WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Forty-eigbtb session Sydney 22-26 September 1997 Provisional agenda item 12.1
WPRfRC4817 3 July 1997
ORIGINAL: ENGLISH
COUNTRY VISITS (Report of the Sub-Committee of the Regional Committee on Programmes and Technical Cooperation, Part I)
The Sub-Committee of the Regional Committee on Programmes and Technical Cooperation met from 16 to 19 June 1997 to review and finalize the report on the country visits made by four of its members to Cambodia and Vanuatu within the framework of item (5) of its terms of reference, with regard to WHO's collaboration in the field of emerging
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and re-emerging communicable <liseases. I·
The attention of the Regional Committee is
drawn to the findings and recommendations of the Sub-Committee presented in this document.
WPRlRC4Sn pagel
1. INTRODUCTION
The Sub-Committee of the Regional Committee on Programmes and Technical Cooperation held its twelfth meeting in Manila from 16 to 19 June 1997. Sub-Committee are set out in Annex I. A list of members attending the meeting is found in Annex 2. The report to the Regional Committee is on the country visits made by four of the Sub-Committee's members to the Kingdom of Cambodia from 2 to 7 June, and to Vanuatu from 8 to 14 June. It summarizes the Sub-Committee's observations, conclusions and recommendations. The terms of reference of the
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I
Dr Ngo Van Hop acted as Chairman and Dr Asinate Boladuadua acted as Rapporteur for the country visits. The visits were undertaken within the framework of item (5) of the terms of reference, with particular reference to WHO's collaboration in the field of emerging and re-emerging communicable diseases. The meeting was opened by Dr S.T. Han, Regionai Director. Dr Isamu J. Abraham was elected Chairman of the meeting and Dr Asinate Boladuadua and Dr Eiichi Seki as Rapporteurs.
2. REVIEW AND ANALYSIS OF WHO'S COLLABORATION WITH COUNTRIES: REPORT ON THE COUNTRY VISITS CAMBODIA AND VANUATU
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2.1
Perspectives and findings during the country visits Within the framework of item (5) of its terms of reference, the Sub-Committee reviewed and
analysed WHO's collaboration with Member States in the field of emerging and re-emerging communicable diseases. In the course of reviewing the report of the members' visits, the Sub-Committee made a number of comments, suggestions, conclusions and recommendations, which are reflected in the final
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WPRfRC4817 page 3
report of the country visits adopted by the Sub-Committee and presented as Annex 3 of this document. Within the constraints of time and the availability of relevant information, the members reviewed the situation of emerging and re-emerging communicable diseases in Cambodia and Vanuatu. The Sub-Committee noted that, although both countries faced threats from the same diseases, the respective disease profiles were very different. In both countries the main emerging and reemerging communicable diseases included malaria, tuberculosis and dengue haemorrhagic fever. HIV/AIDS was a major public health problem in Cambodia. but not in Vanuatu. The Sub-Committee recognized that the disease profiles in the two countries were different, in part, because such diseases could cross land borders, such as Cambodia's, more easily than reaching island states, such as Vanuatu. Nevertheless, the Sub-Committee found several important similarities in the two countries' responses to the threat of emerging and re-emerging communicable diseases. There were also a number of issues distinguishing the two countries. (I) Both governments showed a strong commitmentto taking measures to limit the impact of re~emerging
-emerging and
commuflical:ile diseases. -- Although malaria. tuberculosis, and AIDS were
-less of an immediate-threat in Vanuatu than in Cambodia. both governments were, as far as possible, devoting significant resources to preventive measures. (2)
Certain common control mechanisms were employed in both countries.
These included
directly-observed treatment, short-course (DOTS) techniques to control tuberculosis; insecticideimpregnated mosquito nets to reduce malaria incidence; and targeting at-risk groups with AIDS awareness information campaigns. (3) Improving health information systems was seen as a key strategy in both countries in the
fight against emerging and re-emerging communicable diseases. (4) Both countries were benefiting from an extensive network of partnerships with international
organizations, governmental aid organizations and nongovernmental organizations. (5) Human resource issues were different in the two countries. Cambodia was undergoing a
comprehensive reform of the health service, an important feature of which involved the reallocation
WPR!RC4817 page 4
of medical stafT from the capital to smaller settlements and rural areas. In Vanuatu, the main issue was the lack of trained local staff, which the Government was taking steps to remedy.
3. CONCLUSIONS
(I)
National governments will continue to play the leading role in responding to emerging and
re-emerging communicable diseases. (2) Transfer and sharing of information. technology and experience between countries, and
especially between neighbouring countries. will be an important part of the response to these diseases. (3) Coordination between national governments and their international partners will be essential
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if emerging and re-emerging communicable diseases are to be fought effectively.
4. RECOMMENDA nONS
Recommendations to Member States (I) Accurate, timely and reliable health information is essential if countries are to predict and
respond effectively to changes in their disease profiles and to undertake emergency response activities. Where feasible, health information systems should include use of modem electronic
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technology such as e-mail and use of the I nternet. Rapid dissem ination of information is particularly important as part of a rapid response system. (2) Mobilizing resources from a wide variety of sources is an important element of the fight
against emerging and re-emerging communicable diseases. No country need fight these public health problems on its own; the most effective strategy will involve well-coordinated and managed inputs from international organizations, governmental organizations in other countries and nongovernmental organizations, acting in concert with measures taken by the national government.
WPRlRC4817 page 5
(3)
At the same time Member States should strive to upgrade their own capacities to fight
emerging and re-emerging communicable diseases, particularly in the area of training and deployment of human resources.
