WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTÉ
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU RÉGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Sixty-third session Hanoi, Viet Nam 24–28 September 2012 Provisional agenda item 16
WPR/RC63/11 29 June 2012 ORIGINAL: ENGLISH
PROGRESS REPORTS ON TECHNICAL PROGRAMMES As a follow-up to discussions at previous sessions of the Regional Committee, progress reports on the following technical programmes and issues are presented in this document: (1) Tobacco control (2) Healthy settings (3) Noncommunicable diseases (4) Health-related Millennium Development Goals (5) Health financing (6) Malaria and artemisinin resistance (7) Expanded Programme on Immunization, and (8) HIV/AIDS prevention and treatment. The Regional Committee is requested to note the progress made and the main activities undertaken.
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TOBACCO CONTROL
1. BACKGROUND AND ISSUES
In 2009 the sixtieth session of the Regional Committee for the Western Pacific endorsed the Regional Action Plan for the Tobacco Free Initiative in the Western Pacific (2010–2014) through resolution WPR/RC60.R4 as a guide to promote and advocate for complete implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC). The Regional Action Plan set a target of 2014 for a 10% reduction in tobacco use prevalence in adults and youth for smoked and smokeless tobacco in countries from the most recent available baseline. Across the Region, tobacco use prevalence rates for adults are trending downward in more than half of the countries. Twenty-one countries and areas report a downward trend for tobacco use prevalence for adult males and females. In eight countries—all in the Pacific—there is an upward trend. In two countries, male tobacco use is decreasing while female tobacco use is increasing. There is insufficient data to establish trends in six countries and areas. Detailed evidence is available (see Annex); however there is clearly a need to sustain monitoring and improve surveillance systems in order to accurately capture tobacco use patterns by gender, age and subnational areas, especially cities. Smokeless tobacco use also needs to be monitored more closely.
2. ACTIONS TAKEN
The Regional Action Plan states three key actions: 1) promote and advocate for complete WHO FCTC implementation, 2) mobilize for public action; and 3) strengthen organizational capacity. 2.1 Promote and advocate for complete WHO FCTC implementation Technical support was provided to update national tobacco control legislation in the Lao People's Democratic Republic, Samoa, Solomon Islands and Viet Nam. Several capacity-building activities were conducted on tobacco taxation with the participation of finance and health ministries. Support was provided for the development and publication of the first white paper on the harms of second-hand smoke in China. At a technical meeting on plain packaging, Australia shared its experience, and countries were encouraged to take stronger actions on pictorial health warnings as well as advertising bans. Asian countries met to discuss the general obligations of the treaty
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(Article 5) with specific reference to counteracting tobacco industry interference in public health policy-making (Article 5.3). A workshop on national action plans for alcohol and tobacco control was convened for Pacific island countries. Needs assessment missions were organized with the Convention Secretariat in six Pacific island countries. 2.2 Mobilizing for public action Collaboration with the tourism sector has resulted in smoke-free world heritage site projects in Asia. Paediatric associations and child health-care institutions from several countries have formed an alliance to advocate for policies and actions to protect children and families from tobacco use. Several cities have undergone training on smoke-free cities and have adopted ordinances to that effect. 2.3 Strengthening organizational capacity The role of the health sector in convening and orchestrating multisectoral action for tobacco control was emphasized in a regional workshop on tobacco control indicators that was attended by 30 countries. National action plans were updated in Brunei Darussalam, Cambodia, the Federated States of Micronesia, Mongolia, Palau and Viet Nam. Capacity assessment missions were organized in the Philippines and Viet Nam. A WHO Collaborating Centre on Smoking Cessation and Treatment of Tobacco Dependence was established in the Department of Health of Hong Kong (China), and now serves as a regional training hub. In partnership with the Johns Hopkins Bloomberg School of Public Health, a regional training programme has been developed to further enhance tobacco control leadership capacity in countries.
3. ACTIONS PROPOSED
The Regional Committee is requested to take note of the progress made and the persistent need to reduce tobacco use prevalence rates. High priority should be given to demand-reduction measures related to tobacco prices and taxes; pictorial health warnings; 100% smoke-free indoor policies; and bans on advertising, promotion and sponsorship, including plain packaging.
WPR/RC63/11 page 4 The four-stage model of the cigarette epidemic1 was introduced in 1994 using data from developed countries. New evidence is now available to apply this model to developing countries. Member States are encouraged to determine the relationship between tobacco use and premature noncommunicable disease (NCD) mortality and to use this evidence to further support full WHO FCTC implementation as a way of curbing the NCD epidemic. As all Member States have ratified the WHO FCTC, action is needed to apply the principles and recommendations of Article 5.3 and its guidelines on protection of public policies with respect to tobacco control from commercial and other vested interests of the tobacco industry.
