Coordination - 1)ircclorale General of Communily Health Strengtheningof llealth lnfornlalion Syslem Ccnlre for lleallh Data Stren lh~ningof llcalth Information System - 1)irerloraIc (ieneral of Commanity ~~ea~ti ' Strenglhening~,f Ilealth Inlormalion System - lnspertoratc (ienen~l StrenglheningofIlealth1nformation Systcm111rertoratc(;encralofMcdical(:are Strenglhensng of ilealth information Syslern - Directorate (icneral of C1)C N 1111 Streng1hen.cn of Health Information System - Dirertaratc ticne~al of Focd and Drug ~ontrof Strengtheningof I'Kl'l'Training in Epldemioloa- Directorate (icncral of CDC N 1111 Strcngthen~ng of 1)lsease Surveillance - I)irertorate Cjenersl of (:I)(: B Iil I Strcnglhening of lleallh Informalion Syslem - Ccotre fur Ilealth Inhorato!y Scrvices Strcngthcning of the Managertal I'mress for Natnonal llealth l)evelopmenl - llureau of Planning Strengthening of the Managerial Prmess for National Ileallh I)evelopmeat - Ilarcau ol Organiration Strenglhening of the Managerial Process for National Health Development - Bureau of Penonnel Strengthening of the Managerial Pmcess for National Ilealth Oevelopmenl - Hureau of I'inance Strengthcnin of the Managerial Prnress for National llei~lth llevelopment - Inspcrtoratc fieneral Sucngthcning of the Managerla1 I'rocess for Kational Ilenlll? 1)cvelopmesl - llurcau of (iencral Affairs Stren~lhcning (iovernrnent ollndonesiaIWll0 Collahoral~on Merhasism - . llealth Sysfclns Research at Centre of llealth Sewire llesearch and 1)evelopment. Surahaya - National lnstitutc of Health Research and Developn~ent Srrengthcningofllealth lrgislation-Bureau of Legal Affairs and Puhlir Relations l'r~mary Health Care in lrian Jaya Strenglhening of l{ealth Care Delivery and Primary lleallh (:are - 1)irectorate General ol Community llealth 'THE WORKOF WHO IN SEA INO PHC 102 IN0 PllC 103 IN0 PHC 104 IN0 HMD OIS IN0 HMI) 101 IN0 IIMI) I02 IN0 HMD 103 IN0 IlMD 104 IN0 IlMD 105 IN0 IIMI) IW, IS0 llill 101 IS0 Ilil1 102 IKO RI'D 001 IN0 XUT W5 IN0 OH4 002 IN0 APR W1 INO'1'011 W1 IN0 MCIl 003 IN0 MCH 005 IN0 ADfl W1 IN0 OCH WI IN0 HEE 101 IN0 IIEE I02 IN0 ADA001 IN0 MFI) WI IN0 ('WS WI IN0 CWS W7 IN0 CWS WY IN0 I'CS 001 INO 1'0s 101 IN0 FOS 102 IN0 C1.R 001 IN0 lil)V 001 IN0 I)SI~OUI IN0 TRM LO1 IN0.I-RM 102 IN0 RHB 001 IN0 13'1 001 RB RB RB r)P RH IIB RB RB RB RB KIi KH RB RB KB RB KB IIB 1)P KO KB RH RB ItB KB KB I)P DP RB KB KH Kli IIH K11 RH RB KB 101 Strengtheningof Referral Hospital Nuning- Directorate General of Medical Care Hospital Sanitation - Directorate General of CDC & Ell Stren thening of Cammunlty Participation - Directorate General of Communcty ~ealtf Dcvclo men1 of Nursing Hikher Fduralion System including a I'aculty of Nuning at the Qni~cnityof lndonesla Overall Development and Coordination of Human Resources for Health will> cmphasison Paramcdirals- Centre of Iiealth Manpower Fduration - Pusdiknahrs Development of Numing Penonnel - Centre of llealth Manpwcr Muration - Pusdiknakes Planning of Human Resources for Health - Bvrcau of