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The work of WHO in the Western Pacific Region, 1 July 1999 - 30 June 2000 : Report of the Regional Director to the Regional Committee for the Western Pacific, fifty-first session

December 31, 2000 World Health Organization

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The Work of WHO in the Western Pacific Region: 1 July 1999-30 June 2000 Corrigenda Page 6. Paragraph 2, lines 4-5. Please replace "he had probably been infected with wild poliovirus while attending a major festival" with "he had possibly been infected with wild poliovirus while attending a major festival" . Pages 155, 156 and 158. Please replace Tables 16.1 and 16.2 and Figure 16.1 with the following. Table 16. 1 Regular and extrabudgetary sources of funds implemented in the Western Pacific Region, 1994-1995 to 1998-1999 (US$)

1994-1995 Regular Budget (RB) Extrabudgetary sources (EB)

1996- 1997 74 562 000 44 667 230 37.46

1998-1 999 75 506 800 35 106 500 31.74 224 092 100 117 600 430 34.42

74 023 300 37 826 700 33.82

% of EB resources to total funds (RB and EB) ...,.

-------

- -

---·

·-- --

Table 16.2 Implementation of major programmes funded by extrabudgetary sources, 1998-1999 (US$) (in '000)

Programme Vaccine-preventable diseases Technical cooperation with countries AIDS and sexually transmitted diseases Health in socioeconomic development Malaria Reproductive health Other communicable diseases Leprosy Emergency and humanitarian action Human resources for health

1998-1999 5 356.7 4 474. 3 2 722.3 2 482.5 2 269.7 2 247.6 2 051.3 1 542.7 1 512.9 1415.7

- 2-

Fig. 16.1 Extrabudgetary resources implemented by major donor partners, 1994-1999 10 000 000 9 000 000 8 000 000 ~

:::J

7 000 000 6 000 000 5 000 000 4 000 000 3 000 000 2 000 000 1 000 000 0

.5 c ::I

E 0

Japan

GPAJ UNAIDS

UNFPA

UNDP

AusAID

DFID/

Nippon

Rotary

USAID

CDC

UK Donor partners

WPRIRC5112

THE WORK OF WHO IN THE WESTERN PACIFIC REGION 1 July 1999 - 30 June 2000

Report of the Regional Director to the Regional Committee for the Western Pacific Fifty-first session

World Health Organization Regional Office for the Western Pacific Manila, Philippines June 2000

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The designations employed and the presentation of the material in this report do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation "country or area" appears, it covers countries, territories, cities or areas. Throughout this volume, the $ sign denotes US dollars unless otherwise stated.

C oNTENTs

page

List of abbreviations Introduction Combating communicable diseases 1. Expanded programme on immunization Eraclication of poliomyelitis Hepatitis B Other vaccine-preventable cliseases Improving the quality and scope of immlUlization services

Vlll

3 3 7 9 14

2. Malaria, other vectorborne and parasitic diseases Malaria Dengue Lymphatic filariasis

17 17

22 23 26 26 33

3. Stop TB and leprosy elimination Tuberculosis Leprosy

4. Sexually transmitted infections, including HIV/AIDS 5. Communicable disease surveillance and response Building healthy communities and populations

37 45

6. Healthy settings and environment The settings approach Safe water and sanitation Food safety International Year of Older Persons

53 53 60 63 67 70 70 75 80 85

7. Child and adolescent health and development Integrated management of childhood illness Nutrition Adolescent health and development

8. Reproductive health

CoNTENTS

page

9. Noncommunicable diseases, including mental health Strengthening surveillance for nonconnnunicable diseases Diabetes Mental health Substance abuse

92 97

102 103 105

10. Tobacco Free Initiative Health sector development 11. Health systems reform Managing reform in health systems Health legislation Health care financing Essential drugs and other medicines Traditional medicine Health research, health technology and blood safety

113

113 116 118 120 124 128 134 134 138

12. Hurnan resources development Management, education and training Mid-level and nurse practitioners

13. Health information and evidence for policy 14. Emergency and humanitarian action Reaching Out 15. Information technology Information technology in and between countries Information technology within WHO

142 147

153 153 154 155 160

16. External relations 17. Public information Administrative Services Administrative services

165 168

Statistical annex

CoNTENTS

page

Figures 1.1 AFP surveillance in the Western Pacific Region, 1995-1999 1.2 Partner support for OPV requirements for poliomyelitis eradication, Western Pacific Region, 1992-1999 1.3 Partner support for operational requirements (non-OPV) for poliomyelitis eradication, Western Pacific Region, 1992-1999 1.4 Hepatitis B vaccine supply: number of cmmtries with adequate, partial, or no supply 1.5 Number of countries reporting coverage >50% and >80% with three doses ofHBV 2.1 Malaria cases and deaths in the Western Pacific Region 2.2 Confirmed malaria cases and deaths reported in the Western Pacific Region, 1998 2.3 Percentage of at-risk population covered by vector control (insecticide treated nets or residual spraying) by country, 1998 2.4 Incidence of dengue and case fatality rate in the Western Pacific Region, 1991-1998 3.1 Estimated percentage ofDALYs lost due to infectious diseases in the Region (ages 15-64) 3.2 Notification rate of new smear-positive cases Western Pacific Region and China, 1993-1998 3.3 Projection ofHIV infection and HIV-related tuberculosis cases in Cambodia, 1995-2003 3.4 Leprosy elimination: prevalence of leprosy in priority countries and areas, 1994-1998 3.5 Leprosy elimination, Western Pacific Region total cases and case detection rate, 1988-1998 4.1 Reported, estimated and projected AIDS incidence in the Western Pacific Region, 1988-2003 4.2 Reported HIV (including AIDS) cases in the Western Pacific Region by mode of HIV transmission, 1987-1999 8.1 Major causes of neonatal deaths in developing countries 8.2 Contraceptive prevalence rate (CPR), selected Pacific island countries 9.1 Prevalence of hypertension in the adult population in China(%) 9.2 Age-specific breakdown of cases from cardiovascular diseases in Fiji, the Federated States of Micronesia and Samoa 10.1 Trends in per capita cigarette consumption, by WHO region 12.1 Fellowships by field of study, 1999 16.1 Extrabudgetary contributions by major donor partners, 1994-1999 4 5

5 7 8 19 20 20 23 26 27

27 34 35 37

38 86 90 92 93 106 136 158

CoNTENTS '"

page

Tables 1.1 1.2 3.1 4.1 6.1 6.2 7.1 7.2 7.3 9.1 9.2 Western Pacific Region: EPI coverage data 1995-1998 Critical flUlctions of a National Regulatory Authority Leprosy activities in colllltries that have achieved elimination HIV and AIDS estimations for selected colUltries of the Western Pacific Region, 1999 WHO-supported colllltry-level healthy settings activities (July 1999-JlUle 2000) Member States of the Western Pacific Region who are members of the Codex Alimentarius Infant and lUlder-five mortality rates in selected colllltries of the Region Key IMCI activities in selected colllltries of the Western Pacific Region National Plans of Action for Nutrition in the Western Pacific Region Leading causes of deaths due to noncommllllicable diseases in the world, the Western Pacific Region and China Age standardized gender-specific mortality from cardiovascular diseases per 100 000 population in selected colllltries and areas of the Western Pacific Region (age 35-64 standardized to the world populations standard) Tobacco-related mortality, by WHO region Estimated youth smoking prevalence, selected colllltries and areas Supporting infrastructure for traditional medicine in the Western Pacific Region Implementation status of ICD-1 0 as at December 1999 Regular and extrabudgetary sources of funds in the Western Pacific Region, 1994-1995 to 1998-1999 (US$) Major programmes fllllded by extrabudgetary sources, 1998-1999 (US$) 10 16 35 40 54 65 70 73 78 94

10.1 10.2 11.1 13.1 16.1 16.2

95 105 110 126 144 155 156

Boxes A poliomyelitis case in China due to poliovirus importation Accelerated Measeles Control Project, China How do you ensure vaccine quality? PacELF -Elimination of lymphatic filariasis from the Pacific Tuberculosis emergency in Japan Stop TB special project in the Region Priority colllltries and areas WHO's partnership with UNAIDS in HIV and STI programmes Reaching a consensus on STI and HIVIAIDS Influenza pandemic Nipah virus outbreak in Malaysia and Singapore Healthy Islands in Papua New Guinea Healthy marketplace initiative Healthy Hospital Initiative in the Philippines Ha N oi Call for Action 6

IIIII

13 16 25 28 32 34 39 43 48 50 55 56

59 71

C oNTENTs

page Introduction of the UNICEF/WHO 40-hour breast-feeding counselling course into the curriculum of midwives in Viet N am World AIDS Campaign Training youth leaders in the Pacific islands Safe Motherhood in China Hypertension in China Deaths from cardiovascular diseases in Fiji, the Federated States of Micronesia and Samoa The economics of diabetes Diabetes complications Empowering youth against tobacco use Management of biomedical equipment Integrated drug supply management and drug use monitoring and supervision in Cambodia - an indicator-based system "Safe blood starts with me - Blood saves lives" Blood safety in Cambodia Nurse practitioners Strengthening primary health care services in Cambodia, the Lao People's Democratic Republic and VietNam Mayon Volcano erupts in the Philippines Collaboration with Rotary International "Journalists' Encounter: From Manila to Kobe" Publications 79 81

83 89 92 93 99

102 110 116

122 130

132 139 141 148 159 161

162

THE WoRK OF WHO IN THE WESTERN PACIFIC REGION,

1999-2000

List of abbreviations ACIH ACTMalaria ADB

Agency for Cooperation in International Health Asian Collaborative Training Network for Malaria Asian Development Bank Acute flaccid paralysis Acquired immunodeficiency syndrome Association of South-East Asian Nations Australian Agency for International Development Common Country Assessment Comite International de l'Ordre de Malte Contraceptive prevalence rate Commission on the Status of Women Cardiovascular diseases Disability-adjusted life years Diethylcarbamazine Department for International Development of the United Kingdom Directly observed treatment, short-course European Commission Expanded programme on immunization Food and Agriculture Organization of the United Nations Framework Convention on Tobacco Control Field epidemiology training programme

GAVI GDP GNP GMP HACCP

Global Alliance for Vaccines and Immunization Gross domestic product Gross national product Good manufacturing practices Hazard analysis critical control point Human immunodeficiency virus International Agency for Research on Cancer Inter-agency coordinating committee International statistical classification of diseases and related health problems, tenth revision International Conference on Nutrition International Conference on Population and Development Iodine deficiency disorders International Diabetes Federation Western Pacific Region Integrated management of childhood illness National Institute of Public Administration, Malaysia Immunization Safety Surveillance System Japan International Cooperation Agency Maternal and child health Maternal mortality ratio Noncommunicable diseases National drug policy

AFP AIDS ASEAN Au sAID CCA CIOMAL CPR

HIV IARC ICC ICD-10

csw CVD DALYs DEC DFID

ICN JCPD IDD IDFWPR IMCI INTAN ISSS JICA MCH MMR

DOTS EC EPI FAO

FCTC FETP

NCD NDP

UST OF ABBREVIATIONS

NGOs NPANs NPCB NRAs OPV PAB PHAST PRVBD RBM RDU SAPEL SEAMEOTROPMED SMHF SPC

Nongovernmental organizations National plans of action for nutrition National Pharmaceutical Control Bureau National regulatory authorities Oral poliovirus vaccine Protection at birth Participatory Hygiene and Sanitation Transformation Pacific Regional Vector Borne Diseases Roll Back Malaria Rational drug use Special action project for elimination ofleprosy Southeast Asian Ministers of Education Organization-Tropical Medicine Programme Sasakawa Memorial Health Foundation Secretariat of the Pacific Community

STI TAG TFI TLM TRIPS UN UN AIDS UNDAC UNDAF UNDCP UNDP UNFPA UNICEF US AID WHO

Sexually transmitted infections Technical Advisory Group Tobacco Free Initiative The Leprosy Mission International Trade-Related Aspects Intellectual Property Rights United Nations Joint United Nations Programme on AIDS United Nations Disaster Assessment and Coordination United Nations Development Assistance Framework United Nations Drug Control Programme United Nations Development Programme United Nations Population Fund United Nations Children's Fund United States Agency for International Development World Health Organization of

WHO Western Pacific Region Organizational structure

I ~--------~~---------

Regional Director I

Director, Programme Management

I J

I Country Offices Representatives • Cambodia • China • Lao PDR • Papua New Guinea • Philippines • Malaysia • Mongolia • Samoa • South Pacific • VietNam Country Liaison Offices •Kiribati •Republic of Korea •Solomon Islands •Tonga •Vanuatu

I Building Healthy Communities and Populations

-, Reaching Out Administration and Finance

Combating Communicable Diseases

Health Sector Development

I Expanded programme on immunization

I Healthy settings and environment

I Health systems reform

-, Information technology Budget and finance

I Malaria, other vectorbome and parasitic diseases

I Child and adolescent health and development

I Human resources development

T External relations

I Personnel

I Stop TB and leprosy elimination

I Reproductive health

I Health information and evidence for policy

1 Public information

I General administration I

f Sexually transmitted infections, including HIV/AIDS

I Noncommunicable diseases, including mental health

I Emergency and humanitarian action

Supply

1 Communicable disease surveillance and response

I Tobacco Free Initiative

Introduction y report last year described a period of transition for WHO in the Western Pacific Region . That period is now over. My senior management team is in place and an extensive restructuring at the Regional Office has taken place, sharpening our focus. It has been a busy and productive year, and I am pleased to be ahle to r ~ port str>,<~dy progress in all areas of our work. Last year's report contained several significant innovations . It was more analytical than previous reports. It contained more tables, graphs and photographs and a new statistical annex. It had a new page layout. These changes were approved by the fiftieth session of the Regional Committee for the DrS. Omi, Regional Director Western Pacific in September 1999 1 and I have retained them for this year's report. The Committee also asked me to restructure the report so that it reflected the themes and focuses described in my document WHO in th e Western Pacific Region: A fram ework for action and endorsed by the Regional Committee. Readers will therefore find that WHO's work in the Region is described and evaluated under the four themes and 17 focuses that now guide our work (see the organization chart on the facing page). Although a common analytic framework has been used throughout the report, a degree of flexibility has also been employed. For example, some focuses (such as that on health sector reform) cover a broad range of related issues and therefore require several chapters to cover the focus's work adequately. Others (such as those dealing with the Tobacco Free Initiative and sexually transmitted infections, including AIDS) are targeted on a set of more closely linked issues . In such cases the work of the focus is described in a single chapter. The strength of our new organizational structure is that it is explicitly designed to facilitate a team approach. Thus, in the area of health systems reform for example, experts on health financing, legislation, management, pharmaceuticals, traditional medicine and research work together, drawing on expertise from elsewhere- e.g. from Stop TB or external relations - when necessary. At its fiftieth session in September 1999, the Regional Committee expressed considerable concern about rising levels of tuberculosis in the Region. It declared a "Tuberculosis crisis" and asked me to make Stop TB a special project of the Regional Office. 2 The last year has therefore been an exciting period for all of us engaged in tuberculosis control as we have sought to respond to the Committee's requests . A Technical Advisory Group (TAG) has been formed, a Regional Strategic Plan has been endorsed by the TAG and national interagency coordinating committees have been or are being established in all of the countries

••

Resolution WPRIRC50.R4. Resolution WPRIRC50.R5.

THE WORK OF WHO IN THE WESTERN PACIFIC REGION,

1999-2000

with a high burden of tuberculosis (see pp. 26-32). We now have an excellent springboard to enable us to reach our objective of reducing tuberculosis prevalence and mortality by half by 2010. As the Regional Committee noted last year, tuberculosis is above all a disease of the poor, which must be addressed within the framework of health sector development. We must increase the attention we pay to the socio-economic causes of disease and ill health. It is the poor who suffer most from communicable diseases, maternal and perinatal conditions and illnesses related to malnutrition. It is the poor who are most affected when health services are privatized. It is the poor who live in the unhealthiest environments and who lack safe water and sanitation. That is why one of our priorities is to work with countries to reform health systems in order to reduce the number of people whose access to health care is currently limited by their economic status. Nevertheless, although we must recognize the importance of poverty, we must never allow it to limit our vision. Even in the less developed parts of the Region, tremendous achievements can be seen. Take the integrated drug supply management system in Cambodia for example (p. 122) or the successful implementation of the Integrated Management of Childhood Illness (IMCI) strategy in the Philippines and VietNam (pp. 70-74). Great advances can be made, even when resources are limited. I hope that readers will find this report valuable, not only as a record of the activities of WHO in the Western Pacific Region over the last 12 months, but also as an attempt to identify the major health challenges facing the Region and to assess what needs to be done to address them. My address to the Regional Committee at its fiftieth session and the Framework for action mapped out the path I wanted WHO to follow in the Region. This report is a record of how far we have come.

Combating communicable diseases Communicable diseases continue to be the major health problem in many countries of the Western Pacific Region, with the least developed countries and those people living in poverty in other countries bearing the greatest burden. This theme builds on WHO's collaboration with countries in controlling, eliminating and eradicating communicable diseases in the Region, particularly poliomyelitis. The theme has five focuses, which are described in the following chapters:

1. Expanded programme on immunization Eradication of poliomyelitis Hepatitis B Other vaccine-preventable diseases Improving the quality and scope of immunization services

2. Malaria, other vectorborne and parasitic diseases Malaria Dengue Lymphatic filariasis

3. Stop TB and leprosy elimination Tuberculosis Leprosy

4. Sexually transmitted infections, including HIV/AIDS 5. Communicable disease surveillance and response

1. Expanded programme on immunization Eradication of poliomyelitis

ISSUES The Western Pacific Region is now in the last stages of the certification process for poliomyelitis eradication. Over three years have passed with no new indigenous polipmyelitis case, while surveillance has been maintained at certification standards. Imported wild poliovirus was found in the stool of one case of poliomyelitis reported in China with onset on 12 October 1999. The same imported wild

poliovirus was also isolated from one healthy family contact of this case. The importation of wild poliovirus into China (see box on p.6) resulted in only one poliomyelitis case, but it does highlight the need for every country to remain vigilant by maintaining the highest quality of surveillance for cases of acute flaccid paralysis (AFP), coupled with the ability to respond rapidly to importations, until global certification has been achieved.

WHO RESPONSE Although the certification process is nearing completion, the Region must maintain supplementary immunization in high-risk areas, and continue to carry out high-quality surveillance until global certification is achieved. WHO therefore continues to provide technical support to countries and coordinates with partners to provide funding for vaccine and other costs, including operational, laboratory and surveillance costs. In April 2000, the tenth meeting of the WHO Technical Advisory Group on the Expanded Programme on Immunization and Poliomyelitis Eradication was held in Manila. This meeting reviewed progress to date, and made recommendations to countries to ensure that the transmission of wild poliovirus in the Region had been interrupted. The Regional Certification Commission met in August 1999 to make recommendations on the documentation process, and to examine closely the progress reports provided by each country and area, in accordance with the global criteria for certification ofpoliomyelitis eradication. All poliovirus laboratories in theregionallaboratorynetwork, including the three reference laboratories, have been subject to review and

Immunizing rural communities in Cambodia

COMBATING trOMMUNICABLE DiSEASES ,------,:-==-~===-co====-=============.o===-====

subsequent accreditation. In addition, laboratories of all types throughout the Region have begun the process of containment of wild poliovirus infectious and potentially infectious materials in order to prevent accidental reintroduction of wild poliovirus from a laboratory into the populations of the Region.

RESULTS Since the onset of the last poliomyelitis case due to indigenous wild poliovirus in the Region on 19 March 1997, as of6 March 2000 over 17 900 AFP cases had been reported in the Region. As ofthe same date, the regional non -poliomyelitis AF Prate tor 1999 was 1.39 per 100 000 under age 15, and 86% of all AFP cases had had two adequate stool samples taken within 14 days of onset. Systematic retrospective searches for AFP cases are now underway in several countries, as part of the certification process. Supplementary immunization with oral poliovirus vaccine (OPV) has been conducted in highrisk areas of six of the recently-endemic countries. 1 China, Cambodia, the Lao People's Democratic Republic, Papua New Guinea, the Philippines and VietNam. Figure 1.1 AFP surveillance in the Western Pacific Region, 1995-1999 1

Administering polio vaccine to a child in the Lao Peoples Democratic Republic

Stool collection rates(%)

Non-poliomyelitis AFP rates (per 100 000 under age 15)

100 90 80

1.6 1.4

1.2 70

Target for adequate stools

60 50 0.8

Target for non-poliomyelitis AFP rates

40 30

0.6 0.4

Stool Collection Rates

-+- Non-poliomyelitis AFP Rates

20 10

0.2 0 1995 1996 1997 1998 1999

1. fxPIWDED PROGR/>MME ON IMMUNIZATION

Figure 1.2 Partner support for OPV requirements for poliomyelitis eradication, Western Pacific Region, 1992-1999 Australia 6% Others 4% Japan 39%

the Agency for Cooperation in International Health (ACIH); Rotary International and Rotary International Districts 2650 and 2640 ofJapan. From 1992 to 1999, US$ 49.1 million was provided by international partners to buy 0 PV for supplementary immunization and US$ 24.5 million was provided for operational support (Figures 1.2 and 1. 3).

FUTURE The Regional Certification Commission will review the full documentation from all countries and areas of the Region during its fifth meeting in August 2000, and, subject to the receipt of adequate documentation and the approval ofthe Regional Commission, the Region can be declared poliomyelitis-free at the sixth meeting ofthe Regional Certification Commission in Kyoto in late October 2000. After certification, the Region must maintain its poliomyelitis-free status by carrying out vigilant surveillance and supplementary immunization in high-risk areas, strengthening capacity for rapid response to imported wild poliovirus, and ensuring adequate laboratory containment of wild poliovirus materials until global certification has been achieved.

USA, through

CDC 15%

Rotary International 23%

ITotal:

US$ 49.1 million

Data as of 1 January 2000; includes committed as well as received funds

In China, in response to the poliomyeutis case caused by imported poliovirus, high-risk response inununization was conducted for children under 5 years of age in high-risk areas of 12 provinces, although some provinces have extended the age range to under 10 years.

Figure 1.3 Partner support for operational requirements (non-OPV) for poliomyelitis eradication, Western Pacific Region, 1992-1999

ANALYSIS High-quality AFP surveillance has been sustained throughout the period under review. This is a credit to the commitment to poliomyelitis eradication of all countries and areas in the Region, many ofwhom have not reported poliomyelitis for over 10 years. In particular, the rate of AFP reporting and adequacy of stool sampling has consistently been very high (Figure 1.1 ), although there has been some lack of timeliness in two countries, usually due to logistical problems. The international partnership for poliomyelitis eradication is as strong as ever. Partners include the United Nations Children's Fund (UNICEF), the Governments of Australia, Japan, the Republic of Korea, and the United States of America through the Centers for Disease Control and Prevention in Atlanta; Australia 25°/o

.. 8"/o 17"/o

Rotary International 20"/o

I Total: US$ 24.5 million I Data as of 1 January 2000; includes only received funds

COMBATING COMMUNICABLE DISEASES

==========-====================

A poliomyelitis case in China due to poliovirus importation In December 1999, a case ofpoliomyelitis due to importation ofwild poliovirus with onset of paralysis on 12 October 1999 was reported to WHO from Qinghai province, China. The case was a boy aged 16 months from a minority group with wide trading links, including contacts with neighbouring countries, some of which are poliomyelitis-endemic. The Ministry of Health has treated this case as a public health emergency, and senior health officials, including the Vice-Minister ofHealth, immediately visited the area. Subsequently, major surveillance and supplementary immunization activities were carried out to document the extent of wild poliovirus circulation, and to ensure that circulation has been interrupted. Although the boy had not travelled outside the country, he had probably been infected with wild poliovirus while attending a major festival in the area about two weeks before the onset of illness. Laboratory information showed that the genomic sequence of the isolated virus was very similar to that of wild poliovirus strains found in central and northern India in 1998 and 1999 and significantly different from wild poliovirus strains circulating in China up to 1994, the last year indigenous wild virus was isolated in China. All available evidence therefore suggests that the virus had been recently imported. No other poliomyelitis cases have been detected, despite high-quality AFP surveillance and extensive searches ofhospital records, health facilities, and communities. The detection of this case in a sparsely populated rural area shows that high-quality AFP surveillance continues to be maintained in China. However, the detection also highlighted the need for all poliomyelitis-free countries and areas to remain vigilant against imported wild poliovirus. ·

1. fXP!WOED PROGR/lMME ON IMMUNIZATION

Hepatitis B

ISSUES Hepatitis B is a major problem in the Western Pacific Region . Twenty-five countries and areas have carrier rates of hepatitis B in the general population of over 8%, and some Pacific island countries and areas have carrier rates of 20% or more. Although the exact dh;ease burden can only be estimated, there are very high levels ofchronic liver disease and hepatocellular carcinoma in the Region. Up to 10% of people chronically infected with hepatitis B virus will develop some form of chronic liver disease. The most critical issues for hepatitis B control are ensuring the vaccine is introduced into national immunization programmes, and guaranteeing an adequate and continuous supply of vaccine. All countries in the Region, except for Cambodia and Lao People's Democratic Republic, have now introduced hepatitis B vaccines into their national immunization programmes, and coverage in most countries is good. However, coverage remains less than optimal in China, Papua New Guinea, the Philippines and Viet Nam, primarily because of inadequacy of vaccine supply or difficulties in accessing immunization services. In addition, while most countries have secured hepatitis B vaccines for the immediate future, long-term sustainability remains an issue, primarily because of the price of the vaccine.

health authorities and other partners to develop plans to introduce the hepatitis B vaccine in Cambodia and the Lao People's Democratic Republic, WHO is working to access fimds for hepatitis B vaccine in these two countries through the Global Alliance for Vaccines and Immunization.

RI!SULTS Availability of vaccine throughout the Region has improved (see Figure 1.4). Progress has also been made in attracting funds to finance vaccine requirements in countries where this is a problem. In nearly all countries in the Region where comprehensive vaccine requirement calculations have been undertaken, they have been used to identify government and partner agency funds to meet vaccine requirements . In Cambodia and the Lao People's Democratic Republic, the calculations have been incorporated into five-year immunization plans and have been used in negotiations with partner agencies to ensure that there are adequate vaccine supplies in the medium term. It is likely that in both countries hepatitis B vaccine will be introduced into national immunization programmes in 2000. Many countries in the Region are now achieving high immunization coverage levels with hepatitis B vaccine. In 1998, 26 countries reported more than 50% coverage of infants with three doses, and 23 countries reported more than 80% coverage (Figure 1.5). Figure 1.4 Hepatitis B vaccine supply: number of countries with adequate, partial, or no supply

WHO RESPONSE During the period, WHO continued to collaborate with national health authorities in Cambodia, the Lao People's Democratic Republic , Mongolia , the Philippines, Papua New Guinea and various Pacific island countries and areas to forecast EPI vaccine requirements and costs, including hepatitis B. Collaboration also continued with the United Nations Children's Fund (UNICEF) and the Governments of Australia and New Zealand in a project to expand the use ofhepatitis B vaccine in Pacific island countries and areas. Building on previous work with national 30 • adequate partial

lOIII

25 20

15 10 5 0

1992

1994

1996

1997

COMBATING COMMUNICABLE DISEASES

=============================== Figure 1.5 Number of countries reporting coverage >50% and >80% with three doses of HBV

0 1992 1993 1994 1995 1996 1997 1998

ANALYSIS Data for 1998 hepatitis B vaccine coverage indicate that countries with a reliable supply of vaccine are achieving coverage with three doses of hepatitis B vaccine that is comparable to OPT 3 coverage. Countries that do not have a reliable and continuous supply, such as Cambodia, the Lao People ' s Democratic Republic, the Philippines, and VietNam, or where access to the vaccine is a problem, such as China and Papua New Guinea, continue to have low coverage areas.

FUTURE In addition to continuing to plan and forecast hepatitis B vaccine requirements with governments, WHO will facilitate access to partner agency funds for those countries in the Region needing support to ensure a regular supply of vaccine. WHO will also work closely with countries to improve immunization coverage and to ensure full integration of hepatitis B vaccine into national immunization programmes. The possibility of using combination OPT -hepatitis B vaccines will also be explored.

1. fXPftNDED PROGRM1ME ON IMMUNIZATION

Other vaccine-preventable diseases

ISSUES Implementation of the expanded programme on immunization (EPI) in the Western Pacific Region has resulted in all countries and areas being free of indigenous vvild poliovirus, and a reduction of more than 90% in incidence ofdiphtheria, measles, pertussis, and tuberculosis in children compared to the prevaccine era. Nevertheless, there is still significant morbidity and mortality from vaccine-preventable diseases, particularly measles and neonatal tetanus, in the Region. Some countries (including Cambodia, the Lao People's Democratic Republic and Papua New Guinea) still have low infant immunization coverage rates.

follow-up national measles campaigns in Mongolia and 12 Pacific island countries and areas .1 Technical support was also provided for an expanded and enhanced measles surveillance system in several countries, including China and the Philippines. In accordance with the regional guidelines, several strategies to eliminate neonatal tetanus were promoted, including the development of improved disease surveillance, targeted immunization campaigns, and the use of the "protection at birth" (PAB) method of monitoring progress.

RESULTS In 1998, reported routine immunization coverage for all antigens for the Region remained high (Table 1.1), and most countries reported more than 80% routine coverage with all antigens for infants. Pilot measles campaigns were conducted in Cambodia, the Lao People's Democratic Republic and

WHO RESPONSE The strategies for controlling vaccine-preventable diseases include achieving and maintaining high routine immunization coverage, conducting special immunization campaigns where necessary (for example, for measles and neonatal tetanus) and ensuring highquality disease surveillance. During the review period, WHO worked extensively with countries to ensure that plans were in place to achieve and maintain high routine immunization coverage. Guided by the regional plan of action for accelerated measles control, technical support was provided for evaluating and analysing the national measles campaign in the Philippines, for planning and implementing pilot measles campaigns in Cambodia, the Lao People's Democratic Republic and VietNam, and for planning 1 Fiji, French Polynesia, Kiribati, Nauru, New Caledonia, Niue, Samoa, Solomon Islands, Tokelau, Tonga, Tuvalu, and Vanuatu.

Children queuing for measles vaccinations in the Lao Peoples Democratic Republic

COMBATING COMMUNICABLE DISEASES - -

Table 1.1 Western Pacific Region: EPI coverage data 1995-1998• ---.-~ I '

~-~~

•:~it · ~ ~:•(r -~~~~-'~ ~-''_'' ':-:..~~- ~~:~:~ ':-,:•,, --;- _,;'·~·,

.)~: 1 1 1, 1

1 1

·,·

:,,

American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna Western Pacific Region 98 97 77 92 99 95 92 96 100 97

97 86

72 86

59 87

47 0

74 86

61 87

79 92 93 97 93

80 94

36 86 82

90 97 90 100 98 91 98 100

75 95 75 97 98 72 87 100

72 97 72

36 62 82 79 87

93 96 94 96 94 72

96 75 99

93 99 93*

94 98 71 82

90 83

84 97 58

74 47 59 93 100

93 47 68 82 38 35 50 85 87 36 100

94 64 73

60 54 86 90

82 68

41 31 81 59

64 85

61 99 98

58 91 78

81 57

80 58

90 77

83 69

71 50

70 83

64 81 86 56 88* 87 100

47 82 89 57

90 85

94 78 98

88 56 88 89 100 93 100

93 88 0 90 94 100 100 100 100 100 100

34 84 100

93 100 67 86 100

0 79

98 56

100 57

99 45 90 96 65

100 43 na

88 91

60 86 100 94 95 69

42 86 93 96 98

48 100 96

90 98

90 95

43 98

94 93 69

88 68

91 71 83 53 68

96 100 100

97 65 95 94

99 99 88 67 96 97

99 95 87 73 94 93

99 93 91

99 94

50 91 49 66 71

99 99 87 67

99 99 85 68

99 95 94

94 60

88 72 95

18 82

61 96

15 96

9S 31 92

94 95

• 1999 data are contained in the statistical annex on p. 177. All data from reports received by the Regional Office.

1. fXP!WDED PROGRNAME ON IMMUNIZATION

Table 1.1 Western Pacific Region: EPI coverage data 1995-1998 (continued) ===----- -

----

. . . . ,. - '

• ' •' ! . . . . ....• • •

- ~--

-;•' t ,

----r,.~

•

. •

I''

• • ;-

1' • 0

!' '·. :

, ,; I:_~·

: : (

, :. : ,

• ,

American Samoa Australia Brunei Darussalam Cambodia Chinab Cook Islands Fiji French Polynesia G~m

85 86 99 82 96 99 70 96 91 86 98

87 86 99 70 97 92 88 87

91 86

91 86 98 64 98 95 88 92 91 82

91 86 100 63 97 94 75 52 31

98 68 96 87 75 98

76 31

96 76 96

97 64 98 95 86 92 91

100

84 95 98

91 90

98 98 79 95 87

99 95 97

86 98 94

% 100 88 70 103 58 96 100 94 48 96 78 100 91 60 88 91 78 75 92 50 93 86 100 100 97 91 67 90 91 99 98 73 100 100 100 78 96 80 95

86 82

94 82

94 88

Hong Kong (China} Japan Kiribati Lao People's Democratic Republic Macao (China} Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna Western Pacific Region b

100

97 93 69 88

94 82 67 85 32 88 81 56 88 70 78 88 86 27 104 40 100 98 100 62 53 90 43 31 33 87 75 100 99 94 54 73 100 98 72 100 92 95 88 75 100 100 99 94 82 99 100 97 97 56 98 100 81 52 95 89 54 88 55 92 95 86 80 94 72 87 81 100 98 96 58 87 74 100 95 69 100 97 94 93 94 93 82 100 98 96 46 87 71 100 96 69 100 97 94 87 94 93 96

83 67 92 94 86 79 94 72

77 71 92 86 93 82 93 90 78 81

74 32

54 71

92 91 80 79 91 29 49 87 100

90 71 75 93 36

84 52 74 91 121 41

117 100 97 90 35 90 81 100 94 70 100 96 78 67 95 95 96

114 100 94 83 40 90 85 99 90 68 87 97 100 65 96 75 95

97 74 59 87 85 100 96 64 100 96 55 100 93 71 78 83 99 11

99 96 45 34 86 99 96

45 90 80 96 93 72 100 %

100

96 96 75

77 72 95 95 95

44 8 91

96 94 96 91 95

12" 95 65

HB vaccine coverage not routinely reported for China, but survey data support high coverage in urban areas. HB vaccination carried out in only two cities in VietNam in 1998.

COMBATING COMMUNICABLE DISEASES == = -

=-===---- - - - - - -

ANALYSIS High routine immunization coverage has enabled most countries and areas to achieve a good level of control of vaccine-preventable diseases, but measles remains a problem region wide and neonatal tetanus remains a problem in six countries. 2 Achieving high two-dose coverage with measles vaccine (either through routine delivery or through campaigns) and enhanced and expanded measles surveillance, including laboratory diagnosis, can accelerate measles Measles campaigns are often focused on schools and colleges, as here at control and enable cases to be identified Queen Salote College, Tonga quickly Experience in Mongolia and the Pacific island countries and areas demonstrates this. Following VietNam. In November-December 1999, VietNam Mongolia's national campaign in May 1996, there conducted a campaign in Hai Phong Province, were only 23 reported cases for the rest of 1996, none targeting 327 667 children aged 9 months to 10 years, in 1997, 9 in 1998 and 15 in 1999. After campaigns and vaccinated 326 324 children (99.6% coverage).ln in 13 Pacific island countries and areas in 1997-1998, January-February 2000, Cambodia conducted a there has not been a reported case of measles since campaign in seven provinces, targeting 228 266 March 1998. The national campaign in the Philippines children aged 9 months to 5 years, and vaccinated in 1998-1999 has also led to a significant decrease in 186 824 children (81.8% coverage). In measles incidence. Mass measles immunization March-April 2000, the Lao People's Democratic campaigns are necessary to achieve high two-dose Republic conducted a campaign in Phongsaly and coverage in many countries and experience with Khammoune Provinces, targeting 70 357 children age poliomyelitis eradication campaigns can guide 9 months to 5 years. In addition, a database for measles planning and implementation. Similarly, measles surveillance was developed and installed in surveillance can be integrated with existing AFP Cambodia, the Lao People's Democratic Republic and surveillance systems. VietNam. Continued emphasis on good surveillance, Work has begun on the establishment of a appropriate immunization strategies, and responding regional laboratory network for measles. Regional to reported cases should lead to further reductions in laboratories and national laboratories for most neonatal tetanus. countries have been identified. Plans for accelerated measles control have been included in most long-term national strategies for control of vaccine-preventable FUTURE diseases, including identifying future needs and probable sources of funding. WHO will continue to work with countries to achieve In 1998, the reported regional coverage for two and maintain high routine immunization coverage of doses of tetanus toxoid in pregnant women (excluding infants and other selected population groups to China) was 71%. China, the Philippines and maintain control of vaccine-preventable diseases. VietNam have achieved the elimination goal at the Accelerated control ofmeasles through 95% coverage province or prefecture level and are progressing towards elimination at the district level. Cambodia, the Lao People's Democratic Republic and Papua New 2 Guinea have also made progress, but neonatal tetanus Cambodia, China, Lao People's Democratic Republic, Papua New Guinea, Philippines, Viet Nam is still widespread in these countries.

1. f

XPIWDED PROGR/WIME ON IMMUNIZATION

with two doses of measles vaccines will be promoted. Surveillance data and the knowledge gained from poliomyelitis eradication, the pilot mass measles vaccination campaigns, and the accelerated control of measles project in China will be used to determine which countries and areas should use campaigns followed by high routine two-dose coverage, and which should use one routine dose supplemented by periodic campaigns. WHO will also continue to work with countries

where neonatal tetanus is a problem, to monitor progress and to identity high-risk areas in order to plan specific response activities. The possibility of introducing relevant new vaccines into national immunization progranunes and of increasing use of under-utilized vaccines will be explored (see pp. 14-16). Outbreaks of other vaccine-preventable diseases in the Region will be responded to rapidly and effectively.

Accelerated Measles Control Project, China The Accelerated Measles Control Project, China, is a three-year joint project involving the Ministry of Health, WHO, and the US Government, through the Centers for Disease Control and Prevention in Atlanta. The project began in January 1999 in eight prefectures in Shandong Province and two prefectures in Henan Province. The population ofthese 10 prefectures is approximately 58 million. In 2000, the project expanded to encompass all of Shandong and Henan Provinces, a total population of approximately 180 million. The objectives ofthe project are to (1) reduce the burden of measles in every participating prefecture, (2) develop measles surveillance so that outbreaks can be identified, investigated and controlled rapidly, and epidemics can be predicted and prevented, and (3) use the operational experience obtained during the project to improve implementation of national measles control. Much progress has been made in the first year of the project. Routine measles immunization achieved 98% reported coverage in the project areas, resulting in fewer measles cases. Measles surveillance has been enhanced throughout the project area and laboratories that conduct IgM capture assays to diagnose measles have been established at the prefecture and provincial levels. A system of identifYing, investigating and responding to outbreaks has been implemented. Over 100 outbreaks were identified, affecting at least 1300 persons. The investigation of cases has already yielded useful information on the epidemiology of measles, in particular on how the timing of the second dose of measles vaccine affects the effectiveness of vaccination.

I I'M

COMBATING COMMUNICABLE DISEASES ~- .

Improving the quality and scope of immunization services

ISSUES The quality of national immunization programmes in the Region can still be significantly improved, particularly with respect to national regulatory authorities (NRAs), cold chain and logistics systems, and injection practices. All countries in the Region need to have access to an NRA that meets critical WHO criteria for the regulation of vaccines. Cold chain and logistics systems need to have the capacity to move vaccine surely and safely through the system so that a high-quality product is available at the point of use. In many countries the safety of injections during immunization is a serious problem, with supply and training deficiencies leading to the use or reuse of non -sterile equipment. Although immunization injections on the whole tend to be safer and far less frequent than injections for other purposes, it is critical that they are performed safely.