1
Michael Thun, Richard Peto, Jullian Boreham and Alan Lopez "Stages of the cigarette epidemic on entering its second century", Tobacco Control 2012:21:96-101
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HEALTHY SETTINGS
1. BACKGROUND AND ISSUES
In its sixty-first session in 2010, the Regional Committee for the Western Pacific adopted resolution WPR/RC61.R6 on healthy settings and called for scaling up and expansion of the Healthy Cities approach and revitalization of the Healthy Islands initiative.
2. ACTIONS TAKEN
WHO has worked with WHO collaborating centres and academic institutions to enhance technical support for Healthy Cities initiatives and to achieve healthy urbanization in key strategic areas. Consultations have been held to establish regional and national technical networks for Healthy Cities. Every two years since 2004, during the Conference on the Alliance for Healthy Cities (AFHC), the WHO Western Pacific Regional Office has recognized outstanding work to encourage cities in the Region to continue to innovate and demonstrate effective and efficient ways of promoting and protecting the health of urban populations. During the 4th AFHC Conference in Seoul, Republic of Korea, in October 2010, WHO recognition in defined areas was given to 11 cities in five countries, as well as the Regional Director's Recognition being given to Ichikawa City, Japan, for its excellent and sustainable work. WHO is now issuing a call to Member States for applications for WHO Healthy Cities Recognition 2012. In 2011, Member States nominated Healthy Cities focal points from ministries of health. A Regional Meeting on Promoting Healthy Living and Preventing Noncommunicable Diseases through Healthy Cities, held in Shanghai, China, in August 2011, brought together national focal points for Healthy Cities and noncommunicable diseases to discuss intersectoral actions to promote healthy living. The Macao–WHO Healthy City Leadership Programme, initiated in 2012, supported the first study group of senior city officials from three capital cities: Phnom Penh in Cambodia, Vientiane in the Lao People’s Democratic Republic and Ulaanbaatar in Mongolia. The cities were selected to develop their multisectoral Healthy City workplans for 2012–2014 through Healthy City advocacy
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and planning workshops. WHO will provide further support for implementation. A WHO leadership course will be held in conjunction with the 5th AFHC Global Conference, to be held in Australia in October 2012. In 2010, support was given to three pilot countries to implement the Urban Health Equity Assessment and Response Tool (Urban HEART), followed by an evaluation in 2011. A second training workshop was conducted in the Republic of Korea in 2010. A feasibility study to implement Urban HEART is planned for the Pacific islands countries and areas in late 2012. A new initiative supported the development of a criterion for assessing national accreditation systems through a meeting organized by the Ministry of Health and Welfare, Republic of Korea, with China and Japan, in Seoul in June 2012. WHO’s Environmentally Sustainable and Healthy Urban Transport project will be expanded in the coming year. A WHO workshop on health promoting schools was held in Singapore in May 2012 to develop a multisectoral action plan, with participation of representatives from Cambodia, China, the Lao People’s Democratic Republic and Viet Nam. Implementation guidelines for healthy cities, villages, churches and schools are under development. In order to revitalize the Healthy Islands initiative, the Healthy Islands Recognition Programme was established in 2010, recognizing pioneering initiatives and innovative approaches. In the Pacific, Fiji has established a position for health promoting schools in the Ministry of Education and has received support from the Australian Agency for International Development (AusAID) to implement the initiative in 70 schools. Tonga has expanded its Health Promoting Churches initiative to outer islands, and the Ministry of Health of Palau will complete an evaluation as part of its Health Promoting Workplace initiative this year.
3. ACTIONS PROPOSED
The Regional Committee is invited to take note of the progress made in Healthy Settings, as well as the development of the Regional Framework for Scaling Up and Expanding Healthy Cities in the Western Pacific Region (2011–2015) and the endorsement of the Framework of Action for Revitalization of Healthy Islands in the Pacific by the Meeting of Ministers of Health for the Pacific Island Countries in Solomon Islands in June 2011.