Planning Human Resources for Health - Management Training Centre for Penonnel FAueation Training - Pusdiklat Development of Higher Education in Health Sciences - Consonivm of Health Sciences, Univenityof Indonesia Development of Puhlir IIealth FA'ducation Systems - I'acully of Puhlir Ilcalth. Univenily of Indonesia Strcnglhen~ngof llealth I!d'ducation - Centre for I leallh lidurnlion Strengthening of Puhllc Relations - Bureau of Lcgal Affaln and Puhlit Relat~o,,~ Strengtheningaf National I*ealth System Research and Dcvclopment (~apahilities - Natjonal Institute of Health Research and Dcvelopment Nutrition Improvement Programme Directorate (iencral of C<lmnlunily Health Oral Acalth - Directorate Gcneral of Medical Care Areidcnts Preventnon and Control - Directorate General of Mcdlcal Care Tobacco or Heallh Maternal and Chlld lleallh including Family lleallh - 1)irertorate (icneral <>I Community Ilealth Dcvclopment of a National Strategy and Plan of Aclion for I'romotlon of Sale Motherhood Adolescent lfealth - Dirertoratc General of Comnlunity Health Strengtheningof Orcvpational Health-Dirertaratc Generalof (lommun$ty Heall11 Hcalth of the Elderly - Directorate Gcneral of Cammunlly Health Care of the Elderly - Directoratc General of Medtral Care Prevention and Cdntrol of Alcohol and Drug Abuse - Directorate (iencral of 14md and Drug Q,ntrol Protectionand Promotionof Mental Ilealth-Dircnoralc(icner;~lof Medlcal(:src Strengthening of Iinvironmental llealth - Direelori$te (ieneral of CI)C & lill Rural Water Supply and Sanitation. lkngkulu and lnmpung Provinces Rural Water Supply and Sanitation Project, East Timor Province llealth Kisk Assessment of Potentially Toxic Chemicals - Directorate General of Food and Drug Control Food Sanitation - 1)ireclorate Gencral of CDC & EH l'wd Safety - Ilirerloratc Gencral of Fd and Drug (:onlrol lleallh Iahoratury Scrvlces Cenlre for tlealth lahoralory Sewires Fsscntial Drugs and Vaccines - Directorate General of Food and Drug Control I)rugs,VacrineOual~ly.Safctyand Iiffira~y-Direct~rrrtc(ieneraloI'1~oodnndl)ro~ Control Utilization of l'radlttonal Medicine - Directorate Gcneral of and l)ntg Conlr~l Utilization of Traditional Medicine Practitionc~s in I'IIC - Directoratc (ieneral 01 Community Health Rehahilitation - Directorate General of Medical Care rqanded Prograrnmc on lmmuni?.ation - Directorate General of (:I)(: & Ill! IN~ vnc UOI KII IN0 MAL.001 KLI IN0 PDPOOI KR IN0 CDD 1101 KH IN0 A111 001 KR ISO'l'UIlM~I I111 IN0 I.lil'001 Kl1rYl. IN0 VI'II IKII KT1 IN0 VIYT iI01 RH IN0 Gl'A 001 KI3:PS IN0 OCD 001 KB INO r'no 001 KII IN0 I'III) IlOZ VI) IN0 (:AN IlOl Kt1 INO (YO IN1 Kt1 IN0 11131 IN1 KI1 MALDIVES MAV MI'S ?Ill1 1111 MAV I'II('IIO1 I<IIVI'VI) MAV IIMIIOIII lit1 LlAV M('I1 OIII 11ll'I~'l' MAV MC'I 1002 1.1' MAV CWS 001 KT1 \lAVMALOOl RR MAV (;!'A 001 I:X MAV 1'131) Oil1 VII MAV III3I Oil1 1111 110Ci MI'N 1011 It11 0 1: 0 1111 MO(i IIM1)OOS K11 MOC; OR11 001 KII MOG MCII 002 RII MOG MCl1001 FF MOG CWS 001 RB MOG CL.RM!Z KB MO<i IIIV 002 1)1' Dtseasc