Several new vaccines, such as those against hepatitis B and Haemophilus Influenzae Type B, have become available in recent years and many more are expected in the near future. These new vaccines are usually introduced into national immunization programmes in industrialized countries more quickly than in developing countries. The costs of introducing new vaccines, lack of data on the disease burden and an absence of cost-benefit analyses have been the main factors limiting the introduction of new vaccines. To improve the quality and expand the scope of immunization programmes, the partnerships already developed between agencies and governments interested in supporting immunization need to be expanded. This process can take time but it can also attract new partners, improve coordination, and substantially increase available resources.

WHO RESPONSE WHO is working with NRAs to strengthen regulatory and quality control functions for vaccines and biologicals. In 1998, WHO took part in reviews of national vaccine regulatory functions in China, the Philippines and VietNam. In the review period, there has been ongoing WHO collaboration with NRAs in these countries through in-country workshops, fellowships, technical support and capacity building at expert centres in the Global Training Network (GTN). Specific emphasis has been placed on the development of immunization safety surveillance and guidelines have been developed for this. In several countries WHO has supported the improvement of injection practices through the development of national plans and policies, the introduction of new equipment such as auto-disable syringes and safety boxes, and the testing of methods for the safe destruction of used injection equipment. During the pilot measles campaign carried out in Cambodia in January-February 2000, for example, two newly installed autocombust incinerators were used for safe disposal of syringes, needles and vials.

liD

WHO supports the introduction of auto-disable syringes and safety boxes (the syringe on top of the safety box is a mixing syringe)

1. EXPANDED PROGRAMME ON IMMUNIZATION

Partnerships are being expanded to meet the need to improve quality and accelerate the introduction of new vaccines. WHO 's membership of the Global Alliance for Vaccines and Immunization (GAVI), launched in January 2000, is an important part of that process. This alliance includes WHO, UNICEF, the World Bank, the Bill and Melinda Gates Children's Vaccine Programme, and other partners. The GAVI partners aim to: improve access to sustainable immunization serv1ces; expand the use of all existing safe and cost-effective vaccines; accelerate the development and introduction of new vaccines; and accelerate research and development efforts for vaccines and related products specifically needed by developing countries. WHO is also in the process of preparing a framework to assist policy-makers to determine whether new vaccines should be added to national immunization programmes. This framework will cover assessment of the disease burden, cost-benefit analysis of vaccine introduction, and operational issues. The aim is to work with countries to accelerate the process of vaccine introduction, in partnership with other agencies.

improved through the introduction of auto-disable syringes and safety boxes in measles campaigns in Cambodia, the Lao People's Democratic Republic, and VietNam, following successful introductions in Papua New Guinea, the Philippines (safety boxes only) and various Pacific island countries and areas in the period 1997 to 1999. Major improvements in injection equipment have been made in several provinces in China through projects Supported by partner agencies. The GAVI partners are working together to provide access to new vaccines for the world 's least developed countries. As noted above, Cambodia and the Lao People's Democratic Republic are expected to introduce hepatitis B vaccine in 2000, partly due to the efforts oftheGAVI partners in identifying needs and funding sources.

ANALYSIS Many countries and areas in the Region still do not have national immunization programmes of optimal quality, and many do not yet have access to newer vaccines that could be effectively used. Ongoing WHO support will be needed to sustain the momentum of the development of NRAs. Exercising all critical functions (see box) will be increasingly important as new vaccines are introduced into immunization programmes and the quality of these vaccines will have to be ensured. Many national staff involved in immunization service delivery still need basic training in correct vaccine handling and safe administration. The introduction of new vaccines places major economic and logistical burdens on countries, at a time when there are an increasing number of competing priorities, in the health sector as well as in the wider public sector. The decision to introduce a new vaccine can only be made on the best available evidence of need and cost-benefit analysis. Partner agency support for national immunization programmes has been very significant over the past decade. However, to be most effective this support requires the active involvement of national governments, and close coordination between partner agencies. GAVI offers a way to improve coordination between partners, provided that the focus is maintained on coordination at the national level, with the full involvement of national health authorities.

RESULTS NRAs in China, the Philippines and VietNam have strengthened their vaccine regulatory functions. The Global Training Network has helped to establish a loose network of NRAs in the Region. Countryspecific vaccine regulatory needs have been identified. The WHO guidelines on establishing immunization safety surveillance have been adapted in the Philippines to form the framework for a national Immunization Safety Surveillance System (ISSS). WHO has facilitated the provision of partner agency support for cold chain equipment and training in China, Papua New Guinea and various Pacific island countries and areas. In most countries in the Region cold chain requirements are largely met for the short term, although China and the Philippines still have major needs. Injection practices during mass immuni zation campaigns have been significantly

COMBATING COMMUNICABLE DISEASES -=--=---c========-=--====-==-=~===~===~===o=

FUTURE WHO will continue to provide technical and training support to improve the functioning of national regulatory authorities. Future activities will build on the collaboration achieved to date, including new members of the GTN, such as the International Vaccine Institute (IVI), to strengthen the informal

regional network ofNRAs with a view to improving regulation of vaccine quality. Immunization quality and injection safety will remain major issues and WHO will work closely with countries to ensure that the highest quality services are offered. WHO will work with other partners in GAVI and with traditional bilateral partners to identifY resources to enable the further expansion of existing immunization services, in a sustainable way.

How do you ensure vaccine quality? WHO has identified six critical functions of a National Regulatory Authority with regard to vaccine regulation and control (see Table 1.2). WHO aims to promote the development of the first two critical functions, licensing and surveillance, in all NRAs, regardless of the vaccine source. For those countries that purchase vaccines, two additional functions, lot release and access to laboratories, should be developed. Countries that produce vaccines need to comply with all six of the critical functions. WHO has provided technical support and has developed specific indicators for each ofthe critical functions, which have been used in assessments ofNRAs. Building on a workshop for NRAs held in 1997, and reviews of national regulatory functions in various countries in 1998 and 1999, WHO published a document titled "Immunization Safety Surveillance" in November 1999. These guidelines are designed to guide national health authorities to comply with at least two critical regulatory functions. Table 1.2 Critical functions of a National Regulatory Authority

A documented licensing system Surveillance of vaccine performance* System of lot release Use of laboratory facilities Regular GMP inspections Evaluation of clinical performance**

s s u R E

X X

X X X X

X X X X X X

*Post-marketing surveillance for adverse events following immunization **Pre-licensure clinical evaluations

2. Malaria, other vectorborne and parasitic diseases Malaria

ISSUES Despite progress in control, malaria remains an important public health problem in nine countries of the Region. In Cambodia, China, the Lao People's Democratic Republic, Malaysia, the Philippines and Viet Nam, most malaria cases occur among people living in remote forested and hilly areas where mosquito vectors are abundant. The main at-riskgroups are ethnic minorities, and migrants who venture into these malarious areas, where the health services are often inaccessible and inadequate. Excessive use of antimalarial drugs, in particular by temporary migrants, has led to the creation of very severe drug resistance problems, especially in Yunnan, China, western Can1bodia and south-western VietNam. In Cambodia, the Philippines and Viet Nam, malaria is also transmitted in certain coastal areas by anophelines breeding in stagnant brackish water. However, in these areas, mortality is generally not so high, as the access to health services is better. In the Pacific, malaria is endemic in three countries, Papua New Guinea, Solomon Islands and Vanuatu, where it is less restricted to particular at-risk groups than in Asia. Nevertheless, epidemics occurred in the mid-1990s in the highland areas of Papua New Guinea, where transmission is irregular and people do not therefore become immune. Chloroquine-resistant vivax malaria can now be found in Papua New Guinea as well as in the Solomon Islands, but it has not become a major clinical problem, probably because most of the exposed populations have a relatively high level of immunity Since 1993 vivax malaria has re-emerged in the Republic of Korea, where it was thought to have been eradicated in the 1970s. Soldiers in the north of the country are the main at-risk group. As is usually the case with vivax malaria, there has not been any mortality, and recent data indicate that the transmission peaked in 1998.

Malaria control strategies in the Region are based on early diagnosis and effective treatment, and prevention through vector control. It has been generally accepted that in the remote, thinly populated areas, where most malaria cases occur, diagnosis has to be clinical, as accessible microscopy services of good quality cannot be maintained there. Rapid diagnostic tests, "dipsticks" for falciparum malaria, have therefore been introduced. These tests, which are based on antigen detection in blood, can be used correctly, even by village volunteers and private providers of care. The cost ofthese tests, currently at least US$ 0.6 per test, is an obstacle to their use in remote rural areas. To benefit populations at high risk, their deployment must therefore be supported by public funds as well as monitoring and quality assurance. For prevention, insecticide-treated nets continue to be the main control method in the Western Pacific. In China and VietNam, this intervention is generally supported fully by public funds; however, a large part of the population at risk in these two countries traditionally uses bednets, so public expenditures are mainly for insecticides and operational costs. In other countries, most of the costs of insecticide-treated net interventions are borne by external partners. Various cost-sharing schemes are being explored; the general experience has been that long-term protection of vulnerable groups requires substantial sustained public investment.

WHO RESPONSE WHO has continued to provide technical support for endemic countries through country staff based in Cambodia, Papua New Guinea, Solomon Islands and Vanuatu. Staffbased in VietNam provide additional support for planning, training, operational research and coordination of partner support to programmes for control of malaria and other parasitic diseases.

.,.

COMBATING COMMUNICABLE DISEASES

=============================== intercountry organizations such as ACTMalaria (Asian Collaborative Training Network for Malaria), Southeast Asian Ministers ofEducation OrganizationTropical Medicine Programme (SEAMEOTROPMED) and the Wellcome Trust. In Cambodia, the Lao People's Democratic Republic and VietNam, the European Commission is supporting a major regional malaria control programme, with WHO collaboration. The worldwide Roll Back Malaria (RBM) movement involves a broad range of international partners and will provide additional resources to further reduce the malaria burden through development of health systems. This has provided an important stimulus to governments and partners to improve and better coordinate malaria control efforts. The "Mekong Roll Back Malaria Initiative", which was launched at a meeting organized by WHO in Ho Chi Minh City, Viet Nam, in March 1999, has brought together the six Mekong countries (Cambodia, China (Yunnan Province), the Lao People's Democratic Republic, Myanmar, Thailand and Viet Nam) with various partners. UNICEF and WHO work closely together in this initiative, drawing on the complementary strengths ofthe two organizations and collaborating with other partners (see above) to complement their activities. At a biregional meeting organized by the South-East Asia and Western Pacific Regions in Kunming, China, in November 1999, Mekong countryrepresentatives and technical partners discussed border malaria issues and identified a set of core epidemiological and operational indicators, which could be accepted by all countries and all partners. Together with countries and Roll Back Malaria partners including the private sector, WHO works on determining the most suitable treatment regimens for multidrug resistant falciparum malaria. In Cambodia, pilot projects are deploying pre-packaged combination therapy (which is expected to delay the emergence of drug resistance) together with dipsticks. In the Lao People's Democratic Republic, the national malaria control programme, supported by several partners, in particular the EC, is making good progress in protecting at risk populations with insecticide-treated nets. A comparative trial of five insecticides for net impregnation carried out in Viet Nam by the National Institute for Malariology, Parasitology and Entomology in collaboration with WHO, with financial support from the EC, indicates that considerable cost reductions are possible through rational selection of insecticide.

Treating mosquito nets in Papua New Guinea

As part of its role as primary adviser to governments, WHO has helped bring together a wide range of partners. These include the United Nations Development Programme (UNDP), United Nations Children's Fund (UNICEF), the World Bank, the Asian Development Bank, European Commission (EC), Australian. Agency for International Development (AusAID), Canadian Agency for International Development, Department for International Development (UK), Government of Belgium, Government of Japan, GTZ (Germany), New Zealand Agency for International Development, United States Agency for International Development (USAID) and Rotary Against Malaria. These agencies have provided substantial financial and technical inputs to malaria reduction efforts. Their work is complemented by that of a large number of nongovernmental organizations (NGOs) who support the health sector mainly at province and district level, and by the increasingly important work in training and research carried out by

MALARIA, OTHER VECTORBORNE AND PARASITIC DISEASES

In the Philippines, a special Roll Back Malaria project for eastern Mindanao will strengthen primary health care services by ensuring adequate management of malaria cases and good coverage of at-risk groups with treated nets. A Roll Back Malaria project under preparation in Papua New Guinea will be supported by AusAID, Rotary and UNICEF and will benefit from a revised antimalarial drug policy prepared in 1999 on the basis oftherapeutic efficacy trials in four sites in 1998 supported by WHO.

RESULTS In 1993 regional goals were set for 2000 that called for a reduction in malaria mortality of 80% and of malaria morbidity of 50% compared to 1992. From 1992 to 1998 there was a 50% decrease in reported cases and a 62% decrease in reported deaths in the Region as a whole. While there has been sustained progress throughout the decade in China, Malaysia, Solomon Islands, Vanuatu, VietNam and to some extent in the Philippines, it is worth noting that a comparison of 1997 and 1998 data suggests that the malaria burden is also beginning to decrease in Hospital and district public health st(!ff in the Lao People.~ Democratic Republic plot malaria cases on a map

Cambodia (42% reduction in morbidity and 23% reduction in mortality) and the Lao People's Democratic Republic (23% reduction in morbidity and 14% reduction in mortality). See Figures 2.1- 2.3 for a summary of malaria cases and deaths in the Region and the percentage ofthe at-risk population covered by vector control. Figure 2.1 shows the trend from 1984 to 1998 for malaria cases and 1992- 1998 for deaths; Figures 2.2 and 2.3 are based on 1998 data.

Figure 2.1 Malaria cases and deaths in the Western Pacific Region

Confirmed malaria cases, 1984-1998 1 600 000 1 400 000 1 200 000 1 000 000 800 000 600 000 400 000 200 000 0

Reported malaria deaths, 1992-1998 7000

..-

6000 5000 4000

.....,---

IPM ,---

..-

,...-

3000

,...-

2000

1997

r--

n 1984 1992 1993 1994 1995 1996 1997 1998

1000 0

1992

1993

1994

1995

1996

1998

COMBATING COMMUNICABLE DISEASES ~~

Figure 2.2 Confinned malaria cases and deaths reported in the Western Pacific Region, 1998 Cases Republic of K oreal T I

Vanuat~ Malaysia ~ Papua New

l''

Deaths Malaysia ----,

Solorron

v•tN•m

Papua New

Guinea ~ China

L__ CaniJodia Fhilippines Lao Feople's

Lao Feople's Derrocratic Republic

' - - - - - - - - - - - - - Derrocratic Republic

China

Cambodia China Lao People's Democratic Republic Malaysia Papua New Guinea

66 140 27 090 41 623

621 24 485

Philippines Republic of Korea Solomon Islands Vanuatu

50 709 3 992 72 808 6 181 72 091

0 33

0 183

13 491 20 900

27 651

VietNam

Figure 2.3 Percentage of at-risk population covered by vector control (insecticide treated nets or residual spraying) by country, 1998 0 10

Cambodia E==:=J-----------------------~ China LaoPDR Malaysia Papua New Guinea Philippines Republic of Korea Solomon Islands Vanuatu V1et Nam

f===============:::J I==::::J f===============:: J

~=======================::::J

t==========~----------------_j

MALARIA, OTHER VECTORBORNE AND PARASITIC DISEASES

ANALYSIS In the Region as a whole, the progress which started in China in the 1980s and in most other countries in the 1990s has continued. Cambodia and, more recently, the Lao People's Democratic Republic are starting to make progress with increasing and better targeted vector control activities. Papua New Guinea was successful in preventing malaria epidemics in the highland areas in 1998 and 1999, and is making progress towards reducing mortality, with the institution of an evidence-based drug policy and support from the Roll Back Malaria partners. The new rapid diagnostic tests which have been tried out in practically Nationallvfalaria Centre team in Cambodia taking a blood smear all ofthe endemic countries in the Region and which are used routinely in health needed for quality assurance, monitoring and providing services without microscopy in Cambodia have great potential to improve quality of care and community information to the public. involvement. The price of these tests has gone down over recent years; depending on the standard treatment FUTURE and the risk of malaria, it may now be cheaper to test the patients, and treat only the positive cases, than to The Roll Back Malaria initiative has the potential to provide treatment based on clinical criteria_At the same further increase partner support by raising the profile time, results of studies in the Mekong Region indicate of malaria in the international community, and the that multidrug resistant falciparum malaria cases can be cured by three-day regimens combining two renewed emphasis on the links between malaria control and health sector reform should enhance the effective antimalarial drugs, and that the consistent sustain ability of external investments. With the advent application of such combinations may possibly retard of rapid diagnostic tests and short, effective the evolution ofmultidrug resistance. Such regimens combination treatment regimens, there are better are more expensive than single-drug treatments; for economic reasons, they should therefore be applied prospects than there have been for decades of coping only on the basis of microscopy or rapid diagnostic with multidrug resistance. Nonetheless, there is a considerable risk that, as in the past, achievements will tests . This will also increase the chances of such lead to complacency and reduced public investment. regimens retarding multi drug resistance. This principle Although malaria control can play an important role is now gradually being put into practice in Cambodia, in poverty reduction, external investment must be China and VietNam. Experience to date indicates that maintained to avoid the risk of rebound malaria once suitable regimens and strategies have been outbreaks. defined, considerable additional investments will be

COMBATING COMMUNICABLE DISEASES

=====~====------=-=====================

Dengue

ISSUES Following the dengue pandemic which swept tropical parts ofthe Region in 1998, the incidence and mortality of this disease returned to its usual inter-epidemic level in all countries in 1999. Yet we !mow that epidemics -will recur. Reviews of the experiences of the 1990s have shown that the incidence and geographical distribution of this disease is relentlessly increasing. This is a result ofincreased urbanization without proper water supply and waste disposal services coupled -with increased population mobility.

WHO RESPONSE WHO supports planning for and implementation of long-term control oftransmission, especially through community-based and intersectoral measures to reduce breeding sites and through chemical or biological larviciding. The application of copepods (Mesocyclops) for larviciding in drinking-water containers has proved highly cost-effective in pilot projects in VietNam. This approach, which has been spearheaded by Australian and Vietnamese scientists and NGOs, is now being promoted internationally In Cambodia, it has been possible to reduce Aedes breeding by the application of a chemical larvicide in

some areas, and, with support from USAID, this strategy-will be explored further. In epidemics, the procurement of insecticides for s~ace spraying has been supported in the past, but, given the very weak evidence for this intervention, WHO now supports more limited use of space spraying, and reconunends that it should be subject to evaluation. Increasing emphasis is being given to integrating dengue control into Healthy Cities programmes (see pp. 53-63). Guidelines for managing dengue have been distributed widely. Most endemic countries now have a core group of trainers capable of providing training to clinicians either specifically for dengue or as part of the ~tegrated management ofchildhood illness (IMCI). Dunng 1999, consultants worked -with the Philippines and VietNam to analyse their surveillance systems; in 2000 regional guidelines on case definitions, diagnostic techniques, use of regional resources and networking are being prepared.

RESULTS The numbers of dengue cases and deaths in 1999 were similar to those in the preceding inter-epidemic years, 1996 and 1997. In general, the case fatality rate of denguehas decreased for a number ofyears, as a result of earlier recognition and better management of the disease from the household level to the hospital (Figure 2.4). Dengue surveillance has been strengthened in several countries of the Region.

ANALYSIS Reviews of the 1998 pandemic suggest that in most countries vector control interventions had little impact. Space spraying was often applied too late and in ways which were ineffective, while community-based strategies for longterm reduction of Aedes breeding sites were not applied systematically enough. Furthermore, our understanding of the transmission dynamics of dengue is still

arer:s where the groundwater is salty (as in this village in VietNam), the mhab1tants collect as much rain water as they can and the dengue vectors often breed in the water containers

MALARIA, OTHER VECTORBORNE AND PARASITIC DISEASES

incomplete, and it appears that the vector index thresholds that were recommended in the past were often unreliable.

FUTURE To reduce the impact of future epidemics, it will be necessary to refine vector control interventions through research and evaluation; to strengthen the

role of municipal services in ensuring environments where mosquito vectors do not breed; and to maintain and strengthen the preparedness of curative services. Surveillance needs to be strengthened through clear, practical case definitions, distinguishing dengue fever from dengue haemorrhagic fever. There is still a considerable need to improve case management in health centres and district hospitals through training supported by reference hospitals, especially as the disease is spreading geographically.

Figure 2.4 Incidence of dengue and case fatality rate in the Western Pacific Region, 1991-1998 400 000 350 000 c:::::::::JCases

1.40% 1.20% -+- CFR

300 000 250 000 200 000 150 000 100 000 50 000 0 1991 1992 1993 1994

1.00% 0 .80% 0.60% 0.40% 0.20% 0.00%

•

\ ....-- .

·---1998

1995

1996

1997

Lymphatic filariasis

ISSUES Lymphatic filariasis is a public health problem in many countries ofthe Region, and about 135 million people in the Region are at risk. Ofthese countries, the majority are in the Pacific where the disease has traditionally had a major impact. In the past, surveys revealed filariasis prevalence as high as 48% in some countries in the Pacific. Although in general the situation has improved, it is still possible to find villages with a high prevalence of elephantiasis or hydrocele. A by-product of spraying programmes for malaria control in some countries such as Solomon Islands has been a 1"Local elimination" of lymphatic f!lariasis is defin ed as a cumulative incidence rate over five years of less than 1 new case per 1000 susceptible individuals. When a country with endemic areas has achieved local elimination in all affected

significant reduction in filariasis transmission, but in other, non-malarious, countries there are still high levels oftransmission . The methodology for controlling and eventually eliminating lymphatic filariasis 1 is relatively simple and inexpensive. It consists of an annual mass drug administration for a period of five years using a combination of diethylcarbamazine (DEC) or ivermectin, and albendazole. The combinations are safe and effectively stop transmission of the disease. However, the launching of filariasis elimination programmes in the larger countries in the Region is constrained by the substantial costs of covering all populations at risk. regions, the country can apply for certification of lilariasis elimination. Guidelin es f or certifying lymphatic filariasis eliminati on (WHO/FIL/99/197) . Gene va, World Health Organization, 1999.

COMBATING COMMUNICABLE DISEASES

A village health committee chairman in Vanuatu taking albendazole and DEC tablets as part of the Filariasis Elimination Campaign in 2000

WHO RESPONSE The goal for Pacific island countries is to eliminate lymphatic filariasis from the Pacific by 2010. Some countries and areas such as American Samoa and Samoa are expected to meet that goal, while some larger countries such as Fiji and Papua New Guinea will not be far behind. Other countries such as Cambodia, Malaysia, the Philippines and VietNam are planning filariasis elimination programmes, several of which will be ready to start shortly, if external support can be obtained. WHO-supported elimination and control programmes are already in place in many Pacific island countries. The programme in Fiji began in 1996. Samoa completed its first annual mass drug distribution campaign with DEC and albendazole in November 1999, and plans a second round in September 2000. American Samoa completed the first round in February 2000 and has scheduled a second round for late 2000. Other countries and areas including Cook Islands, Kiribati, Niue, Tonga, Tuvalu and Vanuatu, plan to hold their first round of mass drug administration in 2000. Together with the AusAID-supported Pacific Regional Vector Borne Diseases (PRVBD) project, WHO has worked with countries to produce national

filariasis elimination plans. Rapid diagnostic kits have been provided for baseline surveys and for evaluation. WHO staffbased in Fiji and Vanuatu have provided technical and managerial support to these programmes. A key element in the WHO-supported initiative to eliminate lymphatic filariasis from the Pacific was the formation in 1999 of a coordinating body called PacELF (see box) based in Suva, Fiji. With 22 member countries, PacELF provides the means by which even the smallest countries can access the technology and support needed for effective filariasis elimination programmes. The other major boost to filariasis elimination has been the donation of albendazole by SmithKline Beecham. The availability ofthis highly effective drug has made the goal of filariasis elimination possible.

RESULTS The completion of its first successful round of annual mass drug administration by Samoa at the end of 1999 marked the start of the Pacific's drive to eliminate lymphatic filariasis. The example set by Samoa is expected to be closely followed by other countries. Initial results show that Samoa was able to attain more than 90% compliance, indicating high levels of

MALARIA, OTHER VECTORBORNE AND PARASITIC DISEASES

PacELF- Elimination of lymphatic filariasis from the Pacific Lymphatic filariasis is a potentially debilitating disease that is or has been endemic in most Pacific island countries and areas. Although many of these are small with populations ofless than 5000 people, their total population is 7 miiiion. In 1999 a group of Pacific island countries formed PacELF, to coordinate filariasis elimination activities. Based in Suva, Fiji, PacElf will carry out procurement of drug supplies and serve as the contact point for such partners as WHO and the Pacific Regional Vector Borne Diseases Project. The goal of PacELF is to eliminate lymphatic filariasis from the Pacific by 2010. Given the size of the population to be covered and that fact that prevalence rates are already low, there is an excellent chance that this goal can be attained. PacELF will be the centre of an information and communication system supporting the collection, analysis and dissemination of epidemiological information. Criteria are being established and sampling methods designed to monitor country programmes. Elimination of the disease will be certified on a country-bycountry basis first and then for the entire region.

community support. The good results are due to strong Government commitment. An added benefit of the mass drug distribution campaigns that are part of filariasis elimination is the effect that albendazole has on intestinal parasites. Annual treatment with albendazole, especially in children, reduces the intestinal helminths that cause anaemia, and other nutritional problems in many Pacific island countries. The governments of the Pacific island countries are fully aware of these important benefits to health and are giving high priority to the planning and correct implementation of the filariasis elimination campaign.

have to work together to achieve the goal of regional elimination. The coordination of filariasis elimination and the reduction of intestinal parasites through PacELF is an important building blockofthe Healthy Island concept that WHO is promoting among Pacific island countries. Associated programmes, including those aimed at improving water supplies and sanitation, school health, control of dengue, and other health initiatives can be built on the strong community base created by mass drug distribution campaigns and accompanying health promotion.

ANALYSIS The provision ofalbendazole by SmithKline Beecham and the creation ofPacELF have been important steps towards filariasis elimination. WHO will work with the PRVBD project to provide PacELF with the continued support needed to implement national elimination programmes. Final elimination will be certified on a regional rather than a country basis, so countries will

FUTURE In Cambodia, China, Malaysia, the Philippines and VietNam, filariasis still poses a major challenge. Because of the size of their populations, mass drug administration campaigns in these countries will have to be implemented in stages if the programmes are to be managed properly. For the small Pacific island countries, the target of filariasis elimination by 2010 is an achievable goal.

3. Stop TB and leprosy elimination

Tuberculosis ISSUES Figure 3.2 Notification rate of new smear-positive cases Western Pacific Region and China 1993-1998 (per 100 000 population)

Tuberculosis prevalence

More than one third ofthe Region's 20 population is infected with the 17.1 15 tuberculosis bacilli and 2 million 16.6 people develop tuberculosis every 10 year, according to current estimates. 11 • -D 8.7 Approximately 29% of the global total 5 of reported smear-positive infectious cases are in the Region and about 0 355 000 people in the Region die 1993 1994 1995 1996 1997 1998 every year from the disease. In China -+- Western Pacific Region China alone, about 700 people die from tuberculosis every day. There is low detection and underof disability-adjusted life years (DALYs) lost due to reporting of tuberculosis cases. Of the estimated infectious diseases in the Region (Figure 3. 1). 2 million new cases in the Region in 1998, only The regional notification rate for new smear839 121 were reported, 393 244 ofwhich were smearpositive infectious cases increased from 16.6 per positive infectious cases. 100 000 in 1993 to 23.7 in 1998, an increase of 43%. Mortality is highest among young adults, the most However, in China in the same period the rate economically productive age group. In adults aged increased by 141%. In 1998, 55% of the notified cases 15-64 years, tuberculosis accounted for the majority in the Region were in China (Figure 3.2).

__.__,_

Figure 3.1 Estimated percentage of DALYs lost due to infectious diseases in the Region (ages 15-64) Malaria Others 9% Tuberculosis

Tuberculosis and poverty Tuberculosis is a disease of the poor. Approximately 90% of global tuberculosis cases are in developing countries. Poverty and poor living conditions aggravate tuberculosis. In the Philippines, for example, it has been shown that the tuberculosis rate in low-income urban populations is double that of the general urban population. Health systems need to take the relationship between tuberculosis and poverty into account when carrying out tuberculosis control.

Hepatitis

B/C 5%

, co

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TB AND LEPROSY ELIMINATION

Tuberculosis and health systems The inadequate health systems in some countries in the Region make implementation of tuberculosis control mechanisms difficult, since effective tuberculosis control requires an effective community health care system, an uninterrupted drug supply, high-quality laboratory services and a standardized information system.

RESPONSE The WHO-recommended strategy for tuberculosis control is directly observed treatment, short-course (DOTS). DOTS has been shown to cure nine out of ten tuberculosis patients and to prevent the emergence of multi-drug resistant tuberculosis strains . Implementation of the DOTS strategy strengthens health systems because it requires: a laboratory network with efficient quality assurance; an uninterrupted supply of anti -tuberculosis drugs; involvement of health workers and community in directly -observed treatment; an integrated information system for surveillance, management and evaluation ; and well-trained and supervised staff within both public and private sectors. At the global level, the Stop TB Initiative hosted a Ministerial Conference on Tuberculosis and Sustainable Development in Amsterdam in March 2000 . The conference concentrated on the 20 countries in the world with the highest tuberculosis burden. These 20 countries account for 80% of the global burden oftuberculosis and include Cambodia, China, the Philippines and Viet Nam from the Western Pacific Region . The main objective of the conference was to build and sustain government commitment to effective tuberculosis control as part of overall health sector development. In the Region, the first meeting ofthe Technical Advisory Group (TAG) was held at the Regional

Tuberculosis in industrialized countries Tuberculosis is a public health concem in all countries and areas of the Region, including newly industrialized and industrialized countries. In Hong Kong (China), Japan, Malaysia and Singapore, for example, the number of notified cases declined steadily between 1945 and 1970, but has not declined further for several years. This is partly due to increased detection of new patients among older persons and immigrants. In 1999 Japan declared a tuberculosis emergency (see box on page 28).

Tuberculosis/HIV co-infection

It is estimated that there were 307 000 people with HIV/tuberculosis co-infection in the Region in 1997. Of these, 143 000 were in China and 83 000 were in Cambodia. The impact of HIV on tuberculosis is particularly serious in Cambodia. In 1995, 5% of newly notified tuberculosis cases were HIV -positive and this had increased to 7% by 1996. It is projected that the Figure 3.3 Projection of HIV infection and HIV-related tuberculosis cases in Cambodia, 1995-2003 percentage will reach 16% by Estimated HIV+ D elected 2001 (see Figure 3.3). tuber c ulosis ca s es 2 5 00 0

pop

3 5 0 00 0 3 00 000

Drug resistance 20 000

Drug resistance is a significant problem in some areas in the Region. One out of four provinces in China undertaking drug resistance surveillance has a high prevalence of primary multidrug resistance, mainly because many patients in areas that do not practise DOTS have failed to complete their drug regimens.

250 000 15 0 00

2 00 000 1 5 0 00 0 100 000

1 0 00 0

5 000 50 0 0 0

1 995 -

1 996

1 997

1 9 96

1 999 20 0 0 200 1 2002

2003

Ye ar HIV-ne ga t1v e T B d et e c ted c::::::JHIV-posl t lv a T B d e tecte d -

C ur re n t HIV +

COMBATING COMMUNICABLE DISEASES

Tuberculosis emergency in Japan Alarmed by signs of a resurgence oftuberculosis, the Ministry ofHealth and Welfare declared a 'Tuberculosis Emergency' in July 1999. The number of newly diagnosed tuberculosis cases in Japan rose from 42 122 in 1996 to 44 016 in 1998, the first increase in 38 years. The tuberculosis detection rate was 34.8 per 100 000 population in 1998, which was high for a major industrialized country. The majority oftuberculosis patients in Japan are older persons. However, the number ofcases oftuberculosis in people in their twenties and thirties has been increasing. There have been tuberculosis outbreaks in medical institutions and schools in some prefectures. The Ministry ofHealth is collaborating with prefectural health authorities, medical associations and NGOs to: enhance social mobilization to raise public awareness at central as well as prefectural level through the public health network, the private sector, schools and NGOs; • strengthen data collection from public health centres to evaluate and strengthen tuberculosis control acti viti es; • publish and distribute guidelines for prevention and control of tuberculosis to health centres, mass media, schools, medical associations, etc; • conduct routine radiological examination for tuberculosis suspects in the hospitals for early case detection and prevention of tuberculosis outbreak; • implement preventive therapy at prefecture level for high-risk groups such as older persons with fibrotic lesions; and • conduct a nationwide survey on tuberculosis drug resistance through public health centres. •

Office in February 2000. The meeting endorsed the Regional Strategic Plan to Stop TB in the Western Pacific (see box on p.32) and approved the regional objectives to reduce tuberculosis prevalence and mortality by half by 2010. The TAG recommended that three main countrylevel activities be carried out: (1) a comprehensive five-year (2001-2005) national Stop TB plan should be developed, (2) a national inter-agency coordinating committee (ICC) to assist in implementation of the national plan should be established, and (3) a sustained procurement, quality control, and distribution system, resulting in an adequate supply of quality antituberculosis drugs, should be put in place. The TAG also recommended that Member States should include DOTS indicators among their routinely collected health system performance measures. A Regional ICC meeting consisting of leading partner agencies working in tuberculosis was held in conjunction with the TAG meeting. The Regional ICC committed itself to supporting national Stop TB plans. At the country level, WHO expanded its incountry support for tuberculosis control in China. In the Philippines, WHO collaborated in setting up

tuberculosis diagnostic committees in several provinces to improve the quality of the DOTS programme. WHO also conducted a cost-benefit study of tuberculosis control. The Japan International Cooperation Agency (JICA) and WHO began a project in mid-1999 in Cambodia aimed at enhancing national capacity to sustain DOTS and improving surveillance on drug resistance and HIV/tuberculosis co-infection. Guidelines for controlling tuberculosis through DOTS in Pacific island countries were published by the Regional Office and distributed in July and August 1999. National guidelines for DOTS implementation based on these guidelines were then drawn up in selected countries. Training for laboratory technicians and for health workers on DOTS information systems was conducted in four countries in collaboration with Secretariat ofthe Pacific Community. A meeting for countries with an intermediate level oftuberculosis was organized by the Research Institute of Tuberculosis in collaboration with WHO in Hong Kong (China) in June 1999 to share information and to analyse why the number of tuberculosis cases in Hong Kong (China), Japan, Malaysia and Singapore was either static or increasing.

STOP

TB !WD LEPROSY ELIMINATION

Technical assistance for national prevalence surveys in Cambodia, China and Viet Nam was provided through the WHO Collaborating Centre for Tuberculosis in the Republic of Korea in 1999. Drug resistance surveillance was conducted in three provinces of China and in Mongolia. Advocacy materials for the Stop TB special project and a regional report on tuberculosis control in 1999 were published and distributed as part of the preparation for World TB Day on 24 March 2000.

RESULTS National TB Day at the Philippine Department of Health

The implementation of DOTS is having an impact on tuberculosis prevalence and mortality in several countries of the Region. In China, the DOTS strategy was introduced in early 1990 and over 500 million people now have access to the strategy. It is estimated that since the introduction of DOTS in China, 30 000 deaths have been prevented each year. In the Republic of Korea, the prevalence of smear-positive infectious tuberculosis cases decreased from 240 cases per 100 000 population in 1985 to 90 per 100 000 population in 1995. This was due to a combination of factors, including political support for free case detection and treatment, a regular supply of high-quality drugs and stronger management from central to peripheral levels. The percentage of notified cases that have benefited from DOTS has increased considerably. In particular, the percentage of newly notified smearpositive infectious cases enrolled in a DOTS programme increased from 43% in 1995 to 72% in 1998, due to increased case detection in DOTS areas. The treatment success rate for patients enrolled in DOTS is excellent and has been maintained at over 90% since 1994. However, less than 60% of the Region's population has access to DOTS, a percentage that has not increased since 1996 mainly because of the slow implementation ofDOTS in China. This means that, of the estimated 897 000 new smear-positive infectious cases in the Region every year, only 32% currently benefit from the strategy.

Planning has improved in several countries with a high tuberculosis burden through the development of five-year national plans to secure uninterrupted drug supplies and sustain tuberculosis control in the context ofhealth system development. Most countries have improved their recording and reporting systems, which will allow them to carry out precise analysis oftreatment outcomes in DOTS areas.

ANALYSIS DOTS remains WHO's recommended tuberculosis control strategy in the Western Pacific Region, where it has cured 94% of enrolled patients. Through DOTS, the disease can be cured, transmission can be prevented and the increasing trend of multidrug resistance reversed. However, the percentage of the estimated new sputum positive cases benefiting from DOTS increased only marginally from 26% in 1997 to 32% in 1998. To reach the objective of reducing tuberculosis prevalence by half by 201 0, the DOTS strategy will have to be expanded throughout the Region by 2005. However, most countries with a high burden of tuberculosis are not able to adequately finance tuberculosis control or to purchase sufficient antituberculosis drugs. Political and financial commitment from each country is crucial if the targets of the Stop TB project are to be achieved.

CoMBATING COMMUNICABLE DISEASES

detected in DOTS areas, the national budget for tuberculosis control more than doubled in 2000 compared to 1999. In the Pacific island countries, only 40% of estimated cases were actually notified in 1998. Only a few countries and areas currently implement DOTS. To introduce and expand the DOTS strategy in Pacific island countries technical support will have to be strengthened and political commitment increased. In several industrialized and newly industrialized countries the number of tuberculosis patients has stopped decreasing and may even be increasing. This is due to several factors, among Case detection through case fin ding by sputum smear microscopy examination in general heahh s~rvices is one of the five key elements them an increase in the population of of DOTS older persons whose immunity has decreased; high prevalence among It is essential that countries should form national immigrants; weak case holding; and an increase in lCCs or use existing bodies to ensure consistency in tuberculosis/HIV co-infection. These countries will implementing Stop TB activities at country level, to have to undertake compr ehensive analyses of achieve optimal coordination among partners and to tuberculosis and formulate special plans iftuberculosis secure funding. cases are to be reduced further. In China, an anticipated funding shortfall will There is a concern that drug-resistant tuberculosis have to be addressed. The tuberculosis control bacilli will spread to other areas or countries. To component of the 'Infectious and endemic disease prevent this, implementation of DOTS in areas with control project' covers over 500 million people and high-drug resistance is urgently required. China has achieved excellent treatment outcomes. The provides a striking example of the effectiveness of project is supported by a World Bank loan that will DOTS in preventing drug-resistance; drug resistance end in mid-200 1. Sustaining the achievements already is three times lower in provinces using DOTS than in provinces not using DOTS strategy. made will be a considerable challenge. It is estimated that more than US$ 20 million per year in additional funds will be needed if the DOTS strategy is to be FUTURE expanded nationwide by 2005. Special funds from national and provincial governments for tuberculosis control will therefore be needed. It will also be crucial WHO will strengthen its partnership with technical to build strong partnerships with international and funding agencies to ensure sufficient human and agencies to secure accessible and affordable highfinancial resources are available on a sustainable basis. quality treatment, particularl y in low-income WHO support will focus on th e following areas. provinces or counties. Collaboration with countries in the development The expansion of DOTS in the Philippines has ofcomprehensive five-year national Stop TB plans (200 1-2005), based on the Regional Strategic Plan accelerated since 1997 and by the end of 1999 43% of the population had access to DOTS (as compared with and including a financial component, will be strengthened. 30% in March 1999). This has been achieved because ofthe Government's strong political commitment and Partnerships will be enhanced through the because of the dedication of trained health workers Regional Inter-Agency Coordinating Committee from central to peripheral level. In order to secure and the establishment of Inter-Agenc y anti-tuberculosis drugs for all tuberculosis patients Coordinating Committees at country level in order

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STOP

AND LEPROSY EL/M/NAT/ON

to ensure sustainable financing for tuberculosis control, including highquality anti-tuberculosis drugs. Technical support for the seven countries with a high burden of tuberculosis (Cambodia, China, the Lao People's Democratic Republic, J'iEU DUiiG TliUOC Mongolia, Papua New Guinea, the • PHDI H~~ ..... Philippines and Viet Nam) will be .DtiNG UEU .ueuoMl augmented in order to expand and D U Tlllil GIAil sustain the DOTS strategy to reach the regional target by 2005 . In China, WHO will coordinate with its partners to establish an Interagency Coordinating Committee to Stop TB in order to mobilize resources. Technical support for A healthworker in Viet Nam observing a tuberculosis patient taking his drugs financing of China's national tuberculosis control programme and the introduction of the DOTS strategy in poor range of issues, particularly collaboration with provinces and counties will be strengthened. countries with an intermediate level of Technical support will be provided to introduce tuberculosis. This will cover such areas as the DOTS strategy in Pacific island countries in development of a tuberculosis information system, collaboration with the Secretariat of the Pacific assessment of the tuberculosis status ofimmigrants and operational research. Community. The first Stop TB Meeting in Pacific Islands will be held in June 2000. Support for surveillance of drug resistance, WHO will continue to work closely with with the tuberculosis/HIV co-infection and tuberculosis prevalence will be enhanced. Research Institute of Tuberculosis in Tokyo on a

IIIII

COMBATING COMMUNICABLE DISEASES

Stop TB special project in the Region In September 1999, the Regional Committee for the Western Pacific declared a "tuberculosis crisis" in the Western Pacific Region. The Committee urged Member States to give high priority and to allocate sufficient resources to strengthening tuberculosis control. It also endorsed "Stop TB in the Western Pacific Region" as a special project of WHO in the Region.