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NONCOMMUNICABLE DISEASES
1. BACKGROUND AND ISSUES
The prevention and control of noncommunicable diseases (NCD) has become a regional and global priority. The 42nd meeting of the Pacific Islands Forum Leaders, in September 2011, declared NCDs a human, social and economic crisis in the Pacific island countries and areas, requiring an urgent and comprehensive response. The Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases the same month has forged a global commitment and mandate for NCD prevention and control. In resolution WPR/RC62.R2, the Regional Committee for the Western Pacific urged Member States to fulfil urgently the commitments made in the political declaration and requested the Regional Director to provide technical assistance and capacity-building, develop mechanisms for sustained engagement with key partners and stakeholders, and develop a regional plan of action for the period 2014–2018 that is aligned with the global NCD framework and is consistent with voluntary global targets and indicators. WHO works under five themes to support Member States in the area of NCDs: (1) national policy and multisectoral plans for NCD prevention and control within national health and development plans; (2) population-based, multisectoral actions for risk reduction; (3) health systems strengthening for NCD prevention and management; (4) surveillance, monitoring and reporting for NCD prevention and control; and (5) sustainable partnerships and advocacy. The Sixty-fifth World Health Assembly adopted a global target of a 25% reduction in premature mortality from NCDs by 2025 and called on WHO and Member States to have further deliberations on global targets and indicators.
2. ACTIONS TAKEN
2.1 National multisectoral plans for NCD prevention and control To support the development of national multisectoral plans for NCD prevention and control, a regional meeting was held in Kuala Lumpur, Malaysia, from 11–14 June 2012. The subsequent 4th Pacific NCD Forum, held in Auckland, New Zealand, from 19–21 June 2012, reflected the special needs of Pacific island countries and areas. Country-specific support plans have been developed.
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2.2 NCD risk reduction Member States have been supported in reducing NCD risk factors in their populations. The Japan–WHO Regional Consultation on Improving Healthier Dietary Options for Children was held in March 2012, providing guidance to Member States, and a Healthy Islands through Sports Forum was organized by the Australian Government, in collaboration with the Secretariat of the Pacific Community and WHO in May 2012. The harmful use of alcohol as an NCD risk factor was discussed in a regional meeting in Hong Kong (China) in April 2012. In the same month, an informal dialogue was held with food industries on salt reduction and implementation of a WHO set of recommendations on marketing of foods and non-alcoholic beverages to children. Salt reduction—one of the “best-buy” interventions—was supported in 17 countries and areas. 2.3 Health system strengthening for NCD prevention and control Health systems strengthening for NCD prevention and the introduction of the WHO Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care in Low-resource Settings was supported through multi-country training in Fiji in April 2012, and a regional meeting on strengthening primary health care for NCD prevention and management was held in Beijing, China, in August 2012. A satellite meeting on cancer control was organized jointly by WHO and the International Atomic Energy Agency in Seoul, Republic of Korea, as part of the 4th International Cancer Control Congress in November 2011. 2.4 Strengthening partnerships for NCD Partnerships have been strengthened through technical support for Association of Southeast Asian Nations (ASEAN) meetings on NCD prevention and control in Malaysia and the Philippines. The Steering Committee meeting of the Western Pacific Declaration on Diabetes, a regional strategic alliance of the International Diabetes Federation (Western Pacific Region), and the WHO Regional Office for the Western Pacific, in collaboration with the Secretariat of the Pacific Community, have identified priority areas for action. 2.5 NCD surveillance and monitoring To facilitate NCD surveillance and monitoring, STEPS surveys were supported in six countries. Responding to the World Health Assembly decision relating to the development of a set of global voluntary targets and indicators, Member States were consulted on the agreed target of mortality reduction and other proposed targets and indicators through regional meetings in Kuala Lumpur,
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Malaysia, and Auckland, New Zealand. A draft set of recommendations has been developed for consideration by the Regional Committee. The outcome of the Committee’s discussions will be reported to the global meeting in October 2012 to finalize targets and indicators. Based on the global targets and indicators, Member States will be supported in the development of national targets and indicators in the regional meeting on NCD surveillance to be held in Seoul, Republic of Korea, in November 2012.
3. ACTIONS PROPOSED
The Regional Committee is asked to take note of this progress report. Responding to the decision of the Sixty-fifth World Health Assembly on NCD global targets and indicators, the Regional Committee is requested to discuss and consider for endorsement the recommendations on the draft set of global targets and indicators on NCD prevention and control to be reported to the global meeting in October 2012.