Recommendations to WHO (1) In recent years WHO has developed an effective rapid response capability to support
Member States in their efforts to counter outbreaks of particular communicable diseases. WHO also keeps stockpiles of basic supplies and equipment for control of vectorbome diseases and cholera at strategic locations throughout the Region. Such capabil ities are of crucial importance in the fight against emerging and re-emerging communicable diseases and should be continued and strengthened. (2) As health information was identified by the Sub-Committee as an essential component of the
strategy to counter emerging and re-emerging communicable diseases, WHO should continue to develop the already extensive support which it gives to Member States in this regard. In particular, WHO should maintain its support for surveillance, epidemiology and training in new information technologies. WHO is well placed to improve the diagnostic capability of individual countries both - ihrougtitechilOlogy transfer and byfacilitating access to laboratory analysis in WHO collaborating centres and institutes of excellence.
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Recommendation to the Regional Committee The Sub-Committee proposed that, subject to finalization of details at the time of the Regional Committee session in September 1997, the topic to be reviewed in 1998, in the context of item (5) of its terms of reference, should be Healthy Cities-Healthy Islands, with particular reference to health information systems. The Sub-Committee also proposed that Fiji and Malaysia should be visited in 1998, subject to the agreement of the governments concerned.
• • • In evaluating this year's Sub-Committee's work, and with reference to paragraph 3 of resolution WPRlRC47.RIO, the Sub-Committee felt that it fulfilled several important functions. First, by devoting an intensive period of research, consideration and writing to issues of concern to Member States prior to the Regional Committee session, the Sub-Committee was able to present issues to the Regional Committee in a concise way. In particular the Sub-Committee's country visits
WPRlRC4817 page 6
provided infonnation on the implementation of the ideas contained in the regional document New
horizons in health. While some of this infonnation is available in documentation, the members of the Sub-Committee who undertook the visits felt that face-to-face interaction is still by far the best way of providing the Regional Committee with feedback from Member States. By reviewing and commenting on extensive and detailed documentation, such as the renewal of the health-for-all policy, the Sub-Committee felt it was able to facilitate discussion of these documents at the session of the Regional Committee. Second. for the countries which are visited by the Sub-Committee, particularly for those which are geographically isolated. the visit gives policy-makers an opportunity to receive an outside view on their health policies and systems. Third, by selecting a particular theme. such as emerging and re-emerging communicable diseases, the country visits allow an opportunity to compare and contrast. in a very direct way. the responses of two different countries in the Region to matters ofconc"'rn to all Member States of the Western Pacific Region.
WPRlRC4817 page 7
ANNEXl
TERMS OF REFERENCE
The terms of reference for the Sub-Committee on Programmes and Technical Cooperation are as follows: (I) To review, analyse and make recommendations on the development and implementation of
the General Programme of Work as it affects the Western Pacific Region, especially in setting priorities and addressing policy issues. (2) To examine and approve for submission to the Regional Committee the periodic regional
reports on monitoring and evaluation of the regional strategy for health for all by the year 2000. "(3)~~
Tn study and· proyjde policy guida.nc~ on specific. issues related to the health-for-all strategy
which maybe requested of them by the Regional Committee.· (4) To make recommendations to the Regional Committee on the action to be taken in the
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Western Pacific Region to develop national self-reliance in matters of health by fostering technical cooperatioll among countries or areas in the Region in ways that are relevant to the population. (5) To undertake country visits to review and analyse the impact of WHO's cooperation with
Member States and/or observe developments in relation to the implementation of the regional strategies for health for all.
WPR/RC4817 page 8
WPRlRC4817 page 9
ANNEX 2
LIST OF MEMBERS
CAMBODIA··
Dr Chhour Y. Meng Director of Health Ministry of Health Phnom Penh Cambodia Fax/Tel.: (855) 23-426841 Dr Asinate Boladuadua Director for Primary and Preventive Health Services Ministry of Health and Social Welfare
FIJI""
SuYJi Fiji Fax: (679) 306163 Tel.: (679) 306 177. JAPAN" . Dr Eiichi Seki DeputY Director·... International Affairs Division Minister's Secretariat . Ministry of Health and Welfare .Chiyoda-Ku, Kasumigaseki 1-2-2 ~ 100-45 Japan Fax: (81 )-3-350 1-2532 Dr Hj 1alal bin Halil Khalil State Deputy Director of Health Pahang Tingkat 12, Wisma Persekutuan Jalan Gambut Pahang Darn1 Makmur Malaysia Fax: (06) 763 8543 Tel.: (06) 762 523 J
.MALAYSIA"
"Members who attended the meeting in Manila (16·19 June 1997). ·"Members who undertook country visits to Cambodia (2-7 June) and Vanuatu (8-14 June) and attended the meeting in Manila (16-19 June).
WPRlRC4817 page 10
Annex 2
MONGOLIA"
Dr Tserendorjiin Sodnompil Director Health Management and Information Center Ministry of Health and Social Welfare Enichtaivan Str. I3B lJIaanbaatar 210648 Mongolia Tel.fFax: (00-976-1) 320633 Mr Pita Polapola Assistant Secretary for Health Ministry of Health and Human Resources Development P.O. Box 36 Funafuti Tuvalu Fax: (688) 0832 Tel.: (688) 0403 Dr Isamu J. Abraham Secretary of Health Department of Public Health Services ·'DrTOl1'esHospital. ~ ..
TUVALU'
USA (COMMONWEALTH OF THE NORTHERN MARIANA ISLANDS)'
Commonwealth of the Northern Mariana Islands 96950 Fax: (670) 234 8930 Tel.: (670) 2348950 ext. 2001 VIETNAM" DrNgo Van Hop Director Department of International Cooperation Ministry of Health HanQj
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VietNam Fax: (844) 846-405 I Tel.: (844) 846-4050
'Members who attended the meeting in Manila (16-19 June). "Members who undertook country visits to Cambodia (2-7 June) and Vanuatu (8-14 June) and attended the meeting in Manila (16-19 June).