The first meeting of the Technical Advisory Group in February 2000

The objectives of the Stop TB project were established by the Tuberculosis Technical Advisory Group (TAG) and are to reduce the prevalence and mortality of tuberculosis in the Region by half by 2010 and to ensure that the DOTS strategy is incorporated into country plans for health sector development. The Stop TB special project aims to generate social and political support for the fight against tuberculosis in the Region. The targets of the project are to: detect 70% of estimated smear-positive tuberculosis cases and enrol all detected cases in DOTS programmes; ensure a treatment success rate of at least 85% for smear-positive cases in the DOTS programme; include DOTS indicators in health sector performance indicators; and secure free treatment for all smear-positive tuberculosis patients enrolled in DOTS by encouraging an increase in national resources devoted to tuberculosis control. Following the appointment of nine externai TAG members and a Stop TB Task Force at the Regional Office, the Stop TB project was officially launched at the first meeting of the TAG in February 2000.

'-~~'

STOP

TB AND LEPROSY ELIMINATION

Leprosy

ISSUES By the end of 1998, the global target of eliminating leprosy as a public health problem at the national level (prevalence ofless than 1 case per 10 000 population) by 2000 had been reached by 32 of the 37 countries and areas in the Region, representing 99.7% of the Region's population. Included in the 32 were three countries with fewer than 10 cases each. It is expected that the remaining five countries and areas (see box on p.34) will achieve elimination well before 2005, the new global target. In some of the countries that have reached the elimination target, there are still pockets where the prevalence is higher than the elimination target. There is also a large pool of individuals in the Region who are already infected but have no detectable signs of leprosy. The long incubation period of the disease means that a small proportion of these infected individuals will develop leprosy in years to come. Disease surveillance systems in many countries are still inadequate. In addition, there are no surveillance mechanisms in operation that are specifically designed to address leprosy problem after elimination. Disability and its management and the social stigma that still operates against sufferers are important issues, even in countries that have already reached the elimination target.

reviews, to conduct focal surveys of pockets ofhighendemicity and to strengthen monitoring and supervision mechanisms.

Post-elimination etTorts Countries that have reached elimination at the national level but still contain pockets of high endemicity at the subnational level (such as Cambodia, the Lao People's Democratic Republic, the Philippines and Viet Nam) are being encouraged to develop and implement special projects to eliminate leprosy in these pockets.

Post-elimination surveillance The major components of surveillance systems for leprosy are: referral centres for case diagnosis and management; notification of individual cases; national leprosy awareness campaigns; and periodic evaluation. As new cases are expected to develop for many years to come, there must be a mechanism to identify and collect information on these cases and to treat them promptly. A protocol for a post-elimination leprosy surveillance system has therefore been developed by the Regional Office and is being tested during 2000 in Cambodia and the Philippines. WHO collaborated with its partners in supporting information, education and communication activities and community-based rehabilitation of disabled leprosy patients, notably in Cambodia, China, the Lao People's Democratic Republic, the Philippines, Papua New Guinea and VietNam. WHO's support for leprosy elimination in the Western Pacific Region is carried out in collaboration with a number of partners. These include the International Federation of Anti-Leprosy Associations, the Nippon Foundation, the Pacific Leprosy Foundation and the Sasakawa Memorial Health Foundation (SMHF), among others.

WHO RESPONSE Efforts to achieve the elimination goal WHO is focusing its efforts on the five countries that have not yet reached the elimination target. In the period, the special projects that have been implemented in Kiribati, Marshall Islands and the Federated States of Micronesia since 1996 were followed-up with intensified activities to ensure high treatment completion rates through periodic case

COMBATING COMMUNICABLE DISEASES

Priority countries and areas Guam, Kiribati, Marshall Islands, the Federated States ofMicronesia and Papua New Guinea have not yet reached the elimination target (less than 1 case per 10 000 population), largely because of the high endemicity of the disease, difficulties in accessing certain communities and areas, and population migration. Slow implementation of planned activities and completion of treatment are particular problems in Marshall Islands and Papua New Guinea. The total number of registered cases in these five countries at the end of 1998 was 1268, of which 1033 were in Papua New Guinea. Prevalence ranged from 1.6/10 000 in Kiribati to 21/10 000 in Marshall Islands (Figure 3.4). Efforts were intensified in 1999 to complete planned projects early and to improve treatment completion rates for detected cases by strengthening monitoring and supervision. It is possible that the elimination target will be reached in Guam, Kiribati and Papua New Guinea by the end of2000 and in Marshall Islands and the Federated States of Micronesia by the end of2001. Figure 3.4 Leprosy elimination: prevalence of leprosy in priority countries and areas, 1994-1998

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35 30 25 20 15 10 5 0

. 1994

. 1995

D 1996

D 1997

• 1998

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Federated States of Micronesia

Marshall Islands

Kiribati

Papua New Guinea

Guam

RESULTS The total number of leprosy cases registered in the Region fell by 92% between 1988 and 1998. This dramatic reduction has been mainly due to the implementation ofshort duration multidrug treatment regimens since 1985. However, the detection of new

cases has been constant during the same period (Figure 3.5). Population screening in Kiribati, Marshall Islands and the Federated States of Micronesia, together with the implementation of a Special Action Project for Elimination of Leprosy (SAPEL) in Papua New Guinea has resulted in detection of

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STOP

TB AND LEPROSY EL/M/NAT/ON

Figure 3.5. Leprosy elimination, Western Pacific Region total cases 171 new cases and their treatment and case detection rate, 1988-1998 with MDT during 1999. Six special projects were 25~0 . -- -- - - -- -- -- - - -- -- -- -- -- -- - - -- -- - - -- -- , 012 completed in 1999, targeting pockets of high endemicity in three of the 010 20~0 countries that have reached .§ "' 0.08 "3 elimination (see Table 3.1). / . B~ 15~0 a. A national leprosy week was a ~ 006 a a marked successfully in Cambodia, ]l a :=. 10~0 ~ using mass media and traditional a; 004 a. means ofcommunication to improve $ 50000 0:: "' leprosy awareness. 002 A comprehensive and integrated project for rehabilitation of needy 0 ' - - - -- -- -- -- -- - - -- - - - - -- -- - - -- -- -- -- -- - - ' 0 00 disabled leprosy patients was Year established in Cambodia during • Case detection rate - - - Total cases 1999, supported by the Comite International de l'Ordre de Malte (CIOMAL) and the SMHF. Community-based decline in leprosy prevalence from 41.48/ 10 000 in rehabilitation projects supported by The Leprosy 1996 to 5.80/ 10 000 in 1998. It is anticipated that a Mission International (TLM) are also being similar decline in prevalence will occur in Kiribati implemented in China and the Lao People's and Marshall Islands following similar strategies in Democratic Republic. these countries. Intensified case holding and case review activities in Papua New Guinea during 1999 resulted ANALYSIS in a considerable decline in prevalence from 2.24/10 000 in 1998 to 1. 6/10 000 at the end of The strategy of total population screening and September 1999. preventive therapy in the Federated States of The case detection rateof7.23/100 000 in special Micronesia from 1996 to 1998 resulted in a marked projects that were implemented during 1999

Table 3.1 Leprosy activities in countries that have achieved elimination

Cambodia Lao People's Democratic Republic Philippines

632 714

100

873

1 847 783

27 169

7164 548

3 6

1 490 073

Total

3 970 570

287

197

8 585

COMBATING COMMUNICABLE DISEASES

====-======== ==================

was much lower than the rate of 15.45/100 000 in projects implemented during 1996-1998. It appears that most of the backlog of cases that had remained undetected for years have already been detected and treated. Data from large countries like China, Japan, Malaysia, the Republic of Korea and Viet Nam indicate that prevalence and case detection rates decline continuously but slowly after elimination has been achieved. Constant vigilance needs to be maintained in countries that have reached elimination recently (Cambodia, the Lao People's Democratic Republic, the Philippines and VietNam) to monitor the leprosy situation after elimination.

. FUTURE It will be essential to maintain resource mobilization, technical expertise, motivation ofhealth workers and public awareness beyond the elimination goal. During the transitional period from elimination to freedom from leprosy, tasks such mobilization of resources, sustaining the interest of partner agencies, technical expertise and motivation of service providers, and maintaining public awareness must continue to be carried out. Leprosy surveillance must therefore be integrated into general health services to take care of the few new cases that will occur and to care for leprosy patients with residual disabilities.

4. Sexually transmitted infections, including HIV/AIDS

ISSUES HIV and AIDS

By the end of 1999, it was estimated that almost 900 000 individuals in the Western Pacific were HIV-infected and that there had been at least 15 000 new cases of AJDS in the year (Figure 4.1 ). The HIV epidemic in the Western Pacific Region continues to grow and the total number of people living with HIV in the Region is expected to pass the 1 million mark before the end of2000. However, there is significant underreporting and underdiagnosis ofboth HIV and AJDS. Cumulative totals of 120 039 cases ofHIV infection and 24 483 cases of AJDS had been reported by mid-1999. Ofreported HIV (including AJDS) cases in 1999 35.9% of cases were due to transmission through injecting drug use, 29.3% to sexual transmission (25.8% through heterosexual sexual contact and 3.5% through homosexual or bisexual sexual contact); 5.3% to mother-to-child transmission, and 0.09% to infected blood or blood products. The mode of Figure 4.1 Reported, estimated and projected AIDS incidence in transmission was not reported in the Western Pacific Reg1on, 1988-2003 29% of cases. There were five key features of the HIV epidemic in the 25 Region during the review period, 0 0 all related to the maturing of the E. 20 ro epidemic. m >-

future (for example, it is projected that the annual number of new AJDS cases in Cambodia will reach 30 000 by2005). Efforts need to be made to develop the capacity of health systems while developing alternative methods of care such as home care. (2) Tuberculosis/HIV co-infection increased, particularly in Cambodia, Malaysia and Papua New . Guinea. Tuberculosis/HIV co-infection is now a serious concern in these countries and one which needs to be addressed as a priority (see also pp.26-32). (3) HIV transmission due to injecting drug usc remained the largest reported category, although the proportion of HIV cases due to heterosexual transmission continued to increase (Figure 4.2), necessitating aggressive interventions targeting individuals with high-risk sexual behaviour and prevention and control of sexually transmitted infections (STI). ( 4) Related to the increase in heterosexual transmission, the percentage of HIV (including AJDS) cases due to mother-to-child transmission

(1) There was a significant increase in the number of AIDS cases, with a near doubling of reported cases from 1997 to 1998 (Figure 4.1 ). This created a heavy burden on already stretched health services in some countries, a burden which is likely to increase in

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1988 1989 1990 1991 1992 19931994 1995 1996 1997 1998 1999 2000 2001 2002 2003 c::::::::J Reported --+---- Estimated and proJected Year

COMBATING COMMUNICABLE DISEASES

Figure 4.2 Reported HIV (including AIDS) cases in the Western Pacific Region by mode of HIV transmission, 1987-1999 %of total HIV/AIDS reported cases

70 60 50 40 30 20 10 0 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

---+- Blood products

Mother-infant ----.-Heterosexual

~ Homo/bisexual

------ IOU

increased from 3.7% ofreported cases in 1998 to 5.3% in 1999. In selected areas, it is now justifiable to consider the introduction of the most recent interventions to prevent mother-to-child HIV transmission. (5) The HIV transmission pattern varies from country to country and even within areas in one country. Surveillance systems need to be reinforced to monitor these trends and the response has to be tailored to each country's needs. Many national and international partners are now involved in HIV prevention and control. No single agency or institution can tackle this epidemic by itself and ensuring communication and coordination between all partners involved has to be a priority.

healers) to ensure confidentiality. If they are to be effective, STI prevention and care programmes cannot be limited to the public sector. Such programmes will have to ensure that training, policy-making, and monitoring programme implementation also cover the private sector. Epidemiological surveillance continued to discover increasing gonococcal antibiotic resistance all over the Region. The increase in such resistance will require treatment protocols to be adapted, often by using more costly drug regimens. This problem highlights the need to improve control of the prescription and delivery of antibiotics, and to reduce self-treatment.

Safe blood and blood products Sexually transmitted infections In the review period, research findings reinforced the need to provide effective services for people suffering from sexually transmitted infections (STI). There is evidence that in many countries the majority of STI patients consult the private sector or other health services providers (such as pharmacists or traditional In the context of an expanding HIV epidemic, the safety of blood and blood products needs to be reinforced. Paid blood donation needs to be discouraged and voluntary blood donors encouraged. The establishment of national blood transfusion services regulating blood donation and processing should remain a priority (see pp. 128-133).

WHO's partnership with UNAIDS in HIV and STI programmes WHO continues to support UN AIDS theme groups actively. These theme groups coordinate the UN system's response to HlV at country level and during the period efforts were made by the various UN partners to develop common plans of action to ensure complementarity and better use of available funds. For example, in VietNam, WHO is working together with the other UN AIDS co-sponsors and the government to ensure that condoms are available for STI prevention and that support for AIDS care is properly coordinated with all partners. In Mongolia, WHO has worked with UNFPA and others to provide technical and other support to the Government to improve STl services. In Cambodia, UN AIDS funds have enabled WHO to support the government to improve STI education, diagnosis and treatment in the military health system. At the regional level, efforts have also been made to plan, coordinate and monitor the UN response to the HIV epidemic in the Region. In collaboration with national programmes, UNAIDS co-sponsors have identified the needs at country level, work priorities and the role that each co-sponsor should play. Condom promotion has been identified as the first priority and a plan of action has been developed for a one-year period with all the partners concerned. WHO, together with UNFPA, took the lead in preparing this plan and is now involved in its implementation with Member States. Monitoring and analysis of the progress made and difficulties encountered will be made twice a year. However, the mobilization of additional resources is imperative and, in particular, there is an urgent need to recruit additional experts to support programme implementation at country level.

WHO RESPONSE Prevention of STI, including HIV and AIDS WHO has continued to collaborate with Member States to provide more effective STI education, counselling and services to sex workers and their clients. Pilot STI education and service projects are underway in China, Fiji, Mongolia and Viet Nam. Counselling of STI patients in the Region has been a major focus in the review period, with efforts directed at promoting behaviour change and preventing further STI transmission. Training workshops on STI counselling were held in Cambodia, China, the Philippines and various Pacific island countries. "100% condom use" within the sex industry remains an important strategy. In the period, WHO supported the expansion of the strategy in Cambodia and strengthened condom promotion in China, Papua New Guinea, the Philippines and VietNam . A regional strategy for condom promotion has been drafted . Guidelines on "1 00% condom use" and condom promotion in STI clinics have been finalized and distributed widely in the Region.

Strengthening STI programmes WHO has continued to support Member States to: improve the organization and management of national STI programmes; develop appropriate STI policies; redefine the role of specialist STI services; and improve STI services at the primary health level through the use of the syndromic approach, which enables immediate STI treatment. In the review period, WHO provided technical support to improve STI programmes in Cambodia, China, Mongolia, Papua New Guinea, the Philippines, Viet Nam and several Pacific island countries. In collaboration with the Joint United Nations Programme on AIDS (UNAIDS), a meeting of STI, HIV and AIDS programme managers was held in the Regional Office in September 1999. Two technical guidelines were published and distributed: The role of policy in the prevention and control of sexually transmitted infections and Laboratory tests for the detection of reproductive tract infections. WHO supported STI prevalence studies in China, Malaysia, Samoa and Vanuatu . These studies documented a significantly higher level of STI prevalence than was previously assumed. For example,

CoMBATING COMMUNICABLE DISEASES

Table 4.1 HIV and AIDS estimations for selected countries of the Western Pacific Region, 1999 .' , " ;

• '

•

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Countries with high and increasing HIV incidence - primarily heterosexual transmission Cambodia Papua New Guinea 170 000 5 400 3.3 0.2 10 000 150

Countries with high HIV incidence among injecting drug users and increasing HIV heterosexual transmission China VietNam 500 000 102 000 <0.1 0.24 n/a 3700

Countries with slowly increasing HIV incidence Hong Kong (China) Japan Lao People's Democratic Republic Malaysia Philippines Republic of Korea Singapore 1 400 50 000 13 000 3 800 4 800 <0.1% 0.4 <0.1% <0.1 0.18 >50 900 >50 +/- 30 > 120 3 700 8 100 <0.1 <0.1 +/- 60 +/- 200

Countries with declining HIV incidence Australia New Zealand 11 000 1 200 874400 0.11% <0.1% +/- 200 +/- 30 >15 500

Total

up to 35% of pregnant women in Samoa and Vanuatu were found to have an STI. High STI prevalence rates were also found among people with high-risk behaviour, including truck drivers and sex workers in China (Anhui and Yunnan Provinces, respectively), and among sex workers in Malaysia (Kuala Lumpur) and the Philippines (Manila). Given the high rates of STI in the adult population, there is a danger of increased HIV transmission in Pacific island countries. In partnership with UN AIDS and Member States, during the review period WHO strengthened the capacity of health providers in Pacific island countries to plan and to provide high-quality STI services. For example, courses on the use of the syndromic approach for STI care have been attended by more than 300

professionals from Pacific island countries. A strategic plan of action for STI prevention and care in Pacific island countries (2000-2002) has been drafted. The plan covers capacity building, STI and HIV epidemiological studies and other related research activities, development ofSTI policy and guidelines, and revision of medical and nursing school curricula. In the review period, strategic action plans for STI prevention and control were also prepared in Cambodia and Mongolia.

Blood safety The Regional Office also continued to support improvements to blood safety in the Region (see pp. 128-133).

SEXUALLY TRANSMITTED INFECTIONS, INCLUDING H/V/A/OS

AIDS care WHO's support for AIDS care focuses on reinforcing the capacity of health systems to cope with the expected increase in AIDS cases. Care guidelines have been developed, strategic approaches to AIDS care have been designed and health care workers have been trained. Regional activities focused initially on supporting activities in Cambodia, given the scale of the epidemic there. Development of a National Strategic/Action Plan for AIDS care was supported and national guidelines for AIDS care were finalized. Commercial sex workers in the Philippines receiving health education The AIDS horne care project, begun with support from WHO as a pilot AIDS surveillance report and a regional report on the project in 1998, now serves as a model for other Status and trends o.f STI, HIV and AIDS at the end of countries in the Region . WHO has also supported the millennium. The HIV/STI database, which is AIDS care in the Lao People's Democratic Republic available through the Regional Office website, was and VietNam. A twice-yearly Antiretroviralnewsletter improved and updated. was launched by the Regional Office to inform public health specialists and health care workers of the latest developments in the use of antiretroviral drugs for the prevention and care ofHIV infection.

RESULTS Reduced STI and HIV transmission in some countries Extensive public information campaigns and effective interventions targeted at those most at risk of HIV infection in Australia and New Zealand have clearly demonstrated that the HIV epidemic can be reversed. In Thailand, a country which experienced a severe epidemic in the late 1980s and early I 990s, recent data have shown that HIV incidence can be significantly reduced, even in a country with more limited resources. Progress can be reported in developing countries of the Region. In Cambodia there is evidence that in Sihanoukville province the" 100% condom use" strategy has led to a rapid decrease in the number of registered STI cases and a decrease in HIV incidence has been noted. Stemming the HIV epidemic in the Region will be a long process. Nevertheless, achievements can be noted in several countries in the areas of prevention, strengthening STI programmes, AIDS care and improving epidemiological and surveillance data. It is expected that these achievements, if expanded and

Monitoring the epidemics WHO supported Member States to improve their STI epidemiological and surveillance data. This included: developing and strengthening HIV, AIDS and STI information systems; analysing data; and using the findings for programme planning, monitoring and evaluation. During the review period, technical support to improve surveillance systems was provided to Cambodia, China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines, Viet Narn and several Pacific island countries. HIV/AIDS consensus workshops (see box on p. 43) were held in Cambodia, Papua New Guinea and the Philippines. A regional workshop to review STI, HIV and AIDS epidemiological surveillance in Pacific island countries was held in Fiji in November 1999. The Gonococcal Antimicrobial Susceptibility Programme was strengthened by establishing a sampling, testing and monitoring network throughout the Region . Epidemiological data from the Region were collected, analysed, and disseminated through publications, including the twice-yearly STJ, HIV and

COMBATING COMMUNICABLE DISEASES

Strengthened STI programmes One of the most effective ways of strengthening STI programmes is by ensuring that staff are well-trained. WHO has devoted considerable resources to developing human resources in STI programmes. Senior STI programme staff from Cambodia, China, the Lao People's Democratic Republic, Papua New Guinea and several Pacific island countries have been trained in STI programme management. An operational research project on identifying risk factors for STI infection among asymptomatic female sex workers in the Philippines was completed, and the results are being disseminated. Pilot projects to integrate STI services into maternal and child health (MCH) and family planning programmes are underway in Cambodia and the Philippines. A pilot programme to establish revolving drug funds for sn is being implemented in two sites in the Philippines.

As part of the 100% condom use programme in Sihanoukville, Cambodia, an STI clinic has been established to maintain medical records on sex work establishments and on individual sex workers

Improved AIDS care WHO's work with countries, particularly Cambodia and Viet Nam, is leading to an improvement in standards of AIDS care. Recent results have included development of guidelines for the treatment of AIDS; finalizing of national action plans; resource mobilization; training of health workers; revision of health worker curricula; and piloting of interventions to prevent mother-to-child transmission of HIV. In Cambodia, the AIDS home care project, initiated with the support of WHO as a pilot project in 1998, continued to expand in selected areas and now serves as a model for other countries in the Region. Efforts are now underway to reinforce joint strategies for HIVI AIDS and tuberculosis.

strengthened, will lead to reductions in STI and HIV/ AIDS incidence, as in Australia, New Zealand and Thailand.

Successful prevention programmes The "100% condom use" programme has been successful in selected areas of Cambodia and is serving as a model for other countries, including China, the Philippines and VietNam. A strategy for condom promotion and distribution at the regional level has been prepared. Pilot STI education and services projects are now underway in China, Fiji, Kiribati, Mongolia, the Philippines and Viet Nam. STI education and service programmes have been reinforced for the military and other client groups in Cambodia. Special STI prevention and care activities have been developed for sex workers and other young people in Mongolia. STI counselling has been promoted in Cambodia, China, the Philippines and Pacific island countries.

More accurate epidemiological and surveillance data Our understanding of the HIV and STI epidemics in the Region has improved markedly over the past few years. Epidemiological and surveillance systems are now much stronger and national HIV and AIDS estimations and projections are regularly updated based on a consensual approach. STI prevalence surveys

- - 4.

SEXUALLY TRANSMITTED INFECTIONS, INCLUDING HIVIA/OS

Reaching a consensus on STI and HIV/AIDS WHO has initiated and supported the organization of national consensus workshops. In these workshops, national and international experts work together to analyse the data available and to perform a critical analysis of the surveillance system. Such workshops have been held in Cambodia, Malaysia, the Philippines and VietNam in previous years and in Cambodia, Papua New Guinea and the Philippines during the review period. In each ofthese workshops, country-specific STI, HlV and AJDS estimates and projections were agreed on and specific recommendations were made to improve surveillance systems. For example, the consensus workshop in Cambodia forecast that at least 30 000 new AJDS cases would occur by 2005, enabling the Government to make key decisions on the organization of the health sector and on the support needed from the international community. Consensus workshops have been useful for obtaining high-quality analysis ofthe epidemiological situation to enable broad agreement on the HJV, AJDS and STI epidemiological situation in a country and to guide decision-making.

provide an accurate view ofSTI prevalence in selected populations and are a valuable tool for advocacy and programme design. A plan of action for STI, HlV and AlDS surveillance has been developed for the Pacific island countries. Gonococcal antimicrobial susceptibility is now monitored in 17 countries ofthe Region. Exchange of information has also been improved.

ANALYSIS There is not a single HlV epidemic in the Region, but numerous sub-epidemics, each with its own characteristics (see Table 4.1). With the exception of that in Cambodia, these sub-epidemics continue to be concentrated among individuals with specific highrisk behaviour, such as people with multiple sex partners (especially sex workers and their clients) and injecting drug users, and in specific geographical areas. WHO is working with Member States to focus efforts on improving sentinel and behavioural surveillance ofthese sub-epidemics, and to implement and evaluate targeted interventions. However, behavioural surveillance and other STI prevalence studies, showing low rates of condom use and high and increasing rates of STI among

commercial sex workers, their clients and sometimes even the sexually active population, emphasize the risk that HlV epidemics may spread to the more general population in a number of countries. The extent to which this happens will depend upon how committed governments are to introducing large-scale preventive measures. Stronger political commitment is needed to undertake effective action to prevent larger HIV epidemics in most ofthe countries ofthe Region. With comparatively low HlV prevalence, many countries may become complacent about HlV, yet preventing HlV needs to remain a key priority. Targeted interventions (such as the "100% condom use" and harm reduction programmes for injecting drug users) are needed to reach individuals most at risk ofHlV infection. More accessible and effective STI services are needed in both the public and private sectors, yet most countries are still unable to provide adequate funding for effective STI treatment and prevention, including the provision of STI drugs. This needs to be addressed in the context of wider health service financing issues. In many countries, STI services are still provided largely at the referral level and there is still a strong need to ensure the effective provision of STI services at the primary care level, for example through the use ofthe syndromic approach.

COMBATING COMMUNICABLE DISEASES

measures that need to be implemented in the short term, efforts should also be made to provide more employment opportunities for young women and to introduce education on sexual health into school programmes.

FUTURE It is clear that preventing HI V transmission and responding to increasing AIDS care needs is a daunting task. It is therefore crucial for WHO to continue to work with UNAIDS and Member States and all Health education materials are used to help people at risk tn prevent other partners to ensure continued HJV infection commitment and action to prevent larger I-lfV epidemics. In particular, WHO and its As well as targeting interventions at women in Member States need to work together to identifY the the Region with high-risk behaviour, it is also geographical areas and population subgroups most at important to improve STI services for women as a risk of HIV infection, and to implement targeted whole, for example through MCH and familyplam1ing interventions for these areas and groups. programmes. In selected contexts, the introduction of WHO support will continue to focus on: an tiretrovir al treatment in order to reduce mother-to-child HIV transmission can also be • supporting interventions targeting those most at risk of STI and HIV infection, particularly considered, although its cost-eifectiveness should be condom programmes; carefully considered in each context (e.g. in Cambodia, • strengthening advocacy with Member States for it has been estimated that the cost per case of HIV more intensive and effective STI, HIV and AIDS infection averted was over US$ 1800). prevention and control programmes; The rapid increase in numbers of people with AIDS means that there is an urgent need to improve • supporting epidemiological surveillance by AIDS care provisions, to guarantee confidentiality of providing technical support and guidance at country and regional levels to monitor the epidemic, design medical information and to prevent stigmatization. interventions and measure their impact; Demands on health services, conmmnities and families will increase dramatically over the coming few years. • improving STI programme planning, policies and To prepare for this, strategic and action plans, clinical management, emphasizing STI services at the primary health care level; guidelines and protocols all need to be developed and health workers have to be trained. • supporting the development of AIDS care, HIV is now progressing rapidly in some parts of including the prevention of mother-to- child HIV the Region. Among other consequences, this may lead transmission in countries experiencing an increasing number of people with AIDS; to increasing levels of tuberculosis, increasing the • enhancing harm reduction programmes targeting already heavy burden on the Region's health systems. injecting drug users, in close coordination with the Ultimately the HIV epidemic may significantly affect the health status of populations in many areas of the United Nations Drug Control Programme (UNDCP); and Region. It is known that poverty and low levels of education are often at the root of expanding HIV • coordinating efforts with partners at national, regional and international levels. epidemics. In addition to the urgent and large-scale

5. Communicable disease surveillance and response

ISSUES In all countries of the Region there is a growing need for effective communicable disease surveillance systems that will respond rapidly to outbreaks of communicable disease. Early detection, investigation (including laboratory analysis), and rapid response are essential to control outbreaks. However, these three components are not yet fully functioning in many countries and areas. Recent outbreaks in the Region have included cholera, typhoid fever, dengue and dengue haemorrhagic fever, E. coli 0157, hantavirus, enterovirus 71, new types of influenza A (H5N 1, H9N2), and newly identified zoonotic paramyxoviruses (Hendra and Nipah viruses). In addition to disease outbreaks, antimicrobial drug resistance is an increasing public health problem.

In 1999, a total of 93 72 cases were reported, mostly from China and Viet Nam . However, incidence in these two countries has been reduced by the immunization prograilli1le (from 23 618 cases in 1991 to 8108 cases in 1999 in China, from 3447 cases in 1994 to 1236 cases in 1999 in VietNam). Cases were also reported in Cambodia, the Lao People's Democratic Republic, Malaysia, and Singapore.

Rabies Although the incidence of rabies has been reduced in some countries in the Region by animal vaccination programmes, rabies is still a significant public health problem in many countries in the Region, including Cambodia, China (3 73 cases and 31 7 deaths in 1999), the Lao People's Democratic Republic, the Philippines (282 cases in 1999) and VietNam (77 deaths in 1998).

Cholera and other diarrhoeal diseases Cholera is still a major public health problem in the Region. Significant numbers of cholera cases were reported from Cambodia, China and the Philippines in 1999. Smaller outbreaks occurred elsewhere in the Region. A total of5771 cases of cholera were officially reported to WHO. Although the case fatality rate has been steadily declining since 1991, it has remained between 1% and 2% in recent years, which is still higher than the WHO target of <1 %. Other diarrhoeal diseases such as typhoid fever, shigellosis and salmonellosis also cause significant morbidity and mortality in the Region .

Other diseases There have been many other outbreaks of communicable diseases in the Region in recent years, including leptospirosis, non-poliomyelitis enteroviruses, brucellosis, anthrax, plague and legionellosis.

Antimicrobial resistance Antimicrobial resistance (usually caused by inappropriate use of antimicrobial drugs) is a growing problem in both developed and developing countries in the Region.

.,..

Japanese encephalitis Japanese encephalitis is distributed widely in the Region. It has been controlled successfully in Japan and the Republic of Korea by routine immunization.

Communicable disease surveillance Communicable disease surveillance systems in Cambodia, Malaysia, Papua New Guinea and VietNam have been reviewed by WHO and several common problems have been identified:

COMBATING COMMUNICABLE DISEASES

WHO RESPONSE WHO has continued to provide technical support to Member States to: (1) strengthen communicable disease surveillance, (2) improve the capacity for outbreak response, and (3) facilitate information exchange on communicable diseases.

Communicable disease surveillance The first draft of a guideline for communicable disease surveillance particularly aimed at outbreak-prone diseases such as cholera and dengue has been prepared. The main features of the proposed system are: • Active surveillance. In active Surveillance in rural communities often involves house-to-house surveys, as surveillance, surveillance staff make in this diarrhoeal survEy in Papua New Guinea regular visits to health facilities to report and investigate cases of communicable late reporting; diseases. This ensures timeliness, accuracy and low coverage; completeness of reporting, and minimizes the risk of no zero reporting (as a monitoring indicator in reporting failure. the absence of cases); • Integrated approach . An integrated approach • no coordination between vertical programmes; minimizes overlap among different vertical poor quality of data; programmes. • no universal case definition; and • Clear and universal case definitions. • poor laboratory support. • Rapid reporting, data analysis and.feedback (early warning system).

International Health Regulations The current International Health Regulations (IHR) were developed in 1969, replacing the International Sanitary Regulations, which were adopted by the World Health Assembly in 1951. They were first introduced to ensure maximum security against the international spread of diseases with minimum interference to world traffic. The current IHR cover only three diseases; cholera, plague and yellow fever. A revision of the IHR was called for by the World Health Assemblyin 1995, which underlined "the continuous evolution in the public health threat posed by infectious diseases" and "the threat posed by considerable increases m international travel".

Outbreak response WHO has provided various forms of technical and financial support to control outbreaks in the Region. WHO consultants and/or staff were sent to investigate and respond to outbreaks of cholera in Cambodia, Brunei Darussalam, Fiji and the Lao People's Democratic Republic. They were dispatched within a few weeks of the first notification. In collaboration with Ministry of Health staff, outbreaks were thoroughly assessed to identify risk factors and transmission routes. WHO also provided technical and financial support for patients' care and control and

=========== ================ 5. prevention activities. During the Nipah virus outbreak in Malaysia, WHO staff and consultants were sent to support outbreak investigation and control. Following outbreaks, a meeting of the working group on zoonotic paramyxoviruses was held in Kuala Lumpur, Malaysia, in July 1999 (see box on p.50). This group discussed technical and operational aspects ofHendra and Nipah virus outbreaks. WHO also supported Member States to control outbreaks by providing information on diseases, advising on suitable control measures, and providing supplies.

C OMMUNICABLE DISEASE SURVEILLANCE AND RESPONSE

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Information exchange The first issue of WPRO Communicable Disease Bulletin was published in November 1999. This Bulletin contains data on such communicable diseases as cholera, dengue, influenza, typhoid, and dysentery Data on vaccine preventable diseases are also included. The Bulletin will be published quarterly and will provide up-to-date information on communicable diseases in the Region. An Internet-based data entry system to facilitate rapid reporting and feedback is being tested.

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NIPAH VIrus Outbreak Summary

Pacific Public Health Laboratory Network WHO and the Secretariat of the Pacific Community (SPC) are working together to set up a public heath laboratory network in Pacific island countries. This network will link existing laboratories to ensure rapid and accurate laboratory confirmation of outbreaks such as measles, rubella, dengue and influenza.

Influenza surveillance Influenza virus surveillance is essential to monitor potential pandemic strains and to provide information that can be used to determine the composition of influenza vaccine every year. A laboratory network has been established to monitor influenza activities in the Region. A total of15 National Influenza Centres arc located in 10 countries and there are also two WHO Collaborating Centres in the Region: Melbourne, Australia and Tokyo, Japan. WHO recommends vaccine composition every year based on surveillance data obtained through this network. In China, WHO provided technical support for the preparation of a national influenza surveillance plan. Equipment and reagents were provided to strengthen laboratory capacity in Beijing and provincial laboratories. Laboratory workshops were organized in Beijing, China in October 1999 in collaboration with the Centers for Disease Control and Prevention, the United States of America and the National Institute of Infectious Diseases, Japan. At the regional level, an influenza pandemic preparedness plan is being devised.

Cholera control WHO supported cholera prevention and control in Cambodia and the Lao People's Democratic Republic following significant cholera outbreaks. WHO also provided emergency supplies such as antibiotics, oral rehydration salts, intravenous fluid and water, and laboratory supplies. Guidelines for cholera control were translated into local languages and distributed. National and local training workshops for cholera control were also conducted with technical and financial support from WHO. WHO has stockpiles of cholera emergency kits at two strategic locations (Manila, the Philippines and Suva, Fiji) to provide emergency supplies quickly in case of outbreaks.

COMBATING COMMUNICABLE DISEASES

Influenza pandemic Influenza is one of the most common infectious diseases in the world. It causes seasonal epidemics in temperate climates almost every year. These yearly epidemics occur because of minor changes in antigenic proteins (antigenic drift) in influenza virus A and B, the two viruses that cause epidemics in humans. Currently only three influenza viruses are commonly circulating in humans: A(HlNl), A(H3N2), and B. Avian species are infected with a number of different influenza A viruses. Some animals such as swine are also infected with influenza A. However, avian or animal strains normally do not infect humans (species-barrier). Influenza has the potential to cause a pandemic, or a worldwide epidemic, because of major antigenic changes (antigenic shift). A pandemic occurs only occasionally at unpredictable intervals. When it occurs, however, a large portion ofthe world's population may become infected. This is because no one has immunity against the new strain. Mortality may also be high, especially among the old and the very young. In 1918-1920, a pandemic known as "Spanish Flu" was responsible for 20-40 million deaths worldwide, more than all those killed in the First World War, which immediately preceded it. This pandemic is thought to have been caused by influenza A(Hl N I). Three other pandemics occurred in the 20th century: "Asian Flu" in 1957 caused by A(H2N2), "Hong Kong Flu" in 1968 caused by A(H3N2), and "Russian Flu" in 1977 caused by A(H1Nl). The "Asian" and "Hong Kong" pandemics together killed more than 1.5 million people and cost an estimated US$ 32 billion due to productivity losses and medical expenses. There is evidence that the pandemic viruses originated from animal species ("Spanish" from swine, "Asian" and "Hong Kong" from avian species). Human infections of new strains that have not caused a pandemic have been documented. In 1976, influenza A(H l N 1) related to swine virus was isolated from an army recruit in the United States of America who subsequently died. A massive influenza immunization campaign was carried out, and over 40 million people were vaccinated by end of 197 6. However, the programme was stopped because it was evident by then that the virus spread was limited to the recruit's army camp. More recently, in 1997, A(H5N1) virus was isolated in Hong Kong (China) for the first time in humans from a boy who subsequently died. Until that point influenza A(H5N1) had been known to infect only avian species. By the end ofDecember 1997, a total ofl7 additional cases were confirmed in Hong Kong (China). Many of these cases had severe infections, particularly in adults, five of whom died. Intensive investigation revealed that most cases contracted the virus through direct contact with chickens and not through human-to-human transmission. Further cases in humans ceased following the mass slaughter of chickens by veterinary authorities. In April 1999 two influenza A(H9N2) viruses were identified in two hospitalized children, also in Hong Kong (China). Both had mild symptoms without severe complications, and fully recovered.

Brucellosis control Brucellosis is a re-emerging public health problem in Mongolia. WHO provided technical support for the preparation of a National Brucellosis Control Plan. A pilot vaccination programme was also carried out to assess the feasibility of animal vaccination.

RESULTS Focal points for communicable disease surveillance data have been identified in all Member States. This network will greatly facilitate information exchange in the Region. Dissemination of information on

================-'-~-=-=~=====-=

COMMUNICABLE DISEASE SURVEILLANCE AND RESPONSE

communicable diseases has also been improved by the launch of the WPRO Communicable Disease Bulletin. Improvements to communicable disease surveillance systems will take longer to achieve, but progress has already been made through various seminars and workshops in Cambodia, China, the Lao People's Democratic Republic and several Pacific island countries. These included training on basic epidemiological analysis, computer software such as Epi-lnfo, and data management. A regional plan for control of cholera and other epidemic diarrhoeal diseases has been the basis for national cholera control plans in Cambodia, the Lao People's Democratic Republic and the Philippines, with technical support from WHO. Based on these national plans, control and preventive measures have been implemented, including training workshops and health education for the general public. The first meeting of the Public Health Laboratory Network in the Pacific Islands was held in Noumea, New Caledonia, in April2000 to strengthen laboratory capacities in the Pacific. This meeting was co-organized by SPC and WHO. Antimicrobial resistance has been continuously monitored. The results of this monitoring system showed that this is a widespread problem in the Region in both developed and developing countries, and resistance has been steadily increasing in the past decade. An evaluation ofthe monitoring system is now being carried out in order to carry out a more updated and action-oriented system. Field trials of the revised International Health Regulations (IHR) have been conducted in selected countries in the Region, leading to a number ofvaluable suggestions for improvements.