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HEALTH-RELATED MILLENNIUM DEVELOPMENT GOALS
1. BACKGROUND AND ISSUES
With three years remaining before the 2015 deadline for achieving the Millennium Development Goals (MDGs), countries and areas in the Western Pacific Region are making good progress towards achieving the health-related goals. MDG 1: Eradicate extreme poverty and hunger Most countries in the Region show a decreasing trend in the prevalence of underweight children since 1990. China and Mongolia have already reached the target, while Viet Nam will most likely reach the target by 2015. However, serious problems remain in reducing chronic undernutrition and micronutrient deficiencies, particularly anaemia. Stunting rates have decreased slowly in many countries, but wasting rates have not changed and have even increased in some countries, for example in Cambodia. MDG 4: Reduce child mortality Except for a few countries with high infant mortality rates, most are on track to reduce child mortality. Malaysia and Mongolia have already achieved the targets, while China and the Lao People’s Democratic Republic are most likely to reach the targets in 2015. Twenty-five countries have already achieved measles elimination, while the annual measles incidence for the Region has decreased. Momentum towards maternal and neonatal tetanus elimination has been maintained in all countries concerned, contributing to the achievement of MDGs 4 and 5. MDG 5: Improve maternal health Despite a decreasing trend in the maternal mortality ratio (MMR) of most countries in the Region, MMRs in three countries are still higher than 100 per 100 000 live births: Cambodia, 250; the Lao People's Democratic Republic, 470; and Papua New Guinea, 230. The MMRs in Philippines and Solomon Islands are slightly less than 100 (99 and 93 respectively). The progress, however, is not sufficient to reach the 2015 target in both of the countries. Momentum towards maternal and neonatal tetanus elimination has been maintained in all countries, contributing to the achievement of MDGs 4 and 5.
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MDG 6: Combat HIV/AIDS, malaria and other diseases The HIV epidemic has shown tentative signs of stabilizing across the Region with increased coverage of preventive interventions for most-at-risk populations. However, the coverage of antiretroviral treatment across the Region is still low (34%) and needs to be expanded. Malaria is still endemic in 10 countries in the Region, but malaria mortality and morbidity have been steeply declining since 1990. Between 2000 and 2010, the number of confirmed malaria cases and reported malaria deaths has decreased. Nine out of 10 endemic countries have made sufficient progress to include elimination objectives in their updated malaria strategies. Threats to sustaining the gains made in malaria control include the development of artemisinin resistance and dwindling financial resources in many endemic countries. Most countries are likely to achieve the tuberculosis-related MDG 6 targets, but TB still persists among vulnerable populations that have limited access to health care. Moreover, multidrugresistant and extensively drug-resistant tuberculosis threatens gains achieved in the last decade. MDG 7: Ensure environmental sustainability The Region as a whole has achieved the targets on access to safe drinking-water and basic sanitation. However, progress in some countries is insufficient to reaching the target. The Marshall Islands, Nauru and Papua New Guinea are not on track for both drinking-water and sanitation targets. Cambodia, Mongolia, Tuvalu and Vanuatu are not on track to meet the sanitation target. MDG 8: Develop global partnerships for development The availability of essential medicines remains low in both public and private sectors, especially in the former. High prices make essential medicines unaffordable and limit access, especially when patients have to pay for medicines out of pocket.
2. ACTIONS TAKEN
Nutrition plays a vital role in achieving most health-related MDGs. As nutrition is one of the items on the agenda of the sixty-third session of the Regional Committee, the subject will not be discussed in depth in this document. However, documents for the agenda item on nutrition provide greater detail on the current situation, issues and actions needed to combat malnutrition.
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To improve neonatal health and accelerate progress towards achieving MDG 4, actions taken focus on implementing maternal health, the process of childbirth, essential newborn care immediately after birth, postnatal care and referral of sick newborn children. A framework for reproductive health is being finalized to provide guidance on an integrated approach to addressing specific reproductive health issues, including maternal and newborn health. Many Member States have increased measles vaccine immunization and integrated rubella and congenital rubella syndrome surveillance. In a follow-up to the Global Strategy for Women’s and Children’s Health, WHO established a Commission on Information and Accountability for Women's and Children's Health (CoIA), and seven priority countries in the Region are developing and implementing action plans to improve equity-focused information and accountability on MDGs 4 and 5. To accelerate progress in HIV control, WHO has worked with international partners and Member States to maintain and strengthen political commitment and to increase domestic funding for HIV programmes. WHO worked with the Association of Southeast Asian Nations and other partners to address resistance to malaria drugs and substandard antimalarial medicines in the Greater Mekong Subregion. Regional strategies to combat antimicrobial resistance for malaria and TB have been developed. In July 2010, the United Nations General Assembly declared access to safe drinking-water and basic sanitation a human right. Regional initiatives, including the Regional Forum on Environment and Health and the East Asia Ministerial Forum on Sanitation and Health, call for political leadership and commitment to meet MDG 7. To increase availability and access to affordable quality-assured generic medicines, actions were taken to develop and implement national medicine policies in the Region that are well integrated with health systems strengthening and financing policies, to promote the achievement of universal coverage, to strengthen regulation and quality assurance, and to improve the rational use of essential medicines.