WPRlRC4817
page 11
ANNEX 3
REPORT ON COUNTRY VISITS
1. INTRODUCTION
Four members of the Sub-Committee visited the Kingdom of Cambodia and Vanuatu from 2 to 14 June 1997. The purpose of the visits was: to review the current status of emerging l and re-emergmg • 2
communicable diseases; to assess the mechanisms of prevention and control
programmes for communicable diseases; and to review and assess the impact of WHO's collaboration with national programmes relating to emerging and re-emerging communicable diseases. The Sub-Committee members elected Dr Ngo Van Hop as Chairperson and Dr Asinate ':' Bol~du.adua as~rapp0l!~lJl" __ 1.1 Role of the Sub-Committee
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~-
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Tberole of the Sub-Committee of the Regional Committee on Programmes and Technical _-Cooperation is to provide information, analysis and" recommeJ1dations to the Regional Committee on the development and implementation of various priority issues in the health-for-all strategy in the Western Pacific Region. The terms of reference of the Sub-Committee include undertaking country visits to review and analyse the impact of WHO's cooperation with Member States and observe developments with regard to selected themes. Management and control of emerging and re-emerging communicable diseases was selected as the theme of the country visits in 1997. This tS one of seven regional priorities for WHO, having been added to the original six priorities by the Regional Committee at its forty-seventh session in 1996.
1Emerging diseases are those whose incidence in humans has increased in the past two decades, or which threaten to increase in the near future (examples include HIY/AIDS. £.colLOJ57, ebola haemorrhagic fever, and the new variant of Creutzfeldt-lakob diseases, etc.).
2Re-emerging diseases are those which are known but which have reappeared after a decline in incidence (examples include cholera, dengue/dengue haemorrhagic fever, diphtheria, meningococcal meningitis, malaria and tuberculosis).
WPRlRC4817 page 12
Annex 3
1.2
Global and regional initiatives in the management and control of emerging ana re-emerging communicable diseases In the last 20 years, more than 20 emerging communicable diseases have been identified.
Some of these, such as HIV/AIDS and the hepatitis C virus, have very serious implications. The high infectivity and mortality of other diseases, such as ebola haemorrhagic fever, also pose significant threats, despite the low number of cases. Diseases once thought to have been controlled, such as plague, cholera, dengue fever/dengue haemorrhagic fever, yellow fever and diphtheria are reappearing as public health concerns in many countries. These are defined as re-emerging
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communicable diseases. The development and spread of antimicrobial resistance has also become a worldwide emerging public health concern.
In the WHO Western Pacific Region, for example, a number of epidemics of emerging and re-emerging communicable diseases were reported in 1995 and 1996: these included dengue/dengue haemorrhagic fever epidemics (Cambodia in 1995, and the Lao People's De_mocratic Republic, Malaysia, the Philippines and some islands of the South Pacific in 1996), cholera outbreaks (the Lao People's Democratic Republic in 1995, the Philippines, Malaysia and Mongolia in 1996), meningococcal meningitis outbreak (Mongolia in 1995), diphtheria outbreaks (Mongolia in 1995, the Lao People's Democratic Republic in 1996), and of course the continuing HIV/AIDS pandemic. Developed countries were not spared from the threat of emerging and re-emerging communicable diseases, e.g. the outbreaks of pathogenic E. Coli 0157 in Japan in 1996. Many factors contribute to the appearance and spread of new diseases and the resurgence of old communicable diseases. They include rapid and frequent international air travel; urbanization without provision of an adequate infrastructure including health; an increase in the global food trade; destruction of forests; breakdown of health service delivery; and the development of antimicrobial resistance. As long as these factors exist, communicable diseases will be health problems in
developing and developed countries. A number of outbreaks of emerging and re-emerging communicable diseases have stimulated national and international initiatives since 1992 to restore and improve surveillance and control of such diseases. In 1995, the Forty-eighth World Health Assembly adopted resolution WHA48.J3, which urged Member States to ensure and establish appropriate systems to combat these newly
WPRlRC4Sn page 13 Annex 3
emerging and re-emerging infectious diseases. Action to counter the spread of such diseases includes improving surveillance by strengthening laboratory diagnosis; accelerating information exchange on communicable diseases among Member States; increasing preparedness for outbreaks of communicable diseases at national and regional levels; and ensuring a quick response to outbreaks by coordinating urgent disease control activities. In response to this resolution, WHO created a new division, Emerging and Other Communicable Diseases Surveillance and Control (EMC), at WHO headquarters in October 1995. Also, a new programme of emerging diseases (including cholera and other epidemic diarrhoeas, zoonoses and antimicrobial resistance) was initiated in the 1996-1997 biennium. At the regional level, WHO's Regional Office for the Western Pacific established an Outbreak Response Task Force in April 1996. In September 1996, the WHO Regional Committee for the Western Pacific decided to increase the number of regional priorities from six to seven, by including "Management and control of new, emerging and re-emerging diseases", as a new priority (Decision WPRlRC47(2)). .------ ---- . --~--.-
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-.
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. _.. WHO has recently signed two memoranda of . understanding relevant to the control of .. ~!11erging~~and re-eJ!l~rgingdiseases in J::~mbodia and Vanuatu. In April 1997, WHO and the
Association of South-East Asian Nations (ASEAN) signed a. memorandum of understanding that specifically highlighted new, emerging and re-emerging diseases as one of nine potential areas for collaboration. Cambodia is scheduled to join ASEAN in July 1997. In December 1996, a
memorandum of understanding was signed between WHO and the South Pacific Commission which, inter alia, covered public health surveillance of urgently notifiable diseases. Vanuatu is a member of
the South Pacific Commission.