Vcnor Control- Uirectorate General of CDC Er 1:ll Malaria Control - Directorate General of CDC & EH Parasitic Diseases - Directorate General of CDC & Ell Il~arrhoeal Disease Contml- Directorate General of (:I)(: & 1(11 Control of Arutc Respiratory Infections - nirectoratc General of CI)C & lill 'l'uherrulos~s - IIirertoratc iicncral of CDC & lil I I~prosy- 1)irectoratc (icneral of(:DC & lill Veterinary I'ohlic Ilealth (7~x,noses) - 1)irerlorale (icneral of (:I)(: B lill Senually'l'mnsmitted 1)iseaser and Yam -I)ireclnrate (icncral of CI>C & Ell Acquired Immuno-deficiency Syndrome - Dlrcctorate General of CIIC & lil( Communicable Disease Control with Community Participation - Directorate (ieneral of CDC & fill I'revenuon of ~lindness - Directorate (iencral of Community I leallh I'rimary llyc Care Cancer Control - 1)irectorate (ieneral ofolMed~cal ('arc Cardiovasrolar l)iseases l)ircrtorate (iencral of Medicitl (:are Se>cnttftr Information Network and lleallh Information Sup~rl to the Nal$onal l~tsritute of I leallli Research and lIcvelopn>ent Miiaager<sl I'rocess for National Ilealth 1)evelopment Strcngtheningofllealth Scrviccs l)eliverySyslum hased on 1'rim;try Ileallh ('arc Ilcvel~~pn~ent oi lluman ll~sourcea for llealth ('lilld Spar~ng 1'mgr;lnlme Strenglhen!ng 1)f I'amily Ilealth/Child Spacing Scwices \Vilter Supply and Sanitation Malaria and Other Vertor-bomc Disease Control Prcvcntion and O>otrol of AIDS Primary Iiye Carc I)evelopnlcnt ~~fllealth 1.iteralure and 1.chralyand lnfonnarion Sew~ces Development of National Health Information Sptcrn for ilnproilng the Ilealrh Planning and Management Process Managcrial I'rocess fur National lleallh l)evelopnlenl \li!niigcmenl ofllealth Servtccr Ilumi8n Resc~nrres for Ilc;llth 1)evclopmenl and Strcngllierling 01 Il~sci~r~h Capal,llxlio Ilcscarrh I'n,rnotlon and l)cvcli,pment, iacluding Resc;$rrh on llc;~ltl~ I'mmol~ng Ilchavioer 1)cvclopmenl olOral lleallll Maternal and Child Health Strengthening of MCIIIPP Sewices Strengthening of Environmental llealth Sewices I>cvelopn>ent of Clinical Laboratory Sevicea I)cvelopmcnt of llcpatilis I? Vaccine and 1)iagnostics MO(i DSE Wl RH MOGEPIWI RB MOG'IUHWI RB MOGVPH00l RB MOO Ol'A 001 FX MO(; OCIl WI RI1 MOCi NU) IN1 I<ll MYANMAR MMRRSrWI KB MMRIISI'WZ RB MMR MPNOOZ KIlND MMI< MPN W3 1))' MMRMI'N2W KR MMK IlSK Wl I<# MMRPHC001 KU MMRPHCW3 I(B MMR I'IICMJ Kt1 MMR PllC 005 I)P MMR HMD 010 RB MMR HMDOI4 1)P MMR HMD 016 I)P M,MR HMD 017 FP MMII IIMDOIX VD MMII IIMI)01'J VI) MMK IrMI) 020 KB MMII IBII 001 KII MMR RPIl Gill RHNG MMRRPD002 RB MMR RPD003 f<R MMII NU'I'002 RB MMRNlrI'003 VD MMRORH WI RB MMII AI'R WI KH MMR MCII W KR MMRMCH WS FP MMRADHWI RB MMROCH W2 KB MMRHEEWI RB MMRADAMll DP MMII MNII M)I KI1 lmprovemcnt of Drug Supply and Vaccine Control Bpanded Programme on Immunization Tuberculosis 7mnoses Prcvcnlion and Conlrol of AII)S (:ommunicahle 1)iscases Prevcntion and Conrml Non-Comnlunirahle 1)iseases Pmvention and Conlrnl Health Information Services F.pidemiologiral Suwcillance of