3. ACTIONS PROPOSED
Key areas of action to accelerate the achievement of MDGs 4 and 5 include continuing to increase the coverage and quality of maternal and child health services, reduce inequities and strengthen community action. Referral systems for obstetric complications and newborn illnesses, including improving access to emergency obstetric care and managing the problems of newborn children, will be further strengthened. Member States with ongoing measles transmission need to prioritize activities to interrupt such transmission by the end of 2012.
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On MDG 6, countries need to increase the coverage of comprehensive interventions among key populations. WHO will work with stakeholders to prevent the spread of malaria and protect the gains achieved by intensifying artemisinin-resistance containment efforts. Continued political commitment and investment are needed to ensure high-quality services for diagnosis, treatment and care for all tuberculosis patients, including those with drug-resistant tuberculosis. Improved water and sanitation coverage (MDG 7) requires strong partnerships with agencies responsible for finance, strategic planning and infrastructure development. To improve access to affordable essential medicines (MDG 8), it will be critical to strengthen the capacity of national regulatory agencies to assure the quality of marketed medicines and limit the circulation of substandard and counterfeit products. Also needed are improved resource allocation, adequate financing and financial protection schemes that ensure equitable coverage, especially for poor and vulnerable populations. Achieving the health-related MDGs will depend heavily upon strengthened health systems. Well-functioning health information systems and adequate civil registration and vital statistics continue to be essential for monitoring progress towards the attainment of the health-related MDGs and other national health objectives. Seven priority countries of CoIA and Mongolia will take actions to improve national information and accountability on MDGs 4 and 5. To achieve health equity goals, information systems need strengthened capacity in equity-focused measurement and monitoring, including the collection, analysis and use of health information disaggregated by relevant social stratifiers to guide policy-makers. Collaboration and accountability beyond the health sector is also increasingly necessary to achieve health-related MDGs. Many countries will need sustained efforts beyond 2015 to attain the health-related MDGs. Persistent or widening gaps in income levels within and between countries will likely lead to increased health inequities and reduced quality of health service delivery. Epidemiological and demographic dynamics impose an increasingly complex burden of infectious diseases, along with NCDs, mental health, injuries and the consequences of violence, including violence against women and girls. The debate on development goals after 2015 has already begun and will feature prominently in forthcoming global meetings.
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HEALTH FINANCING
1. BACKGROUND AND ISSUES
Health-care financing is more than simply mobilizing resources for health spending. It also entails making the best use of those resources to maximize the health benefits they can obtain, and ensuring that everyone is able to access health services while being financially protected from the costs of care. At its sixtieth session in 2009, the WHO Regional Committee for the Western Pacific adopted a resolution endorsing the Health Financing Strategy for the Asia Pacific Region (2010–2015), with the aim of achieving universal health care coverage. Regional targets and benchmarks were adopted to encourage countries to monitor their own progress. Endorsement of the Strategy was followed in 2010 by publication of the World Health Report — Health System Financing: the Path to Universal Coverage.
2. ACTIONS TAKEN
In the past three years, the WHO Regional Office for the Western Pacific has been engaging closely with Member States and development partners in assisting national governments to improve their health financing policies. Actions have been taken in the following areas. 2.1 Establishing universal coverage as the vision of national health system development The Regional Office facilitated the launch of the Health Financing Strategy for the Asia Pacific Region (2010–2015) and the 2010 World Health Report in six countries: Cambodia, China, the Lao People’s Democratic Republic, Mongolia, the Philippines and Viet Nam. Universal health care coverage has been endorsed as the overarching goal of health reform in these countries. Moreover, health-financing strategies have been developed in the Lao People’s Democratic Republic, Mongolia and the Philippines, with WHO support. The Regional Office has also produced a short video featuring universal coverage and health system financing.