1.3
WHO collaboration WHO collaborates with Member States on the management and control of emerging and
re-emerging communicable diseases by: (1) (2) disseminating information on current diseases and disease profiles of specific countries; establishing a regional network consisting of WHO collaborating centres;
WPRlRC4817 page 14 Annex 3
(3)
providing technical support for the establishment of policies, the development of plans of
action, and the formulation of mUltidisciplinary action groups at country level; (4) coordinating various activities carried out by WHO, Member States, other international
agencies and nongovernmental organizations during emergencies, such as technical issues, human resources and supplies and equipment; (5) increasing emergency preparedness by providing supplies and equipment at regional and
country levels, and coordinating emergency procurement and transportation during outbreaks; (6) coordinating public relations in collaboration with media during endemic and epidemic
situations; (7) assessing and supporting further training in surveillance. preparation for possible epidemics,
laboratory diagnosis and epidemiological skills for health workers; and --
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(8)
identifying possible sources of funds for outbreak control activities.
LCAMBODIA
Four members of the Sub-Committee visited the Kingdom of Cambodia from 2 to 7 June 1997.
2.1
Background
The Kingdom of Cambodia covers an area of 181 035 square kilometres. It is bordered by Thailand to the west, by the Lao People's Democratic Republic to the north, by Viet Nam to the east, and by the Gulf of Thailand to the south. The country has an estimated 10.4 million inhabitants, with approximately 1 million living in the capital, Phnom Penh. About 95% of the popUlation is of Khmer origin. The remaining 5% includes over 30 minority ethnic groups inhabiting the mountainous north and north-eastern areas. About two-thirds of the popUlation lives in the central plain area south of the Tonie Sap Lake, where the population density is about 100 per square kilometre. The urban
WPRlRC4817 page 15 Annex 3
populations of Phnom Penh and Battambang are growing rapidly.
Cambodia's per capita gross
national product in 1993 was US$ 222. The adult literacy rate is 35.2% (1993 data). 2.1.1 Healtb status
Infant mortality in Cambodia is still more than 100 per 1000 live births. The under-five child mortality ratio is more than ISO per 1000 live births, compared with the regional average of only 42 deaths per 1000 live births. The annual population growth rate is 2.S%. About 50% of the popUlation is under 17 years of age. Approximately one in five households is headed by a female. Women constitute more than 60% of the adult popUlation and playa major role in food production through manual labour. Hospital data from 1996 show a maternal mortality ratio of 473 per 100 000 deliveries and suggest a large number of induced abortions. Large-scale under-reporting of all vital health events is '>:a.lso_evtdent, _ IllI2?.t!he Governll}ent aPJlroye~ the_ use pflll9def!l contrac:eptives for health reasons and in 1995 it developeda comprehensive birth-spacing policy.
L~sstha~25%of thecountry'spopulafiol1 has easy access to h~~lthcservices while only a small-percentage (19%) of the population has access to a safe and reliable supply of water. The cpublic health service suffers from shortages of funds. The.-Ieading causes of death are malaria, dengue haemorrhagic fever, diarrhoea, acute respiratory infections, accidents, typhoid fever, tuberculosis and anaemia. The leading causes of hospital admissions are diarrhoea, malaria, acute respiratory infections, dysentery, tuberculosis, malnutrition, anaemia, dengue and accidents. Road traffic accidents will soon exceed injuries caused by landmines. Malaria is regarded as a major public health problem, leading to an estimated 10 000 deaths annually. The infectious agent responsible for most cases is Plasmodium jalciparum, which can be fatal in up to 40% of cases if untreated. In many areas it has developed a degree of resistance to most commonly-used drugs. The vector responsible for the bulk of the disease, Anopheles dirus, is a forest-dwelling mosquito, and is less commonly found in cities, towns and permanent villages. The
WPRlRC4Sn page 16 Annex 3
incidence of malaria in Cambodia is high, with 30-50 cases per 1000 population per year. However, the number of cases diagnosed by microscope decreased from 85 000 in 1994 to 73 000 in 1996. Tuberculosis is considered to be one of the most significant infectious diseases in Cambodia, particularly in rural areas. The estimated number of cases of tuberculosis has increased from II 000 in 1991 to 15 500 in 1996. This is partially due to the improved case reporting system. In many rural areas, nearly 50% of hospital beds are used for tuberculosis patients. The prevalence of the condition is estimated at 400 per 100000 population, which would give a total case load of more than 40 000. During epidemic periods, dengue is considered to be the second leading cause of hospitalization of children in the capital, and among the ten leading causes of deaths in children. As a result of the scarcity of clean water and shortage of sanitary facilities throughout the country, diarrhoeal diseases and related communicable diseases continue to be major causes of child morbidity and mortality. The expanded programme on immunization (EPI) is well structured at national level with a - -workplan prepared each year and an annual national conference attended by officials from each of the 21 provinces. However, staff in rural areas need further training in basic management and
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supervisory skills. NationwideEPI coverage has shown significant improvement since 1994. Over the next decade, the emerging communicable disease that will pose the most serious public health problem in Cambodia will be HIV/AIDS. The first case of HI V infection in Cambodia was reported in 1991. The first case of AIDS was reported in 1993. The spread of HIV infection is now a very serious public health problem. In 1997, HIV seropositive rates for selected categories are: commercial sex workers (CSW), 40.9%; military, 5.5%; police, 5.9%; and pregnant women, 1.7%. In one area, the seropositive rate among pregnant women was 6.1 %, suggesting that the threat of HIV infection for the general popUlation in that area is extremely serious. The mode of
transmission of HIV in Cambodia is mainly through sexual intercourse (HIV infection through intravenous drug use is much less common). The 20-29 age group is most affected by HIV. Because of the increase in seropositive rates among pregnant women, the number of children born with AIDS is increasing.