Comn~unicable Diacases Health Selvlecs Planning and Managcnlent Stren thening of h'ational Capabilities in I'lanning, Managcmenl and I'ulancing of 11ea1ti kctor Managerial Proresa for National Health Developmcnl Health Sysren~s Rcacarch Primary Ilealth Care and Uaslc Health Services Ilospital Sclslcer Managcmenl Supply Systcm and Maintenance and Kepanr Workshop for llealth Fquiprnenr Re,nforcemcnt of the lnsrrt~mentat~on Divlsion (Workshop) of thc Departmcnl nf Medical Research Development of I'nxcdures and Stall'kaining of Medical Education Methodologies for the 'l'ralninr and Ilcalth 'l'cams, including Physicians, in support of I'eople's l\calth - Development of Human Resources for Health Strengthening of the Nurstng Services Human Resources Development for the lnstitutesof Medicineand Dental Medicine Strengthening of thc Departments of Obslctrics and Gynaecol~~y of tl?e Jnrilulc of Mcdicine Health Manpower Plsnningand Information Syslem Work Slady on i)~u!r~ons and Sections of 1)eparlment ~~flle~tltl~ HP'A I.cadenh8p I)evelopmenl Development of llcallh IMucation Ilealth Research I" Support of I'cople's Health I'rogramme Research Training I'mgramme Development of Research lnfraslructure Nutrition WHO/UNI(:BI' Nutrition Support Programme Primary Oral Health Care Accident Prevcntion I'amily llcalth Care Slrengtheningof MCH kwices Development of physical Health Workers' Ilealth Health Care for the Elderly UNIBurma Programme for Ilrug Abuse Control, Trealment and Ilcsearch Component -Phase 11 (hmntuoini-oriented Mental Ilcalth ('arc programme MMI(CWS00i RH tnwronmental liealth Plannlngand Management VMRRUD W1 KB Urban Enwronmental Health MMl1 IIlV 002 MMR lil)V 003 MMII IlSl,. [Kll MMR'I'I~M 001 MMRTRM 002 MMR KHI) W1 MMR lil'l 001 MMl1 VI3CMJI MMII CI)Il MI MMII A111 IXJZ MMII'I'UIIIYJI MMR 1.11' Mll MMl1 GPA 001 IMMR GI'A W? MMR GPA003 ,MMII I'H1l 001 MMl1 PI11) 002 MMII 1'131) OR3 MMII CAN IXJI MMll CVI) 001 MMl111111001 NEPAL Nlil' 155001 NICI' IlSl'IYJl Slil'Ml'N001 NliI' MPN 002 NEP MPN 200 NEP PIIC001 YI.:P I'IIC003 NItP IIMI)00S Nlil'11MIl 1108 Nlil'IIIIIOtII !4Iil'lll'll 001 NEI' NUI'MJ3 NIT NUT W KEl' APR 001 NEP MC11003 NI'T MCI I 005 Nlil' MNI) W1 " Ilevelopment ofl'rodurtion and Quality Control ofiliulogirals and I'harmaceut~ral Pmducts Standardization, Pharmacological and 'Ibxicolagieal Evaluation of 'Traditional Drugs and llerbal Medicine Develooment ofl'raditional Medicine Man~ower Community-oriented Programme for Disability Prevention and Rehahilitation - Phase I Expanded Programme on Inlmuniration Vector-llornc Ilisease Control Control and I'revenlion of Uiarrhoeal 1)iseaaes Aculc Respiratory Infertionr (:onlrnl ~luberculos~s Contrul liepnxy Control and Research Activities Prevention and Control of AlDS Control of AlDS and other Sexually Transmitted Diseases Support lo the National AlDS Control Programme Trachoma Ciintnll and I'revenl~on of nlindness I'rogrammc I'rcvcntion of 13eafness I'rcvenrion of Illiodaess Citnrer Contn,l (:ardiovascular Iliseases Ilevclopmenl of 