WHO recommends that surveillance systems for selected outbreak-prone diseases should be based on active surveillance, a method that has been very successful in the eradication of poliomyelitis. This will make surveillance more action-oriented and will enable rapid outbreak response. Outbreak response capacity is limited in many countries . Major constraints include lack of trained staff, and a shortage of financial resources. Greater use of the field epidemiology training programme (FETP) will improve training of national and local staff New FETP programmes were launched in Japan and the Republic of Korea in addition to existing programmes in Australia and the Philippines. Laboratory capacity to support surveillance needs to be improved; at present it is limited by inadequate training, equipment and supplies in many countries. Regional and national laboratory networks should be established to improve laboratory diagnosis at all levels.

FUTURE Regional guidelines for communicable disease surveillance and response will be disseminated by WHO. Technical support will be provided to countries to enable them to prepare their own national guidelines · for surveillance. National and provincial level staff working in surveillance and outbreak response will be trained in collaboration with the field epidemiology training programmes in Australia, Japan and Thailand, also with Centers for Disease Control and Prevention, the United States of America. Quick and effective outbreak response mechanisms will be established at the Regional Office by the roster system, improved stockpiles, and close collaboration with institutions in the Region. National capacities for outbreak response will also be strengthened. More efforts will be made to improve information exchange between WHO and Member States, including an Internet-based data system. A regional influenza pandemic preparedness plan will be established, based on the global pandemic preparedness plan that was published in April 1999. Influenza surveillance will be strengthened, particularly in China, Mongolia, the Philippines, VietNam, and Pacific island countries. Antimicrobial resistance monitoring will be

ANALYSIS Communicable disease surveillance will become more and more important due to rapid globalization (increasing international travel and trade), the emergence of newly identified diseases, and rapid dissemination of outbreak rumours by the media and Internet. However, existing systems are not able to detect and respond to outbreaks quickly or effectively enough in most Member States. Even when surveillance data are available, they are often not properly analysed at national and provincial levels, due to a lack of trained staff and other resources.

COMBATING COMMUNICABLE DISEASES

thoroughly reviewed in collaboration with WHO Headquarters to ensure that the regional monitoring programme can be integrated into a global monitoring programme.

The revision of the International Health Regulations will be completed and this will strengthen global surveillance and response to communicable diseases.

Nipah virus outbreak in Malaysia and Singapore Outbreaks of the newly identified Nipah virus occurred in Malaysia and Singapore from October 1998 to May 1999. During the outbreak, 265 cases (including both confirmed and unconfirmed cases) and 105 deaths were reported in Malaysia and 11 cases and 1 death were reported in Singapore. The Nipah virus is an entirely new virus that belongs to the paramyxovirus family and is related to the Hendra virus discovered in Australia in 1994. Zoonoses are infections that normally infect domestic or wild animals, but under special circumstances can infect humans, resulting in severe illnesses and deaths. In recent years populations around the world have been increasingly subject to outbreaks of infectious diseases which have reservoirs among animal species due to factors such as deforestation, increasing international trade and movement of domestic animals. Available data suggest that the fruit bat is the natural reservoir for this virus. Pigs were initially infected by the virus, and people who had contact with pigs (mainly pig farmers) were in turn infected. The precise transmission route of infection from bat to pig, pig to pig, and pig to human is still under investigation. Clinical signs ofNipah virus infection in humans are similar to those of other forms of viral encephalitis such as Japanese encephalitis. They include fever, headache, confusion, seizure, and coma. To date, there is no specific vaccine or anti-viral treatment available for Nipah viruses. WHO was involved early in the outbreak and sent consultants to provide technical support. After the outbreak, WHO organized a meeting of an expert working group in Kuala Lumpur in July 1999 to discuss recent zoonotic paramyxovirus outbreaks, including Nipah and Hendra viruses. The workshop participants made the following recommendations: In the event of further outbreaks ofNipah virus, infected and in-contact domestic animals should be slaughtered. A simple and effective diagnostic tool for Nipah virus infection should be developed. • A clear epidemiological description of the disease should be developed, risk factors identified and transmission routes for infection determined. Communicable disease surveillance mechanisms should be developed in all countries in order to provide the capacity to detect, investigate, and respond to outbreaks of emerging diseases. The natural history of the Nipah virus in its wild reservoir should be described.

Building healthy communities and populations The aim of this theme is to improve the health of communities and populations through integrated approaches which stress the links between development, the environment and health. WHO supports and is expanding the "settings approach", for example, Healthy Cities and Healthy Islands. This approach has been particularly successful in developing an intersectoral, integrated approach to improving the health of people in selected environments. The approach is characterized by strong community action and supportive public policies. Particular issues faced by the theme include high maternal and infant mortality in some countries, an increasing bmden of noncommunicable diseases in almost all countries, a steady increase in tobacco consumption and poor safe water and sanitation coverage. The theme has five focuses, which are described in the following chapters: 6. Healthy settings and environment The settings approach Safe water and sanitation Food safety International Year of Older Persons 7. Child and adolescent health and development Integrated management of childhood illness Nutrition Adolescent health and development 8. Reproductive health 9. Noncommunicable diseases, including mental health Strengthening surveillance for noncommunicable diseases Diabetes Mental health Substance abuse I 0. Tobacco Free Initiative

6. Healthy settings and environment

The settings approach

ISSUES The pursuit of economic development has brought about overall economic improvement in the Region, although the wealth that has been created is rn1equally distributed. It has also changed the physical and social environments in which people live, and these changes have in turn affected their health and well-being. Recent rapid industrialization and urbcmization in developing countries of the Region have led to: • concentrated living space and unhygienic conditions in poor urban districts, allowing infectious diseases to spread quickly; • physical ha zards , such as explosive and inflammable materials, traffic hazards and noise near industrial facilities and in urban areas; • increased energy use in the industrial and transportation sectors, leading to more air pollution; • use of potentially toxic chemicals in agricultural farms, manufacturing plants and homes, creating risks of acute poisonings and chronic health problems; • uncontrolled population migration from rural to urban areas for jobs and education, leading to changes in family and community structures; and • psychosocial stress in homes, schools and workplaces. Global economic development has also affected fragile physical environments and unique social structures in the Pacific region . This has meant . . m creases m : • trade, particularly imports of consumer goods, leading to more solid waste, such as

Members of the community whitewcL~hing walls in the Healthy Cities project in Marikina, the Philippines

non-biodegradable packaging waste, paper, aluminium and tin cans, discarded vehicles, lead batteries and waste lubricant oil, which pollutes streams and coastal water; • use of fertilizers and pesticides, leading to contamination of groundwater; • importation of food items, changing the dietary patterns of Pacific islanders and causing health problems such as obesity and diabetes;

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Table 6.1 WHO-supported country-level healthy settings activities (July 1999-June 2000)

Model projects development

Marketplaces

Lao People's Democratic Republic (Vientiane Municipality; Champassak, Luangprabang, Savannakhet and Vientiane Provinces) Mongolia (Darkhan and Ulaanbaatar) Papua New Guinea (Port Moresby) Viet Nam (Haiphong and Hue) Mongolia (Uiaanbaatar) Viet Nam (Haiphong and Hue) Philippines (Manila) Lao People's Democratic Republic (Vientiane Municipality) Mongolia (Darkhan) Viet Nam (Haiphong and Hue) Fiji Niue Papua New Guinea Samoa Solomon Islands

Workplaces Hospitals Case-study reports Cities

Islands

• increased tourism and a more mobile lifestyle, both of which increase vulnerability to infectious diseases; and • information on foreign cultures, which may adversely influence community and social life and cause psychosocial stress.

WHO RESPONSE People spend their daily lives in specific settings, such as cities; villages; food markets; and workplaces. These settings provide unique physical and social environments that support livelihoods and health. WHO has therefore promoted an approach that integrates health protection and health promotion in specific settings, using intersectoral and communitybased action. A more integrated approach to urban health problems in the Region began in the early 1990s. Support for Healthy Cities projects started in 1994, and the concept was applied to island settings in ~he Pacific in 1995, leading to the companion Healthy Islands initiative. Projects to encourage healthy villages, workplaces, marketplaces and hospitals were begun in 1997, often as part of Healthy Cities or Healthy Islands projects. The general strategy employed by WHO for the promotion ofthe settings approach involves:

• developing model projects m selected countries; • documenting the experiences of these projects as case studies; • publishing regional guidelines; • formulating regional action plans; and • establishing effective national coordinating mechanisms. Table 6.1 summarizes WHO-supported activities covering healthy marketplaces, workplaces, and hospitals during the review period. In addition, WHO began to develop healthy tourism activities in the Region during the period. With respect to regional action plans and guidelines, WHO reviewed experiences in implementing various healthy settings initiatives in the Region during a meeting on Health Protection and Health Promotion: Harmonizing Our Responses to the Challenges of the 21st Century held in the Regional Office in August 1999. The meeting also formulated a regional action plan on healthy settings for 2000-2003 and reviewed draft regional guidelines on healthyworkplaces which were subsequently finalized. A WHO workshop on Healthy Cities: Preparing for the 21st Century, in Malacca, Malaysia, in October 1999, developed a regional action plan on Healthy Cities, and reviewed draft regional guidelines on Healthy Cities.

6. HEALTHY SETTINGS AND ENVIRONMENT

Healthy Islands in Papua New Guinea In December 1999, a Healthy Islands Framework for a Plan of Action for Papua New Guinea was completed in collaboration with WHO. The document offers a vision for the 21st century for the whole country to serve as a guide to government departments, the private sector, nongovernmental organizations and all development partners in the implementation of the Healthy Islands initiatives. It contains the vision, characteristics, objectives, strategies and responsibilities for settings such as healthy cities/ towns, healthy marketplaces, health-promoting health facilities, health-promoting schools, healthy public transport, healthy restaurants, healthy villages, and healthy workplaces. Following Parliament's approval in February 2000, a multisectoral National Coordination Committee for Healthy Islands was formed to oversee the planning, development, and evaluation of Healthy Islands settings as well as to provide the technical support necessary for their successful implementation. The Department of Health provides the Secretariat.

The opening ceremony for the Yalu Healthy Village

Village elders have maintained the first Healthy Village in Yalu, Morobe, since it was launched in 1996. The health-promoting schools programme has its own multisectoral National Coordinating Committee. Eleven provinces have launched the health-promoting schools programme and there are plans to extend the programme to all 19 provinces and the National Capital District by 2001 . In Port Moresby, the biggest market in the country, Gordons Market, was selected as the pilot healthy marketplace project. At a food safety seminar and healthy marketplace workshop in November 1999, a plan of action for the market was prepared. The National Capital District Commission embarked on a 200 000 kina (US$ 75 000) rehabilitation programme which will be a model for other markets nationwide. Despite the many hurdles experienced in these initiatives, the Healthy Islands concept is gaining acceptance from the leaders of the country to the grassroots level. It is proving to be a unifYing factor in altering behaviour and lifestyles.

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BUILDING HEALTHY COMMUNITIES IWD POPULATIONS

Healthy marketplace initiative The healthy marketplace initiative promotes better markets by looking not only at food safety, but also at the structure ofbuildings, water supply and waste management, training and educating vendors and raising awareness of consumers. Since 1997, healthy marketplaces have been promoted in Phnom Penh, Cambodia; Baoding, China; Vientiane, the Lao People's Democratic Republic; and Haiphong, VietNam. In 1999, the initiative was expanded to include marketplaces in Mongolia and Papua New Guinea and Hue, VietNam. In Cambodia plans have been made to include other markets in and outside Phnom Penh. In the Lao People's Democratic Republic, markets in Champassak, Luangprabang, Savannakhet and Vientiane Provinces have been included. A typical process employed for developing a healthy marketplace is as follows. After a marketplace is selected and a healthy marketplace committee is established, orientation courses on food safety and on improving the marketplace are conducted. Seed funds are provided to rehabilitate the market and to disseminate information, education, and communication materials for vendors and the public. These healthy marketplace initiatives have achieved both structural and behavioural changes. Water pipes and proper sanitation facilities have been installed to enable vendors and customers to clean themselves and wash their hands. Food and non-food stalls have been separated. In some markets, roofs and drainage have been renovated to keep the area dry. Food vendors have been trained to keep food safe. After three years of implementing the initiative it is now important that experiences are documented, not only to improve the approach, but also to provide examples for other countries.

Healthy market place in Viet Nam

Supporting countries to establish effective national coordination mechanisms is an important part ofWHO 's work in this area. In cooperation with WHO, the Department of Health in the Philippines established a task force on Healthy Cities and selected three cities in Metro Manila (Makati, Marikina and Quezon) in which to begin the initiative. The national Healthy Cities coordination committees in the Lao People's Democratic Republic and VietNam have prepared national plans for developing Healthy Cities initiatives. To support the sharing of experiences in developing healthy settings activities, WHO has

cosponsored or organized a number of intercountry meetings, including two international conferences on Healthy Cities (the International Conference on Healthy Cities and Urban Policy Research in Tokyo in March 2000 and the Australian Pacific Healthy Cities Conference in Canberra in June 2000). WHO collaborated with the National Institute of Public Administration, Malaysia (INTAN) and the Japan International Cooperation Agency in conducting a four-week course on the Promotion of Healthy Environments in Urban Areas (Healthy Cities Programme) in Malaysia in September-October 1999. Through its Collaborating Centre for Environmental

HEALTHY SETTINGS IWD ENVIRONMENT

Health at the University of Western Sydney, Hawkesbury, WHO conducted a three-week course on Environmental Management for Health: Community-based Approaches for Healthy Islands in Fiji in September-October 1999. WHO also sponsored overseas participants to attend a one-week short course on Healthy Cities and Communities at the Flinders University of South Australia, Adelaide, in October 1999. There were also study tours organized for officials involved in Healthy Cities projects in China, Mongolia and the Philippines. To support the networking of Healthy Cities, a regional database with information on Healthy Cities projects, including contact addresses, has been made available through the Regional Office website.

Another significant outcome of WHO's work is that the exchange of information and experience that is so essential to the successful implementation of healthy settings activities is now greatly enhanced. Regional guidelines on healthy workplaces and Healthy Cities have been published and are being supplemented by a regional database that has been established as part of the Regional Office website. Intercountry meetings, conferences, training programmes and study tours supported by WHO have also provided excellent opportunities for exchanging experiences among participants, and encouraged them to develop their own projects further.

ANALYSIS The experiences of developing Healthy Cities projects were analysed at the WHO workshop in Malacca, Malaysia, in October 1999 which drew the following conclusions: • Variations in Healthy Cities: There arc significant variations in the way Healthy Cities projects have been implemented, reflecting differences in levels of economic development, local history and culture, and political and administrative structures. • Building on existing city initiatives: A new Healthy Cities project should review relevant existing initiatives and, whenever possible, integrate them into the project. • Strong political support: Strong political support is essential for the implementation and sustainability of a Healthy Cities project. Without it, a project has little chance of achieving organizational changes, cooperation across sectors or reallocation of resources. • Need for a coordinating structure : A coordinating structure to encourage sectors to work together is essential, although the exact nature of the structure will differ from city to city. • Active community parti c ipation and involvement: Involving community representatives from the beginning of the project development is vital, and the way this is done depends on the local traditions of civil society and the experience and skills of the project personnel.

RESULTS The most important result of WHO's work in this area is that the concept of healthy settings is clearly starting to take root, not only within health sectors, but with partners in other areas. This was demonstrated during the meeting on Health Protection and Health Promotion in August 1999 and the WHO workshop on Healthy Cities in Malacca in October 1999. Several model projects on healthy workplaces, marketplaces and hospitals which started during the review period have already achieved positive outcomes (see boxes). For instance, the healthy workplaces project in VietNam, which engaged a total of30 small and medium-scale enterprises in Haiphong and Hue, has significantly improved the physical conditions of the workplaces (dust and noise have been controlled and workers have received personal protection equipment), workers' lifestyles (16%-85% of the workers in the enterprises involved in the project in Hue gave up smoking) and organization of occupational safety and health programmes (responsible officers have been designated and monthly reporting established). The healthy marketplaces project, initiated in late 1997 in Haiphong, VietNam, has also improved the physical conditions of marketplaces (water and sanitary facilities have been constructed; dry goods, vegetable and meat vendors and eateries have been relocated; and drainage and roofs have been rehabilitated) and behaviour patterns (litter has been reduced) .

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BUILDING HEALTHY COMMUNITIES AND POPULATIONS

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• Effective leadership: A common feature of successful Healthy Cities projects is a strong and effective individual who can begin the process, mobilize support and get the activities go mg. • External support and encouragement: External support from national coordinating units, WHO and other international partner agencies is vital for training, study visits and technical advice. • Need for short-term achievements: Some initiatives that can demonstrate achievements in the short term are important to maintain political and community commitment. • Ensuring sustainability of Healthy Cities initiatives: Factors contributing to the sust<1inability of Healthy Cities initiatives include strong political support, community ownership and the demonstration of positive outcomes. • Need for evaluation, monitoring and indicators: There is a need to develop an evaluation framework which includes process indicators and short-, intermediate- and longterm outcomes of the project.

exchange of experiences. In this connection, the national Healthy Cities coordinating committees in Lao People's Democratic Republic and VietNam have strengthened their coordinating capacity, while that in Mongolia needs further improvement. There is a need to develop a framework or methodology to enable healthy settings initiatives to improve evaluation oftheir activities .

FUTURE The development of model projects on healthy workplaces, marketplaces and hospitals will continue, and case-study reports will be disseminated to other potential users. More cities and countries will join Healthy Cities programmes. WHO will work with Pacific island countries to address selected priority health issues related to Healthy Islands, using the settings approach. More training opportunities for people engaged in Healthy Cities and Healthy Islands projects will also be provided. WHO will collaborate with Member States in evaluating healthy settings projects and developing "good practices" in evaluating these projects. WHO will also collaborate with national coordinators for Healthy Cities and Healthy Islands to strengthen their capacity to support and coordinate healthy settings activities at the local level. Networking between people engaged in Healthy Cities projects will be further supported through study tours, regional meetings and the updating of the regional database to allow more direct communications between cities. The Regional Office is playing an active role in drafting global guidelines for healthy tourism. These will be formulated in the second half of 2000 and finalized in early 2001. They will include specific guidelines on health and sanitation for ships and aircraft.

These lessons were incorporated into the regional guidelines on Healthy Cities. Exchange of information and experience will remain crucial to the success of Healthy Cities and Healthy Islands projects. A good example is the working relationship that has been established between Healthy Cities projects in Malaysia and those in the Philippines. WHO arranged for consultants from Malaysia with experience of Healthy Cities projects to visit the Philippines and for their counterparts in the Philippines to undertake a study tour to Malaysia. When the number of healthy settings initiatives is increased in <1 country, national-level coordination becomes importi:lnt to provide guidance and facilitate

HEALTHY SETTINGS AND ENVIRONMENT

Healthy Hospital Initiative in the Philippines An extended care centre for children who have long-term illness or whose parents are ill was begun at the San Lazaro Hospital (SLI-1) in the Philippines at the end of 1999. The centre is designed to be linked to the community across a broad range of public health concerns. Because of its clientele and its unique relationship with the Department of Health, the SLH offered an excellent opportunity to pilot such an approach. Precious Jewels Ministry (PJM), a nongovernmental organization, has extensive experience in providing care and support for HlV-infected children and their families in the Philippines, which made it well suited as a partner in the project. A Memorandum of Agreement was signed by the Department of Health, WHO and PJM covering the operation ofthe Centre for an initial period of three years. The objectives of the project are to: 1. develop a model framework and plan of action for an extended care centre that serves as a catalyst for interaction between the hospital and the community in meeting public health needs; 2. provide for the health and developmental needs of children living in families with chronic illnesses; 3. respond to the psychosocial needs of children and their extended families who are coping with lifethreatening and chronic illnesses; 4. assess the health status and psychosocial development of children infected and affected by chronic illness; and 5. enhance resource utilization through collaboration and resource-sharing and develop a sustainable programme that fosters mutually beneficial partnerships. In developing this project, one of the primary issues of concern was sustainability. Such projects often collapse after the initial implementation period when funding is no longer available from external support agencies. Therefore, it was agreed early in the project development process that the partners did not want to proceed unless long-term sustainability could be reasonably assured. The centre is therefore included in the regular programmes and associated operating budgets ofSLH, PJM, and others, as appropriate (this commitment is reflected in the Memorandum of Agreement). Another issue of primary concern is maintaining effective community linkages. To achieve such linkages, the centre will select priority communities, including some where nongovernmental organizations and government departments are already working reasonably well in areas related to public health, especially chronic diseases.

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BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Safe water and sanitation

ISSUES Access to safe water and adequate sanitation Disease outbreaks are constant reminders of the threat to health caused by unsafe water and inadequate sanitation. Contaminated water and poor sanitation still cause more than 500 000 infant deaths a year in Asia and the Pacific, as well as a huge burden of illness and disability. Diarrhoea associated with contaminated water poses a particularly serious threat to health. A survey of countries in the Region at the end of 1999 highlighted the following issues: • The percentage of the population with access to adequate sanitation is only about half that with access to safe water and this gap is expected to 11-m:~en if it is not addressed. Based on reports received from 15 countries in the Region as of the end 1999, 43% of the population had access to adequate sanitation as compared to 74% of the population with access to safe water. In the same 15 countries in 1990, the percentage of the population with access to safe water was 71%, while the percentage with access to adequate sanitation was 79%. Thus the health benefits bought about by safe water are to some extent dissipated by inadequate sanitation. Drinking water contaminated by faecal matter is a problem in several countries. So too is helminth infestation, particularly among schoolchildren, due to the use of fresh and inadequately composted excreta in agriculture and aquaculture. • Access to safe water and adequate sanitation is lower in rural populations than urban and the gap is expected to widen if it is not addressed. As of the end of 1999, 63% ofthe population in rural areas had access to safe water ( 66% in 1990) compared with 94% in urban areas (87% in 1990). In rural areas 28% of the population had access to adequate sanitation (76% in 1990), compared with 71% in urban areas (91% in 1990). During this

period the total population ofthe 15 countries grew by 104 million and there was a considerable population shift from rural (decreased by 99 million) to urban areas (increased by 203 million). • More than half of the countries in the Region lack the infrastructure to ensure water safety and quality and a significant number ofpeople are exposed to chemical contaminants ofboth natural and industrial origin. Of the 37 countries and areas in the Region, 15 reported having national drinking water quality standards based on WHO guidelines. Of the remaining countries, 8 reported that they did not have any national standards, and 14 did not report. Industrial pollution and endemic fluorosis due to excessive amounts ofnaturally occurring fluorides and arsenicism due to excessive amounts of naturally occurring arsenic in drinking water are public health concerns in a number of countries. • There are major constraints to increasing service coverage and ensuring sustainability. There were 23 countries who reported on this issue. The main constraints to increasing service coverage were (in order): an inadequate cost recovery framework; funding limitations; inadequate operation and maintenance; insufficient trained professional and support staff

Water is a limited resource Human use of fresh water systems has risen sharply in recent years. From 1950to 1995, wateruseinAsia increased three-fold. The exploitation of water resources and contamination by pollutants have seriously degraded water quality, reducing the amount of clean water available. In addition, rapid population growth has resulted in a decline in the annual per capita availability of fresh water in developing countries ofthe Region. One of the underlying reasons for the decline in the availability of fresh water is that water is not considered to be an economic commodity, and is undervalued.

HEALTHY SETTINGS AND ENVIRONMENT

National, subregional and regional cooperation needs to be increased if conflicts over shared use of water resources are to be avoided. While agriculture will continue to use most water, demand for fresh water is growing fastest in the urban and industrial sectors, and countries will need to establish a policy on allocating scarce water resources among competing sectors. Countries will have to accept that growing populations, poor management, leakage, wastage, and contamination mean that per capita availability of safe drinking water wiJI be significantly reduced in the future.

WHO RESPONSE WHO's efforts in the Region are focused on capacity building to ensure sustainability of water and sanitation systems. These efforts often take place as part of Healthy Cities and Healthy Islands initiatives, using the "healthy settings" approach. Projects to improve sanitation lie at the heart of many of WHOs Healthy l~lands project~- here a pour-flush toilet is being a.ssemhled in Fiji

Portable field test kits, laboratory equipment and supplies were provided.

Community involvement Ensuring safe water The ultimate goal ofthe healthy settings approach is to build healthy communities. In Mongolia, a new site was selected for the healthy village initiative. Ensuring access to safe water and adequate sanitation will be an important element of this initiative. To ensure community ownership, which is the key to success and sustainability, the participatory hygiene and sanitation transformation approach (PHAST) developed by WHO is being introduced in the Region. PHAST was introduced in VietNam during the reporting period. A comprehensive national water quality programme was started in Cambodia in the last quarter of 1999 and it will continue until the first half of 2001. The programme builds on previous support for drafting legislation and standards to ensure water quality.

Development and strengthening of human resources Technical support was provided to the Federated States of Micronesia and Tonga to assess human resource needs in the water supply sector in December 1999. Plans of action were developed.

Providing technical and logistical support Cook Islands and Kiribati received technical and logistical support on leak detection and control, water quality monitoring and general management of water supply and sanitation facilities. Typhoid and cholera outbreaks were investigated in collaboration with the Governments concerned and logistical support was provided to improve water supply and sanitation facilities. Support was provided to Fiji to construct and rehabilitate water supply and sanitation facilities.

Development and testing of appropriate technologies Simple and cost-effective water disinfecting methods will help to ensure safe water. WHO has, therefore, supported the development of appropriate technologies such as on-site production of a chemical disinfectant for water that was field tested in the Lao

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

particularly in mainland Asia, lack of fresh water and adequate sanitation do not have the dramatic impact of some other causes of illness. As noted above, the gap between water and sanitation coverage is growing. There appear to be two main reasons for this: first, sanitation is given low priority by many governments because it is generally considered to be a household responsibility and, second, donors are more interested in supporting water rather than sanitation projects. Many of the unserved or underserved communities in the Region are in remote or water-deficient areas. This is exacerbated by the lack of Residents of a village in Papua New Guinea discuss latrine building adequate roads to enable construction materials for wells and latrines to be brought in. These constraints affect the initial capital People's Democratic Republic. A comparison between cost and recurrent costs of both water and sanitation the possible use of renewable resources for systems. disinfecting (e.g. solar energy) and more conventional Progress in extending national water supply and technologies (e.g. chemical disinfectants) was also sanitation coverage needs to be sustained. National carried out. capacities to manage facilities need to be strengthened and community-based management improved. RESULTS Participatory approaches such as PHAST need to be promoted. In the majority of countries and areas safe drinking More needs to be done to increase sanitation water coverage is improving, but sanitation coverage coverage in informal settlements and rural is much lower than optimal. There has been a general communities. Without adequate sanitation the risk improvement in the quality of services and of epidemics will increase. However, larger sustain ability of facilities. populations, higher population densities and Progress has been made in overcoming the increased access to water will make more costly shortage of trained staff in the Federated States of off-site disposal of excreta and wastewater essential Micronesia and Tonga. Assessments of human in many human settlements. resources needs were made and human resources Management of water and sanitation requires a development plans and a draft training curriculum holistic approach incorporating the following: were drawn up. • water conservation; • wastewater treatment and recycling, especially ANALYSIS in urban areas; • economic instruments that treat water as a Although progress is being made towards national scarce economic resource; goals for safe water and adequate sanitation, many • coordinated management of water resources; people in the Region still do not have access to safe • water management policies that are organized water and adequate sanitation. Yet, despite the fact at appropriate levels, such as a river basin; that pressure on water resources is rising dramatically, • research on available resources;

HEALTHY SETTINGS AND ENVIRONMENT

• resource allocation strategies that lead to shared and equitable water use; • legislation to enforce and update regulations on water use; • programmes to raise awareness of the economic value of water; • policies to combat environmental degradation; and • improved international cooperation on environmental issues.

FUTURE WHO will continue to support countries to manage their water supply and sanitation facilities. Member

States will be provided with technical and logistical support to develop capabilities to monitor and ensure the safety of drinking water; to reduce the losses in their drinking water supply systems due to leakage; and to improve management, operation and maintenance. Much ofWHO's work to improve water and sanitation coverage will take place as part of Healthy Cities and Healthy Islands initiatives. Support for participatory approaches will increase and development and field testing of alternative technologies will continue. Collaboration to ensure the judicious use of water resources will be maintained and partnerships will be expanded and new relationships established to mobilize the resources needed to improve access to safe water and adequate sanitation.

Food safety

ISSUES Despite the efforts of national food safety authorities to promote food safety and enforce regulations, foodborne disease outbreaks are still frequent in the Region. In developing countries (excluding China), the morbidity and mortality associated with diarrhoea is estimated to be about 2700 million cases each year, resulting in 2.4 million deaths of children below the age of five. 1 Many countries do not have adequate legislation and regulations governing food safety; where they exist, the will and capacity to implement the law is often lacking. There is often no effective means of informing vendors and consumers about food safety issues. Many countries are unable to detect biological and chemical contamination of food and water,

Food safety: report by the Director-Deneral, EB I 05/10, 2 December 1999.

conduct outbreak investigations, or carry out regular inspections of food premises. Residues of pesticides and other chemical contaminants excessively or improperly used in food production and processing are cause for increasing concern, as is food contaminated with biological agents. In the Pacific, ciguatera, scombroid and paralytic shellfish poisoning are common occurrences. Globalization of food trade is multiplying the opportunities for international food safety crises, as was shown during the period by the crisis over dioxincontaminated food from Belgium. These can have considerable economic consequences for some countries in the Region and cause widespread consumer anxiety. In general, there is a need for a significant improvement in information exchange on food safety issues. This needs to take place both at the international level with regard to international food crises, and within countries with regard to public

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

developed in Viet Nam. A training course on food safety policies was conducted in the Federated States of Micronesia. Participants from Cambodia, Mongolia, Solomon Islands and Viet Nam attended various international meetings on food standards and the Codex Alimentarius. One participant from Viet N am attended an International Workshop on Total Diet Studies held in the United States of America.

Training National capacity building was supported through international and national training courses on food safety, involving participants from China, Cook Islands, Guam, the Lao People's Democratic Republic, Macao (China), Malaysia, the Federated States of Micronesia, Mongolia, Niue, the Republic of Korea, Singapore, Vanuatu and VietNam.

Street .food vendors in the Region pose a challenge for food safety

information on safe food preparation and preservation .

WHO RESPONSE Food safety legislation, regulations and policies WHO supports the development and implementation of national food safety plans and programmes, incorporating Food and Agriculture Organization (FAO)/WHO recommendations for food standards adopted under the Codex Alimentarius. 2 WHO supported several countries to strengthen their legislative frameworks for food safety. National legislation on food hygiene and safety regulations and an integrated national plan for food safety were

Food and water surveillance During the reporting period, a framework food and water surveillance system was developed with the support of collaborating institutions. The framework has been implemented in Cambodia, the Lao People's Democratic Republic, Mongolia, Papua New Guinea and Viet Nam. Workshops on surveillance of water and foodborne illness were held in Cambodia, the Lao People's Democratic Republic and VietNam.

Healthy marketplaces The Codex Alimentarius Corm11ission is the body responsible for compiling the standards, codes of practice, guidelines and recommendations that constitute the Codex Alimentarius, which is comprised of !c1od standards for commodities, codes of hygienic or technological practice, limits tor pesticides residues, guidelines for contaminants, food additives and veterinary drugs. This Commission was established by an FAO resolution in 1961, followed by a WHO (WHA) resolution in 1963 . FAO/WHO. Understanding Codex Alimentarius. Rome, Italy, 1999. 2

As part ofWHO's support for the healthy marketplace initiative (see p.56), the development of model markets was promoted, with the participation of all stakeholders, food producers, vendors, consumers, market managers and the health authorities. Courses on the use of hazard analysis critical control point (HACCP) were held in Cambodia, the Lao People's Democratic Republic, Mongolia, Papua New Guinea and VietNam.

HEALTHY SETTINGS AND ENVIRONMENT

Table 6.2 Member States of the Western Pacific Region who are members of the Codex Alimentarius

Brunei Darussalam Cambodia China Cook Islands France Japan Kiribati New Zealand Papua New Guinea Samoa Singapore• United Kingdom United States of America Vanuatu VietNam

Australia Fijib Republic of Koreab Lao People's Democratic Republic Malaysia Micronesia, Federated States of Mongolia Philippines Solomon Islands Tonga

•Member of Codex Alimentarius and has plans to establish a national committee. bNo National Codex Committee, but has a national focal point.

RESULTS About 65% of countries and areas in the Region now have food safety policies and most are members of the Codex Alimentarius (see Table 6.2). Ten countries in the Region have institutes that participate in the Global Environment Monitoring System for Food (GEMS/FOOD). The framework food and water surveillance system has been initiated in five countries.

ANALYSIS In many countries food safety legislation and regulations need to be strengthened. Attention also needs to be given to improving the ability to detect and monitor microbiological and chemical contamination of food and to inform and educate the public on safe food preparation and preservation .

While the food industry plays a key role in ensuring the safety of processed food, much remains to be done to support the informal sector, for example, to ensure safe preparation and preservation of street foods. Low-income groups tend to be the most vulnerable to foodborne diseases because of their reliance on street food and this must be taken into account when framing national policies. In addition, the development of food and water surveillance systems needs further strengthening in many countries of the Region. Countries must be able to react rapidly to outbreaks of foodborne diseases, and, in cases of international accidents like the dioxins crisis, to obtain accurate information quickly and provide it quickly to the public. The promotion of the FAO/WHO Codex Alimentarius is important as it provides guidelines on the production of foods for domestic and

BUILDING HEAlTHY COMMUNITIES AND POPULATIONS

international markets. The number of countries with Codex Contact Points and multisectoral Codex Committees in the Region needs to increase if internationally agreed food standards are to be applied.

FUTURE Food safety was declared a global priority for WHO for 2002-2003 at the 105th session ofthe Executive Board in January 2000. WHO will therefore be

increasing its collaboration with its Member States to improve the safety and wholesomeness of food in markets, shops, streets, institutions and homes. Support for the framework food and water surveillance system will be strengthened in cooperation with collaborating institutions in the five countries where the system has been put in place. The system will be gradually extended to other countries in the Region. Support for strengthening national food safety plans and adopting and enforcing food legislation will be provided.

HEALTHY SETTINGS AND ENVIRONMENT

The International Year of Older Persons in the Western Pacific Region The year 1999 was a significant year for older persons. Countries all over the world paid tribute to their older citizens while recalling the important contributions that older people make to society. The theme for World Health Day on 7 April 1999 was "Active Ageing". The Day sparked off a series of activities and media events designed to create awareness of the positive aspects of ageing. Activities that were undertaken to commemorate the Year of Older Persons can be grouped under three main headings: developing policy and strategy; providing health education and health promotion; creating awareness of ageing and health issues. Development of policy and strategy

American Samoa Australia

Governor issued a proclamation on World Health Day recognizing and paying tribute to the important role of older persons in society. Federal funds were provided for the 'National Strategy for Ageing in Australia'. Consultative meetings with older persons on active ageing were held across the country to seek their views on what could be achieved during the Year to improve their health and well-being. At a national symposium held on World Health Day, the Vice Premier released a statement calling on society to provide older persons with fair and equal living opportunities, greater economic support and better medical treatment and health services. The meeting in the Great Hall of the People in Beijing, China was attended by the Vice-Chainnan of the Standing Committee, National People's Congress, the Vice -Ministers of Health, and the Vice-Minister of Civil Affairs. A workshop for key stakeholders was held to evaluate and develop the draft policy on health care of older persons. Conferences to promote the health of older persons were held by national and prefectural government bodies. A seminar on ageing and health was attended by representatives of the health, housing, welfare, social security and labour sectors and representatives of nongovernmental organizations. The Minister of Health reiterated the Governmenfs commitment to enhance the quality of life of older persons. At a launching ceremony held in Malacca, the Minister also emphasized the role and responsibilities of the individual and of society in healthy and active ageing. Officials of the Ministry of Health and Social Welfare visited six districts in Ulaanbaatar and introduced government policy and the national programme on care of older persons. The First Public Health Summit on Degenerative Diseases was held. The Secretary of Health led other officials and health practitioners from the public and private sectors in reviewing the situation and drawing up appropriate strategies and mechanisms to address the problem. Activities were undertaken to promote and enable active ageing, and to develop or strengthen care giving systems. These include retirement preparation programmes and a programme on new skills for people who have changed careers or who want to strengthen existing careers. A policy conference on the ageing population entiUed, 'Facing Challenges, Seizing Opportunities' was held to engender high level discussions among policy-makers, planners, academics, volunteer workers' organizations and other concerned individuals.

China

Fiji Japan Macao (China) Malaysia

Mongolia Philippines

Samoa

Singapore

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Community events

American Samoa

Elderly males and females spoke on ageing and how to keep active. Older persons who participated in the celebrations engaged in Tai chi and joined in dances. Health services that were provided included blood sugar monitoring, weight and health screening. Health education materials were distributed and free health advice was provided to older persons. A campaign for healthy lifestyles was conducted and the community was advised to eat healthy food, keep fit by working, exercising and dancing. Blood pressure and blood sugar measurements were taken. Community awareness activities were conducted. Nurses were provided with copies of the Care of the Older Person Training Manual. Educational brochures, posters, etc were distributed throughout the country. A nationwide poster and essay contest was organized. Numerous community activities took place across Japan. Particular emphasis was placed on activities involving senior citizens and children. The National Health Day celebration was marked by sports activities and competitions including a five-kilometre health run. A forum on ageing was held and was participated in by senior government officials, representatives of the United Nations and other agencies. Medical check-ups, health education and health promotion activities were conducted in hospitals. One of the highlights was the presentation of the Health Ministry's Senior Citizen Award to the country's oldest person, at 142 years of age. The secret of his extraordinary longevity was shared with those who participated. The Minister of Heath also announced the designation of 163 health centres to provide free health services to older persons. · Six teams of doctors visited health centres in remote areas and provided services to some 20 000 older persons. 50 fourth grade students and 70 older persons joined day-long activities which demonstrated the theme, 'Healthy Ageing Begins Early in Life'. The activities included sharing of healthy foods, traditional stories, exchange of health information, health screening, and other physical activities. Commemorative activities included the tolling of a bell, a concert, exhibitions and promotional activities, and a 'Three Generations Walk Evenf. The Government organized events to celebrate the Day of the Elderly and the Month of Respect to enhance traditional filial piety. Activities included essays/poems/posters competitions and a talent quest on revival of traditional songs by those over 65 years. Activities were held throughout the year to promote awareness on ageing issues. Well ness fairs were also organized at clinics in every district. Health education talks in all clinics in Honiara and provincial centres were held and free insecticide treated mosquito nets were distributed. World Health Day was marked by a variety show featuring performances by senior citizens. The Day was launched by the Minister for Health and Minister for the Environment. An interactive learning session for older people focusing on exercise, independent living, foot care, and looking and feeling good was organized. Seminars and conferences were held. Special morning devotions for older persons, special church services and a walk for health were part of the celebrations for World Health Day. A mini marathon was held for boys and girls aged 12 to 15 years of age who were given encouragement by the oldest people in the city.

China Cook Islands

Fifi Japan Kiribati Lao People's Democratic Republic Malaysia

Mongolia Northern Mariana Islands Republic of Korea

Samoa

Singapore

Tonga Vanuatu

HEALTHY SETTINGS AND ENVIRONMENT

Media events

Australia

A community kit which included a range of information on the Year including practical ideas which can be implemented at the local level was developed. The kit was targeted at community organizations, business groups, and local governments to ensure participation at all levels in the community. A media kit, a website, special coin and stamp issues to mark the Year contlibuted to the broad framework for the promotion of a culture of positive ageing. In April, a health awareness week was organized where the topic of active ageing was discussed on radio and television programmes, including interviews with older people on their experiences. Information kits were distlibuted to the media and arrangements were made to include activities related to the Year in their programmes.

Cook Islands

French Polynesia Japan Malaysia

Educational materials on risk factors of ageing were distributed to the community and professionals. An essay contest and a mascot contest were held. A regional seminar on 'Media and the Ageing in Society' was conducted. A special 30-minute panel discussion on ageing and related issues was also held and was aired on national television on World Health Day. A big billboard with the message, 'Active Ageing Makes a Difference', was put up in Ulaanbaatar. Poster displays were organized and a booklet on Older People With Disabilities was published. Seminars and conferences on ageing and related issues were also held with health officials serving as resource persons. Commemorative symposia and seminars on the subject of ageing were held. Public awareness events such as press conferences, broadcast and print media releases were held in American Samoa, Fiji, Japan, Macao (China), the Federated States of Micronesia, Mongolia, Nauru, Northern Mariana Islands, Papua New Guinea, the Philippines, Samoa, Solomon Island, Tonga, Vanuatu, VietNam and Wallis and Futuna.