WPRlRC4Sn page 17 Annex 3
2.1.2
Health policy and strategy The Government of the Kingdom of Cambodia affinns its mission to improve the health and
well-being of all Cambodian people by: (I) making full use of both public and private health care systems, and improving their quality; (2) giving emphasis to health education, preventive and curative health care in rural areas; (3) reducing infant and maternal mortality ratios through mother and child health care; (4) controlling communicable diseases, especially malaria, tuberculosis, dengue haemorrhagic fever and acute respiratory infections; (5) interrupting the spread of sexually transmitted diseases (STDs), especially HIV/AIDS; and (6) improving the supply of drugs, where possible by local production using local raw materials. The Kingdom's priority health service goals are: (I) to improve and extend primary health services through district health systems, with special
emphasis on participation by the community and religious leaders; .(2) 0
to promote good nutritional, hygiene and birth-spacing practices within families and thereby --~-
improv~ the health and well-being --. ofwomen and children; -- --- -----
- (3), _ to reduce the incidence of communicable diseases, especially malaria, tuberculosis, dengue -~.
'haemorrhagic fever, diarrhoeal and acuterespiratory diseases, STDs, including HIV/AIDS; (4) to improve hospital services in Phnom Penh and provincial capitals; and to ensure provision
of accident and emergency services; (5) to ensure acceptable standards of medical and nursing care throughout the health care
services and to update health staff skills through in-service training; (6) to improve the supply and distribution of essential drugs and medical equipment to all public
hospitals and health centres in Cambodia; and (7) to establish a regulatory framework for management and quality control of the private health
sector, for both medical care and pharmaceutical services.
WPRlRC4817 page 18 Annex 3
The priority health development strategies are as follows: (I) District health systems will be strengthened in order to support community health services.
District health systems will be developed and personnel trained to manage government health facilities and services, to run the district hospital, to implement community-based programmes, to control the district budget and to collect health information. (2) Provincial health structures will be developed to support and strengthen the district health
systems. The provincial hospital will provide a total, integrated health care service. (3)
Eventually, national programmes will become part of the integrated decentralized district
care system. (4) Hospitals will be integrated into the system at each level throughout the country in support of
primary health care. (5) c. -
The Ministry of·Health will actively seek additional re~ources for healihprogrammes from-
the iflternationalcommunity. It will provide direction and· coordination for these resources. (6) . The -mix and level of human resources in. all institutions will be appropriate, efficient,
sustainable and consistent with meeting priority health requirements within the country's economic resources. (7) The Ministry of Health will seek to improve the efficiency of the sector by collaborating with
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the private and public sectors to improve the delivery of health services. This will include exploring the introduction of user charges, incentive schemes, and appropriate regulatory frameworks to raise service standards.
2.1.3
Health resources Health care is the responsibility of the Ministry of Health. However, care of the physically
disabled and occupational health are the responsibility of the Ministry of Social Action; health care of the military is carried out by the Ministry of Defence; health care of the police is under the Ministry of Interior; and health care of plantation workers is under the Ministry of Agriculture.
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Annex 3
The Ministry of Health is the lead agency for implementing government health policies. It works closely with other ministries, agencies and organizations with health functions, especially Planning, Rural Development, Social Action, Agriculture, Education and the Cambodian Red Cross. It also works closely with all international and nongovernmental organizations.
The Ministry of Health is responsible for preparing an annual health plan and budget for the whole country and for allocating resources throughout the health system. administers the following: central institutions (the National Centre for Hygiene and Epidemiology (CNHE), the National Malaria Centre (CNM), the National Tuberculosis Centre (CENA n, the National Leprosy Centre, the National Institution for Public Health, the National Centre for Maternal and Child Health, the Centre for Venereology); training institutes =,.' .-. .
It funds and directly
(t~e
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Faculty of Medicine, Dentistry ~E~Xharmacy, Technical School of ~_
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.. Medical Care, four regional training centres); and
-- -,.--
- - . ' ...... ~
-hospitals (the CallTlette Huspilat;-the pre.ih'NorodomSihanouCHospital, the National C
Paediatric Hospital, the Preah Ko~~om~k Hospital (17 April) - surgical, December 2
_J.{o~'~it~L~ENTa:!ldN~ik,~al
BtoodTransfusion
Ce~ntr~(CNTS),
January 7 Hospital -
women, Kuntha Bopha Hospital - children).
2.1.4
Health administration and reform
There are 19 provinces, two municipalities and 176 districts in Cambodia.
The
administrative organization of the provincial and district health system has in the past followed the central administrative system, whereby each province and district had a health service, headed by a provincial director. The Department of Health service at provincial level is similar to that in the Ministry of Health and includes pharmacy, a hygiene and epidemiology station, planning and statistics, finance and budget, and administration. The Ministry of Health is now in the process of reorganizing health services according to population size rather than according to strictly administrative boundaries. The previous system was
WPRfRC4Sn page 20 Annex 3
composed of four levels of health delivery: national, provincial, district and commune levels. Thenew system will be composed of three levels of health delivery: central (national institutions, training centres and hospitals), referral (referral hospitals at operational district level, located according to demographic criteria) and commune (health centres). Under the previous system, there was only one qualified hospital, i.e. a provincial hospital, in each province. Under the new system, one qualified hospital (referral hospital) will be established to cover a population of 100000-200000. A referral hospital covers 10 health centres each of which covers a population of 10 000-20 000. This reform increases the number of qualified hospitals in rural areas and eases the access from first-level health facilities at commune level (health centre) to better equipped hospitals.
2.2
Visits and findings The Sub-Committee members visited a number of facilities in Phnom Penh municipality,
Kandal Province and Siem Reap Province. Communicable diseases in the category of emerging and re-emerging communicable diseases are prevalent and cause serious public health problems nationwide. These diseases include malaria, dengue haemorrhagic fever, acute respiratory infection and diarrhoea, including cholera, tuberculosis and HIV/AIDS. The Government has launched national disease control programmes for all these communicable diseases in close collaboration with WHO and other international and """
nongovernmental agencies.