1.thrary and Information SeMccs Ilcvrlopment of informatics I'aci\itics in Snppn of l\eai\h Sytem Ileveloprnent 01 Bpidenliological Su~veillanre and lnf~lrmation System Covnlry lleallh Programming Health Planniogand Programmingand Health Information System Managerial Process for National Health Devclopment Community Hcalth Development and Development of Referral System through Primary Ilealth Care Allernatwe Approaches to Primary llealth Care I>cvelopmeot of lluman I<csources krr llcalth I>evclopn,ent of Nutsing Penonnel I'lanningand M;~nagcalent I'ul,lir lnfc~rmation and Iidurat~on for llealth Kercarrh Pruniotion and Ilevelopmer~t Nutrition WHOIUNICEF Nutrition Support Programme Accident Prevention Programme Maternal and Child Health including Family Planning Centre lor Fan* Health Protectionand PromotionofMental tlealth, including Alcoholism and Drug Abusc NliP CWS WI NEP LU'S W3 NEP CLR 001 NEP IISE W2 NFPTRM WI NliP Rt11+001 NEI' I:.Pl Wl NF.P VI3C W1 NEP MA1.001 NEPCDD W1 NEP ARI WI NEP TUB MI NEP 1.W WI NHP V1'11WI %I<l' VlYI'00l Nlil' (iPA00I NI~t1' OCD 001 NEI' PUD WI NEP ran 002 NEP NCD W1 NI'I'III11 WI SKI LANKA SRI.lISl'WI SKL HSI' 002 SKI. HST 003 SKI. MPNWI SIII. MPN 002 SKI. MPN 200 SK, I'IIC 101 SKIPtlC 102 SIl1. I'IIC 103 SKI. PHC 104 SKI. PllC 105 SRl.IIMD 011 SIII. IIM1)01? SI11. IIMII014 SKI. 1IMl)OlK S111.11MIIOl'J SKI, llMD020 SKI. llMD 101 SKI. HMD 102 SIU. HMD 103 SKI. HMI) 104 SKI. IEl4 071 RB Community Water Supply and Sanitation DP Training of Manplwcr for Drinking Water and Sanitation I'rogrammc (I'hase 11) REND Developmcnl of Laboratory Senices based on PHC RBND Drug Policy. Legislation and Information RB Promotion of Traditional Medicine 1111 Cnrnmunily lbscd RchahiIital!on Kt1 Expanded I'rogramme on Immunization KB Vector 11lology O,nlrol RB Control ol Malarta KR Control of Dlarrhwal Diseascs KB I'revention and Control of Acute Respiratory Inleclions KB Control of'l'uherculosis KBND Control of l rproy I<L( Contml of 7m,n<hes and lmd Safety KI1 I'rcuention and Conlrol of jexually Transmiltcd 1)iscases. ~ncluding A11)S FX Prcvcnlinn and (:onlrol of AIDS 1111 Control of Other Communirahle IIiseases KBiVRiVD Prevention and <.'onlrol of Ulindness REND Prevenlion and Control of Deafness KB Prevention and Control of other Non-communicable Diseases RR Development of Ilealth Lilcrature and Library and Information Sewices Strengthening of llcalth Informallon System Strengthenmgol Ep8demiolugital Surveillance Nalional Health Information Syslem (buntryllcalth l'rogrammlng Srrenglhen~ngul I'lanningand Management Managerial Pmrcss for National Health Developmcnl I>evelopment of I'rimary llealth Care - PIIC Management and Inlcmectol;tl Coordinalion Devclopmenl of I'nrnary llealth Care -Traditional Med#c!ne IIevelopment of I'rimary Health Care - Referral Hospitals (Secondary) Development of Primary llealth Cart -Tertiaty llosp~lals Development of Primary Health Care - Biomedical lingineering Sewices Nursing Fducalion I'ort-graduate Medical I3ucalion 1)evelopment of