Mongolia New Zealand

Republic of Korea Various

Several countries in the Region joined the WHO-initiated Global Embrace, a global walk event on or around 2 October 1999 participated in by cities, towns and countries around the world to celebrate Active Ageing. Cambodia, Cook Islands, Fiji, French Polynesia, Mongolia, New Zealand, Papua New Guinea and the Philippines organized intergenerational walk events which were followed by either sports competitions or other entertainment activities such as performances by older persons, photo exhibitions or dancing and singing. Activities that marked World Health Day and the International Year of Older Persons in 1999 helped to promote greater social awareness and political commitment to ageing and health issues. They also defined the role of different stakeholders at different levels of care, and developed positive images of older persons. The role of the community and young people in promoting an environment of equal opportunity and respect was emphasized in advocacy events. The shift in focus from older persons as recipients of care to older persons as active participants in the healthy and successful ageing process has been recognized as a key strategy for improving the quality of life of older persons.

7. Child and adolescent health and development

Integrated management of childhood illness

ISSUES Significant gains in the health status of children have been achieved in the Western Pacific Region over the past few decades. However, these improvements have been uneven. Some countries still have unacceptably high infant and under-five mortality rates, and most developing countries contain at least pockets ofhigh mortality. The situation is often worst in remote rural areas. Six common preventable or easily treatable childhood illnesses (acute respiratory infections, diarrhoeal diseases, malaria, malnutrition, measles and dengue haemorrhagic fever) account for about Table 7.1 Infant and under-five mortality rates in selected countries of the Region

70% of childhood deaths and at least 75% of episodes of childhood illness. in low- and middle-income countries of the Region, imposing a major burden on health services. The signs and symptoms of these common conditions often overlap, although this is not always recognized by first-level health workers, most of whom are trained in vertical disease-specific approaches. In order to reduce childhood mortality and morbidity significantly and to promote the healthy growth and development of children, the prevention and management of the major causes of death, illness and disability in young children needs to be improved in a systematic and focused way, particularly at the peripheral level. For any public health interventions to have an impact, they need to be closely linked with the general development of the health sector. Families and communities also need to be closely involved to ensure that sick children reach health services.

Cambodia China Lao People's Democratic Republic Mongolia Papua New Guinea Philippines VietNam

89• 33b 104' 35• 77d 45• 37•

115• 42b 170' 48• 100d 67' 52'

WHO RESPONSE The integrated management of childhood illness (IMCI) strategy was developed in response to the need for child health programmes to go beyond single diseases and to address the overall health ofthe child. WHO joined forces with the United Nations Children's Fund (UNICEF) to develop this strategy, which at country level involves three components: improving health workers' skills through the provision of locally adapted integrated case management guidelines and activities to promote their use; strengthening health systems to support IMCI; and improving family and community practices. Other major areas that have an effect on child health and are therefore coordinated with IMCI

liD

•1998 b 1997 c 1995 d 1987-1996 Reference: Western Pacific Region Country Health Information Profiles, 1999 revision.

CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT

implementation include breast-feeding promotion, elimination ofmicronutrient deficiencies, control of anaemia and improving school health (see pp. 7584). The IMCI strategy was introduced into the Western Pacific Region in I 995, and implementation began in the Philippines and VietNam in 1996. The strategy is usually implemented in a phased manner: introduction; early implementation in a limited area to gain experience; and expansion. Particip ants a/ tile rcgiohal tra.in ing course on fMC! held in In order to build capacity for IMCI Davao, the Philippine'J. in Ja11 uary 2000 receiving training in how to cmuluct a clinical e.wmdnation implementation, WHO conducted two regional training courses on IMCI The IMCI strategy is being expanded in the (August 1998 and January 2000) and one course on Region . In 1999, the Philippines and VietNam IMCI facilitation skills (January 2000) at Davao reviewed their experiences of the early Regional Hospital in Tagum City, the Philippines. The implementation phase and moved on to the expansion courses were attended by key government staff and phase, broadening the scope of activities and resource persons from nine countries and by geographical coverage. Cambodia, China, the Lao representatives from partner agencies in the Region . People's Democratic Republic and Mongolia arc in At the regional level, meetings and joint missions were the early implementation phase. Discussions on the conducted to ensure that collaboration between IMCIIMCI strategy have also been held in Papua New related programmes and partner agencies in health is Guinea and a joint WHO/UNICEF orientation strengthened. UNICEF, the World Bank, the Asian meeting is being planned for Fiji, Kiribati, Solomon Development Bank (ADB), the European Union, Islands and Vanuatu. bilateral agencies and nongovernmental organizations To assess the status of IMCI implementation, (NGOs) are the main partner agencies working with share experiences and lessons learned and strengthen governments and WHO in support ofiMCI.

Ha Noi Call for Action The Ha Noi Call for Action on Integrated Management of Childhood Illness urges all governments and partners involved in child health and development in the Western Pacific Region to implement IMCI in order to improve child health care and reduce the mortality and morbidity of young children . It also highlights the need to strengthen partnerships and coordination and mobilization of resources. The Call for Action argues that IMCI should be an integral part of primary health care and should be included in health sector reforms. It points out that the strategy directly addresses the rights of the child to survival, healthy growth and development by improving quality of care at health facilities, strengthening health systems and empowering caregivers and communities to adequately care for young children. The Call for Action was developed at the first intercountry workshop on IMCI in the Western Pacific Region held in HaNoi, VietNam, in October 1999. More than 50 participants, including government officials from seven countries (Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines, Viet Nam) together with representatives of NGOs, multilateral and bilateral agencies attended the workshop. The meeting was organized by WHO in close collaboration with UNICEF.

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

partnerships for IMCI, the first intercountry workshop on IMCI in the Region was organized by WHO in close collaboration with UNICEF in HaNoi, VietNam in October 1999. Participants came from the first seven countries where IMCI implementation or discussions on the strategy had begun (Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Philippines and Viet Nam), as well as from several partner agencies. The meeting pledged strong support for IMCI and adopted the "HaNoi Call for Action on IMCI" (see box on p. 71). This calls upon governments and partners in child health and development to adopt and implement IMCI to improve child health care and reduce mortality and morbidity in children. The positive reception of IMCI by grass-roots level health workers and government decision-makers and the growing demand for training led WHO to establish a global development project on IMCI preservice training with a limited number of medical schools worldwide. The project aims to identifY ways in which IMCI can be incorporated in the curriculum of medical students. The Western Pacific Regional Office is part of the development team, as is the University ofMedicine and Pharmacy in Ho Chi Minh City which is incorporating IMCI into the paediatric curriculum ofthe medical degree students for the first time in 2000. Evaluation results of the first round of teaching will be available later in the year and will be used to further develop approaches for other schools in the Region which wish to include IMCI in their curricula.

RESULTS IMCI has greatly increased collaboration among various child-health-related programmes and partner agencies in health . Activities are now better coordinated, thus making more effective use of available hunun and financial resources. The adoption of IMCI has also increased the technical capacity of countries to address child health issues in a more holistic way. Working groups on child health have been established in all countries where IMCI has been adopted or where discussions are underway. In the Philippines, IMCI has now been included in all major projects in child health, including the Early Childhood Development project, supported by ADB and the World Bank. In VietNam, a directive

on Enhancement of the Implementation of IMCI in Viet N am was issued by the Minister of Health in October 1999. The directive requests specified bodies at all levels to give priority to IMCI in order to improve the management of child health care, reduce costs and mobilize resources. They are also requested to include IMCI in plans of action. In VietNam, IMCI is also included in a significant number of major health projects supported by the World Bank, the European Commission malaria control programme, bilateral agencies and NGOs. A number of signs of improvements in child health care at grass-roots level can already be seen. Routine follow-up visits to newly trained health workers and review meetings in the Philippines and VietNam at the end ofthe early implementation phase showed that there were significant improvements in the quality and consistency of the clinical care given to children. Some health facilities had reorganized their work-flow to make case management more efficient and more emphasis had been given to availability of basic supplies and essential drugs in districts implementing IMCI. Health workers greatly appreciated the friendly attitude and problem-solving exercises of the followup visits, which were designed to help trained health workers get started with IMCI case management procedures in their daily clinical work. The debriefing meeting at the end of the follow-up visit provided valuable feedback on the overall health care system in the district and province and was useful in identifYing ways in which primary health care services for sick children could be improved. It is still too early to demonstrate that the implementation of IMCI has led to a quantifiable reduction in childhood illness. At least two to three years of full implementation after the early implementation phase will be needed before any meaningful evaluation can be conducted.

ANALYSIS IMCI is a relatively new strategy that builds on the experience of the existing elements in the health care system. As it represents a move away from a vertical approach to combating diseases in children, one of WHO's most important tasks will be to facilitate capacity building for an integrated approach among various child health related programmes at central,

CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT

Table 7.2 Key IMCI activities in selected countries of the Western Pacific Region ... : P . ·','

-00:::

! •': J •

• I

, · o 'pi• I t ,\

,' I

'' '• •

o'p

1•

Cambodia China Lao People's Democratic Republic Mongolia Pacific island countries (Fiji, Kiribati, Solomon Islands, Vanuatu) Papua New Guinea Philippines VietNam

Jan 1998 May 1998 Nov 1998 Dec 1998

Jun 1998 Nov 1998 Sep 1999 Jun 1999

Oct 1998 Jun 1999 May 2000 Aug 1999

Jun 2000 Dec 1999 Apr 2000

Mar 2000

Apr 2000

Being planned Jul1998 Jun 1995 Mar 1995 May 1996 May 1996 May 2000 Jun 1997 Jun 1997 Jul1997 Jun 1997 May 1999 Apr 1999

provincial and district levels. Improving coordination among all concerned partners, institutions, services and professional groups remains a major challenge. Capacity and consensus building in order to establish a broad base of support for an integrated approach is a long process. IMCI is usually implemented in a phased manner, which involves initial discussions between the government, WHO and other interested partners; an orientation meeting; establishment of an organizational structure (an IMCI working group and a higher-level steering committee); development of a national plan; and the adaptation of IMCI case management guidelines. These must all be carried out before implementation, including training ofhealth workers, can begin. It will therefore be some time before results can be seen. Experience in the two countries in the Region that have moved on to the expansion phase shows that health system support and involvement offamilies and communities is crucial for IMCI. Community practices and participation need strengthening so that families can respond appropriately to childhood illness. An enabling, safe and supporting environment should be created, so that families can contribute to their children's health and nutrition in a responsible way. Drugs need to be in place and referral services should be available to provide specialized care for

severely ill children who cannot be treated at firstlevel facilities. It is recognized that a well-functioning health system is crucial for a successful delivery of essential health services, such as integrated child health care. Every opportunity should therefore be taken to link JMCI with efforts to improve the general health system as soon as the strategy is introduced. Given the broad implications ofthe IMCI strategy, the involvement of all partners in child health is crucial to its success. This is important both in the early phases ofiMCI when the broad base and consensus is being built and in the expansion phase when capacity building is taking place.

FUTURE While efforts will continue to be made to improve children's chances of survival and to reduce morbidity from the most common conditions, more emphasis will be devoted to developmental aspects ofhealth, in order to ensure the healthy growth and development of the child. Development of tools, materials and support to strengthen the balanced implementation ofiMCI and evaluate its effectiveness are already underway and further efforts will be made to introduce the strategy

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Community involvement is essential to ensure that sick children reach health services

into preservice trammg in more institutions in the Region. The strategy will be expanded wherever acute respiratory infections, diarrhoeal diseases, measles, malaria, dengue haemorrhagic fever and malnutrition are public health problems. WHO will work with countries to make IMCI an integral part of primary health care, as urged in the Ha Noi Call for Action . WHO will continue to support the phased introduction of IMCI, with intersectoral collaboration between various programmes within the Ministries of Health and close collaboration with interested partners.

CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT

Nutrition

ISSUES Nutrition is an essential element of health throughout the life cycle. A healthy infant depends to a large extent on its mother being well-nourished. Inadequate food intake and malnutrition are known to impair physical and mental development of children of all ages, but particularly in utero and in the early years . Some 49% of deaths among under-five children in developing countries are estimated to be associated with malnutrition, mostly due to impaired immune response to infectious and parasitic diseases. This continuing burden ofmalnutrition is rooted in poverty, underdevelopment and inequality, and population growth rates greater than economic growth rates or food production. Commonly found malnutrition problems include protein-energy malnutrition (PEM), a consequence of not enough food being available, particularly in view ofthe increased requirements for energy and protein when infectious and parasitic diseases are frequent; iron deficiency anaemia (IDA), the most widespread nutritional disorder, responsible for significant maternal and childhood mortality and morbidity; iodine deficiency, the greatest single preventable cause of brain damage and mental retardation; and vitamin A deficiency, the single greatest preventable cause of childhood blindness. In Asian and Pacific countries, excluding China and India, it is estimated that child malnutrition alone is responsible for 12.3% oftotal deaths, 20.1% of all years oflife lost due to premature mortality and 14.5% of all disability-adjusted life years. 1 In addition to childhood malnutrition, there are many nutritionrelated noncommunicable diseases (NCD) among older children, adults and older persons in the Region . These include cardiovascular diseases, diabetes, cancer and obesity For example, 30%-40% of cancer cases are considered to be diet-related and preventable by the adoption of a healthy diet and exercise. Obesity is a key risk factor for a range of serious NCD,

including cardiovascular diseases, diabetes, various forms of cancer and gastrointestinal, liver, and gallbladder diseases . Since many lifestyle-related di~eases originate in habits developed during ch1~dhood ~nd adolescence, it is essential that healt11y eatmg habits be promoted at the beginning of the life cycle.

National plans of action for nutrition To address the multiple nutrition and food safety problems that countries and areas often experience, WHO, in collaboration with the Food and Agriculture Organization of the United Nations (FAO), encourages countries to develop national plans of action for nutrition (NPANs). In 1992, representatives of the 159 countries that participated in the Inten~ational Conference on Nutrition (ICN) cm~m1tted themselves to developing or improving natiOnal plans of action for nutrition by the end of 1994. As this commitment has not been fully met, FAO and WHO continue to work with countries to develop, implement and review plans. A national plan of action for nutrition is a comprehensive plan employing a multisectoral approach and coordinated interventions on nutrition by various sectors. A plan is usually based on the end-of-decade goals agreed at the ICN and the nine action-oriented strategies described in the World Declaration and Plan of Action for Nutrition developed at that conference. Since 1995, progress in developing and implementing such national plans has not been evaluated regionally

Micronutrient deficiencies The adverse effects of micronutrient deficiencies are profound and include premature death, general poor health, blindness, growth stunting, mental retardation, learning disabilities and low work capacity Anaemia is estimated to affect 40%-50% of pregnant women and preschool children in the Region, 27% ofthe Region's population is estin;1ated to be at risk of iodine deficiency, and vitamin A

...

The global burden of disease, WHO, Geneva, 1996.

8utLO/NG HEALTHY COMMUNITIES AND POPULATIONS

deficiency constitutes a public health problem for women and children in at least nine countries. 2 Vitamin D deficiency affects young children in parts ofthe Region.

During the reporting period, technical assistance was provided to Fiji and the Federated States of Micronesia to assess and review the current status of their national plans of action and to plan future activities.

Infant and young child feeding practices In about half ofthe countries in the Region more than 90% of infants are initially breast-fed. 3 However, rates of exclusive breast-feeding in the first four to six months and continuation of breast-feeding during the first and second year of life are usually much lower. In 23 ofthe 34 countries reporting to WHO, less than 75% of women are said to practise exclusive breast-feeding in the first four rnonU1s. The fact lhal many births in the Region take place outside health facilities is a significant constraint to promoting appropriate breast-feeding practices which will have to be addressed by enhanced community participation. In later years, inappropriate complementary foods and unbalanced diets contribute to childhood malnutrition.

Micronutrient deficiencies The battle against micronutrient deficiencies is an important area of WHO's work. In August 1999, a working group meeting on Accelerating Progress in Preventing and Controlling Micronutrient Malnutrition was held in collaboration with FAO, UNICEF, the Micronutrient Initiative, the Institute for Mt:dical Research ofMalaysia and otltt:r pa11J1t:rs. The working group reviewed the status of the development and implementation of national micronutrient malnutrition policies and programmes in the Region and identified constraints in achieving the end-of-decade goals 4 of the FAO/WHO International Conference on Nutrition (1992) . To prevent and control iodine deficiency disorders (IDD), WHO, with the support of a collaborating institution, helped to prepare a proposal to tackle the major IDD problem in Tibet, China. As a result, funding was committed by the Australian Government for a three-year project to eliminate IDD in Tibet, in collaboration with WHO. Workshops on the control of iodine deficiency disorders were held in Cambodia, China and Mongolia. Technical support was provided to Cambodia to draft a plan of action for the control of iron deficiency anaemia and to the Philippines and Viet Nam to support the implementation of a project on preventive weekly iron/folate supplementation. A study on the determinants of rickets in Mongolian children is being conducted with WHO support.

WHO RESPONSE WHO aims to improve the nutritional status of all sectors oftl1e population, especially mothers, children and other vulnerable groups.

National plans of action for nutrition A workshop on National Plans of Actions for Nutrition: Constraints, Key Elements for Success and Future Plans was held in Kuala Lumpur, Malaysia, in collaboration with FAO, UNICEF and the Institute for Medical Research of Malaysia in October 1999. The workshop reviewed progress in countries, identified outstanding problems, established key elements for success, identified needs and made plans for the future. 2

Infant and young child feeding practices WHO strongly advocates exclusive breast-feeding, starting immediately after birth and continuing until the child is four to six months of age. Breast-feeding should be continued, up to two years of age or beyond, 4

Cambodia, China, Kiribati, the Lao People's Democratic Republic, Marshall Islands, Federated States of Micronesia, Papua New Guinea, the Philippines and Solomon Islands.

Brunei Darussalam, Cambodia, Cook Islands, Fiji, Japan, Kiribati, the Lao People's Democratic Republic, Marshall Islands, Federated States of Micronesia, Niue, Papua New Guinea, the Philippines, Samoa, Solomon Islands, Tonga, Viet Nam, Wallis and Futuna.

To reduce iron deficiency in women to one-third of 1990 levels; to virtually eliminate iodine deficiency disorders and vitamin A deficiency and its consequences (including blindness).

CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT

while appropriate and adequate complementary foods are introduced. Appropriate infant feeding practices are promoted through baby-friendly hospitals and the implementation of the International Code of Marketing of Breast-milk Substitutes, which helps to ensure that baby formulas are used only when breastmilk cannot be provided. In VietNam, WHO has supported the introduction of the UNICEF/WHO 40-hour breast-feeding counselling course into the curriculum of midwives. Three participants from the Lao People's Democratic Republic, Niue and VietNam were supported to attend a Certificate Course in Breast-feeding: Practice and Policy The integrated management of childhood illness (IMCI) (see pp .70-74) is a valuable strategy for improving infant and young child feeding practices. Age-specific feeding recommendations during sickness and health are an important element of the strategy and country-specific feeding recommendations have been developed in Cambodia, China, Mongolia, the Philippines and VietNam. WHO monitors infant and young child feeding practices and progress is presented to the Regional Committee every two years. In collaboration with the reproductive health focus , a publication entitled Towards healthier mothers, children and families : a nutrition guide for community health workers is being prepared. This guide promotes the breast-feeding techniques of the UNICEF/WHO 40-hour breast-feeding counselling course and the feeding recommendations ofthe IMCI guidelines.

Mongolian child with rickets

Micronutrient deficiencies Substantial progress has been made in the battle against micronutrient deficiencies. The means for preventing and controlling micronutrient deficiencies are, in many cases, already available. The use of iodized salt has greatly reduced the prevalence ofiDD worldwide over the last 10-15 years. Vitamin A supplements have been shown to reduce morbidity and mortality in vitamin A deficient children . New approaches for the prevention of iron deficiency anaemia through the use of weekly supplements and the fortification of foods such as rice, wheat flour and soy sauce hold considerable promise. In the Philippines and VietNam, trials for testing preventive weekly iron/folate supplementation have been completed and results will be analysed in 2000. Cambodia has developed a national policy and plan of action for controlling iron deficiency anaemia. The control of micronutrient deficiencies, especially in children under five years of age, is also being addressed through the IMCI strategy.

RESULTS National plans of action for nutrition Despite the constraints identified at the workshop on NPANs held in October 1999, and limited resources devoted to national plans of action, progress can be seen. In many countries the formulation of NPANs has stimulated support for the development and implementation ofnutrition projects from government ministries, UN agencies and nongovernmental organizations (NGOs). The status of countries and areas in the Region with regard to NPAN development and implementation is given in Table 7.3 .

Infant and young child feeding practices The baby-friendly hospital initiative is still expanding and there are more than 7000 baby-friendly hospitals in the Region. VietNam has modified the UNICEF/ WHO 40-hour breast-feeding counselling course and introduced it into the curriculum of midwives (see box on p.79).

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Table 7.3 National Plans of Action for Nutrition in the Western Pacific Region

•

,·

''I

•

• •

•

• •

China Cambodia Fiji Japan Kiribati Lao People's Democratic Republic Malaysia Mongolia New Zealand Northern Mariana Islands Philippines Tonga VietNam

American Samoa Australia Brunei Darussalam Cook Islands French Polynesia Republic of Korea Marshall Islands Federated States of Micronesia Palau Papua New Guinea Samoa Solomon Islands Tuvalu Vanuatu

Guam Hong Kong (China) Macao (China) Nauru New Caledonia Niue Singapore Tokelau Wallis and Futuna

• Such as a nutrition policy or a health policy which includes nutrition. Note: Status as at October 1999. Does not include Pitcairn Islands.

ANALYSIS National plans of action for nutrition National plans of action for nutrition (NPANs) are a useful tool for addressing the whole range of nutrition and food safety problems. However, the development ofthese plans requires multisectoral collaboration and a high level of political commitment. Scarcity of human resources and finances greatly influences the sustainability of projects and programmes, including monitoring and evaluation. Successful NPANs depend on recent and good quality information on the nutritional situation of the country. Strategies and priorities must be backed up by adequate resources. Continued high-level political commitment, a multisectoral approach and participation by local communities are also essential for success.

Major constraints experienced in the implementation of NPANs include low political awareness, unfavourable socioeconomic environments, resource scarcity, ineffective control and management systems and the lack of sustainability of some initiatives. Monitoring and evaluation are important not only to describe progress, but also to document experiences and lessons learned. Lack of data, partly due to lack of monitoring, hinders the attempt to acquire funds and thus the sustainability of initiatives. External support for the development and implementation of national plans of actions is also needed.

Micronutrient deficiencies Much remains to be done, particularly with regard to iron deficiency, to achieve the end-of-decade goals

CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT

Introduction of the UNICEF /WHO 40-hour breast-feeding counselling course into the curriculum of midwives in VietNam Most training for midwives on breast-feeding in VietNam is done in in-service settings. However, preservice training is being increasingly recognized as essential to ensure that all health care staff are knowledgeable and skilled in promoting breast-feeding from the beginning oftheir professional career. This is particularly true for midwives, approximately 700 to 1000 of whom complete their training every year. After preliminary discussions in 1997 between WHO, the Ministry of Health and the National Breast-Feeding Committee, a plan of action to introduce the UNICEF/WHO 40-hour hreast-feeding counselling course into the curriculum of midwives in VietNam was prepared. In 1998, 20 schools teaching midwifery were selected and a directors' workshop was conducted. Training materials were adapted to the Vietnamese education system and 40 teachers were trained on breast-feeding counselling and on how to conduct the course with a large group of students. Preparatory activities ended in May 1999 and the new course started in October 1999. In April2000 the course was evaluated and it will be further modified as required.

adopted at the FAO /WHO International Conference on Nutrition referred to above. However, there is reason for optimism that preventive weekly iron/folate supplementation may help to reduce iron deficiency anaemia (seep. 88). To respond successfully to the technical, social, economic and cultural challenges posed by the widely diverse countries and areas in the Region, WHO will continue to work closely with its partners to reduce iron deficiency anaemia in the Region.

expansion of the baby-friendly hospital initiative to private hospitals. The International Code ofMarketing of Breast-milk Substitutes needs to be implemented throughout the Region . Measures to grant working women at least 12 weeks of maternity leave and to facilitate breast-feeding will also provide a supportive environment for breast-feeding that does not yet exist in many countries.

FUTURE Infant and young child feeding practices The exclusive breast-feeding rate is still declining in the Region . At its fiftieth session in September 1999, the Regional Committee recognized that additional ways to promote breast-feeding needed to be explored. New strategies are continually being developed, for example the

National plans of action for nutrition WHO will continue to collaborate with partner agencies in supporting countries to develop their national plans of action. Future activities are being planned, in collaboration with FAO, UNICEF, and

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

other partners, including the Asian Development Bank and international NGOs. Technical support will be given to countries who are reviewing progress and re-orienting their national plans of action.

Infant and young child feeding practices The considerable achievements of the baby-friendly hospital initiative will be built upon by making private hospitals baby-friendly and by reassessing and monitoring the existing baby-friendly hospitals. Preservice training of midwives and other health workers will be expanded in VietNam and introduced in other countries ofthe Region. In collaboration with the IMCI, sustained breast-feeding when mother and child leave the hospital will be promoted and supported. WHO will work with countries to improve maternity legislation and to introduce measures facilitating breast-feeding in the workplace.

Micronutrient deficiencies WHO will continue to regard improving nutritional status as an essential part of improving child health. It will support the testing and adoption of new approaches to preventing and controlling micronutrient malnutrition and to reducing iron deficiency anaemia among women of reproductive age and children.

Adolescent health and development

ISSUES Adolescence is a period of rapid physical and mental development. Adolescents are confronted with both opportunities for and risks to their health and development. More than ever, adolescents have greater opportunities to educate themselves and to maximize their potential. At the same time, however, adolescents are exposed to health risks because of poverty, exploitation, gender discrimination, war, violence, changes in social and economic situations as well as their own risky behaviour. All these factors can have immediate consequences, e.g. sexually transmitted infections (STI), including HIV/ AIDS, and unplanned pregnancies, and long-term impacts e.g. noncommunicable diseases (NCD) such as diabetes and cardiovascular diseases. There is increasing recognition that behaviour formed in adolescence (defined by WHO as 10-19 years) has lasting implications for individual and public health. It is estimated that many premature deaths among adults are largely due to behaviour (such as smoking) initiated during adolescence. There is also significant mortality and morbidity among young people due to accidents, suicide, violence, pregnancy-related complications or illnesses. Many of these deaths and illnesses are preventable.

Rapidly changing societies and lifestyles are bringing a new sense of urgency to concerns about adolescent health and development. The Western Pacific Region has the fastest increase in tobacco use in the world. Most adults begin to smoke during adolescence, and up to half of male adolescents aged 15 to 19 in some countries in the Region smoke (see Table 10.2 on p. 110). Changing social norms are leading to increases in sexual activity among adolescents. Consequently, significant numbers of young people experience unplanned pregnancies, unsafe abortions and pregnancy-related complications, as well as increasing risks of STI, including HIV/AIDS. The mental health of young people is a major issue in a number of countries, with concern growing about youth suicides in Australia, China, New Zealand and Pacific island countries. There is increasing concern about inappropriate eating habits, particularly those leading to obesity, many of which are established during adolescence.

WHO RESPONSE WHO is working together with UN and other partner agencies to develop appropriate tools and interventions to address key adolescent health

7. CHILD AND ADOLESCENT HEALTH AND DEVELOPMENT

concerns. This collaboration is in part based on the "Framework for Country Programming for Adolescent Health" developed during a United Nations Population Fund (UNFPA), United Nations Children's Fund (UNICEF) and WHO Study Group on Programming for Adolescent Health in 1995. Within the Region, a multidisciplinary working group has been established at the Regional Office and has developed a framework to guide WHO's work in adolescent health and development. Key elements of this framework include advocacy with leaders in Member States, building technical capacity, and strengthening health services. The focus of WHO's work in this area is to enhance adolescent health and development by strengthening the work of focuses in key technical areas such as reproductive health and STI, including HlV/AIDS; substance abuse, including tobacco use; mental health; nutrition; and NCD. In Mongolia, WHO is part of a UN-wide effort to improve healthy behaviour among adolescents by improving access to interactive education programmes and developing and testing innovative models for health and counselling services. Substance abuse (particularly tobacco and alcohol) and sexual and reproductive health will be key focuses ofthis work.

In China and VietNam, broad-based assessments have been undertaken to determine how adolescents perceive their priority health concerns and how they use health services. WHO will support governments to develop action plans and these will be implemented with the support of related ministries within the Government, other UN agencies, and nongovernmental organizations (NGOs). WHO's reproductive health initiative "Making Pregnancy Safer" (see pp 85-91) is particularly relevant to adolescents, given the large number of adolescent pregnancies in many countries . In particular, the focus on preventing unsafe abortions highlights a growing problem in some countries. With the majority of STI and new HlV/ AIDS cases occurring among young people, adolescents are a special concern for STI programmes. Advocacy efforts at the regional and national levels drew attention to these issues during the World AIDS Campaign in 1999, which focused on youth (see box). Interventions to develop and demonstrate effective approaches to young people are underway in Fiji, Kiribati and Mongolia. Pilot projects in these three countries will introduce clinical health services for sexually active young people, in a confidential and nonjudgmental environment. The majority of sex

World AIDS Campaign The theme for the World AIDS Campaign in 1999 was young people. To support country level activities, the Regional Office produced a youth-friendly activity kit containing suggestions for activities related to awareness and prevention ofHlV and AIDS. A press kit to support appropriate and sensitive coverage of HlV and AIDS was also produced. The Regional Office conducted a regional workshop for journalists emphasizing HlV and AIDS issues related to young people. Various activities were implemented at the country level on World AIDS Day on 1 December 1999. For example, young people in remote districts in Mongolia were given information on STI and HlV/AlDS through dissemination of education materials and condoms, a poster drawing competition, and media events. These activities were followed by the establishment of WHO-supported youth-friendly outreach services and a pilot project in a clinic in Ulaanbaatar. In Viet Nam, various activities for and by young people were implemented. An HIV/ AIDS media communications campaign was supported by both public and private sectors. In addition to WHO support, the activities were sponsored by such companies as Nike and Adidas, showing the potential to mobilize the private sector for HlV/AIDS prevention efforts.

8UJLDING HEALTHY COMMUNITIES AND POPULATIONS

workers and injecting drug users are also young, and are a key focus for fllV/ AIDS and STI prevention efforts.

be implemented with the support of the relevant government ministries, UN agencies, including WHO and NGOs. In Mongolia, STI education and service programmes for young people are being improved.

RESULTS The integrated approach to adolescent health and development described above is a relatively recent development. Previously, WHO's activities related to adolescents in the Region took place across a range of areas, such as STI, including fllV/AIDS; substance abuse; tobacco or health; and nutrition. It is therefore too early to be able to present explicit results or data resulting from this new approach, although many of the results presented under the sections on Sexually transmitted infections, including fllV/AIDS and the Tobacco Free Initiative have a direct bearing on the health of the Region's 10-19 year olds (see pp. 37-44 and 105-110). It should, however, be noted that more and more countries in the Region are beginning to recognize the very particular threats that adolescents face and to reflect these in their programmes. In China and Viet Nam, for example, adolescents' own opinions on health and health programmes have been sought and these are being used to form the basis for national plans of action on adolescent health. These plans will

ANALYSIS Adolescence was once considered one of the healthiest periods in human life and traditionally it has not attracted much attention from governments. It was felt that adolescents had survived the diseases of early childhood and were not yet affected by health problems associated with ageing. With the growing recognition of the wide-ranging health problems faced by adolescents because of a combination of biological, psychological and social factors and the rapidly increasing number of adolescents in the world (today more than half of the world's population is below 25 years of age), more attention has been given to health issues related to young people in recent years, but this has often not been translated into national policies and programmes. The underlying causes of adolescents' health and development problems are closely connected and the solutions to these problems are also interrelated. In general, adolescents need to be provided with a safe and supportive environment in which to live. They need to be able to acquire accurate information about their health needs and to build the life skills needed to avoid risk-taking behaviour. Counselling must be available, especially during crisis situations, and adolescents should have easy access to health services, particularly reproductive health services. Within countries there is a need to build awareness of the importance of adolescent health and development issues; strengthen the technical capacity to address these issues; support countries to develop appropriate policies and strategies; and to make health services for adolescents more available, acceptable, accessible, and affordable.

FUTURE A framework for adolescent health and development in the Region has been developed, and WHO is working with Member States to implement this framework. Specific support is being given to:

A young father in Solomon Islands, which has one of the highest birth rates in the Region

CHILD AND ADOLESCENT HE/lLTH AND DEVELOPMENT

Training youth leaders in the Pacific islands The most effective youth programmes are those led by youths themselves. To help develop leadership skills, a Youth Leadership Development Workshop was held in Suva, Fiji, in February 2000. WHO supported this workshop in partnership with the US Peace Corps, the Secretariat for the Pacific Community, and other UN agencies in the Pacific (United Nations Development Programme, United Nations Educational, Scientific and Cultural Organization, UNICEF and UNFPA) . The workshop focused on developing leadership skills, identifYing health needs and designing projects that addressed those needs. The second half of the course covered health issues and was designed to enable future youth leaders to: 1. understand and participate in the process of assessing community health needs, match these to available community resources, and develop solutions; 2. generate and document youth-led solutions to health issues, and, where appropriate, to develop project proposals; 3. speak in public about health issues affecting the community, presenting adolescent perspectives and possible solutions; 4. discuss the meaning of terms such as "quality oflife", "wellness and well-being", and "life goals" in relation to daily life in their communities; 5. understand and discuss how health, or the lack of it, can facilitate, or impair, the attainment of a high quality oflife; 6. identity the personal and environmental causes of the major health problems affecting their communities, compile simple qualitative and quantitative evidence, and present findings effectively; and 7. describe effective health-related interventions, from life skills and personal health practices to policy, education, and pricing. The participants came from 11 Pacific island countries. Teams were composed of Peace Corps volunteers and staffbased in the country and young nationals with a range of experience working in youth development. The main indicator ofthe success of the workshop was the range and quality of the youth-developed action plans that were produced, which augured well for future involvement of the participants in promoting healthy development. The action plans addressed a range of health issues, including tobacco control interventions among young people in Tonga, promotion ofhealthier ethnic relations in Guadalcanal province in Solomon Islands, and activities that encourage general health as well as sexual health among adolescents. The partner agencies will follow up on the outcomes of these action plans and take their collaboration to a second stage: the fostering of national activities focused on healthy living for youth. Training young people to take the lead in health development is a worthwhile investment in the future health ofthe Region's adolescents.

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Behaviour formed in adolescence has lasting implications for public and individual health

• increasing awareness of the interrelated nature of the health problems of adolescents; • strengthening technical capacity in adolescent health in the Region by increasing the number of individuals and institutions capable of assisting in the development of national policy, including preparing strategic plans and interventions for adolescent health and development; and • supporting countries to develop, with the participation of adolescents, intersectoral policies, and making health services more available, acceptable, accessible and affordable to adolescents.

8. Reproductive health ISSUES Maternal mortality Despite the medical advances of the 20th century, women still continue to suffer and die as a result of complications related to pregnancy and childbirth. Every year, 30 000 to 50 000 women in the Region die from pregnancy-related complications. While the estimated average maternal mortality ratio (MMR) for the Region is 120 per 100 000 live births, there are marked differences among countries. More than 40% of all maternal deaths occur in five developing countries: Cambodia, the Lao People's Democratic Republic, Mongolia, Papua New Guinea and the Philippines. In these countries, the MMRs range from 158 to 650 per 100 000 Jive births. The unacceptably high MMRs in these countries are due to a variety of reasons, including lack of access to high-quality obstetric and family planning services; lack of appropriate service protocols on essential and emergency obstetric case management; absence of basic equipment, medicine or supplies; misdiagnosis; inadequate referral systems; and poor health-careseeking behaviour. Levels of maternal mortality are usually inversely related to the economic status of a country. Political commitment to safe motherhood may be lacking in some countries. Several countries have no comprehensive national action plans or mechanisms to implement safe motherhood programmes. Coordinating international partners is often an issue in reproductive health, as many agencies and nongovernmental organizations (NGOs) provide technical and financial support to national Safe Motherhood initiatives. Some countries, however, have difficulty coordinating these agencies and using resources effectively.

Perinatal and neonatal mortality

The complications that cause the deaths and disabilities of mothers also damage the infants they are carrying. Newborns die or an~ disabled because of poor maternal health, inadequate care during pregnancy, inappropriate management and poor hygiene during delivery and the first critical hours after birth, as well as a lack of appropriate care for the newborn. The most common cause of neonatal deaths (i.e. deaths of children under 28 days of age) is birth asphyxia, which accounts for more than 20% of neonatal deaths in developing countries globally, while neonatal tetanus, which is completely preventable, accounts for 14%. Every year 28-30 million babies are born in the Region. More than 1 million die before their first birthday and more than 300 000 during the first day oftheir birth. If China is excluded, more than 90% of infant deaths in the Region occur in Cambodia, the Lao People's Democratic Republic, the Philippines, Health worker in Viet Nam demonstrating the use of an IUD Papua New Guinea and Viet Nam,

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Figure 8.1 Major causes of neonatal deaths in developing countries

WHO RESPONSE Reduce maternal mortality

Sepsis and meningitis

Others 5.2%

7.2% Congenital

--~--

Asphyxia 21.1%

Identify priority issues and countries The scope of reproductive health has broadened since the Cairo International Conference on Population and Development (ICPD) in 1994. Reproductive health now includes family planning, safe motherhood, women's health care, prevention and treatment of infertility, prevention and control of STI, including H1V/AIDS, prevention of abortion and management of its consequences. Given this broad canvas, because of limited resources and the need to focus its efforts where the need is greatest, WHO has identified the five countries with high MMRs as its priority targets and is focusing its regional strategy on making pregnancy safer and improving family planning in these countries.

Birth injuries 10.6%

Pneumonia 19.0%

14.1%

Source: World Health Organization, Essential Newborn Care, Report of a Technical Working Group, WHOIFRH/MSM/96.13

which account for only 42% ofthe Region's population excluding China.

Develop national action plans Given the considerable need for both comprehensive information on reproductive health and a national

Women's health Women in the Region made significant gains in areas such as health, work, and education during the last decades of the 20th century. Since the early 1970s women's life expectancy has increased from 67 years to 73 years, and, despite the regional disparities noted above, the overall MMR has decreased significantly. These health gains have transformed the quality of women's lives and created conditions favouring sustained fertility reduction and consequent demographic and lifestyle changes. However, there is still gender inequity in access to basic health services, especially in countries where women have low social status, little access to high-quality health services, high rates of unwanted pregnancies, especially amcng teenagers, unsafe abortions and a high incidence of sexually transmitted infections (STI), including H1V/ AIDS.

A pregnant woman has her blood pressure checked at a clinic in Fiji

REPRODUCTIVE HEALTH

Umiinom ako ng IRON TABLET upang maging malusog ang babyko 4SA BAWAT10 BUNTISAY MAY IRON DEFICIENCY ANEMIA. ILAN SA MGA SINTOMAS AY PAGKAHILOAT PAMUMUTLA.

A regional workshop on maternal mortality reduction was held in the Regional Office in MayJune 2000. This was the first workshop in the Region to focus exclusively on maternal mortality reduction. During the meeting, each country's situation, policy, action plan and intervention strategies were reviewed by the participants and consultants and national plans of action were drafted.

Improve the quality of care Service protocol development and training are crucial if the quality of obstetric care is to be improved . Technical support was provided to the Lao People's Democratic Republic to develop service protocols on essential obstetric care for national and local use. WHO also collaborated with Cook Islands, Mongolia, Samoa and Solomon Islands to develop service protocols, revise the midwifery curriculum and assess safe motherhood needs. Clinical training aids were provided to Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea and VietNam. Improved emergency obstetric care at district and provincial hospitals is a very basic condition for maternal mortality reduction . Essential obstetric equipment was provided to district hospitals with high maternal mortality in the Philippines, while outreach supervision and monitoring were supported in remote provincial and district hospitals in the Lao People's Democratic Republic. All bagh feldshers (mid-level practitioners) who provide reproductive health services at grass-roots level in Mongolia received medical kits containing basic items.