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2.2 Providing technical support and building national capacity to strengthen evidence-based policy-making. Establishment and development of national health accounts. National health accounts are the first source of information when starting health financing policy dialogue. Together with WHO headquarters, the Regional Office for the Western Pacific provided technical support to Pacific island countries as well as China, the Lao People’s Democratic Republic, Malaysia, Mongolia, the Philippines and Viet Nam to build their capacities to produce national health accounts. Evaluation of the current situation on access to services, catastrophic health expenditures and the poverty impact of out-of-pocket payments. Together with WHO headquarters, the Regional Office for the Western Pacific supported household survey data analysis in six countries: Cambodia, China, the Lao People’s Democratic Republic, Mongolia, the Philippines and Viet Nam. Country-specific policy briefs and analytical reports were produced in country with WHO support, providing insights for policy-making and also building in-country capacity. Health financing reviews with focus on institutional arrangements. The WHO Regional Office for the Western Pacific facilitated reviews of health financing institutional arrangements in Mongolia and Viet Nam. The reviews highlighted the strengths and weaknesses of the systems and contributed to the ongoing policy dialogues in these countries. Health Financing Country Profiles (1995–2008). This regional publication allows easy comparison of health expenditure trends and health financing systems across the Western Pacific Region. Capacity-building on the United Nations OneHealth tool. This tool enables health systems planners to move beyond costing by disease-specific programmes by taking the detailed components of such costings and linking them together in a uniform format. It aims to facilitate the development of national health strategies, policies and plans. Together with WHO headquarters, the Regional Office for the Western Pacific ran a regional-level training course on the OneHealth tool in 2011. Participants from Cambodia, China, the Lao People’s Democratic Republic, Malaysia, Mongolia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam participated. A country-specific workshop was then held in Cambodia using available country data. 2.3 Facilitating policy dialogue Together with ministries of health and international development partners, WHO supported the Lao People’s Democratic Republic in formulating its first national health financing strategy, and the
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Government made a commitment to double the health budget. In China, WHO provided input to resource allocation on public health services at primary-level facilities; pharmaceutical policy reform and public hospital reform. High-level forums on universal coverage and health financing were coorganized in Cambodia, the Lao People’s Democratic Republic, Mongolia, the Philippines and Viet Nam. In Viet Nam, the Regional Office undertook a new and innovative approach, with strong engagement by the Regional Director in a high-level policy dialogue. The Regional Director and the Minister of Health co-chaired a high-level forum on national health insurance and universal coverage. The forum gathered all major parties involved in shaping policy and managing national health insurance, including the Party Commission, the National Assembly, the Prime Minister's Office, Viet Nam Social Security, and the ministries of Finance, Health, and Labour – Invalids and Social Affairs, as well as central and provincial government authorities. The active participation and strong commitment demonstrated by the Regional Director and the Minister of Health maximized the impact of the forum. 3. ACTIONS PROPOSED
The WHO Regional Office for the Western Pacific will continue to provide support to Member States to implement the Health Financing Strategy for the Asia Pacific Region (2010–2015), specifically in the following areas: (1) Raising sufficient resources: more money for health. Facilitating country-specific, high-level policy dialogue and engaging with key players in health financing to raise the priority of health on the national political agenda. (2) Reducing out-of-pocket payments and strengthening pooling. Providing advocacy on expanding population coverage by using prepaid financing and protecting against catastrophic health expenditures. (3) Improving efficiency: more health for the money. Sharing experiences on provider-payment mechanisms and managerial arrangements, including information systems and monitoring functions; strengthening pharmaceutical policy on price setting, prescription behaviours and reimbursement drug lists.
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(4) Strengthening country capacity. Providing technical support to countries on tracking resources and monitoring universal coverage; conducting capacity-building workshops in collaboration with WHO headquarters and other partners on national health accounts, OneHealth and social health insurance. Furthermore, the WHO Regional Office for the Western Pacific will support countries in carrying out health-care financing reviews with a focus on institutional arrangements, which have proven to be a good entry point for national policy dialogue.
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MALARIA AND ARTEMISININ RESISTANCE
1. BACKGROUND AND ISSUES
Malaria is still endemic in 10 of the 37 countries and areas in the Western Pacific Region. These countries follow the Regional Action Plan for Malaria Control and Elimination in the Western Pacific (2010–2015), endorsed by the Regional Committee in 2009.2 Significant progress has been achieved: from 2000 to 2010 confirmed malaria cases were reduced by 34% and malaria deaths by 62%. The biggest challenge to malaria control and elimination is the development of resistance of Plasmodium falciparum parasites to artemisinin derivatives. Artemisinin-based combination therapies (ACTs) are uniquely effective medicines recommended by WHO for uncomplicated malaria; their scale up has been the key to success. WHO first warned about emerging artemisinin resistance in 2005 when studies on the Cambodia-Thailand border showed that Plasmodium falciparum parasites took longer to clear from patients' blood. Oral artemisinin monotherapies are a major factor in the development of artemisinin resistance. WHO has since 2006 called for a halt in the provision of oral artemisinin-based monotherapies.3 Despite effective action in most Greater Mekong Subregion countries, monotherapies are still produced and used in some of them. Substandard and counterfeit medicines are also widespread in the subregion and contribute to resistance development. ACTs are still efficacious in the subregion, but in two hotspots in western Cambodia current combinations are compromised, necessitating a change to non-ACT that is more expensive and requires additional patient follow-up.