Nalional l~~stitute of lleallh Sciences Ilevclopment of llun,an Kcsourrrs for llealth I)evclopment of llurnan Resources for Iorensic Medicine Dcvclopment of llcgional Training Centres in Coll;ihoralioa wllh Ihe flalional Institute of Ilealth Sciences Undergraduale Medical Education - Universityof Colombo Undergraduate Medical Education - Univenify of Ruhuna Undereraduate Medical Fdueation - Univenitv of Pcradeniva - Undergraduate Medical 1':duralion - Univcrsityof Jaffna llcallh I'duratirm SlU. RPD 001 SRL NUT 002 SRL ORH 001 SRL. APR 001 SI11. MCl l 009 SIIL. MCII 010 Sltl,O(:ll (Kll SIII. ADA MI SKI. ADA 002 SRL MND 001 SRL CWS 001 SRL FOS 001 SRL C1.11001 SKI.. EI)V 001 SIII.'l'IIM 002 SRI. RIIII WI SIII. IIPIUIll SRI. VH(:001 SRI. MA1.001 SRL CUD W1 SlIL ARI 001 SRl.'l'Un 001 SRI. I.liPiNlI S111,VPII IM2 SIII. VIYI'UOI SRI. GI'A Gill SRI. PIII) W1 SRL PBII W? SRL CAN 002 SRI. CVD 002 SRI. CVI) 003 5111. IIIII (HI1 1111 RII RII RB KII I:P KII I'l) IIP RII RB RH RII HIIIVI) I)P 1<11 RII,VI RH RD RB RBIVD RIt KII RIIVI) KII rx IIB VD RH Rn VO KIi Research Promotion and Development Nutrition Communiry Oral Health Ilevelopment oia National Programme on Accldent Prevention I)evelopmcnt of Family llcalth I'rogramme Strengthen~ng l:amlly I'lanning Services Worken' Ilratth I'revention and 'l'rcalmenl of I'roblems Related lo ihc Ahusc of Ilrugs Drug Ahvsc Monitocing System Mental Health Communily Waler Supply and Sanitation Food Safety Strcngthcning ol Laboratory *Gees I'ssential Dnlgs and Vaccines 1)evelopmcnt oi'l'radilional Mcdirinc - Phase ll (i,mmuntty-Oriented Rehabilitation Setviccs Fzpandcd I'n,gramme on ln~munizatbn I)#sease Veclor Conlrol Malaria Control Control of Diarrhwal Diseases Control of Acute Respiratory Infections Tuberculosis Contml l'eprusy Conlrol Acccleralcd Ralxes Conlrol (hmpaign Control oiScrually l'ransmilted Diseases Prcvcntion and Control of All)S I'revenlion of Blindness Primary Eye &re Prevention and Control of Cancer Prevention and Conrmt of Cardiovascular Dcseases Prcvcntion of llheumal~c FeveriRhcumaIic llcarll)iscase I)cvclopn~cnt of Ilealth 1,iterdture and 1.ihraly Network THAILAND THA HSl'W1 RB'FH Health Situatirln and Trend Assessment 'IIIA MI'S 200 '1.1 IA 1'1 I(: m2 l'l lA 1'1 IC 003 'I'IIAIIMLlOIS l'llAIEH001 IHA KPD 003 THA AIIK 001 'THA TOH 001 TlIAMC11010 Development and Strengthening of the National Derenlralired Management System - RTGIWIIO Fxecutive Committee Managerial Pnress lor National Ileatlh l)evelopmenl Support ni O,mmunity-hased Self-Managed Primary Ilealth <$re llevelopn~enl Ilealth Systems Reonenlation and llcvclopmenl in Support 01 I'IIC Ilevelopmenr oi lluman Rerourrcs for Health I'ubltc Inlormarion and Wucation for Health Research Promotion and Development, including Research on Health Promoting Whavlour Prevention of Accidents Smoking and Health hpans~on of I'umlly I'lanning SeMccs I h? IIII5 WORK0F WHO IN SEA A -- TIIA MCH011 THA OCH W1 THA HEE 001 THA PSFW1 'IHA ('EH 001 '~IIA I:OS 001 TIIA lil)V 001 'I'IIA DSE 001 THA I'RV 00 I THA VBC Wl TllA MAI. 001 TllA KDV001 'I'IIA (;I'A(~I I'l lA <;PAW? 