Poster in the Philippines promoting iron tablets

action strategy, the Ministry of Health in the Lao People's Democratic Republic conducted a strategic assessment of reproductive health in March and April 1999, in collaboration with WHO Headquarters and the Regional Office. A national Dissemination Workshop on Strategic Reproductive Health Assessment was then held in Vientiane in June 1999. In order to understand the reasons for maternal deaths and to develop specific intervention strategies, workshops on "Maternal Death Review" were held in China (August 1999) and Mongolia (SeptemberOctober 1999) in cooperation with WHO Headquarters. The methods covered in the workshops were then used by most provinces in China and Mongolia to review their cases of maternal deaths. This has been very helpful in the supervision and monitoring of maternal health care and in improving the quality of service delivery.

Promote rational family planning in Pacific island countries Ten United Nations Population Fund (UNFPA) funded country projects on reproductive health are being executed by WHO in Pacific island countries. Among others they cover training of multipurpose reproductive health/family planning care providers, safe motherhood, family planning, counselling to prevent abortion, and the integration ofSTI and HIV/ AIDS management into family planning and maternal health care services. The project also ensures that there are three or more kinds of contraceptive available in

8UJLO/NG HEALTHY COMMUNITIES IWO POPULATIONS

each country. In 1999, WHO participated in a subregional mid-term and annual programme review of these UNFPA projects which showed that the objectives of the projects were being met. The review was followed by the provision of technical support to governments to develop national action plans and programmes to increase contraceptive practice and decrease the number ofunwanted pregnancies.

Strengthen partnership and cooperation with international agencies and nongovernmental organizations In addition to its close links with UNFPA, WHO works with a number of other international agencies and NGOs in the Region. For example, in the Lao People's Democratic Republic and Mongolia, consultants collaborated with the Government and other United Nations agencies to develop service protocols and improve the health information system. In the Philippines, safe motherhood and reproductive health were discussed with the Government, UNFPA and the United Nations Children's Fund (UNICEF), leading to the drafting of a work plan and the development and adaptation of training materials and standards of maternal care. Antenatal care in the Marshall Islands

Prevention and control of iron and folate deficiencies Preventive supplementation with weekly iron and folic acid for women of reproductive age given before they conceive is a new strategy to prevent iron and folate deficiency. Since intestinal cells are renewed every five to six days, weekly doses of iron are more easily absorbed than daily doses and cause almost no side effects. Thus, compliance in taking the supplements tends to be greater. To prevent anaemia, this new approach aims to persuade women of reproductive age to purchase and take iron/folate tablets once a week, before and during pregnancy. Neural tube defects may also be prevented by this strategy. Social marketing and community mobilization are being used to promote the new strategy, in collaboration with government health services and a pharmaceutical company. In the Philippines and VietNam, two countries with high prevalence of iron deficiency anaemia, preventive supplementation is being tested in selected areas. Both countries have finished the 12-month trial. Results are being analysed and will be available in the second half of 2000. In addition to weekly supplementation, increasing efforts will be devoted to food fortification.

Reduce perinatal and infant mortality A training course on neonatal health care, including hands-on training in basic skills of infant resuscitation, was conducted in collaboration with the Osaka Medical Center and Research Institute for Maternal and Child Health (a WHO Collaborating Centre for Matemal and Child Health) in March 2000. Institutional plans to improve neonatal care were developed. Basic equipment, such as incubators and resuscitation tables for newborns were provided to the Federated States of Micronesia, Mongolia, and the Philippines.

-..r.ll ~

REPRODUCTIVE HEALTH

Increase awareness of women s health and improve the health status of women A workshop on women 's health was held in Beijing, China, in October 1999. The meeting reviewed the progress made and lessons learnt by countries five years after the ICPD and the Beijing Conference on Women. It also identified regional and national priority areas and indicators for women's health and adopted a Call to Action, designed to provide guidance to countries on women 's health and human rights. In cooperation with WHO Headquarters, several social science research projects on women's health are being carried out in the Region. These include research into the reproductive health status and needs of young female migrant workers in urban China, which is part of a multicentred study. Rapid assessment tools for determining adolescents' perspectives on health and health programmes have been piloted in China and VietNam. WHO has also collaborated with Malaysia in designing and carrying out a teaching package on women's health for undergraduate medical students.

RESULTS National policy development Most com1tries with high maternal mortality have now developed national programmes on safe motherhood. During the regional workshop on m atern al mort ality reduction referred to above, ili cse were subjected to rigorous scrutiny, leading to many rclln cmcnts e~nd highlighting the interventions that had been most effective.

Service protocols and curriculum development Service protocols on essential and emergency obstetric care for community and district hospitals have been developed in the Lao People's Democratic Republic and Mongolia in cooperation with WHO Headquarters . The protocols have already been discussed with national authorities and experts and will be used nationwide.

Safe Motherhood in China Although at 64 per 100 000 live births China's maternal mortality ratio is about half of the regional average, in absolute terms this still represents a very large number of maternal deaths ( 15 000-20 000 per year, or about half of the maternal deaths in the Region). Most of these maternal deaths occur in lowincome areas. According to a report from the Ministry of Health, the maternal mortality ratio is more than 100 per 100 000 live births in ten provinces. In response to the ICPD programme of action , the Chinese Government has devoted considerable resources to the safe motherhood programme. A total of200 million RMB (US$ 24.2 million) from central and local governments was allocated to the programme from 2000 to 200 I. About half of the allocation will be used to strengthen first-level referral hospitals by providing basic obstetric equipment to township hospitals. About 30% will be used to train midwives and obstetric doctors on essential and emergency obstetric case management and the remaining 20% will go to pregnant women from poor families to help them to gain access to health services. National and provincial obstetric specialists will be assigned to rural hospitals which lack skilled obstetricians to provide emergency services. Hands-on training for midwives and obstetricians will also be provided.

8utLOING HEALTHY COMMUNITIES AND POPULATIONS

Figure 8.2 Contraceptive prevalence rate (CPR), selected Pacific island countries

0::

0..

Cook Islands

Federated States of Micronesia

Fiji

Kiribati Marshall Islands

Samoa

Solomon Islands

Tonga

Tuvalu

Vanuatu

Country

Cook Islands and Solomon Islands have developed midwifery curricula adapted from the curriculum developed by WHO Headquarters. WHO provided technical support for Cook Islands to revise the curriculum for nursing schools by broadening the former "obstetric unit" into a "reproductive health unit". As noted above, WHO worked with the Government of Malaysia to integrate women's health into the w1dergraduate medical curriculwn. A women's health teaching package for medical students was also developed and formally adopted during a national workshop

In some countries there has been an encouraging trend towards greater involvement of men in family planning. In Kiribati, for example, this is reflected in the increase in the number of men who had a vasectomy in recent years which is much higher than the number of women who underwent sterilization. This has been achieved by effective information, education and communication prograillllles, and mobilization ofmen who had undergone the operation as family planning motivators and promoters.

ANALYSIS While most countries have made commitments to reduce maternal mortality and many have developed action plans to help them to achieve this, programme implementation remains difficult and uncertain. Government funds are often very limited and there is too much reliance on external funding in many developing countries. Most

Impmvement of contraceptive use rate Over the course ofthe UNFPA project to promote rational family planning, contraceptive use increased in most Pacific island countries (Figure 8.2).

REPRODUCTIVE HEALTH

programmes have to be implemented vertically, especially if they are supported by donors, and therefore sustainability is sometimes a problem. Projects funded from extrabudgetary sources often compete for the time and efforts of personnel or cause unnecessary duplication, in part because of inadequate collaboration and networking with and among involved agencies. Vertical stand-alone programmes are not the most effective way of reducing maternal deaths. Programmes to make pregnancy safer need to be integrated into the health system to ensure success and sustainability. For example, referral and information systems need to be strengthened and health financing needs to be in place to ensure accessibility to everyone. The presence of skilled attendants at birth and timely and appropriate referrals are crucial if maternal and infant mortality are to be reduced. Too often, women are seen too late in referral facilities because of problems of distance, lack of transportation or communication or because the facility lacks expertise, equipment, drugs or other supplies. It is critically important that reliable data should be available to evaluate each facility's strengths and weaknesses. All these point to the fact that reducing maternal mortality requires national legislation and policy, coordinated, long-term efforts within the health systems, and action from within families and communities.

readily available. Training on data analysis and utilization must be carried out. Referral systems will have to be improved through training, adaptation of protocols and manuals and provision of basic equipment. Communities will have to be mobilized to facilitate easy access to referral centres. WHO will continue to support regional and country training courses on making pregnancy safer. The new "Integrated Management of Pregnancy and Childbirth" strategy will be piloted in the Region . Sustained efforts will be made to raise extrabudgetary funds and WHO will take the lead role in working with countries and other partners to make pregnancy and childbirth safer throughout the Region.

Reduce perinatal and neonatal mortality The participants who attended the trainers' course held in Osaka (see above) will be encouraged to conduct training courses in neonatal health care. Technical support from WHO collaborating centres to countries will be facilitated. Advocacy for breast-feeding will continue to be emphasized through collaboration with governments and UNICEF. Reassessment of babyfriendly hospitals will continue.

Increase awareness of women's health WHO will promote the ideals of the Call for Action adopted by the workshop on women's health in 1999. In particular, it will investigate what role the Organization should play in combating domestic violence. Research will be carried out on the accessibility and acceptability of reproductive health services among different groups of women during periods of socioeconomic reform. The reproductive and noncommunicable diseases focuses will work together to support selected countries to develop national plans for early cervical cancer screening.

FUTURE Maternal mortality reduction The effective implementation of national plans of action will be essential if maternal mortality is to be reduced. Information systems will have to be strengthened to enable proper monitoring of the plans and hospital registration systems will have to be upgraded so that basic maternal health information is

9. Noncommunicable diseases, including mental health

Strengthening surveillance for noncommunicable diseases

ISSUES Dramatic increases in life expectancy, combined with profound changes in lifestyles are leading to epidemics of noncommunicable diseases (NCD), mainly cardiovascular diseases (CVD), cancer and diabetes, throughout the world. In 1998, an estimated 43% of all disability-adjusted life years (DALYs) were

attributed to NCD. In low- and middle-income countries the figure was 39%, while in high-income countries it was·81 %. NCD account for 63% of global deaths. They are expected to account for an increasing share of the disease burden, rising to 73% by 2020. In the Western Pacific Region, NCD are a major health concern in most countries. CVD are one of the leading causes of death in 32 of the Region's 37 countries and areas, accounting for 3 million deaths

Hypertension in China Hypertension is one of most important risk factors for ischaemic heart disease, stroke, congestive heart failure and renal failure. The prevalence of hypertension in China has increased for the past 40 years and there are currently about I 00 million Chinese who suffer from hypertension. Figure 9.1 Prevalence of hypertension in the adult population in China(%)

14 12 10 <D

11 .9 r--

g> 8 a.

" " " ~

5.11

7.73

6 4 2

0 1959 1979 1991

Source: Prevalence and development trends of hypertension in China, Chinese Journal of Hypertension, 3, Suppl. 1995

NoNCOMMUNICABLE DISEASES, INCLUDING MENTAL HEALTH

Deaths from cardiovascular diseases in Fiji, the Federated States of Micronesia and Samoa In developing countries, cardiovascular diseases (CVD) often occur at an earlier age than in developed countries. A large percentage of patients who die from CVD (ischaemic heart disease, hypertension and cerebrovascular disease) do so between the ages of30 and 64 years. Figure 9.2 Age-specific breakdown of cases from cardiovascular diseases in Fiji, the Federated States of Micronesia and Samoa

35 30 25 20

"::R. 0 15 10 5 0 0-4

5-14

15-24

25-34

35-44

45-54

55-64

65-74

75+

Age groups (years)

I~SAMOA -B- FSM ----13-- FIJI I

Source: t: pidemiological assessment of NCD in Fiji, Federated States of Micronesia and Samoa, MR/ 1 999/0680, I169 and 1170. Manila, WHO, 1999. Note: Data from Fiji and the Federated States of Micronesia are population-based mortality figures. Data from Samoa are hospital-based morbidity figures.

in the Region each year. Cancer is one of the three leading causes of death in 26 countries and areas and it is estimated that about 3.5 million cancer cases occur each year. There has been a steady increase in lung cancer in the Region. The current number of people with diabetes in the Region is estimated to be 30 million and it is projected that there will be at least 55 million adults with diabetes in the Region by2025 . Strengthening assessment ofthe NCD burden and

monitoring trends are critical to the planning, implementation and evaluation of NCD prevention and control programmes. Without good epidemiological data, it will be impossible to set appropriate and measurable targets for the d evelopment of effecti ve and evidence-based programmes, or to evaluate the outcomes of programmes. However, there are still many barriers to efficient NCD surveillance in the Region :

8UtLOING HEALTHY COMMUNITIES AND POPULATIONS

Table 9.1 Leading causes of deaths due to noncommunicable diseases in the world, the Western Pacific Region and China

lschaemic heart disease Cerebrovascular disease Chronic obstructive pulmonary disease Lung cancer

1 2 5 9

13.7 9.5 4.2 2.3

3 1 2 6

11.1 14.3 12.0 3.6

Source: World Health Report, 1999

• Baseline data such as mortality from CVD and cancer, prevalence of diabetes and hypertension, and information on major lifestyle-related risk factors are not available in many developing countries, particularly small island countries and less developed countries. • The data available in many developing countries are often very old, not regularly updated, collected by nonstandard methods or based only on hospital statistics. • Current international methods of NCD surveillance are often research-oriented and therefore unsuitable for small, isolated or less developed countries. • Adequately-trained epidemiologists and statisticians capable of carrying out NCD surveillance are often lacking. • Although many surveys and epidemiological studies have been conducted, the absence of good national or regional databases makes it difficult to share and exchange results.

WHO RESPONSE Support for epidemiological assessment and national capacity building Assessment of the disease burden provides scientific evidence and trend analysis that can be used for effective planning, implementation and evaluation of services. It should be regularly undertaken at

regional and country levels every three to five years. Surveys, epidemiological studies and surveillance systems for NCD at country and local levels (including population-based cancer registries) and training health workers are key elements 2 9.5 of national capacity building. For small 1 15.8 countries and areas, periodic surveys may be an efficient and cost-effective alternative to the establishment of an NCD surveillance system. An evaluation of the hospital-based cancer registry in the National Oncological Centre in Mongolia was conducted in collaboration with the International Agency for Research on Cancer (IARC) in August 1999. Cancer registry training was provided by IARC and the Regional Office in May 2000. In addition to an ongoing cardiovascular disease survey, a diabetes survey in Mongolia was supported by WHO in 1999. The survey provided extensive evidence of the prevalence of diabetes and its associated risk factors in the country. A hypertension survey conducted in 1999 in HaNoi, VietNam, revealed a hypertension prevalence of 16.1% compared with 11.7% in the first national hypertension survey in 1991. In December 1999, a national diabetes survey in VietNam was proposed by WHO and, in January 2000, WHO supported the integration of the second national hypertension survey with the diabetes survey in a national NCD risk factor survey. The framework of a protocol on NCD risk factor surveys was developed in collaboration with the National Heart Institute and Endocrinology Hospital in HaNoi. As part of a regional demonstration project on community-based integrated prevention and control ofNCD, community assessment, improvement of the project protocol and related training began in project sites in China and the Philippines in June 2000. A comprehensive assessment of the current NCD situation and epidemiological capacity in Fiji, Micronesia and Samoa was supported from October to December 1999. The assessment updated NCD baseline data on noncommunicable diseases and highlighted the importance of training in epidemiological skills and of establishing a lifestylerelated risk factor profile.

NONCOMMUNICABLE DISEASES, INCLUDING MENTAL HEALTH '

Development of an NCD information network and an NCD surveillance database Rapid developments in information technology have greatly facilitated the establishment of regional and national networks for technical collaboration and information exchange. Such networks will support information exchange, epidemiological monitoring, research and training, strategy and programme development, public education and health counselling in the Region. In collaboration with a WHO collaborating centre on population-based cardiovascular disease prevention in Tasmania, Australia, and other partners, a Regional Profile on Cardiovascular Diseases , Diabetes, Associated Risk Factors and a Regional Database on Cancer in Western Pacific Region were published in September and December 1999, respectively. They were the first systematic regional NCD databases and,

taken together, they demonstrate the alarming size of the NCD epidemic in the Region. A regional NCD information network was begun by the Regional Office in early 2000. The project includes a diabetes information network (see pp. 97-1 02) and national N CD surveillance databases. It has been actively supported by China, the Republic of Korea and Viet Nam. This initiative is part of a region wide trend to make more regional and national NCD databases accessible through the Internet, thereby providing a stronger scientific foundation for public health interventions.

Development of standardized and simplified epidemiological methods Most current international epidemiological methods are research-oriented and arc often unsuitable for public health interventions in developing countries.

Table 9.2 Age standardized gender-specific mortality from cardiovascular diseases per 100 000 population in selected countries and areas of the Western Pacific Region (age 35-64 standardized to the world populations standard)

American Samoa Australia China (rural) China (urban) Cook Islands Fiji Hong Kong (China) Japan Mariana Islands New Zealand Palau Philippines Republic of Korea Singapore

1995 1994 1994 1994 1995 1995 1994 1994 1995 1993 1993-1995 1991 1994 1994

263.6 104.6 31.4 45.5 93.3 398.9 44.3 26.3 55.2 162.4 248 .6 87.1 26.5 151.7

23.8 29 .4 7.8 13.1 95.2 103.8 14.1 6.9 0.0 48.8 0.0 33.3 7.3 52.8

88.0 19.3 100 .8 102 .6 93.3 71 .1 36 .7 44.0 124.4 22.0 55.7 70.4 96.5 52.0

208.4 12.4 71.9 71.8 0.0 54.8 24.8 23.1 47.0 26 .6 0.0 35.5 59.5 41.1

156 .2 183.7 176.9 329.5 105.4 113.8 226.8

58 .1 140.5 129.8 377 .1 53.6 47.5 95.6

E-

188.0 242.9

103.2 117.2

Source: Profile of cardiovascular diseases, diabetes mellitus and associated risk factors in the Western Pacific Region, 1999. Note: ASR =Age-standardized rate. An age-standardized death rate is a summary measure of the death rate that a population would have if it had a standard age structure. Standardization is necessary when comparing two or more populations that differ with regard to some basic characteristics (age, race, socioeconomic status, etc) that independently influence the risk of death.

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Therefore, it is important that simplified and standardized methods of data collection, analysis and monitoring which can be applied in developing countries are developed and that training in implementing these methods is provided. A regional review group on NCD surveillance, comprised of international and regional experts, national programme managers and field workers, met in Melbourne, Australia, in November 1999. The group reviewed the WHO MONICA Manual and the WHO publication Diabetes and noncommunicable disease risk factor surveys - a field guide and other epidemiological instruments, including a proposal for simplified NCD Hypertension survey site in Tianjin, China (the banner reads "Everyone should know their blood pressure and measure it regularly ') surveillance from WHO Headquarters. It recommended that a comprehensive set of simplified indicators, an NCD risk factor survey The two databases have been incorporated into the and monitoring methods be developed. A draft of a Regional Office website. manual on CVD monitoring prepared by the WHO Simplified methods for surveys and monitoring Collaborating Centre for Cardiovascular and a set of indicators for NCD risk factors have been developed. These will greatly assist the simplification Epidemiology at the University of Newcastle, Australia, was reviewed by the group and is and standardization of NCD data collection and undergoing further international review analysis in the Region. These simplified methods and indicators will be particularly appropriate for use in developing countries.

RESULTS

The availability ofNCD data at country and regional levels has gradually improved. WHO-supported surveys have provided evidence of the prevalence of diabetes and its associated risk factors in Mongolia, and hypertension prevalence in Ha Noi, Viet Nam. NCD baseline data have been collected and assessed for programme development in Fiji, the Federated States of Micronesia and Samoa. Meanwhile, following training by IARC and the Regional Office, a hospital-based cancer registry is being replaced by a population-based cancer registry at the National Oncological Centre in Mongolia. So far 16 countries and areas of the Region have established population-based cancer registries. The databases on NCD epidemiology and cancer include best available data from government reports, published articles and WHO questionnaire surveys.

ANALYSIS Strengthening NCD surveillance is a long-term task and needs firmer commitment from governments, continuous technical training and sufficient resource allocation. Although promising trends can be observed in some countries, a number of major constraints rem am. • In most developing countries national strategies and coordinating mechanisms on NCD surveillance are either not established or are not regularly evaluated. • Traditionally, many countries have not focused on effective workforce development and capacity building but have limited themselves to producing data through surveys and studies.

NONCOMMUNICABLE DISEASES, INCLUDING MENTAL HEALTH

• Good-quality mortality data are not available in many developing countries. The main difficulty is the lack of well-developed vital registration and sentinel points for disease surveillance. Incidence data are not generally available due to lack ofreporting systems, poor facilities and the absence of diagnostic expertise. • Data on NCD risk factors are very limited, as proper survey and monitoring methods have not been widely introduced. Ad hoc surveys for NCD risk factors are often not well coordinated with existing information systems.

Strengthening NCD surveillance, particularly of risk factors, is therefore a priority for effective development of prevention and control programmes. Support for surveillance will concentrate on the following broad areas: • sustainable development of national capacity to conduct NCD surveillance, particularly training and improving technical skills and facilities of national institutions; • evaluation ofcurrent practices and development of appropriate national strategies for NCD surveillance, strengthening coordination with different information systems to develop vital registration and NCD risk factor surveillance; • training in standardized and simplified NCD epidemiological methods; and • development of an Intemet-based regional NCD information network emphasizing development of national NCD surveillance databases in collaboration with WHO collaborating centres, other institutions and nongovernmental organizations.

FUTURE Major risk factors for NCD such as tobacco use, unhealthy diets, physical inactivity and obesity continue to increase. Ischaemic heart disease, diabetes, and cancer, particularly lung cancer, all continue to increase, particularly among vulnerable populations, such as older persons and low-income groups.

Diabetes

ISSUES Prevalence Diabetes mellitus (predominantlytype 2 diabetes) 1 is a major and grO\ving health problem in almost all countries. Globally, the prevalence of diabetes in adults aged 20 years and over was estimated to be 4% in 1995 and is projected to rise to 5.5% by 2025. Over the same period, the number of people with diabetes will increase from 135 million people to 300 million, about 75% of whom will live in developing countries.

In the Western Pacific Region, the current number of people with diabetes is estimated to be 30 million. This will rise to at least 55 million adults by 2025. Of these, 38 million will be in China and 9 million in Japan. The prevalence of diabetes exceeds 8% in 12 countries and areas ofthe Region and in some Pacific island countries it exceeds 20%. In countries where lifestyle changes began only recently (e.g. Cambodia, VietNam) diabetes prevalence is relatively low, but there are signs that this is changing. In these countries rapid increases in prevalence can be anticipated unless urgent preventive action is taken.

Low awareness 1

Type 2 is the most common form of diabetes and is characterized by disorders of insulin action and insulin secretion, both of which are usually present at the time that this form of diabetes is clinically manifest.

Despite WHO's work with Member States to combat the diabetes epidemic, diabetes is still a low priority in many countries. There is also low awareness of

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

the disease among the international community, the public, decision-makers and health workers. There is an urgent need for advocacy and the establishment of a regional alliance against diabetes.

Need to strengthen national capacity Increases in diabetes usually result from increased life expectancy and changes in lifestyles such as less healthy diets and less physical activity If anticipated increases in diabetes prevalence are to be prevented, countries need to strengthen their strategies for prevention. Diagnosis and treatment of diabetes and its complications (see box on p. 102) must be improved. Even in developed countries, many people with diabetes remain undiagnosed or are improperly treated. One reason for strengthening prevention is that diabetes is an extremely costly disease in economic terms (see box on p. 99). In addition to the direct costs of diabetes care, developing countries experiencing increases in diabetes will face indirect costs, as the largest rise in the number of people with diabetes is likely to occur in the economically-productive age group (20-64).

broad partnership against diabetes, including WHO, IDF WPR, SPC, governmental agencies, WHO collaborating centres, international and regional agencies and industrial partners. The meeting endorsed the Western Pacific Declaration on Diabetes and the plan of action for its implementation.

Preventing diabetes by increasing awareness The Declaration is an important step, but it must be complemented by national and local awareness-raising activities in order to encourage healthy lifestyles, enhance individual, family and community responsibilities, and develop a supportive environment. "NCD Awareness Weeks" focusing on diabetes control and promotion ofhealthy lifestyles were held in Fiji, the Federated States ofMicronesia and Samoa in September-November 1999. Diabetes and noncommunicable diseases (NCD) campaigns were held in Malaysia and Tonga in conjunction with World Diabetes Dayonl4 November 1999. These activities not only targeted health workers and the general public, but also decision-makers. In order to provide information on major risk factors, particularly unhealthy diets, obesity and physical inactivity, and

WHO RESPONSE Western Pacific Declaration on Diabetes In Europe the St. Vincent Declaration on Diabetes Care and Research (1989) and in the Americas the Declaration ofthe Americas on Diabetes (1996) have demonstrated how successful regional partnerships can have a significant impact on diabetes prevention and care. Since 1998, the Regional Office and the International Diabetes Federation Western Pacific Region (IDF WPR) have worked together to prepare the groundwork for a Western Pacific Declaration on Diabetes. WHO was closely involved in the regional congress of IDF WPR in Sydney in August 199lJ, which declared a Call for Action on diabetes in the Asia-Pacific region as an initial step towards a Declaration. A joint meeting on the Declaration was organized by the Regional Office and IDF WPR in June 2000, in Kuala Lumpur, Malaysia, cosponsored by the Secretariat of the Pacific Community (SPC). The meeting was attended by representatives of the

Taking a patients blood pressure at a diabetes clinic in Fiji

NONCOMMUNICABLE DISEASES, INCLUDING MENTAL HEALTH

The economics of diabetes Diabetes imposes a considerable burden on health systems and societies. The costs include direct costs to people with diabetes, their families and health care sectors, indirect costs to society ("productivity costs"), and intangible costs (adverse effects on quality oflife). In Australia, at least US$ 720 million was spent on diabetes health care in 1995 compared with US$ 550 million in 1990. It is projected that by 2010 costs will have risen by a further 50%. In New Zealand, 5% of the health budget is spent on direct diabetes care and a further 5% on diabetesrelated disability allowances. In Japan, the annual direct cost to the health care sector of diabetes is about US$ 16.94 billion (6% of the total health budget in 1998). In China, the estimated direct cost of care for people with diabetes in 1996 was US$ 3.5 billion. Sources: The Economics of Diabetes and Diabetes Care. A Report of the Diabetes Health Economics Study Group, WHO and International Diabetes Federation, 1998. Diabetes Health Economics, International Diabetes Federation, 1999.

interventions, a WHO core NCD information kit was prepared in June 2000 in collaboration with the WHO Collaborating Centre for Health Education at the Universityofthe Philippines. Preparation of an NCD advocacy manual, designed to mobilize national and international support, began in June 2000.

Integrated, multisectoral, community-based approaches Diabetes, cardiovascular diseases and some cancers have many common risk factors. An integrated approach that targets all major common risk factors for NCD is therefore a cost-effective prevention and control strategy. Such an approach should include primary, secondary and tertiary prevention, health promotion and education, and preventive measures across sectors and disciplines. WHO supports the establishment of demonstration projects on community-based integrated prevention and control ofNCD, including diabetes, so that the lessons learned from such projects can applied more widely. WHO demonstration projects on communitybased integrated NCD prevention and control began

in Beijing, China, and the Philippines in the second half of 1999. The major thrusts for these projects include lifestyle modification; development of community-based, integrated diabetes and other NCD services; and improvement of technical expertise in diabetes and hypertension management. Diabetes prevention and control will be integrated into health promotion initiatives, such as Healthy Islands, Healthy Cities and health-promoting schools (see pp. 53-59). The Healthy Cities and Healthy Islands approach provides an excellent vehicle for prioritizing NCD and diabetes and developing integrated NCD prevention and control programmes. With WHO support, demonstration projects were developed within the Healthy Islands initiatives in Fiji and the Federated States of Micronesia in the second half of 1999. In collaboration with the Australian Centre for Diabetes Strategies, Sydney, Australia, the diabetes prevention and care programme in Tonga was reviewed in June 2000 and was recommended as an appropriate model for other Pacific island countries. Meanwhile, a comprehensive NCD project in Jiadin, Shanghai, China, was supported within the Healthy Cities framework. The project received strong political support and leadership and a 10-year NCD prevention

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

and control programme and a plan of action were developed. A comprehensive WHO protocol and guidelines for development of demonstration projects on community based NCD intervention are being developed in collaboration with the National Public Health Institute of Finland. WHO emphasizes NCD prevention and control in primary health care. A WHO manual on prevention and control of noncommunicable diseases in Primary Health Care is being developed based on the experience of community health services in Singapore. A regional workshop on the integration of NCD prevention and In Pacific island countries diabetes fool problems control into Healthy Cities and Healthy are particularly common Island programmes was held in in November 1999. The conference emphasized the Melbourne, Australia, in November 1999 with the need for national NCD surveillance databases and support of the International Diabetes Institute, Internet training courses on diabetes. WHO will Melbourne; the Victoria Health Promotion coordinate the regional NCD information network, Foundation; the Department of Human Services, including the WPDIN. Australia, China, Japan, the Victoria; Australia; and the SPC. The workshop Republic of Korea and Viet N am have actively reviewed current practice in Healthy Cities and participated in the project. Healthy Islands programmes, and developed general guidelines on the integration ofNCD prevention and control into Healthy Cities and Healthy Island RESULTS programmes. Australia, China, Fiji, Malaysia, the Philippines, and Singapore have developed national strategies and/or programmes on diabetes control or integrated prevention and control of noncommunicable diseases. The importance of the diabetes issue is gradually being recognized by more countries, particularly in the Pacific area. The Western Pacific Declaration on Diabetes has helped to catalyse a regional alliance. Models for community diabetes control in Shanghai and integrated diabetes prevention and control and health promotion in Tonga have been established. Projects demonstrating integrated NCD prevention and control within the Healthy Islands framework have begun in Fiji and the Federated States of Micronesia. Publications and guidelines have been developed by WHO in coordination with partners. These include:

Diabetes information network Rapid developments in computer and information technology have facilitated the establishment of regional and national networks through the Internet. Such networks can be used for information exchange, epidemiological monitoring, establishment of databases, research and training, programme development, public education and health counselling. The Western Pacific Diabetes Information Network (WPDIN) is one of the regional diabetes programme's priorities. With WHO support, the WHO Collaborating Centre for Diabetes Treatment and Education, Kyoto National Hospital, Japan, and the WHO Collaborating Centre for Diabetes, University of Pittsburgh, USA, held the First International Conference on Development of the WPDIN in Kyoto

9. NoNCOMMUNICABLE DISEASES,

INCLUDING MENTAL HEALTH

• IDF/WHO joint guidelines on Type 2 diabetes: practical targets and treatment (2 ed), published in August 1999; • The Asia-Pacific persp ective : redefining obesity and its treatment published in February 2000 by a regional group of experts supported by WHO, IDF, the International Diabetes Institute Australia, the International Association for the Study of Obesity, and the International Obesity Task Force; and • Development offood-based dietary guidelines (focusing on prevention of noncommunicable diseases), published in August 1999 in collaboration with the International Nutrition Association and an expert group in Australia.

from successful experiences applied more widely. NCD prevention and control should be integrated into more healthy settings projects. Developing national strategies and programmes, improving national capacities for prevention and care, establishing accessible diabetes care for all, and raising awareness of the need for healthier lifestyles are all badly needed if the diabetes epidemic is to be stemmed.

FUTURE WHO will strengthen the regional alliance against diabetes through the Western Pacific Declaration on Diabetes. It will work with its partners to raise the profile of diabetes with national governments in the Region and international community. WHO will intensifY its collaboration with national governments to strengthen national capacity for integrated NCD prevention and diabetes care . Particular attention will be paid to the development of national strategies, lifestyle modifications, diabetes education at community and district levels and improvements to health services. The demonstration projects on community-based integrated NCD prevention and control in China, Fiji , the Federated States of Micronesia and the Philippines will be further strengthened and expanded to other countries. Effective interventions will be documented with a view to applying them more widely. The Diabetes Information Network will be strengthened and national NCD surveillance databases established where they do not already exist. WHO standard and simplified methods for NCD epidemiological assessment will be promoted.

ANALYSIS Countries of the Western Pacific Region are experiencing rapid economic and social changes, caused by rapid globalization in finance, trade and communications, urbanization and population ageing. The prevalence of major risk factors for diabetes is increasing in many developing countries. Unless effective prevention and control are implemented, diabetes and other NCD will continue to grow. The regional alliance that has been established by WHO, IDF WPR, SPC and other partner organizations should be strengthened. It is critical that the Western Pacific Declaration on Diabetes attracts strong support from the Region's governments. The Declaration's plan of action must be adequately funded and regularly evaluated. Demonstration projects on community-based integrated prevention and control of diabetes and other major NCD need to be expanded and lessons learned

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Diabetes complications Diabetes is a life-long condition and people with diabetes may develop complications. Unfortunately, even in developed countries, there are large numbers of undiagnosed patients with diabetes, or patients who are not receiving appropriate treatment. Only about half of the sufferers from type 2 diabetes are diagnosed. This means that a substantial proportion of people with diabetes may already have developed at least one diabetes complication by the time they are diagnosed. The most important long-term complications associated with diabetes are as follows. Diabetic eye disease (retinopathy and cataract) is the leading cause ofblindness and visual disability in adults in many countries. After 15 years ofliving with diabetes, approximately 2% of people become blind while about 10% develop severe visual handicaps. • Diabetic nephropathy (kidney damage) is the most common single cause of end-stage renal failure and it affects one-third of people with diabetes. By the age of 50, about 40% of people with young-onset diabetes develop severe kidney diseases that may require dialysis and/or a kidney transplant. • Heart disease and stroke account for 75% of all deaths among people with diabetes in developed countries. The risk of death from heart disease and stroke is increased about three-fold in the presence of diabetes. In many Asian countries stroke and renal failure are the commonest causes of death among people with diabetes. • Diabetic neuropathy is the most common complication, with 50% or more of people with diabetes affected. It can lead to sensory loss and damage to the limbs and is a major cause of impotence in diabetic men. Diabetes is the second most common cause of amputation of the leg (accidents are the most common cause). In Pacific island countries, diabetes foot problems are particularly common and in some islands these are the most common initial manifestations of diabetes. • Diabetic ketoacidosis, and infections such as pneumonia and tuberculosis, often lead to hospitalization.

Mental health

It has been estimated that mental health problems accounted for approximately 11.5% of the disabilityadjusted life years (DALYs) lost worldwide in 1998. In the Western Pacific Region, socioeconomic changes brought about by rapid industrialization, modernization and urbanization have led to stressrelated anxiety and depression, schizophrenia, other neurological and psychosomatic disorders, and apparent increases in alcohol dependence, drug abuse and suicide.

In the Region's largest country, China, mental health problems are estimated to account for 20% of the total burden of disease. According to a survey in 1993, the prevalence rate for all types of mental disorders was 13.4 per 1000 population. The suicide rate is estimated to be 22.2 per 100 000 population. Currently, there are 7. 8 million patients with schizophrenia. The strategies developed by the Chinese government include strengthening multisectoral

NONCOMMUNICABLE DISEASES, INCLUDING MENTAL HEALTH

coordination among all government agencies, establishing comprehensive national mental health programmes, allocating appropriate resources for mental health programmes, developing integrated community mental health services, raising mental health public awareness and promoting mental health legislation. A China/WHO Mental Health Awareness-Raising Conference was held in Beijing in November 1999. This high-level meeting was attended by representatives from many ministries and nongovernmental organizations (NGOs) and by the WHO Director-General and the Vice-Premier of the Chinese government. During the meeting, WHO's new Global Strategies for Mental Health was launched. The Global Strategies aim to improve the population coverage and quality of psychiatric and neurological care throughout the world, particularly in developing countries. It was announced that WHO would intensify its attempts to move mental health up the international political agenda. To do this WHO would work to secure the commitment and involvement ofUN and other international agencies, NGOs, professional associations, and the private sector. It would also support campaigns and community-based programmes targeting depression/ suicide prevention, schizophrenia and epilepsy. In particular the Organization would strengthen its collaboration with the mental health programme of the government of China. WHO's work in China is based on the same principles that underlie the promotion of mental health elsewhere in the Region. WHO supports countries to develop policies and appropriate programmes, to strengthen the capacity of mental health services through human resources development and to develop

community-based mental health services. In part this is carried out in association with the WHO global programme Nations for Mental Health which was implemented in China and Mongolia in 1999. During the period WHO also worked with Fiji, New Zealand, Papua New Guinea, Samoa, Solomon Islands and Tonga to improve understanding of mental health issues, train mental health staff, strengthen community-based psychosocial services, draft legislation and establish mental health education as an entry point for health-promoting schools. The WHO regional mental health programme also focuses on development of community-based mental health services and improvements to the quality oflife of the mentally ill. Close links will be established with partner agencies working in health promotion and the control of other noncommunicable diseases. The need to promote positive mental health is being recognized by more and more countries. There has been a move away from institutional to community-based treatment and care and a shill from an approach dominated by the perspective of mental health treatment specialists to one that accommodates the perspectives, right and wishes of patients, their families and countries. Awareness of the advantage of integrating mental health care into primary health care services has grown. Accessible community-based mental health services are gradually being developed throughout the Region. Mental health is now one of WHO 's global priorities. It will be the theme for both World Health Day 2001 and the World Health Report for 2001. In the Region, WHO has already started to strengthen its support for mental health and plans to increase its capacity further in the future.

Substance abuse

Substance abuse has become one of the most prevalent public health issues in the Region . In addition to high levels of psychoactive drug and solvent abuse, the abuse of amphetamine-type stimulants has escalated in many countries.

Excessive use of alcohol is an important public health issue in many countries of the Region . Continuous and heavy alcohol misuse may cause dependence, injury, death and disability from traffic accidents and various diseases. Alcohol is often a

BUILDING HEALTHY COMMUNITIES f!J'JD POPULATIONS

factor in domestic violence and other criminal activities. WHO emphasizes primary prevention of substance abuse and works with countries to train health and other workers in drug abuse prevention. For example, WHO supported a regional training programme at the ASEAN Training Center for Preventive Drug Education in the Philippines in November 1999. A study group from Malaysia and the Philippines participated in the Japan International Cooperation Agency programme on "Drug Abuse Prevention Activities: Cooperation with Japan and the USA" in October-November 1999. Information and

advocacy materials on prevention and control of substance abuse were widely disseminated to many countries of the Region. WHO will continue to support the development of appropriate preventive educational activities, not only for substance abusers but also for non-abusers, such as the International Day against Drug Abuse and Illicit Trafficking. Activities will focus on youth, schools, communities, offices and clinics. WHO will continue to support training on prevention and control ofsuhstance ahuse, assessment of patterns and trends of substance abuse and development of regional and national databases.