2. ACTIONS TAKEN
In 2007, WHO spearheaded development of an artemisinin resistance containment strategy, and in 2008 launched an initiative to contain the spread of artemisinin resistant malaria along the Cambodia-Thailand border, with—until December 2011—funding from the Bill & Melinda Gates 2 3
Resolution WPR/RC60.R5. World Health Assembly resolutions on malaria in 2007 and 2011 (WHA60.18, WHA64.17), and United Nations General Assembly resolutions on malaria in 2008 and 2011 (A/RES/63/234, A/65/L.70)
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Foundation and others. Introducing innovative approaches, the initiative significantly reduced falciparum malaria in targeted areas, and is now continuing with support from the Global Fund to Fight AIDS, Tuberculosis and Malaria. Meanwhile, further evidence of artemisinin resistance emerged in southern and central Viet Nam and south-east Myanmar, and resistance was confirmed in western Thailand bordering Myanmar. WHO launched the Global Plan for Artemisinin Resistance Containment in 2011, with annual funding requirements of US$ 175 million. Commitments have so far been limited. In 2011, Myanmar and Viet Nam started containment activities based on the Global Plan, but funding is insufficient. Recently, key donors under the leadership of Australia and WHO jointly assessed the response to artemisinin resistance in the Greater Mekong Subregion. Their report contributed to the development of a Regional Framework to contain artemisinin resistance in the subregion and will guide future investments in country and regional action. To strengthen high-level advocacy for this urgent global public health concern, WHO facilitated a meeting with representatives of the Association of Southeast Asian Nations (ASEAN) and development partners in April 2012.
3. ACTIONS PROPOSED
The Regional Committee is invited to discuss challenges of artemisinin-resistant malaria and to urge countries to take immediate steps to contain it and prevent further resistance development. Member States in the Greater Mekong Subregion are requested to intensify and expand operations to contain and eliminate artemisinin-resistant malaria, based on the Global Plan, through the following actions: (1) halt the use of oral artemisinin monotherapies; (2) monitor the quality of antimalarial medicines and stop counterfeits; (3) ensure universal access to specific diagnosis, safe quality medicines and malaria prevention; (4) effectively target high-risk populations, especially mobile and migrant populations; (5) strengthen health services using malaria as entry point; (6) build political support; (7) secure financial resources; (8) accelerate priority research, especially on safe primaquine use; and (9) strengthen coordination within and between countries. Member States with endemic malaria are urged to improve and expand antimalarial drug efficacy monitoring, and accelerate implementation of the Policy Package to Combat Antimicrobial Resistance, adopted by the Regional Committee in 2011.4
4
Resolution WPR/RC62.R3.
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Development partners are urged to support country efforts and ensure adequate financial resources, including for WHO to meet increasing demand for technical assistance and coordination. Intergovernmental organizations, such as ASEAN, are urged to intensify actions against malaria, supported by high-level political commitment.
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EXPANDED PROGRAMME ON IMMUNIZATION
1. BACKGROUND AND ISSUES
The Western Pacific Region is on the verge of eliminating measles. Annual measles incidence decreased to 4.3 cases per million people during the first quarter of 2012. An important public health achievement is being realized through hepatitis B control; the Region as a whole and at least 30 countries and areas in the Region will likely reach the 2012 milestone of less than 2% hepatitis B infection rates in children. Member States have demonstrated a strong commitment towards hepatitis B prevention that has led to this tremendous success. To maintain these gains and momentum, the Region’s Expert Resource Panel recommended 2017 as the target year for the goal of less than 1% infection rates in children. In 2011, a serious poliomyelitis outbreak in China reaffirmed the continued risk for all the Member States of re-infection with the poliovirus. With high-level political commitment, strong intersectoral coordination and accountability, China mounted a rapid and vigorous outbreak response, which lead to interrupting wild poliovirus transmission in less than six months of the onset of the first polio case. This was a major achievement. But we need to recognize that continued immunization gaps, including in older age groups, and decreasing awareness of requirements of acute flaccid paralysis surveillance leave several countries vulnerable for poliomyelitis.