Some indicators suggested that the malaria control programme was
having some success; for example, where the programme had been thoroughly applied, the incidence of malaria cases had decreased. However, cases of tuberculosis and HIVI AIDS are sti II increasing, suggesting that further integrated and intensified disease control activities are necessary. Health
reforms are underway at referral level, which are expected to facilitate and strengthen the prevention and control of communicable disease control activities.
2.3
WHO collaboration WHO collaboration in the control of emerging and re-emerging communicable diseases in
Cambodia is currently taking place through specific WHO-supported programmes which have been established on prioritized emerging and re-emerging communicable diseases, i.e. the control of
WPRlRC4Sn page 21 Annex 3
diarrhoeal diseases and cholera, tuberculosis, dengue haemorrhagic fever, AIDS and sexually transmitted diseases including HIY/AIDS, and malaria. Each programme is discussed below. International
Emergency disease intervention activities were conducted during outbreaks.
communicable disease information is disseminated to the government through the WHO Representative's Office in Phnom Penh.
Diarrhoeal diseases and cholera
The objective of the programme is to reduce childhood mortality through control of diarrhoeal diseases (COD), acute respiratory infection (ARI), and cholera. WHO collaboration
includes support for workshops/training courses on case management for provincial and community health workers; clinical training courses on ARI, COD and cholera; supplies and equipment for surveillance; and translation and preparation of documents and materials in Khmer. Tuberculosiscconlrol~_
.
-This programme aims.tQstreri.8thenan-d extend_t~e_national tuberculQsis control programme ::--~~~-=--:.:~-.--~---
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throughout the country; develop research on tuberculosis; and develop a surveillance system for drug ri!sista~ce .. Collaboration
includes technical collaboration through· WHO staff,information exchange
'""'
and training health workers on tuberculosis case management. Prevention and control o/malaria
The goals of the programme are to reduce sickness and death due to malaria by prompt diagnosis and improved case management and to reduce incidence of malaria by timely diagnosis and treatment, combined with the use of insecticide-impregnated mosquito nets and other preventive measures. Workshops and training courses were supported and various forms of technical support (covering case management, laboratory diagnosis and vector control) were provided by WHO staff based in Phnom Penh.
WPRlRC4817 page 22 Annex 3
Control of dengue haemorrhagic fever (DHF) The thrust of collaboration in DHF control is to develop a programme to ensure long-term surveillance and control; to create plans of action for responding rapidly and effectively to epidemics; to develop an efficient and timely data collection and analysis system; to strengthen and systematize entomological surveillance activities; to improve capability for diagnosis and treatment of DHF; to increase public awareness of DHF control and prevention; to develop community outreach activities; to provide training; and to increase operational research. A WHO staff member based in Phnom Penh provides technical support to the programme.
Sexually transmitted diseases including HIVIAIDS The objective of the programme is to promote public awareness of sexually transmitted diseases, to train health care workers and to strengthen laboratory facilities. A WHO medical officer oased in Phnom Penh provides teChnical support for training and otheractivities.
- 2.4
Conclusions and recommendations
Emerging and re-emergingcommunicable diseases (I) The country has set as one of its seven priority goals in health servIces to reduce the
incidence of communicable diseases, especially those classified as emerging and re-emerging diseases. The Ministry of Health has prioritized six major emerging and re-emerging communicable diseases programmes: tuberculosis control; STDs including HlV/AIDS; prevention and control of malaria; control of dengue haemorrhagic fever; CDD and cholera; and ARl. HIVIAIDS and
tuberculosis are among the most serious problems in the country followed by malaria, acute respiratory infections, diarrhoea including cholera, and dengue haemorrhagic fever. WHO
collaboration has been focused on all the prioritized emerging and re-emerging communicable diseases in Cambodia. (2) In order to prevent the spread of communicable diseases, further efforts are needed to It is recommended that the Government and its
improve primary health care in rural areas.
international governmental and nongovernmental partners combine to effect such an improvement.
WPRJRC4817 page 23 Annex 3
(3)
Strengthening of diagnostic support services
In
referral hospitals is essential in order to
improve the quality of rapid and accurate diagnosis and proper case management. (4) Malaria is a major cause of mortality. Drug supply and treatment methods are adequate.
Many patients with severe malaria die because they live far from referral hospitals aDd arrive too late for treatment. Preventive measures need to be improved and more insecticide-treated mosquito nets
o
should be supplied to unprotected populations. particularly in the north-west provinces. (5) WHO should encourage the mobilization of resources to help combat the major public health
problems of malaria, tuberculosis and HIV/AIDS.
Information (6) National surveillance systems on emerging and re-emerging communicable diseases are those c?vering dengue,cholera, HIV/AIDS and malaria.
~eing iml>ro~edin Camb~dia"partic~larly
Dissemination of epide~iC infoi1nation~can be further i~provedat national level. It was noted that a rapid information exchange mechanism~ between Cambodia~lInd_ tht! neighbouring countries of Thailimd,~theLic; People's Democratic Republic and Viet Nam, h~as !lot yet been established. It is
recommended that discussions beheld with these countries to establish a common early vigilance ~mect1iinisrri
to combat emerging and re-emerging commu!licablecdis~ases.
Support from WHO in the
area of health information systems will be necessary to improve the collection of information on epidemics of other communicable diseases.
Health reform and health system (7) Reform of health systems has been taking place in Cambodia since 1996. The Ministry of
Health has been able to make major changes in its role. These changes include improved emerging and re-emerging communicable disease control at national, provincial and referral levels. (8) Many positive elements of reform were observed during the country visit, such as integration
of health care services in rural areas; development of a minimum package of activities (MPA) and a complementary package of activities (CPA); and the first stages of a system of user fees for certain kinds of health care. "
WPRlRC4817 page 24 AnnexJ
(9)
About 60% of Cambodia's medical doctors are based in Phnom Penh. To achieve the goals
of primary health care, the Government is taking steps to send more doctors to peripheral areas. It is the Government's aim for each health centre to have one doctor.