'I'IIA 0(:1) 001 'IIIA PBI)001 '7 IA PBD 002 THA CVD W2 TI IA NCD 00? 'THA 11111 001 'I'IIA GPA 001 IUR RB RB KR KIJ 1)11 IUBNL) KB IUB KB RB KB FX 1<13 HH VD VD VD RB KR IllZ INTEKCOUNTRY OK1 l1CO 103 RB OW EXMOO1 RH ICPDGPOOI RH 000 GPD 001 RRiAS I I'M Rl1 I(:I2 COl1 001 RH IN10 ('011 1(m As ICP IISC 001 R1l OW ISS W1 KB 000 11ST001 KR 000 HST 002 RR 000 11Sl' lW RE 000 MI'N Mll RRNII O(NI MI'X 003 I)P I('PMI'N004 ST Maternal and (:h!ld Ilcalth, including I'amily Plannlng Workers' llealth I3ealth of the Elderly Psychosocial Factors ~n the Promotion of Health and lluman Development (:ontrol of Environmental Health Ha?.ards Develo mcnt of Regional Cenlrc of Food and Drug Adm~nistration for (:onsumcr 1Icalth $rr,lerlion at 'Trang l'molnrc Promotion of I'ssential Ilrugs - 1)istribution and Rstionali,ation of l)rug Uscs at the PIIClrvel I>cvelopmcnt of Pharmaceut!cals and Biologicals Traditional Medicme Disease Vector Control Malaria Control Vaccine and Research and Dcvelopmenl AIIX I'revcnt~on and Chntml Programme All)S Prevention and Control 1)isease I'revcntion and Control Activities Primary l'yc Carc I'revcntion of Lllindness Prevenlion of Rheamat~r I~everIKheumatic Heart Disease Preventton and Control of Non-cornmunieable Diseases llealth Information Support National MU' for I'revention of AIDS Regional D,m!nittees Executive Management Regiooal Director's Dcvelopmenl Programme <;enera1 Programme 1)cvelopmcnt Staff llevelopment and'l'ralning I.iaison wth ILS('AI' (;<rrrdinatioo wth other Organizations I leallh-for-A11 S~rateky C<x~rdination Informatics Management Strenglhenmg or Epiderntol~gical Sumillanre System National Health Information Systems Development I4ealth Situation and Trend Assessmenl Managerial Pmcess for Health Dcvelopmcnt Strengthening Ilcallh Managerial Capabilities Strcngthening<:;~pacilyafU'Kc'Officcsand.loint (iovernmcnl/WI 10 ('oodlnaul,n Mechanisms I ll100 I<DNUNK Promotion of Ilcalth for All with I'rimaryllealth (:arc as Kcy Approach inchldltlg Appropriate'Yechnal<,~ for fleallh WO I'HC OW I)I' Intensification of Adion Programme far Primary Health (:arc MMPIK 100 KL) Organimtion of llealth Syslcms Bascd on Primary Health Care 000 HMD 014 IlBmBND Developrncnt of Human Resources for Health I MI Oh Sr HI'A lraderrhip Devclopn,ent (KKI IlMI)OIR 1)l' 1)cvelnpmcnt of llealth I rarning Materials

ANNEXES Annex I ORGANIZATIONAL STRUCTURE , ,,,,,h . A'ulr Rnpmlori inlrilml . r"mmunr.blr Dir- . rvrnmunlli Hullh .%.",id . lhanhrra D8u.m . Dlscnr~ Iluilh SPCem . Fnlom,,l,.g ."d Y..,", Con,",, . tnxrunmmu, i*.i,h . T*",,li hug in< Ylrnn.. . e Prnylrnrn~ on ?m.,\mn . iLl"", KIvlvrrrl -"",urn . hs#v H.sICM.mb PI###wn& . lirlllh rnd &hFlnu. . ilcallh ilhlr.l"~T~hn.bw . il<.l,h rromn,,m . linlrh S,,".,,"" ."d lr.,,d I .I FIELD PROGRAMMES ....... I

Key facts

Organisation World Health Organization (WHO)

Document type Technical Documents

Adoption date October 30, 1991

Source World Health Organization