2. ACTIONS TAKEN
Member States continue to improve routine immunization and conduct supplementary immunization activities against measles while strengthening measles and rubella surveillance systems. A high-level consultation on measles elimination and hepatitis B control was held in April 2012 with agreements on verification mechanisms, updated field guidelines and regional and country measles elimination action plans. A 2017 target year for the goal of less than 1% hepatitis B infection rates in children was discussed and largely supported. WHO responded promptly to the poliomyelitis outbreak in China, deploying staff from headquarters, the Regional Office and country office to the outbreak area less than a week after the notification. Since then all three levels of the Organization continued to support the Ministry of
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3. ACTIONS PROPOSED
Member States with ongoing endemic measles virus transmission should prioritize activities to interrupt transmission by the end of 2012 and initiate verification processes. To maintain the momentum and success of hepatitis B control, Member States should further discuss and consider 2017 as a target year for the goal of less than 1% infection rates in children and aim to establish a target year during the sixty-fourth session of the Regional Committee for the Western Pacific in 2013. Member States need to take additional measures to reduce the risk of outbreaks caused by the international spread of wild polioviruses or the emergence of circulating vaccine-derived polioviruses including supplementary and routine immunization activities, high-quality surveillance, regular risk assessments, and vaccination of travellers to and from poliomyelitis-affected areas.
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HIV/AIDS PREVENTION AND TREATMENT
1. BACKGROUND AND ISSUES
In 2010 an estimated 1.3 million adults and children were living with HIV in the Western Pacific Region, with a prevalence rate of 0.1%. New infections declined from 150 000 per year in 2001 to 130 000 in 2010. The number of annual AIDS-related deaths rose from 33 000 in 2001 to 80 000 in 2010, but has stabilized over the past four years. More than 90% of people living with HIV in the Region are from five countries: Cambodia, China, Malaysia, Papua New Guinea and Viet Nam. Key populations (sex workers, men having sex with men and people who inject drugs) continue to drive the HIV epidemic. While focusing the HIV response in these countries, it is essential to maintain low HIV prevalence in other countries with HIV cases (Fiji, the Lao People’s Democratic Republic, Mongolia and the Philippines). The Philippines is among the few countries globally where the HIV epidemic is rising. Implementation of effective and evidence-based prevention and treatment approaches, including HIV prevention as the result of early antiretroviral treatment (ART) among infected individuals, is on the rise. Except for China and Malaysia, the majority of countries rely on external funding for HIV prevention and care. There is a real danger that the gains of recent years might be eroded by dwindling resources.
2. ACTIONS TAKEN
The World Health Assembly in 2011 endorsed the Global Health Sector Strategy for HIV/AIDS (2011–2015). An operational plan was developed with WHO support and in alignment with the UNAIDS 2012–2015 unified budget and its results and accountability framework. A Memorandum of Understanding and joint action plan was developed between the WHO Regional Office for the Western Pacific and the UNAIDS Regional Support Team, Asia Pacific, to synergize interventions and technical support. Several countries have pioneered effective health sector responses. Nine key countries are developing national HIV strategies for 2011–2015 and beyond. National efforts are being made to
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translate global strategies and normative guidance into appropriate interventions based on country contexts. The availability of HIV testing and counselling continues to increase. The number of HIV testing and counselling services rose by 260% from 2009 to 2010. However testing and counselling services among key populations remain limited. There has been a more-than-tenfold increase in ART coverage from 1700 in 2004 to 203 200 in 2010, although coverage stands at just 43%. Cambodia has achieved more than 90% ART coverage. In some countries, notable progress has been made in reducing prevalence among sex workers, but the gaps remain among people who inject drugs and men who have sex with men. About 36% of pregnant women living with HIV had received antiretroviral drugs for preventing mother-to-child transmission of HIV. Key countries are now developing action plans to eliminate mother-to-child transmission of HIV and congenital syphilis. Linkages between HIV and other programmes including TB, sexually transmitted infections (STI), hepatitis, and maternal and child health have been developed, but should be further strengthened.
3. ACTIONS PROPOSED
The Regional Committee is invited to take note of this report and the issues and challenges associated with implementation of the Global Health Sector Strategy for HIV/AIDS (2011–2015) in the Western Pacific Region. Member States are requested to accelerate implementation of the priority interventions, including: (1) increasing coverage of comprehensive interventions among key populations to prevent new HIV infections and ensuring early treatment; (2) renewing efforts to achieve and sustain universal access to ART with standard quality care; (3) committing to the elimination of mother-to-child transmission of HIV and congenital syphilis; (4) integrating HIVrelated services into the broader health system to sustain the scale up of the HIV response; strengthening systems for STI control, linked to comprehensive HIV prevention strategies; and (6) using data from HIV surveillance and monitoring to guide programmatic action.