Coordination of international cooperation (10) At present, international organizations, nongovernmental organizations and partner agencies
support health care services in Cambodia at both central and provincial levels. Coordination of such activities by international organizations and their partners should be strengthened where possible.
3. VANUATU
Four members of the Sub-Committee visited Vanuatu from 8 to 14 June 1997.
3.1
Background The Republic of Vanuatu is located in the Western Pacific, between latitude 13 degrees and
23 degrees south, and longitude 166 degrees and 172 degrees east. Vanuatu is one of the group of countries known as Melanesia, and is surrounded by the Solomon Islands to the north-west, Fiji to the east and New Caledonia to the south-west. The archipelago that constitutes the republic contains over 80 islands and runs roughly north-south in a Y -shaped chain, spanning nearly I 100 kilometres from the Banks and Torres group to the barren Matthew and Hunter islands. Vanuatu's total land area is 12 189 square kilometres, making it the smallest nation in Melanesia, although it is large compared to countries in Polynesia and Micronesia. Although Vanuatu's land area is small, its sea area extends over 680000 square kilometres including the exclusive economic zone. The country's population is estimated at 177 400. The population of Vanuatu is increasing at approximately 2.4% a year and 42% of the population is under 14 years of age. Approximately 20% of the population lives in urban areas. Vanuatu's per capita gross national product in 1991 was US$ 360.
.: . .' .
WPR/RC4817 page 25
Annex 3
3.1.1
Health status Respiratory diseases are the leading cause of morbidity in Vanuatu, while diseases of the
circulatory system are the leading cause of mortality. Malaria has now been controlled in most high-risk areas with the introduction of impregnated mosquito nets with a 73% coverage of the total population at risk. The target is for all households to be provided with impregnated mosquito nets by the end of 1997. ongoing. The Department of Health depends heavily on the media to educate the public on disease prevention. Health education is also provided at clinics and local theatre groups have helped to promote health messages. Most diseases such as diarrhoea, respiratory infections and skin infections have now been controlled and the number of cases has decreased . .Lifestyle_ changes~llye)ed~ to._ancc.incre~sl:
Immunization against the seven targeted diseases (including Hepatitis B) is
ill J)1orbidity and _mortality. caused -by transmitted
- noncommunicable diseases .such -~~;--~-~~ .:,-~:.-~---:-=-
a~ diabete.s,.andhe~dise!lse,.·Althou~hsexually -=----'~~=-..:
diseaseshav_e increased, no cases ofHLY or AIUS have been repQrtedil]_Yanuatu ... . -::-:::--~~--
.. --, --.-=
--~~.,-
_.-
--
-- " -
-'
-
•
---
Adequate supervisi9n and managemenl-.of health. c;tre:io vanuatu are hampered by the _ scattered and varied topographical features of th·e.coun.try, an~
by a shortage of funds. The lack of
adequate funds for supervisory visits and the impassable roads during the rainy season limit supervisory coverage.
3.1.2
National health priorities A primary health care approach was endorsed by the Council of Ministers in 1984 as the
cornerstone ofthe health development ofYanuatu. Major policies and programmes include: (I)
control of malaria, diarrhoeal diseases, and acute respiratory infections; prevention and control of childhood diseases, including hepatitis B and neonatal tetanus,
(2)
through surveillance and immunization;
WPRlRC4817 page 26
Annex 3
(3)
health educatien and prometien activities with a fecus en the regienal decument New- .
horizons in health, placing particular emphasis en health-premeting scheels; (4) ratienal develepment (using ebjectives, appreaches and the indicaters included in New
horizons in health) and implementatien ef the Secend Natienal Health Plan (1997-2000) based en assessment efthe first plan; (5) develepment and strengthening ef the health werkferce planning precess, with special
attentien to. be paid to. the planned expansien ef services and programmes and faculty imprevement at the Vanuatu Centre for Nursing Educatien (VCNE); (6) imprevement ef referral hospitals as well as further develepment and improvement of quality
ef health care in rural health services; (7) .
strengthening ef the natienal tuberculesis centre I programme and eliminatien ef leprosy by
the year 2000; .(8) premetion ef better health fer wemen and children through adequate antenatal and postnatal
care, family plallning a~d improved nutritien; (9) (10) surveillance and centre I efSlDs, inclUding HIV/AIDS; and provision of safe water supply, waste disposal and premetien ef a healthy environment
within the framewerk efHealthy Cities-Healthy Islands.
3.1.3
Health resources In 1991 the Department of Health preduced a Health Workferce Department Plan fer 1992-
1996. This envisaged a total werkferce of 612 staff, of whom 444 would be permanent officers and 168 casual werkers. The implementatien is being carried eut by the Gevernment. The Department ef Health budget represents abeut 10% of the tetal gevernment budget. Salaries ef staff represent 60% of this, the ether 40% is spent en health services. The Department ef Health receives substantial bilateral cellaberatien for existing programmes, particularly the
,".:
..
WPRlRC48n page 27 Annex 3
preventive programmes.
In 1996, the Department of Health submitted a budget for preventive
programmes which represented approximately 25% of the total health budget.
3.2
Visits and findings The Sub-Committee members visited Port Vila and North Efate.
--
In Vanuatu, the two prevalent communicable diseases in the category of emerging and re-emerging communicable diseases are tuberculosis and malaria. As a result of the ongoing national disease control programmes, prevalence of these diseases is now relatively low. Although
HIV/AIDS has not yet been identified in Vanuatu, the government continues to conduct public education to spread awareness of the disease. Vector surveillance and control activities have been strengthened to avert a resurgence of dengue fever/dengue haemorrhagic fever. WHO plays a key role in supporting the above activities in planning and implementation at central and peripheral
. WHO collaboration in the control of emerging and re-emerging communicable diseases in WHO collaboration . . ,
-
-~.~
-
- --
--
--
- Vanuat~ is currently' taking place through the programmes of clinical and health technology, and malaria control. Global and regional information on communicable disease epidemics is
disseminated to the government through the WHO Country Liaison Office based in Port Vila. The major focus of collaboration with ongoing programmes is as follows.