10. Tobacco Free Initiative

ISSUES Smoking is probably the single largest preventable cause of premature death and disability worldwide. Yet, despite the overwhelming body of evidence linking smoking to over 40 diseases, tobacco consumption continues to increase in the Western Pacific. Already it is estimated that 60% of the men and 8% of the women in the Region smoke. These figures are much higher in some countries. In fact, the Western Pacific has the highest rate of increase in tobacco use of any WHO region (seep. 172 for prevalence data). . The consequences of tobacco use are staggermg. Globally, every year, an estimated 4 million people die from smoking-related illnesses. This translates to close to 11 000 deaths per day, 2000 of which are in China. One in four tobacco-related deaths occurs m the Western Pacific Region. If tobacco Table 1 0.1 Tobacco-related mortality, by WHO region

Africa Americas Eastern Mediterranean Europe South-East Asia Western Pacific World total

125 772 182 1273 580 1093 4025

Source: Based on data from the UN Department for Economic and Social Information and Policy Analysis, Industrial Statistics Section and the UN Comtrade database as published in the World Health Report 1999. Geneva, WHO, 1999.

consumption remains unchanged, by 2030 smoking is expected to kill 10 million people annually worldwide and 70% of these deaths will come from the developing world. Smoking also harms nonsmokers. Exposure to environmental tobacco smoke can cause death, disease and ill health. Women and children are particularly vuh1erable. In Australia, for example, as many as 20% of nonsmoking women of childbearing age have spouses who smoke. These wives of smokers have.up to a 20% increased risk of lung cancer from passive smoking. Recent studies also indicate an association between second-hand tobacco smoke exposure and cardiovascular disease, stroke, nasal sinus cancer and invasive pneumococcal disease. Among infants and children, the risks of reduced birth weight, sudden infant death syndrome, asthma, respiratory infections including pneumonia and bronchitis, reduced lung function and middle ear-infections are increased by exposure to environmental tobacco smoke. It is estimated that 700 million children, almost half of all children worldwide, live in a home of a smoker. Within the Western Pacific, the proportion of children exposed to second-hand tobacco smoke may be considerably higher. Separate surveys have indicated that 66% of children and youth in Mongolia and 84% of schoolchildren in the Lao People's Democratic Republic come from families with at least one smoker. The large number of women and children exposed to environmental tobacco smoke makes this a substantial public health threat in the Region. The costs of tobacco use extend beyond health outcomes. An increasing body ofliterature indicates that the economic costs oftobacco exceed its estimated benefits to the economy. The Bellagio statement on tobacco and sustainable development (which was developed at a 1995 meeting of international organizations and indi victuals on sustainable development under the auspices of the Canadian International Development Research Centre)

lm.-w

BUILDING HEALTHY COMMUNITIES AND POPULATIONS

Figura 10.1 Trends in per capita cigarette consumption, by WHO region 3000

2500

·m -u

1:1 -u

2000

ffi .,

"' QJ

1500 - + - Africa

:; -u

"' ill a. ., "' "'

1000

Americas Eastern Mediterranean

500

--*- Europe -liE-

South-East Asia

0 1970-1972 1980-1982 Time Period

--+- Western Pacific

1990-1992

*Annual per capita consumption figures based on a three-year average over the indicated periods. Note: These tigures exclude other tobacco products and may underestimate tobacco consumption. Source: Tobacco or Health : A Global Status Report, Geneva, WHO, 1997.

concluded that: "Tobacco consumption is a major threat to sustainable and equitable development. In the developing world, tobacco poses a major challenge, not just to health, but also to social and economic development, and to environmental sustainability. " 1

WHO RESPONSE Reducing tobacco use is a major public health priority in the Region. Effective tobacco control policies can make a real difference to the prevalence of tobacco consumption and its associated health outcomes. To be effective, these policies must combine measures focusing on health promotion; education and advocacy; legislation; regulation; and pricing. A coordinated effort at both national and regional levels is necessary to create awareness of the dangers of 1

tobacco use among key policy-makers, political leaders and the general public. Effective and timely interventions are needed to offSet aggressive marketing tactics from the tobacco industry. In addition, there is an urgent need to counter the increasing prevalence oftobacco use among women and adolescents. The global Tobacco Free Initiative (TFI) was established in July 1998 to coordinate a global response to the tobacco epidemic. The Western Pacific Region has played an active role in promoting this initiative. The Regional Action Plan on Tobacco or Health for 2000-2004, endorsed by the Regional Committee at its fiftieth session in September 1999, emphasizes: • generation of national and regional support for the adoption ofthe international Framework Convention on Tobacco Control (FCTC); • development and implementation of national plans of action for tobacco control; • use of targeted and timely health promotion and advocacy initiatives;

Tobacco Alert, October 1995.

10. TOBACCO FREE INITIATIVE

• initiation of mass media campaigns for quitting tobacco use; and • enhanced coordination of TFI activities at global, regional and national levels. The Western Pacific Regional Office has channelied significant resources and efforts towards regional participation in the development of the FCTC and possible related protocols. WHO support enabled participants from developing countries to represent the Region at both the first and second FCTC working group meetings. The Western Pacific Region is the lead WHO region in the development of a possible protocol on tobacco smuggling for the second FCTC wor.king group. WHO mobilized support for the FCTC through a personal communication from the Regional Director to all heads of Government, stressing the importance of the Framework Convention. At the same time, WHO is working with countries to strengthen national and local capacities to control tobacco use. Recognizing the key role that national focal persons (NFPs) can play in promoting and implementing national plans of action for tobacco control, WHO convened the first Meeting ofNational Focal Persons on Tobacco or Health at the Regional Office in August 1999. The meeting provided an opportunity for NFPs to review the tobacco epidemic in the Region, share tobacco control experiences and develop a common understanding of the 2000-2004 Action Plan. In the period under review, WHO continued to provide support for capacity building in countries. Workshops were held in China, Fiji, Macao (China), Malaysia and the Philippines on the development of national plans of action for tobacco control and on the design and implementation of smoking cessation programmes. WHO worked with countries and areas including Macao (China), Malaysia, the Philippines and the Solomon Islands, providing technical support, particularly in the areas of tobacco regulation and tobacco control legislation. Health promotion and advocacy initiatives were carried out through mass media campaigns. In collaboration with the Philippine Department of Health and the United Nations Children's Fund, WHO designed a communications campaign that was produced and pilot-tested in the Philippines in October 1999. Entitled "It's Okay To Say You Mind", the

campaign features 15-second advertisements for radio and television, with complementary materials for print media . The campaign uses the imagery of the orchid in an ashtray, used for 1999 World No Tobacco Day. The campaign's emphasis is on empowering nonsmokers to exercise their right to clean, smokefree air. Copies of the media materials from this campaign were distributed to all Member States through their respective NFPs, for adaptation and use in their countries. A special advocacy kit, including a video, is being developed for children. A separate advocacy and educational module for health care professionals, containing self-instructional materials and a template for academic presentations, is also being produced. Numerous advocacy materials and publications, including a primer on the FCTC and a workbook to assess country readiness for the FCTC, were created and disseminated to the NFPs. A journalists' workshop was held at the Regional Office, in coordination with the tuberculosis and HlV/ AIDS focuses to build public awareness of the issues surrounding tobacco use and health through the media. World No-Tobacco Day 2000 used materials from the "Don't Be Duped" and the "It's Okay To Say You Mind" communications campaigns. Now celebrated by all countries and territories within the Region, the Day highlighted the importance of tobacco control, particularly with regard to media and advertising and the protection of the rights of nonsmokers.

Children are often exposed to tobacco promotion at an early age

8UtLDING HEALTHY COMMUNIT/E_, AND POPULATIONS

The TFI focus at the Regional Office served as a clearinghouse for important global and regional documents, which are reproduced and distributed to Member States through the NFPs. As part ofits efforts to monitor and evaluate the effectiveness of the regional Tobacco Free Initiative, WHO supported several research activities in the Philippines. The Country Profiles on Tobacco or Health were updated and published for distribution to Member States.

• Fiji and the Philippines have established national coordinating bodies for tobacco control; and • six countries and areas (Fiji, Guam, Palau, the Philippines, Tonga and Viet Nam) have developed national policies or plans of action for tobacco control. In the area of legislation, significant developments have occurred in several countries: • the Republic of Korea passed a Protection of Adolescents Act in July 1999, specifYing stricter measures to reduce adolescent access to tobacco products; • Fiji's Tobacco Control Bill came into force in November 1999; • the Solomon Islands and Tonga adopted draft tobacco control legislation during the last quarter of 1999; and • a provision banning all tobacco product advertising in print media in Hong Kong's Smoking (Public Health) Ordinance came into effect on 31 December 1999. Legislative initiatives are ongoing in other countries in the Region, including Papua New Guinea, the Philippines and VietNam. Pilot testing for the communications and advocacy campaign was completed in February 1999. Data from the pre- and post-campaign surveys showed that television was an effective medium for reaching the target population and that smokers were influenced by the campaign message. Copies of the campaign materials have been distributed to all Member States through their respective NFPs. In addition, several publications were developed, including a primer on the FCTC, a workbook to assess country readiness for the FCTC, leaflets and fact sheets on tobacco use and its consequences and a booklet on smoking cessation. These and other advocacy materials have been disseminated within and outside the Region and displayed during tobaccorelated meetings.

RESULTS The Western Pacific Region was represented at both the first and second working group meetings on the FCTC. As a result of these meetings, the necessary groundwork for the FCTC process is now in place for the negotiation phase. A draft of the proposed technical components for the FCTC protocol on tobacco smuggling has been prepared for review, accompanied by a background paper on tobacco smuggling. Several countries have made progress towards achieving the goals of the Regional Action Plan. Within the past year:

Regional Action Plan on Tobacco or Health 2000·2004 WORLD HEALTH ORGANIZATION WESTERN PACIFIC REGIONAL OFFICE • 1999

10.

TOBACCO FREE INITIATIVE

ANALYSIS The gains during the past year, while significant, are small when compared to the challenges that remain for effective tobacco control within the Region . Government ownership, control and/or subsidyofthe tobacco industry are major obstacles that will need to be addressed. Equally important is the concern in tobacco-growing countries over perceived short-term economic displacement from tobacco control measures that would reduce supply. The tobacco industry will probablyuse political and economic leverage to hinder efforts to promote effective tobacco control policies in countries within the Region . It considers the AsiaPacific region a growth area for marketing tobacco products with the potential to replace the shrinking markets in North America and Europe. The industry's resources are formidable, making independent attempts at tobacco control by individual countries unlikely to succeed. This highlights the critical role of the FCTC in supporting countries that want to pursue tobacco control; as an international convention, it is an international mark of support for national efforts to control tobacco. At the same time, it will provide direction to and facilitate coordination among the countries that are initiating tobacco control programmes. Generating support for the FCTC among the political leadership within the Region is therefore a priority. In countries where the government owns or subsidizes the tobacco industry, political support for tobacco control will largely depend on the strength of the economic arguments that demonstrate the overall losses from tobacco use. In these countries, sound economic analyses are needed that address their specific situations. The collaborative efforts of health agencies and civic groups, such as nongovernmental organizatim~s (NGOs), can play a crucial role in moulding publ~c opinion. Using the media and advocacy, pubhc awareness and demands for action against tobacco can be raised to a level sufficient to make political leaders take notice and action. While the FCTC will provide guidelines for tobacco control at the international level, implementation will be determined at the country level. Thus, the success of the FCTC will hinge on countries' abilities to carry out tobacco control

programmes. In the Region, several countries still do not have national plans of action for tobacco control. Legislation remains weak or nonexistent in a number of Member States. Human and institutional capacity needs to be built and gaps in resources identified and filled . This needs to occur in parallel with the efforts to raise support for the FCTC among the Region's political leaders and to raise public support and demand for tobacco control. TFI's success will depend on the ability to address these priority areas before 2003 .

FUTURE The immediate challenge for WHO and Member States is to build on the momentum of the past year and to work towards a sustained and measurable reduction in smoking prevalence. Increasing political support for the endorsement of the FCTC in 2003 will be crucial for future tobacco control efforts. WHO will continue capacity building

It's okav to sav vou mind. T'he orchid In an ashlnlly Is a signal that tho,. are no,...smoken In the fOOmno!Himok~

who P'Qfw 10 br..the cl&ln, ~~•tree elf.

8UJLDING HEM THY COMMUNITIES AND POPULATIONS

and technical support to ensure that each country has a National Plan of Action on Tobacco Control by2001 and effective tobacco control legislation by 2003. Efforts will be directed towards establishing collaborative efforts with partner agencies; securing resources to maintain effective health education,

communication and advocacy campaigns; designing and implementing activities to address smoking among women and adolescents; developing mechanisms to support country-level research; and updating and disseminating regional and countryspecific data to monitor the impact of tobacco control.

Empowering youth against tobacco use As tobacco consumption decreases in the developed world, the tobacco industry is increasingly focusing attention on potential growth markets. The adolescent market is a prime target for tobacco industry advertising. The effects of such advertising can already be seen in rising smoking prevalence rates among the young within the Region. The TFI focus in the Regional Office has begun to address issues affecting adolescents and tobacco, beginning with an International Consultation on Tobacco and Youth held in Singapore in September 1999. Greater attention needs to be paid to this vulnerable population group if the tobacco epidemic is to be successfully controlled within the Western Pacific Region (see also pp. 80-84). Table 10.2 Estimated youth smoking prevalence, selected countries and areas

Country/area American Samoa Australia Cambodia

Estimated youth smoking Age Prevalence (%)

Country/area Mongolia Papua New Guinea Republic of Korea

Estimated youth smoking Age Prevalence (%)

14-18 14-17 15-19

Males Females Males Females Males

8.1 5.3 12.1 15.5 17.0 5.8

12-18 10-15

Males 23.9 Females 8.9 Males 22.0 Females 18.0

Senior high Males 32.0 school Females 7.5 students

China (Jiangxi Province) Hong Kong (China) Japan

high school students

Singapore Tokelau Vanuatu

18-19 15-29 12-18

Males 20.0 Females 3.7 Males 50.0 Females 47.0 Males 58.0 Females 18.0

15-19 3'd year

Males Females

4.2 1.3 36.9 15.6

Males senior high Females school students

Lao People's Democratic Republic

11-1

43.2

VietNam

<18

7.0

Sources: These estimates were derived from questionnaires, reports from countries, published data, local research, and in cases where no specitic data exists, relateri information. Note: Data on youth smoking prevalence may not always reflect national data. Among the few studies that exist within the Region, several are based on small sample sizes or pertain to specific subsets within the population.

Health sector development This theme aims to address the issues that health policy-makers face as they struggle to adapt their health systems to the changing needs of their populations and to achieve maximum impact from their investment in health. Health reform can take many forms, from improved health financing to changes in delivery of health care. WHO intends to strengthen its capacity for health situation analysis and its capacity to support countries in the planning process, especially those countries undergoing health reform. Human resources development is a vital component of health sector development and includes not only technical training of health personnel but also management of the health workforce. Other important areas covered by this theme include essential drugs and other medicines, traditional medicine, health research, health information and emergency and humanitarian action. The theme has four focuses, which are described in the following chapters: 11. Health systems reform Managing reform in health systems Health legislation He2.lth care financing Essential drugs and other medicines Traditional medicine Health research, health technology and blood safety 12. Human resources development Management, education and training Mid-level practitioners 13. Health information and evidence for policy 14. Emergency and humanitarian action

11. Health systems reform Managing reform in health systems ISSUES Despite considerable differences in levels of development of different health systems, for a wide variety of reasons all countries in the Region are reforming or planning reforms to their health systems. This reform process is itself posing a number of challenges to policy-makers.

Privatization Private practice is now a critical issue for a number of countries. Many people have little choice but to usc private practitioners, which means that the poor often have no access to services at all. Regulation is often minimal. There arc very serious concerns regarding the nature of the services being provided and the quality of some care. This trend towards privatization is an urgent issue, requiring both policy decisions and guidelines, as well as appropriate regulation . WHO needs to do more to support countries to improve safety nets for those unable to access services.

Decentralization and planning capacity In many systems, decentralization is a key feature of reforms. It is often undertaken to improve consumer responsiveness and community input, as well as to shift the development emphasis towards primary health care and prevention and away from highly specialized hospital care. However, the success of decentralization is often jeopardized by inadequate management and planning at regional or local levels at the beginning of decentralization, and by poor mechanisms for monitoring and accountability. Furthermore, not all functions can be decentralized; those that cannot include national policy formulation, and control and regulatory functions. Sometimes, the distinction between functions that should be carried out at the central level and those that should be undertaken at peripheral levels is not clearly defined. Development ofhuman resources can require a considerable lead time, and a number of countries have recognized that they lack staff with good slcills in management and planning, particularly at the local level. Governments, however, often want to undertake health reforms with some degree of urgency and therefore require technical support to ensure that these reforms are well planned and managed while the in-country human resource capability is being improved.

Maintenance of facilities and equipment Many countries in the Region have significant problems with out-of-date and poorly maintained facilities and equipment. The capability to manage or maintain medical equipment in most developing countries remains weak. This is a critical issue, as there are now signs that more medical equipment (e.g. x-rays, ultrasound units and laboratory auto-analysers) is being deployed at the district level. The growth in capabilities to manage or maintain this equipment has lagged far behind the rate of deployment. As a result, non-functioning and poorly maintained medical equipment is a significant and worsening problem in some countries, affecting the ability to provide effective services. In a number of cases, relatively minor problems (e.g. loose or missing nuts and bolts, or broken wires) stop equipment from functioning . Shortages of spare parts and of technicians with basic training in maintenance often mean that equipment is not repaired.

HEALTH SECTOR DEVELOPMENT

---

===~=~~~=--=====

==-----=- ,~-=~-=

WHO RESPONSE Technical support for various aspects of planning was provided to China, Fiji, Malaysia, the Federated States ofMicronesia, and VietNam. This included reviewing current health plans, identifYing options and gathering information in preparation for the next plan. In some instances, support also included training in planning for local staff, or recommendations on how to strengthen local planning capabilities. ln China, WHO collaborated in a workshop on health resource allocation standards. A number of projects were also undertaken focusing on improving the provision of health services in rural areas and establishing models for a rural community health care system. Several activities were undertaken in the Lao People's Democratic Republic, including a comprehensive inpatient cost analysis of central, regional and district hospitals, and a follow-up financial

provided for a review of the current financing and management of hospital facilities, focusing on financial viability and quality of care. Technical support for biomedical equipment was provided to Cook Islands, Fiji, the Lao People's Democratic Republic, Mongolia, Samoa and Vanuatu. This included developing management policies for biomedical equipment, undertaking inventories, developing standard specifications, training local technical staff, and repairing equipment.

RESULTS

Clear results of technical assistance and other collaborative measures in health sector reform are difficult to demonstrate over a short time period. However, a worthwhile interim result is the increased understanding of the need to use a comprehensive approach to changing health systems. It is now recognized that changes planned on a piecemeal m a n a g c 111 e 11 i Health systems reform can basis often create more workshop . The be defined as a sustained process of problems than they solve. management needs change in policy, in:titulioJial aud operational In relation to of provincial <Jlld arrangem ents, .~u ided by .~o vernment, designed to specific areas oftechnical district hospil<~l impro••e tlte frmcfiouin.~ and performance assistance, support for ad m i n i Sl r <1 lor s various aspects of were assessed, a of the health system, and ultimately planning has contributed workshop was held the health status of the population valuable information that and a draft countries have been able curriculum and to use to develop future country health plans. Countries training course for the administrators were developed. have reported that WHO's collaborative projects A review of previous WHO technical collaboration in covering medical equipment have resulted in the country was undertaken to determine what inputs recognition that a much more comprehensive would be most useful in future. The review also looked approach to the effective management of biomedical at how the various activities related to each other, so equipment is required. In Cambodia, progress with that support could be provided in a more balanced the Health Sector Reform Project has led to the and coordinated way. extension ofthis project for a further year. With regard to facilities, technical support was provided to Fiji for a workshop to assist senior managers in formulating their department or unit ANALYSIS plans, and to initiate a process for national health policy formulation. Technical assistance was also provided to Vanuatu to identity options for future The health sector is complex, and as a result it is development of the Northern District Hospital. In difficult to plan for or to anticipate all possible effects Guam, a workshop was held on facilities planning ofhealth sector reform or ofbroader economic or social and construction review of health regulated policies. This seems to be particularly the case in establishments. In the Philippines, support was relation to private practice. With market-oriented

11.

HEALTH SYSTEMS REFORM

approaches being adopted more widely, opportunities FUTURE for private practice are being recognized by an increasing number of health professionals. This is particularly true when public sector wages are below Internationally, there is increasing recognition of the the cost ofliving, as they are in some countries of the relationship between health and various Region. socioeconomic factors . This includes the impact In addition, many health professionals have of general economic policies on health, and the lower become increasingly frustrated with poor resources health status of the poor. It is therefore important in the public sector - a problem which is greatest in that governments consider the impacts on health rural areas, and as a result many have moved to urban when designing changes or reforms within the locations or entered private practice. In an attempt to broader economic and social sectors. WHO aims to control utilization or generate revenue, user charges increase its contribution to international discussions have been introduced in many public systems, in some on these topics whenever opportunities present cases without any provision of basic safety nets to themselves. ensure that poor people can continue to access services. WHO will also examine how it can collaborate Further, because the provision ofhealth services (apart more efficiently and effectively in the management of from those connected with traditional medicine) has biomedical equipment. Consideration will be given in the past usually been delivered mainly by the public to facilitating access to technical resources, possibly sector, there are often few or no regulations governing through a website. A policy that requires countries to private practice. have a coherent approach to the management of Effective management of biomedical equipment biomedical equipment in place before equipment has remained a key issue for a number of countries. supplies is under consideration (sec box on p. 116). Well maintained and functioning medical equipment Overall, WHO aims to provide high-quality is essential for the delivery of effective and safe health technical support by ensuring that work in this area services. Good management ofbiomedical equipment is comprehensive and developed through a team requires inventories of equipment, a plan for approach, covering health care financing, human preventive maintenance, trained technicians, access resources development, and information and systems to technical specifications and manuals and spare research and analysis. parts, and a clear lines of responsibility for ensuring that equipment is maintained and appropriate equipment is requested or purchased. Without U1is, no one is certain what equipment should be available or where it is; when equipment breaks down no-one is informed that it needs repair; and no life-cycle planning is undertaken to plan for the replacement of important equipment. Donors, too, can contribute to the problem by supplying equipment that is not compatible with previous makes of equipment, which results in different types of spare parts being required. Technicians are often not familiar with equipment supplied by donors (in some cases operating and Most of the Regions health sectors are increasing the allen/ion technical manuals may not even be they devote to primary health care, as in this mobile health clinic in a rural school in Brunei Darussalam supplied).

. ,..

HEN..TH SECTOR DEVELOPMENT

Management of biomedical equipment In order to ensure that there is operational support for biomedical equipment and that equipment is selected on the basis of suitability, WHO is proposing that, in principle, certain policies and practices should be in place in each country before the Organization supports the purchase of new equipment. These include:

• An official multidisciplinary team (such as a 'Medical Equipment Commission' or similar, appointed by the Minister) should be in place, with named members and records of meetings held. AJl medical equipment acquired for health facilities ofthe Ministry of Health should be approved by this team (unless districts are permitted to purchase equipment below a certain cost). • There should be established policies for approval of requests, including demonstrable clinical need; available funding; maintenance services and support; specified procedures for approval; standardized essential equipment; provision of manuals and training from the supplier; inspection of all new arrivals of medical equipment; a national medical equipment inventory; appointment of a technical officer responsible for commissioning of equipment; user training; monitoring of equipment performance; and a policy on decommissioning. • There should be confirmed sources ofmaintenance, including alternatives such as in-house staff, facilities, tools and an operating budget for supplies, or externally contracted maintenance. • The national inventory of medical equipment should be updated at least annually. • There should be regular reporting, including maintenance reports. • Preventive maintenance programmes should be implemented • There should be active membership in medical equipment special interest groups. It is suggested that, in principle, before any support for equipment is received from the Regional Office, at least the first five of these requirements, policies and procedures should be in place and operational.

Further consultation, with additional supporting information, will be undertaken with Member States in the Region.

Health legislation

ISSUES Health legislation is one means of formally expressir.g policy decisions and enabling implementation. It is essential, for example, in situations where government, or an agent of government, may infringe on the rights of individuals, or where some protection is required for consumers in vulnerable circumstances, or to ensure that government expenditure is legitimate and is collected or applied in particular ways.

Legislation often lags behind changes in international trends and public expectations on human rights, the rights of and protections for consumers of health services, changes in technology, and new and more flexible approaches to regulation. This is understandable, as the issues inherent in these areas are often controversial, and politicians who raise them can be targeted by strong 'pro' and ' anti' lobbies. However, outdated legislation can place the safety of consumers at risk, and can result in difficult ethical and administrative dilemmas for those responsible for the delivery of health services.

-=---=---

===~==~

11.

HE!lLTH SYSTEMS REFORM

In recent years, health legislation in countries of the Region has often not been reviewed or revised to bring it into line with changes that have occurred either in the health sector or more broadly in society. Some of these changes have arisen because of major changes in economic policy, for example, the emergence of a significant private sector in countries without legislation governing services provided by private practitioners. In some countries, policy and legislative changes are needed to contain burgeoning costs of health care, and to put in place health insurance schemes and social assistance.

safety, nutrition and national regulatory authorities for drugs and vaccines. The results of these activities are reported in the chapters covering these areas. WHO will pursue a more comprehensive approach to health legislation in future and the results of these activities will be reported in due course. Some results from WHO's support for legislation related to health can already be seen, particularly in Tonga, where there has been substantial progress in drafting legislation.

ANALYSIS In a number of countries, there is often a shortage of legal advisers working in, or available to, government health ministries. In part, this points to a need for the increased need for legal advisers with an understanding of the health sector in some countries. The situation becomes even more complex when governments are asked to deal with new agreements resulting from globalization and liberalization of trade, including drugs and food products. However, care should be taken that this docs not result in lawyers driving the policies; legal staff should always work as part of the policy development team. In small countries the health ministry may not be large enough for in-house legal expertise to be developed, so close working partnerships will be required with, for example, justice ministries or attorney-generals' departments. It is important that some expertise in health legislation (in its broadest sense) be developed within each country.

WHO RESPONSE WHO is developing a strategy for health legislation, in collaboration with national governments, development partners and collaborating centres. The strategy will include identification of gaps in legislation in countries, capacity building and training as well as the development of guidelines on drafting and implementing legislation. During the review period, WHO provided advice to Tonga and Vanuatu on refinements to legislation, including licensing of health professionals , implementing legislation on public health, registering health practitioners, and developing policy on mental health. WHO also collaborated with the Republic of the Marshall Islands, where the emergence of private providers has created a need for regulation to ensure consumer safety. Support was provided to develop broad policy proposals on regulation of, among others, health professionals, health providers, medicines, medical devices, blood, blood products, tissues and organs, radioactive substances, setting of standards for facilities, equipment and processes, and protection for consumers' rights and information.

FUTURE Through the adoption of a comprehensive strategy and increased collaboration with national governments, development partners and collaborating centres as well as linkage with global networks, WHO will increase its support for health legislation. To support the immediate needs of governments in dealing with the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), practical information guidelines are being prepared.

llDI

RESULTS In recent years, WHO has provided support for health legislation in the Region in specific areas such as food

HEALTH SECTOR DEVELOPMENT

Health care financing

ISSUES There are four major sources ofhealth care financing (government, health insurance, private out-of-pocket payments and external funding) and all countries in the Region rely on a mixture ofthese. However, there are significant differences in the emphasis countries give to each financing source. For example, Australia and New Zealand use earmarked taxes to cover expenditures for health care. There is universal social health insurance in Japan, Mongolia, the Republic ofKorea and Singapore, while China, the Philippines and Viet Nam are making efforts to extend the coverage of social health insurance. Many Pacific islands rely heavily on external funding to meet their health needs. The level of national spending on health is still low in the Region and only Australia, Japan, New Zealand and Samoa spend more than 5% of their gross national product (GNP) on health (one ofthe Health for All Strategy's global indicators for resource allocation). This suggests that alternative sources for health care financing will be needed if health expenditure is to come close to matching the Region's health needs. For some countries, government spending on health has been falling in recent years and the financing gap is often filled by out-of-pocket payments. There is clear evidence from several countries of a deterioration in the health status of vulnerable, low-income populations, particularly when social safety nets do not cover the entire population. In China, for example, the share ofhealth spending from the government budget (excluding government health insurance) decreased from 32% to 14% between 1986 and 1993. 1 In 1993, it was reported that out-of-pocket payments accounted for 26% of total health spending in rural areas and 16% in cities. 2 There is a similar trend in the Philippines,

where out-of-pocket payments increased from 45.8% ofthetotal expenditure on health in 1991 to 49.4% in 1995. During the same period, the percentage ofhealth spending by the government decreased from 36.5% to 33.3%. 3 A sharp decline in government financing ofhealth services in Mongolia during the economic crisis in 1991 ~ 1993 resulted in many maternity homes being closed down. A survey conducted jointly by the MinistryofHealth and the United Nations Population Fund (UNFPA) in mid-1993 revealed that only 52 of the 371 maternity homes that had existed at the end of 1990 were still functioning. 4 The maternal mortality ratio per 100 000 live births jumped from 120 in 1990 to 240 in 1993 (it subsequently dropped to 158 in 1998). However, maternal mortality in rural areas is twice as high as in cities. In the Lao People's Democratic Republic, the government budget was the single source of health care financing for many decades, but, during the recent reform period, government participation in health care financing has decreased significantly. According to data from the Ministry of Health, government financing decreased from 31.6% of total health spending in 1994~1995 to 11.5% in 1997~1998. Declines in government funding have led to public hospitals in many countries being given financial autonomy. Because they receive fees for payment, in order to increase revenue, many health service providers have generated demand for inappropriate but profitable health services or products, especially pharmaceuticals and high technology diagnostic services. Evaluation and assessment of health system performance in connection with resource allocation is often not carried out. The concept of national health accounts, showing how funds are allocated and spent in health, is fairly new and has not been widely adopted. Currently, the Regional Office has

1 United Nations Common Country Assessment Report, Beijing, China, 1999. 2

3 4

Philippine National Health Accounts, 1991-1997. P. Nymadawa, Vulnerability issues in Mongolia, paper presented at ADB Social Sector Forum, 1999.

China 2020, World Bank series, 1997.

11.

HEALTH SYSTEMS REFORM

comprehensive information on health care financing only in the few countries with relatively wellestablished national health accounts. No standards or guidelines on national health accounts have yet been developed within the Region and the standard of national health accounts varies considerably. Lack of appropriate policy and regulations to guide the health financing system has Led to a substantial erosion in the equity, quality and efficiency of the health care system.

efficiency of national health systems and encourage cost-effective health interventions at both national and international levels is critical. WHO is therefore expanding the scope of its collaboration to support initiatives aimed at finding additional ways of mobilizing resources to finance health services. It is also working with countries and other agencies to improve health services (e.g. with the Human Security Fund of the Government of Japan and the Asian Development Bank to strengthen social safety nets).

WHO RESPONSE WHO is significantly increasing its support for health financing in the Region and is taking systematic measures to support Member States to strengthen their health care financing and social protection measures. As a first step, WHO is reviewing health care financing in the Region, government policies and needs. The discussions on social safety nets at the ministerial round table held during the fiftieth session of the Regional Committee in September 1999 were an important part of this process. The next step will be to support countries to develop budgeting and pricing systems at national and district levels, which will form the basis for reliable data on national health accounts. The Organization is currently preparing guidelines for the development of comparable national health accounts in all Member States. It will also measure the performance of health systems at the national level in relation to resources spent on health. As a result of discussions with the governments of Brunei Darussalam, Cambodia, China, Malaysia, the Federated States of Micronesia, Mongolia and VietNam, among others, WHO is giving significantly more emphasis to strengthening health care financing capacity, including the design and implementation of health insurance, stronger budgeting and pricing mechanisms, and national health accounts. WHO is collaborating closely with national governments in resource mobilization, decentralization, restructuring of hospital sectors in order to provide more community care, rationing of supply and demand, cost containment and development of social safety nets for health through social health insurance and social assistance. Since government resources are limited, the need to identifY alternative sources of funding, improve the

RESULTS WHO's support for health financing initiatives in the Region has increased in the last year. Some progress can already be seen in a number of countries in Region. For example, in the Lao People's Democratic Republic, a master plan on social health insurance for all population groups has recenlly been developed. A Social Security Decree passed in January 2000 will provide social health insurance for public and private workers and their families. At the same time, the Ministry of Health plans to pilot community-based health insurance. In VietNam, an ongoing review of existing health care financing and resource allocation methods is being carried out. As a result, WHO is targeting its support for improved access by the poor to essential basic services on voluntary health insurance at rural community levels. It will be some time before the Organization's new emphasis on health systems reform yields more wideranging results.

ANALYSIS Stable and effective health care fmancing mechanisms that ensure access by all to high-quality health services are an essential part ofWHO's vision for the Western Pacific Region. Low levels of government spending on health in most countries have increased inequity in delivery of services. Public spending on health is skewed towards hospitals and, in many cases, other more cost-effective public health programmes are underfunded. According to the World Bank, only a quarter of government health spending (often less) is devoted to essential public and preventive services.

IUW

HEALTH SECTOR DEVELOPMENT

Countries facing economic crises and currency devaluations have often found it difficult to manage and sustain levels of financing for health. Revenue shortfalls are often compounded by poor budgeting, planning and management. Recent economic developments have created new financing issues . In the Republic of Korea, for example, gross domestic product (GDP) per capita dropped from US$ 10 543 in 1996 to US$ 9511 in 1997 and again to US$ 6823 in 1998 . The unemployment rate increased from 2% in 1996 to 6. 8% in 1998. Although social and health services are still available to almost the entire population, the number of poor and unemployed homeless people needing social protection has increased significantly. 5 There is no single model of health care financing or health care financing reform . Reforms being undertaken in both developed and developing countries reflect the specific needs of each country.

Nevertheless, many countries in the Region face common problems and WHO will develop strategies emphasizing issues that are shared by countries with similar levels of social and economic development, in order to maximize the effect of the Organization's technical support and collaboration.

FUTURE Particular emphasis will be given to countries in economic transition and Pacific island countries. WHO will support national efforts to develop appropriate and sustainable health care financing mechanisms and social safety nets, including social health insurance. As well as working to establish social safety nets for health, WHO will provide technical input for the development of appropriate regulations, financial planning and budgeting mechanisms. A regional databank on health care financing will be developed and Member States will be supported to develop national health accounts and tools for evaluating and monitoring health system perfom1ance.

Kyun Kim, Cash assistance in Korea, paper presented at the ADB Social Sector Forum, 1999.

5 Sang

Essential drugs and other medicines

ISSUES Supply and management of pharmaceuticals Consistent availability of good quality essential medicines remains problematic in some countries and areas of the Western Pacific Region. There are many reasons for this, including the isolated geographicai location of some countries, the high prices of pharmaceuticals, relatively low budget allocations for drugs, inefficient selection and management of pharmaceuticals, and lack of infrastructure for drug management and storage. Many countries lack monitoring and supervisory mechanisms for drug supply and management.

Counterfeit and substandard drugs The distribution of counterfeit and substandard drugs has increased in recent years. Counterfeit drugs mimic authentic branded or generic drugs. Substandard drugs are produced with little or no attention to good manufacturing practices. Distribution, marketing and use of substandard and counterfeit antimalarials, antibiotics, antipyretics and antiasthmatic drugs, among others, have been reported in recent years. Poorer communities attracted by lower-priced medicines are particularly at risk from such drugs. Substandard drugs are a result of a lack of resources to implement good manufacturing practices, poor planning in the manufacturing process, and an absence of quality control. Distribution of counterfeit

11.

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drugs thrives when laws and regulations either do not exist or are poorly enforced and drugs can be obtained without prescriptions.

regulations and legislation but to enforce them efficiently.

WHO RESPONSE Irrational drug use practices Medically ineffective, harmful and/or economically inefficient prescribing practices can be found in many of the Region's health facilities and communities. Inappropriate drug use jeopardizes the quality of the therapy provided to patients and wastes limited resources available for pharmaceuticals. There is overuse of antibiotics, injectable products and multivitamin preparations and multiple prescribing in poly-pharmacies in many health facilities . The underlying causes of irrational prescribing practices are complex and involve multiple factors and actors. Providers, patients, health care environments and pharmaceutical promotion may all contribute to the problem. One of the most important reasons for irrational prescribing practices is that , because payment for consultations and drugs is usually made directly out of the patient's pocket, there are financial incentives to overprescribe. Although training is an important part of implementing an effective rational drug use (RDU) strategy, conventional training has proved to be ineffective when it is the only intervention. Innovative approaches are needed to support training, particularly in hospital facilities and private practices where RDU interventions have been limited so far. WHO supports countries to develop and implement a national drug policy (NDP) or elements of an NDP. An NDP includes drug regulation and legislation, drug selection based on the essential drug concept, good manufacturing practices and quality assurance, drug management, rational drug use, and human resources development. The overall goal ofWHO's support is to ensure regular availability and accessibility of essential medicines of acceptable quality. In formation exchange covering the use and management of pharmaceuticals among drug regulatory authorities in the Region is an effective way of improving pharmaceutical policy. The establishment of an electronic network for information exchange on various aspects of drug supply management, quality assurance and rational drug use in Pacific island countries was discussed during a workshop on Information Exchange in Management and Use of Pharmaceuticals, Biologicals and Herbal Medicines held in Nadi, Fiji, in October 1999 and is now in place. Elsewhere in the Region, WHO has been working closely with a WHO Collaborating Centre for Drug Information at the Universiti Sains Malaysia to improve information exchange through the use of an electronic discussion group. With regard to quality assurance of pharmaceutical products, WHO has worked closely with the Australian Therapeutic Goods Administration on quality control of pharmaceuticals in some Pacific island countries and with collaborating centres for quality control in Malaysia and Singapore. In December 1999 a training workshop on the Monitoring, Detection and Control of Counterfeit Drugs was organized in Manila, the Philippines, in collaboration with the Philippine Bureau of Food and Drugs. The objective of this workshop was to improve the capacity to undertake detection and control of counterfeit and substandard drugs in countries of the Region . Technical assistance was provided to Cambodia to improve its national laboratory capacity for quality control and to Malaysia to implement good laboratory practices at the National Pharmaceutical Control Bureau (NPCB).

Unlicensed drug outlets Unlicensed drug outlets hinder efforts to improve pharmaceutical distribution, marketing and use. Drug sellers, often without proper qualifications or training, practise as both 'prescribers and dispensers', making a diagnosis and deciding on the medication to be dispensed. Prescription drugs such as antibiotics are often sold without prescriptions, and are dispensed to patients without proper information on how they should be used. In Cambodia, for example, restricting the number of unlicensed drug outlets is a priority of the Drug Regulatory Authority, but the enforcement of law and regulations cannot be dealt with by drug regulatory authorities alone. In many countries in the Region, the challenge is not only to formulate drug

HEALTH SECTOR DEVELOPMENT

Integrated drug supply management and drug use monitoring and supervision in Cambodia - an indicator-based system An integrated and comprehensive drug management and drug use monitoring and supervision system in Cambodia has been designed to ensure the supply, availability and appropriate use of drugs in public facilities, from health centres to hospitals. This is a considerable achievement since such systems are rarely implemented in developing countries. In Cambodia the system has been in operation for about five years and has been implemented by the Essential Drugs Bureau at the Ministry of Health with support from some international donors. Indicators on drug supply, management and use are collected every three months and sent to the Essential Drugs Bureau fur analysis ami feeubat:k. T11e iuuit:aluu; 1 t:vt:al Lhal this muuiLUl iug aw.l SUI.Jt:l visiuu mechanism has been effective in improving rational use of drugs in these health facilities. With WHO support, supervision and monitoring mechanisms at provincial and district levels are being strengthened.

The problems of irrational drug use in the Region require a comprehensive strategy combining several interventions, implemented as part ofthe health care service system. In Cambodia, an innovative strategy consisting of integrated drug monitoring and supervision of drug supply and drug use has been in place for years and WHO recently provided support to improve the implementation of this system in provincial and district levels through RDU training and monitoring and supervision workshops at the provincial levels (see box). An assessment of antibiotic prescribing practices was conducted in VietNam and a national conference on antibiotics was organized in Hanoi in February 2000, with support from WHO. The conference formulated a national strategy on improving the quality of antimicrobials and on reducing microbial resistance. Technical support to increase the use of treatment guidelines in accordance with the List ofEssential Drugs was provided to Fiji and Mongolia in order to improve prescribing practices. In Cambodia, a national workshop was held with WHO support to incorporate elements of the RDU into the curricula of medical, dental paramedical and pharmacy schools. In order to improve prescribing practices in hospital facilities, a workshop on Drug Information Service and Hospital Pharmacy Therapeutics Committee was held in Penang, Malaysia, in October 1999 in collaboration with WHO Headquarters, the South-East Asia Region and the WHO Collaborating

Centre for Drug Information. A working group with members from the South-East Asia and Western Pacific Regions was formed to develop and formulate strategies to improve drug use in hospitals. WHO has also continued to provide technical support to enable countries to strengthen the regulation of pharmaceuticals. In the review period, such support was provided to the Lao People's Democratic Republic and Papua New Guinea. On-site staff training was undertaken in Cambodia in order to improve the skills of drug registration staff WHO supported the participation of a number of staff from the Region in an international course on drug policy issues in Mumbai, India, in December 1999.