Medical and health technology This programme supports the rationalization and modernization of clinical laboratory and radiological services with a strong emphasis on provincial level facilities. The collaboration includes strengthening of laboratory facilities including a blood bank, as well as technical support to local training and fellowship programmes. Further development of radiological services is supported
through provision of consultants, support to local training and fellowship studies abroad.
WPRlRC4S17
page2S Annex 3
Malaria control
There is a comprehensive malaria control programme in Vanuatu. This includes diagnosis and effective drug treatment to reduce and prevent sickness due to malaria. The national control programme is making good progress.. An important goal of the malaria control programme is to provide complete coverage of the population at risk from malaria, using insecticide-treated mosquito nets. The target date for achieving this goal is December 1997. Some additional activities will be required on the Island of Efate and Sanma Province in order to achieve complete coverage before the target date. A WHO staff member provides technical support on various activities in line with the above goa\. The activities includt:: improving managerial and technical support to various programme strategies; training of health workers in case diagnosis and chemotherapy; and increasing national capacity in entomological studies and survey methodologies.
Dengue control
Dengue control activities are being carried out through the malaria programme. Vector and disease surveillance activities have already been conducted in high-ri.sk areas in Port Vila. Vector control activities have been launched. These include public education and a clean-up campaign. To ensure maximum safety, two WHO workshops for case management and rapid laboratory diagnosis will take place in September 1997.
TUberculosis/leprosy
Tuberculosis and leprosy are prevalent in Vanuatu, although the number of cases is relatively small. In 1996, the prevalence rate of tuberculosis was 91.5 per 100 000 population while the
mortality ratio was 4.7 per 100000 popUlation. The age group 16 to 49 was the most affected and accounted for 49% of total tuberculosis cases, i.e. 282 cases in the two-year period covering 1995 and 1996. The prevalence rate of leprosy was 1.6 per 100000 popUlation in 1996. To improve disease control activities further, the government has set specific targets for the tuberculosis and leprosy control programmes.
. . . '...... .
....:
.. ..
WPRlRC4817 page 29
Annex 3
With regard to tuberculosis control strategy, in 1995 the government allocated seven fulltime members of staff at the provincial level. BCG coverage among children reached 95% in 1996. Microscopic diagnosis of sputum smears has been established in five provincial hospitals and the cure rate was nearly 95%. This was largely due to communication between the community and health institutions (aid post, dispensary and health centre) as observed during the Sub-Committee's
-
visit to peripheral areas. WHO's collaboration has been delivered through technical advice, supplies and coordination of international partners.
3.4
Conclusions and recommendations
Emerging and re-emerging diseases (i) - - The two major-communicable diseases of relevance to the overall_ theme of emerging and
re-emerging diseases are- malaria -and tuberculosis. These two diseases are now under control, -.following a well-organized national disease control programme -in close collaboration with WHO_ The Sub-Committee recommends that efforts in this regard be continued.
-.
(2)
Although no HIV cases have been detected in Vanuatu, -it is recommended that the
Government should continue to deliver HIV/AIDS awareness messages to the public and further intensify health education to the sexually active populations. It is particularly important that such messages be provided to people who have recently settled in Port Vila from rural areas.
Human resource development (3) The need to train more Ni-Vanuatu medical doctors is recognized by the Government and
efforts have been made in the past few years to send students to the Fiji School of Medicine and The University of Papua New Guinea for training. However, since this process will take a long time to show positive effects, the Sub-Committee recommends that refresher courses be organized to upgrade the skills of mid-level health workers (e.g. nurse practitioners and midwives). In particular, there is an urgent need for training in medical statistics and epidemiology for key personnel in charge of communicable disease prevention and control.
WPRlRC4Sn page 30 ADDex 3
Health information system (4) It is noted that the Ministry of Health has reviewed its monthly statistical and
epidemiological reporting system.
However, there is a need for timely analysis and quick
dissemination of epidemic infonnation to peripheral health workers and the community at large.
Rapid international information exchange (5) Since it is an essential element of the control of emerging and re-emerging communicable
diseases, it is recommended that the WHO Country Liaison Office facilitate the use of e-mail by the Ministry of Health to transmit and receive epidemic infonnation from various sources.
Environmental sanitation (6) Current activities on vector control and prevention of environmental contamination to control
food~ and water-borne diseases in suburban and rural are-as should be sus~ined and improved. Reproductive health (7) - The Government is consi4.ering integrating tne _family planning programme and the
STD/HIV/AIDS programme into an overall reproductive health programme. The aim is to address both the high popUlation growth rate and the increasing incidence of STDs.
Essential drug list (8) The essential drug list for dispensaries and health centres has not been updated for some
time. It is recommended that it be revised and periodically updated.
Training (9) It is recommended that the Government and WHO continue to conduct pre-service and in-
service training courses for health workers on the prevention and control of emerging and re-emerging communicable diseases, such as dengue haemorrhagic fever and cholera. It will also be necessary to develop and store training materials at central level.
WPRlRC48/7
page 31 Annex 3
Transportation, communication andfacilities in rural areas (10) It was noted that, in rural areas, there were problems with community access to health
centres. Medical equipment in the centres is often insufficient. Communication between health centres and the Ministry of Health could be improved.
4. ACKNOWLEDGEMENTS
The members of the Sub-Committee acknowledge with sincerity the collaboration and hospitality rendered to them by the Governments and the peoples of Cambodia and Vanuatu.