RESULTS Information exchange on pharmaceuticals is now available for Pacific island countries through an electronic discussion group covering such issues as product selection and availability, pricing, quality and use. In the area of counterfeit and substandard drugs there has been incremental progress. Good Laboratory Practices have been improved at NPCB Malaysia; this is particularly important since it is anticipated that the Centre will become one of the main resource centres in the Region. Quality control testing of some pharmaceutical products in referral laboratories in

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Australia, Malaysia and Singapore is being carried out. A comprehensive RDU strategy is being implemented in Cambodia. Data on drug supply, management and use are collected every three months from health facilities and made available at district and provincial levels as well as at the Essential Drugs Bureau at the Ministry of Health. Public education on rational drug use is being carried out on television and through dissemination of posters and other educational materials. Baseline data on use of antibiotics in VietNam are being collected. Following the national conference on antibiotics referred to above, a national strategy to improve quality of antibiotic use and antimicrobial resistance is being developed. Drug registration mechanisms have been improved in some countries and computerized drug registration is now in place in the Lao People's Democratic Republic and Papua New Guinea (where new drug legislation has also recently been enacted).

governing drug evaluation and registration, need to be adopted and enforced. Collaborative efforts to deal with problems of counterfeit and substandard drugs are needed. Such products can move from one country to another very easily, making international collaboration essential. Innovative strategies to improve RDU are needed in all the countries of the Region. Experiences from other countries must be shared and, if appropriate, replicated. The integrated monitoring and supervision of RDU in public facilities in Cambodia is a real achievement with lessons for other countries.

FUTURE WHO will continue to work with Member States to develop, implement and evaluate NDP, especially the essential drug programme. Information exchange will be encouraged and electronic information exchange expanded to cover all Member States. Improvement of quality assurance and measures to deal with counterfeit and substandard drugs will be the main focus of WHO's collaboration with Member States. WHO will support countries to develop and implement innovative strategies for RDU as part of the existing health care system. The experiences of the Cambodian integrated system on drug supply, availability and use will be shared with other countries. Strategies to improve the use of medicines in hospitals that were developed by the working group on Pharmacy Therapeutics Committee will be field tested. WHO will support countries to develop and implement regulation of drugs. Effective regulation is one of the keys to quality assurance, adequate supplies of essential products and safe, effective and rational use of pharmaceutical products. Improving human resources in the pharmaceutical sector will remain an important part ofWHO's strategy.

ANALYSIS To ensure the availability and affordability of essential medicines of acceptable quality, the drug management cycle including drug selection, procurement, distribution, quality assurance and use must be improved. Public funding for essential drugs is essential and the pharmaceutical and health sectors need to convince governments of the importance of ensuring access to essential drugs. The current trend towards open markets and privatization means that there is always a tendency for the number of pharmaceutical products (many of which may be nonessential and expensive products) in the market and the health care system to increase. This will hinder access to essential medicines for those in need, especially from the lower income segment of the population. Effective regulations, particularly

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Traditional medicine

ISSUES Increasing interest in traditional medicine Traditional medicine is used by a significant percentage of the population in the Western Pacific Region. In China, it accounts for around 40% of all health care delivery, while in Hong Kong (China), it has been estimated that 60% of the population has consulted a traditional medicine practitioner at one time or another.' In Nauru, a survey on traditional medicine conducted in June 1997 reported that traditional medicine was used by 60% of the survey population and 71% of patients undergoing treatment in hospitals. 2 In Singapore about 45% of the

Report of the Working Party on Chinese Medicine. Hong Kong, October I 994. 2 Traditional Medicine Survey, June I 997, Traditional Medicine Workshop "Save plants that save lives" Report of Proceedings (unpublished), Appendix: 10.

population has consulted traditional Chinese medical practitioners. 3 In industrialized countries, the use of alternative or complementary medicine has increased significantly in recent years. In Australia, it has been estimated that 48.5% of the population used at least one non-medically prescribed alternative medicine in 1993, 4 while studies conducted in the United States of America show that the percentage of the population that had used alternative therapies increased from 33.8% inl990to 42.1% in 1997. 5 The increased use of traditional remedies by the public has been reflected in increased interest from medical doctors, medical educators and researchers. Medical doctors and other health workers are increasingly integrating therapies used by traditional systems of medicine into their daily practice. For example, in the Philippines, approximately 100 medical doctors were trained in acupuncture in 19961997. Traditional remedies have been incorporated into health care in general hospitals in several countries, in Singapore, for example, two acupuncture clinics affiliated with government hospitals have been set up.

Need for an evidence-based approach The increasing use of traditional medicine means that more scientifically sound evidence of the efficacy and safety of traditional

Cupping technique applied to acupuncture points

Traditional Chinese Medicine: A Report by the Committee on Traditional Chinese Medicine. Singapore, Ministry of Health, October I 995 . 4 Maclennan, et a!. Prevalence and cost of alternative medicine in Australia. Lancet, 1996; 347:569-573. 5 David M. Eisenberg et a!: Trends in alternative medicine use in the United States, 1990-1997, lAMA Nov. 1998, Vol 280.

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medicine is needed, for practitioners and for governments. Unfortunately, the practice oftraditional medicine is still based mainly on clinical experience gained over a long period of time. The different philosophical backgrounds oftraditional and modern medicine make it difficult for one system to judge the other. Since the introduction of modern medicine into the Region, a gap has developed between practitioners oftraditional and modern medicine. Traditional medicine is often rejected by medical doctors trained in Western medical schools, as it is not considered to have a scientific basis. There is a lack of mutual respect and understanding between practitioners of the two forms of medicine.

Herb garden outside a health clinic in Viet Nam

Integration and recognition of traditional medicine The widespread use of traditional medicine has highlighted the need for governments to define the role of traditional medicine and to give appropriate recognition to its practitioners. A national policy on traditional medicine is particularly important for clarifYing the role of traditional medicine in health care delivery systems, identifYing the role of the government, ensuring the proper practice oftraditional medicine, and protecting the safety of users.

33.1% ofthe drug market in 1995. 7 ln Malaysia the market for traditional medicine is estimated at about RM 1 billion annually and more than 16 000 traditional medicine products have been submitted to the National Phamuceutical Control Bureau, Ministry ofHealth, for registration.8 Generally speaking, uncontaminated herbal medicines in recommended doses are safe. However, adverse reactions to herbal medicines are possible and side-effects from herbal medicines have been reported from China, Hong Kong (China), Japan and Macao (China), among others. Standards for evaluating the safety and quality of herbal medicine and herbal medicine products have not been well established.

WHO'S RESPONSE Towards an evidence-based approach

Safety and quality of herbal medicines The increasing geographical reach of traditional medicine was demonstrated by an Australian study published in 1996 which indicated that imports of Chinese herbal medicines had increased four-fold since 1992. 6 In China, herbal medicines represented 6

WHO organized an expert meeting on 'Traditional and modern medicine : harmonizing the two approaches' in November 1999. The meeting noted 7

Health Newspaper (in Chinese), 9 January 1996.

Bensoussan, A and Myers S.P. Towards a safer choice, the practice of traditional Chinese medicine in Australia. Macarthur, University of Western Sydney, November 1996.

More than 16 000 had been submitted by the end of 1997. Status rep ort of the S teering Committee on Alternative Medicin e February 1998 (unpublished).

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that an evidence-based approach would help to harmonize traditional and modern medicine. Such an approach should include research using scientifically sound methods and improving access to information. As part of its support for research into traditional medicine, WHO has published guidelines for research on herbal medicines and acupuncture. These propose that the basic principles of modern scientific research should be applied to research on traditional medicine, although, at the same time, the nature and characteristics of the traditional practice of medicine should respected. An international meeting to discuss research methods for traditional medicine was held in Hong Kong (China) in April 2000. WHO also provides training opportunities for practitioners of modern medicine who are interested in obtaining an understanding of traditional medicine. The Organization is exploring the possibility of including education on traditional medicine in formal higher education systems with several countries. It is also working with countries to improve information

collection and dissemination on the use of traditional medicine products in the Region.

Policy on traditional medicine WHO has collaborated with interested countries and areas in the Region to develop policies to support the proper use of traditional medicine. Support for national policies on traditional medicine has been provided to Hong Kong (China), the Lao People's Democratic Republic, Malaysia, Mongolia, Papua New Guinea, the Philippines, Singapore and VietNam . A regional workshop on Development of a National Policy on Traditional Medicine was held in Beijing, China, in October 1999. The objective of the meeting was to support more countries in the Region to develop their own national policies and programmes on traditional medicine and to this end the meeting produced a detailed proposal on how to prepare a policy on traditional medicine. This has been

Table 11.1 Supporting infrastructure for traditional medicine in the Western Pacific Region

Cambodia China Hong Kong (China) Japan Lao People's Democratic Republic Macao (China) Malaysia Mongolia Philippines Papua New Guinea Republic of Korea Singapore Solomon Islands VietNam Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Yes Yes

Yes Yes Yes

lml

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disseminated to countries in the Region. As a followup activity, a special government forum to discuss government policy on traditional medicine was held during an international conference on traditional medicine organized by Chinese Government and cosponsored by WHO in April 2000.

Safety and quality of herbal medicines WHO is supporting Member States to improve the quality of herbal medicines. Since 1992, several workshops and training courses on the quality of herbal medicines and control of heavy metals in herbal medicine have been conducted in China. A collaborative research project on pesticide residue in medicinal plants was also conducted in China. WHO has worked with interested countries to apply good manufacturing practices (GMP) to the manufacture of herbal medicine products. To raise awareness of possible adverse reactions to herbal medicines, a national workshop on adverse reactions to herbal medicines was held in September 1999 in Guangdong Province, China. It was the fourth such meeting since 1997. . A list of commonly-used medicinal plants has been drawn up in several countries in the Region. The basic criteria for selection were: (1) they should be available locally; (2) they should be used for the control of common health problems; and (3) reference materials on their safety and efficacy should be available. A monograph on commonly-used medicinal plants is being prepared.

RESULTS There has been encouraging progress in efforts to establish a supporting infrastructure for traditional medicine in the Region (see Table 11.1 ). During the review period, a provision on the proper use of traditional medicine was drafted and proposed for the new national health plan (200 1-201 0) for Papua New Guinea. In Hong Kong (China), a Chinese Medicine Ordinance was approved by the Legislative Council. The attempt to harmonize the approaches of traditional and modern medicine by adopting an

evidence-based approach to research into traditional medicine and by improving mutual understanding through research, training and information sharing is at a relatively early stage, but some advances can be seen. During the review period, traditional medicine researchers in Cambodia, China, the Lao People's Democratic Republic, Malaysia, Mongolia, the Philippines, Republic of Korea and VietNam received training on research methodology. Full-time education and training on traditional medicine is offered by medical schools and other higher education institutions in Australia, China, Hong Kong (China), Japan, Mongolia, Republic of Korea and VietNam. Short introductory courses on traditional medicine are provided in universities in Cambodia, the Lao People's Democratic Republic and the Philippines. Malaysian herbal monograph, Volume 1, an official document providing a standard reference source on the quality and safety specifications of selected medicinal plant species, and WHO monographs on selected medicinal plants, Volume 1, were published in 1999. Based on the experience of the Lao People's Democratic Republic, the Philippines and Viet Nam, 12 commonly used medicinal plants have been selected in Cambodia and a small booklet entitled Your medicines in your garden has been published. With regard to assessing heavy metals and pesticide residues in herbal medicine products, useful data on levels of pesticide residues in selected medicinal plants and the testing methods for pesticide residues resulted from WHO's collaborative research project in China. A database on adverse reactions to herbal medicines reported in China has been established in Guangzhou University of Traditional Chinese Medicine.

ANALYSIS Although acceptance of traditional medicine has grown during the last few years, traditional medicine is not officially recognized in most countries. Even when a government has formally announced its support for the proper use oftraditionalmedicine, this is not always accompanied by strong political, legal or material support. Doubts about the appropriate role

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for traditional medicine may remain, and scientifically-based evidence on traditional medicine is being produced only slowly. There is also slow progress in developing quality standards and regulations on herbal medicines, in part because few resources are devoted to assessing traditional herbal remedies.

FUTURE Traditional medicine makes a significant contribution to the health of the peoples of the Region. Its

influence is growing as more people are prepared to look for alternative approaches to maintain their health. WHO will continue to support Member States to formulate and implement national policies on traditional medicine. Scientific research on traditional medicine will be further strengthened and efforts will be made to Improve access to information, facilitate trials, and train practitioners. WHO will continue to promote mutual understanding between traditional and modern medicine.

Health research, health technology and blood safety

ISSUES Health research: policy, strategy and coordination Health research is not a priority in many countries in the Region, most of which lack qualified researchers, funding, and policies for promoting, managing and coordinating health research. Poorly equipped and manned research facilities and inadequately prepared research proposals further weaken medical research in the Region. Weak linkages to the international academic community and poor communications between researchers, policymakers and health workers often delay the dissemination and application of research findings. There is a need to ensure that the results of health research are fed back into national health systems.

centres in the Region 1 varies greatly. Some centres are invaluable partners for WHO, playing active roles in WHO's programmes. Others are relatively inactive.

Health laboratory technology Health laboratory and radiology technologies are essential for diagnosing and treating many diseases, and for monitoring and evaluating health programmes. Although health laboratory technologies are being strengthened in most countries of the Region, they are usually less developed at intermediate and peripheral levels than at the central level. Developing countries of the Region often find it difficult to maintain laboratory equipment, ensure a supply of good quality reagents, train laboratory staff and apply appropriate technologies. Many countries lack national networks of health laboratory services and quality assurance programmes.

WHO collaborating centres There is a need to strengthen links between WHO and its network of collaborating centres in the Region. For example, in some cases the links between the activities of the collaborating centres and the objectives of the Organization are not always clear. The performance of the 219 WHO collaborating

Blood safety Voluntary nonremunerated blood donation is a universally recognized condition for the continuous and adequate procurement of safe blood and there are encouraging signs that most countries in the 1

As at end of 1999.

= = = = = = = = = = - - --

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Region are moving in this direction. Nevertheless, many still rely either on paid donors or on family donations to meet their requirements. Systematic screening of blood units is not carried out at the peripheral level in some countries. In many cases, blood transfusions are carried out for conditions for which they may not be the most appropriate, costeffective or safe therapeutic intervention.

WHO RESPONSE Health research: policy, strategy and coordination WHO supports countries to strengthen their national capacity to conduct biomedical, epidemiological and health systems research. Globally, the Organization's health research policy has recently been reviewed by WHO Headquarters and the six regional offices. Experts from outside the Organization also assisted WHO in the review. A working group on policies and strategies to support WHO in health research was held in March 1999. One ofthe conclusions of this exercise was that greater investment is needed to expand the knowledge base for WHO's work. Throughout the Organization, a culture is needed that respects the standards and role of science, giving WHO the capacity to act creatively to couple state of the art research to global health needs, paying special attention to the poor. This was followed by a meeting in May to review WHO collaborating centres, and another in November on the WHO advisory committee on health research. The outcome of the review was reported to the 105th session ofWHO Executive Board in January 2000. The Executive Board then adopted two resolutions on research strategy and mechanisms for cooperation designed to strengthen collaboration in health research. In the Region, the main emphasis of WHO's support for research is on applied or operational research, rather than on basic research. By supporting research in the Region, WHO is also helping to improve research capacities. During the period under review, WHO supported eight research projects by scientists from China ( 1), the Lao People's Democratic Republic (2), Malaysia ( 1), Mongolia (2) and VietNam (2). The Strategic plan for health research

in the Western Pacific Region.· 1997-:!001 is used as the basis for screening research proposals received by the Regional Office. Research projects covered nutrition, environmental health, traffic accident injuries and control of communicable diseases, such as malaria and hepatitis. Research is oriented towards priority health concerns; for example, traffic accidents represent a growing health problem in VietNam and many accident victims experience long-term psychiatric problems after acute head injuries suffered in accidents. WHO is therefore supporting a national survey on mental disorders caused by traumatic head injuries to identify the cause of head injuries, to examine the extent to which these could be prevented by the use ofhelmets by users of motorcycles and their passengers and to improve the quality of mental care for patients. In 2000, a new edition of the popular Health Research Methodology : a guide for training in research methods, first published in 1992, will be published. The second Lao-VietNam symposium on health research was held in Vientiane, Lao People's Democratic Republic, in January 2000. The symposium helped to engender a "south to south" approach to health research and its value therefore extended beyond the dissemination of the scientific results contained in individual papers. WHO also plays a role in providing guidance on the ethical aspects of health research. Operational guidelines for ethics committees reviewing biomedical research drafted by WHO Headquarters were reviewed during a meeting in Bangkok, Thailand, in January 2000. Participants from several countries in the Region attended. In Mongolia, international ethical guidelines for biomedical research involving human subjects and the international guidelines for ethical review of epidemiological studies were translated.

WHO collaborating centres As noted above, a review of the role of WHO collaborating centres has been conducted by WHO regional offices and Headquarters. The review reaffirmed that WHO collaborating centres are an essential and cost-effective cooperation mechanism, which enables the Organization to fulfil its mandate to support medical research. A meeting held in

HEALTH SECTOR DEVELOPMENT

"Safe blood starts with me- Blood saves lives" "Safe blood starts with me - Blood saves lives" was the theme for World Health Day in 2000. Globally, more than 75 million units of blood are donated each year. However, there is not always sufficient safe blood available where and when it is needed. There are shortages of healthy blood donors and properly screened blood and blood is often used inappropriately. Only 20%-30% of the world's health systems are able to provide safe and adequate blood support. The aim of World Health Day was to raise awareness of blood safety issues by encouraging Member States to commit to and support national blood programmes and to implement legislation for a national blood programme. Countries were also encouraged to promote donations from voluntary, nonremunerated blood donors from low-risk populations. People everywhere were asked to protect their blood and to safeguard their health through good nutrition, clean and healthy lifestyles, proper prevention and early treatment of disease. Activities to celebrate World Health Day were organized throughout the Region . A video message on safe blood by the Regional Director was distributed widely. A brochure on "Safe blood starts with me - Blood saves lives" was translated into Chinese, Mongolian and other languages. Messages on blood safety were broadcast by television and radio stations in several countries and posters and stickers were displayed in major cities. Low-risk groups, such as students, were encouraged to become voluntary nonremunerated donors. Many activities attracted high level political support; for example, in Singapore, World Health Day was presided over by the Minister ofHealth . In Malaysia and Singapore scientific symposia on appropriate clinical uses ofblood were held. In the Philippines, a walk to increase public awareness of the need for voluntary blood donation and safe blood and blood products was held on World Health Day. In Cambodia and Viet Nam, mass awareness and health promotion campaigns on blood donation were launched, targeting low-risk groups, such as students. Educational talks and exhibitions on blood donation at public areas and schools, donor appreciation ceremonies and public forums were held throughout the Region.

May 1999 made a number of recommendations to strengthen collaboration with WHO collaborating centres. These were reviewed in July 1999 by the Director-General and Regional Directors, before being discussed by the Executive Board in January 2000. The Executive Board adopted a resolution to endorse the proposed changes. To avoid the designation of collaborating centres without direct relevance to a WHO programme, and to terminate arrangements with centres that no longer have any activities linked to WHO, a more collective, competitive and transparent process for designation or redesignation has been adopted. At least two years of collaboration with WHO are now required before

collaborating centres are designated and regional and global screening committees have been established to review proposed collaborating centres . A more rigorous and standardized evaluation process has been instituted, including the development of an institutional profile.

Health laboratory technology WHO activities in the area of health technology are concentrated on strengthening quality assurance programmes for clinical laboratory services. The Regional External Quality Assessment Scheme assesses quality control in laboratories in 16 countries

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of the Region . Meanwhile, WHO is working with Member States to establish National External Quality Assessment Schemes. During the period, support was given to increasing the number of qualified laboratory staff in countries such as China, Mongolia, the Philippines, Samoa, Tonga, Vanuatu and VietNam by providing training in health laboratory and radiological technology.

Blood safety Many countries have acute shortages of blood for transfusion because they lack suitable donors, their storage facilities are insufficient and there is not enough local technical knowledge. During the period, WHO continued to stress that governments have a responsibility to ensure an adequate blood supply and to monitor its safety. Voluntary blood donation, appropriate screening of blood and effective clinical use of blood and blood products are priority areas for WHO's support for blood safety. In Shanghai, China, a comprehensive project on blood safety began in 2 000, supported by WHO, the Shanghai municipal government and the WHO collaborating centre for blood safety in Shanghai. The project promotes voluntary blood donation, safe blood and blood products, and effective clinical use ofblood and blood products.

RESULTS The Strategic plan for health research in the Western Pacific Region : 1997-2001 was translated into Chinese, Japanese, Mongolian and Korean during the period, thereby making it more accessible to researchers in the Region. Dissemination of research results has been improved by making the findings of research projects supported by WHO available on the Regional Office website. The summary of annual reports submitted by WHO collaborating centres in 1998 has also been made available on the website. WHO has been working with governments to improve management of WHO collaborating centres in individual countries. For example, a national meeting involving the heads of all WHO collaborating centres in China was held in

September 1999 and the annual meeting of heads of WHO collaborating centres in Malaysia was held December 1999. These meetings provided an opportunity to share information and items ofcommon concern as well as to discuss progress and possible collaboration among centres. The annual meeting of WHO collaborating centres in Shanghai, China was held in January 2000. A self-evaluation of 19 WHO collaborating centres in Shanghai, China, was conducted by the Shanghai Public Health Bureau with WHO support at the beginning of2000. Laboratories from 14 Pacific island countries, as well as from the Lao Democratic People's Republic and Viet Nam, now participate in the Regional External Quality Assessment Scheme. 2 Performance indicators show that the quality of participating laboratories has improved over the past five years. Blood transfusion services have been strengthened through advocacy for nonremunerated blood donation and government commitment to nonremunerated blood donation in several countries, including Cambodia (see box on p. 132), China and Viet Nam. In the Philippines, a combined effort by the Philippine National Red Cross, the Department of Health, WHO and other interested bodies has significantly reduced the percentage of paid donors over the last six years. Nevertheless, difficulties in transporting blood from centre to centre remain. In most countries in the Region, blood units are screened for hepatitis B and C, HIV and syphilis at central level blood facilities. The improvement in research capacity in developing countries is reflected in the number of research proposals received and the number of research projects from developing countries funded by WHO .

ANALYSIS Limited resources, including financial and human resources, hinder efforts to promote health research in the Region. As mentioned in the previous report,

Cook Islands , Fiji, Kiribati, Marshall Islands, the Federated States of Micronesia, Nauru, Niue, Palau, Papua New Guinea, Samoa, Solomon Island<>, Tonga, Tuvalu and Vanuatu.

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Blood Safety in Cambodia The many years of civil war in Cambodia completely destroyed the National Blood Transfusion Services (NBTS). Between 1990 and 1997, with the support ofthe International Committee ofthe Red Cross, the Ministry of Health was able to establish blood transfusion centres in Phnom Penh and 13 provinces. Today, it is estimated that the NBTS covers 80% of the population. However, the HIVI AIDS epidemic and the presence of other transfusion -transmissible agents like hepatitis B and C, combined with a lack of technical and financial external support since 1997 and low levels of blood collected from regular voluntary donors have meant that blood safety is now regarded as a public health priority by the Ministry of Health. Cambodia is currently experiencing the fastest growing HIVI AIDS epidemic in Asia. In 1999, 4.1% of blood units collected at the National Blood Transfusion Centre in Phnom Penh were HIV-positive. This represents by far the highest prevalence ofHIV among blood donors in the Asia-Pacific Region. A similar worrying picture can be seen for hepatitis B and C. These problems are directly related to the low number of voluntary blood donations and the consequent chronic shortage ofblood. This creates a high dependence on family-replacement blood donors and professional paid donors. There is high prevalence ofHIV among professional donors, which puts the health of the blood recipient at risk. Lack of resources have made it difficult for the Ministry of Health to implement countrywide mobile blood collections or to launch a campaign to promote voluntary blood donation. WHO and the National Red Cross Society are working with the Ministry of Health and the National Blood Transfusion Centre to improve the NBTS. Mobile blood collections targeting low-risk population groups such as high-school and college students have been Voluntary blood donation by monks in Cambodia as part of activities to carried out, mainly in Phnom mark World Health Day 2000 Penh and surrounding districts. The National Blood Policy is being revised in order to strengthen regulation ofthe collection, production and utilization ofblood and blood products. Staff have been trained in blood services management and laboratory quality assurance programmes. All of these activities are included in a mid-term development project that will be submitted to potential financial donors. This joint effort has started to achieve results: the percentage of HIV-positive blood units has already decreased from 5.6% in 1998 to 4.1% in 1999. This is directly related to an increase in the percentage of voluntary donors from 6% in 1998 to 17.5% in 1999.

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there is no evidence so far that countries have used the Strategic plan for health research to reorient their own research agendas. More investigation is needed into why this is the case. Countries iii the Region have continued to improve their health laboratory and radiology services. However, few appear to have national policies for laboratory services. WHO encourages countries to formulate a strategic plan to strengthen national laboratory networks and to integrate laboratories into the rest of the national health system. Such strategic plans should cover training and laboratory supplies. WHO's advocacy for nonremunerated blood services has had some successes in the Region . However, I 00% voluntary blood donation may be a long-term goal in some countries because of economic, cultural and behavioural factors. Lack of technical, human and financial resources in some countries impedes the development of cost-effective and sustainable blood services.

FUTURE WHO will continue to provide support to Member States to strengthen research capabilities by organizing training courses on research design and methodology, awarding research training grants and funding research projects from developing countries. Researchers in the Region will be encouraged to collaborate with researchers from other countries and other regions. Communication with national focal points on health research, such as national health research councils, will be strengthened.

The Regional Office will work closely with WHO Headquarters and other regional offices, particularly the Regional Office for South-East Asia, to promote health research and to investigate ethical issues. WHO collaborating centres in the Region will work together with WHO and other institutions to support work in the priority areas identified by WHO. Evaluation of the work of WHO collaborating centres will be carried out on a more regular basis. Support will be given to countries to strengthen the infrastructure and management of laboratory services and to establish quality assessment systems. The Regional External Quality Assessment Scheme will be expanded to other countries of the Region. Countries will be encouraged to establish National External Quality Assessment Schemes. Training in health laboratory and radiology technology will continue to be supported. WHO's support for clinical laboratories in the Region will be linked to WHO's priority programmes, such as Stop TB and Roll Back Malaria. Ensuring an adequate supply of blood from voluntary donors and quality assurance for screening of blood will remain major concerns. Efforts will be made to improve the procurement of safe and adequate blood by targeting potential low-risk blood donors and encouraging them to become regular donors. WHO will continue to promote screening of blood for hepatitis C in those countries where such screening has not yet been introduced and to expand screening for transfusion-transmitted infections by the appropriate use of reagents in accordance with each country's resources. Training on appropriate and effective use of blood and blood products will be supported.

12. Human resources development

Management, education and training

ISSUES Health workforce management A balanced health workforce is fundamentally important to the satisfactory delivery of health services. All around the world, major changes are occurring in the financing, structuring and functioning of health services. These will compel public health policy-makers to take a much broader and more dynamic appro ach to health workforce development than in the past. Major issues affecting the health workforce of the Region include the following. •

this is a particularly important issue for Pacific island countries, it is relevant to all countries.

Education and training

•

Improving standards oftraining in some countries is a priority. Curricula need to be reviewed to reflect new health systems, training institutions need to be accredited, and coordination between Ministries of Education and Ministries of Health needs to be strengthened. Resource materials that are relevant and in line with cultural situations need to be published. There are many remote communities in the Western Pacific Region that would benefit from distance education. There is huge potential for an In many countries quantitative workforce plans expansion of distance education in the Region. have been developed but they are often difficult WHO's programme of fellowships enables health to implement. This results in inefficient workers to go abroad for training that is not available utilization of staff and in their own country, or, inappropriate training. when appropriate, to attend Health sector reform will not achieve More emphasis on the courses in their own its full potential without a planned quality of the health country. The key issue in workforce, which under ·tands fmd workforce is needed in reviewing the fellowship supports health reforms. almost all countries. programme is to determine Legislation governing whether it has contributed to the implementation of national health workforce the accreditation and registration of health practitioners is not common. Where it exists, plans aimed at meeting the needs of populations and it is often not systematically implemented. This health systems. often results in the delivery of services by inadequately qualified health workers. WHO RESPONSE It is difficult to attract well-trained staff to the public sector and rural areas, due to low Health workforce management salaries, lack of incentives and poor working conditions. This leads to a public/private and rural/urban imbalance in the distribution of the WHO's support for health workforce management health workforce which may affect the health focuses on workforce management programmes which of rural populations. give priority to leadership skills, policy-making and In- and out-migration of skilled health management. For example, in Cambodia and the professionals is a growing problem. Although Lao People's Democratic Republic, the workforce

12.

HUMIW RESOURCES DEVELOPMENT

development plans were reviewed with support from WHO. WHO and the Government of China convened a national workshop in Yantai, Shandong, China, in September 1999. The workshop recommended that a 10-year strategy for health workforce development be formulated by the Government, in collaboration with international partners. It also recommended that the Government should immediately develop and implement a strategy to strengthen health sector management.

Education and training WHO 's strategy to strengthen education and training focuses on identifYing the most relevant training issues and on reinforcing regional institutions. The fellowships programme is kept under constant review to ensure that recipients of WHO fellowships apply their new skills on their return to their countries. A meeting held in Sydney, Australia in August 1999 developed a document entitled Promoting the health of communities: guidelin es for health professional education which was published in December 1999. The guidelines are intended for use in the revision of health professional education throughout the Region and emphasize preventive rather than curative care. An accompanying Teaching Guide for Educators ofHealth Professionals was also drafted and is undergoing review prior to publication. The Executive Committee of the Association for Medical Education of the Western Pacific Region (AMEWPR) and WHO met in July 1999. Guidelines for improving medical education were drafted and it was agreed that the sixth biennial meeting on Medical Education in Diverse Clinical Settings: Rural and Urban Communities would be held in July 2000 in Australia. With regard to fellowships, the majority (68%) were awarded for three types of studies or training: public health, education, communication and research activities, and for postgraduate study. The balance (32%) were for undergraduate medicine, dentistry, nursing/midwifery, diagnostic and laboratory services and environmental sciences (Figure 12.1). In 1999, for the first time, female fellows (54%) outnumbered males (46%) . For study tours, however, the percentages were almost exactly reversed: males

(53%) and females (47%). There is evidence of a trend towards shorter programmes: 45% of fellowships were awarded for one month or less, 33% were for more than one month but less than six, and 22% were for programmes of more than six months. To give governments and field offices an overview of the fellowship process and their role in it, a booklet on Fellowship Procedures was prepared by the Regional Office and circulated to all field offices in January 2000. The objective ofthis booklet is to ensure priority areas receive enough attention. A global meeting of the regional fellowship officers held in WHO Headquarters in February 2000 recommended that study tours (which arc used only in some regions) be gradually phased out. Study tours are increasingly viewed as lacking in impact, noncost-effective and resistant to evaluation. The meeting also recommended that WHO should develop a system to continuously monitor fellowship activities to ensure that fellowships contribute to the elfcctiveness ofWHO programmes. With regard to distance education, developments during the review period are described in the chapter on information technology (see pp. 153-154).

Health workers require train ing in record-keeping and administration as well as clinical care

HEALTH SECTOR DEVELOPMENT

Figure 12.1 Fellowships by field of study, 1999

Diagnostics and laboratory sciences 10% Education, communication, research 19%

Medicine. dentistry 7%

Public health 31%

Environmental sciences 8%

Nursing/ midwifery 7%

Postgraduate studies 18%

RESULTS Health workforce management WHO's support for health workforce management, particularly in countries undergoing transitions to market economies has led to an increased focus on management of the health workforce. Moves towards decentralization, devolution and private providers have helped to shift the emphasis from quantitative to qualitative workforce planning.

Education and training Throughout the review period there have been positive developments in the field of medical education, in particular with regard to intercountry cooperation between medical schools in the Pacific. Since feilowships are only one ofthe approaches used to achieve the objectives ofhuman resources for health programmes, their impact will often be influenced by other factors which will dictate how fully health workers utilize their new skills, knowledge and attitudes. Nevertheless, there are indications that fellowships are becoming an integral part of overall implementation of technical programmes rather than an isolated activity

A 1999 fellowship impact study utilized survey questionnaires, and, in selected countries, individual interviews and focus group discussions, to analyse the strengths and limitations of the fellowship programme, and to assess the impact of fellowships undertaken from 1992 to 1997 on fellows' personal and professional growth. WHO sent 3000 survey questionnaires to former fellows across the Region which generated a response rate of 15%. The study revealed that 66% of the fellows who returned the survey had obtained a promotion. However, a large number (46%) had moved into the private sector or abroad. The impact study also indicated that, while fellowships provided valuable training and experience, there was sometimes a lack of opportunity for the fellows to apply their new skills on their return. Computer-based distance education is becoming a viable proposition for countries with access to affordable telelinks (see pp. 153-154). This form of educational delivery is still in its early stages, but there have been some encouraging developments, particularly with regard to postgraduate and continuing education. Meanwhile, more traditional forms of distance education, such as radio and distribution of printed material and audio tapes. are continuing.

12.

HUMAN RESOURCES DEVELOPMENT

ANALYSIS Health workforce management Health workforce development is a complex and extensive process that requires expertise from many disciplines. The workforce represents almost 70% of health services expenditure, but not nearly enough is spent on maintaining its quality. Much more attention needs to be paid to education, economic incentives, supervision, management and legislation. Career development for the health workforce has not been adequately addressed in many countries. The low salaries of public sector health workers and the poor incentives often hinder them from taking part in continuing education. Low salaries also affect workers' willingness to provide health services in remote rural areas where the potential for additional income is low.

potential for using distance education to upgr<~de the skills ofhealth professionals in the Pacific, particularly in view of the fact that the resources allocated for fellowships are expected to diminish. Infrastructure being built in the Pacific to provide education via satellite has great potential.

FUTURE Health workforce management WHO is undertaking a study on the migration of skilled health personnel in P<1cific island countries and areas. This will be the first detailed study of the migration of skilled health professionals in the Paci fie and will examine the impact ofthe loss of workers, particularly on the smallest states. The study will evaluate the obstacles to maintaining and improving the quality of health care and health care institutions posed by high rates of in- and out-migration of skilled health professionals. It is anticipated that the study will be completed by the end of2000.

Education and training More attention needs to be paid to the quality of education of health professionals rather than to the quantity of health workers produced. This should include further emphasis on quality assessment in educational institutions, covering assessment techniques, curricula and teaching methodologies. Some institutions in developing countries, while not having the resources of those in developed countries, nevertheless manage to produce highquality health workers . The approaches of such institutions need to be studied and transferable features disseminated to other institutions. In many countries in the Region, the Ministry of Education is responsible for the education of health workers . However, remuneration of the health workforce is often the responsibility of the Ministry of Labour or the Civil Service Commission. In many countries the dialogue among these bodies needs to be improved. The increasing importance of distance education, including in-service training, will require further analysis of the different models in use. There is great

Education and training WHO will continue to focus on the effectiveness and appropriate utilization ofthe health workforce in both public and private health sectors. This will include working with Ministries of Health and other government departments to improve coordination of training and remuneration ofhealth workers. Training programmes for community health workers, mid-level practitioners, and non-professional health workers will continue to be supported in countries where the number of health professionals is insufficient to provide health care delivery, particularly in remote areas. The effectiveness of training programmes, especially fellowships, will be continuously monitored. A rapid follow-up study of 1998-1999 fellowships is planned, which will also include analysis of the data collection tool.

l@iM

HEALTH SECTOR DEVELOPMENT

Mid-level and nurse practitioners

ISSUES Provision of primary health care services to communities Many countries in the Region have found it difficult to produce sufficient numbers of medical practitioners to serve all communities. Even in countries with adequate medical workforces, it has proved difficult to retain doctors in rural areas. In some rural and outer island settings, populations are quite small and it is hard to justifY posting medical practitioners there. Yet all communities require access to care. Many countries have therefore trained "mid-level" practitioners, among them nurse practitioners, to provide the full range of primary health care services, both preventive and curative, in rural and isolated communities. Mid-level practitioners have been given various titles, including physician assistant, medical assistant, medex, health assistant and health officer. Nurses who have received advanced training to provide this expanded scope of practice are called nurse practitioners (see box).

The use ofmid-level practitioners raises important health care issues. First, the quantity and quality of care provided by such workers must be properly assessed. This is essential if the quality of primary health care is to be improved. Second, if they are to carry out their functions effectively, their needs must also be taken into account. This is particularly important if high-quality staff are to be retained in isolated rural areas.

Education and training Mid-level health care workers providing essential health services in many rural and isolated communities need to be well trained for this important role. This raises an important issue: it is vital that those who train nurse practitioners, health assistants, medical assistants, and other mid-level practitioners are expert clinical teachers. Faculty members of mid-level training programmes must possess the requisite clinical expertise and knowledge of educational and clinical teaching strategies and skills to pass on necessary diagnostic reasoning and problem-solving skills to their students.

Resources Many of the institutions that train mid-level practitioners are limited in size and scope. In many there are few learning materials, particularly in local languages. Although many training institutions in the Region are attempting to revise and update curricula and teaching/learning methods to promote self-directed and small group learning, independent learning and problem-solving skills, they are inhibited by resource shortages. Many training institutions also lack adequate computer hardware and software, and training in Internet methodologies is usually limited or non -existent.

Mid-level practitioners provide care in all settings, including the home here a health worker gives preventive care to a Mongolian family

12.

HUMAN RESOURCES DEVELOPMENT

Nurse practitioners Nurses comprise the largest category of health workers regionally and globally. Nurses trained as mid-level health workers provide important national resources for public health, and countries that have previously trained non-nurses as mid-level practitioners are beginning to explore the option of training nurse practitioners. Nurses need a shorter training programme, usually of one year's duration, as opposed to up to three years for non-nurses. Nurses and midwives also usually have community-based experience and are already trusted by their communities, which is another reason why they are suitable as mid-level practitioners. However, career ambiguity may sometimes result when non-nurse mid-level practitioners, who often do not have clear career structures, are employed. Furthermore, nurses, who have extensive prior education and clinical experience, often more easily attain the diagnostic decision-making abilities required for the advanced practice role. The role of nurse practitioners is also a logical expansion of nurses' strong background in community health care, health promotion and preventive health care activities, which helps to ensure that their practice is a blend of curative and health promotion skills.

WHO RESPONSE Provision of primary health care sen·ices to communities WHO provides technical support for training all types of mid-level practitioners . Support includes strengthening and developing advanced training programmes, curricular development, drafting policies and legislation and developing and implementing clinical protocols or guidelines for use by mid-level practitioners. Essential diagnostic equipment and references are also supplied to training programmes. During the review period, WHO supported the training of medical assistants in Kiribati; health assistants in the Marshall Islands and the Federated States of Micronesia; nurse practitioners in Vanuatu; and health officers in Tonga. Since 1998, WHO has been collaborating with the Government of Fiji to implement the first two cycles of a new nurse practitioner training programme. Support has included the provision of training materials and essential books and diagnostic equipment; development and revision oftraining curricula and implementation oftraining programmes; and development of programme and provider evaluation tools. Clinical practice guidelines for nurse practitioners have also been produced. WHO carried out a review of the roles, education and practice of mid-level and nurse practitioners in 11 Pacific island countries in 1999. Technical and logistical support available to these practitioners was

also evaluated. The evaluation consisted of structured interviews with mid-level health workers, trainers and stakeholders; one-to-one and focus group discussions; interviews with providers and observations of practice pattems; facility assessments; and reviews ofcurricula, policies, evaluation tools, reports and records . A two-week Clinical Teaching Strategies workshop was held in Suva, Fiji, in July 1999. The workshop was targeted at trainers of mid-level practitioners from nine Pacific island countries. These activities were in line with the provisions in the Rarotonga Agreement which call for a strengthening of mid-level and nurse practitioner training programmes in the Pacific.

Resources WHO continues to provide support for mid-level and nurse practitioner training institutions in the Region through the provision ofbooks and training materials, including teacher and student references; Safe Motherhood technical publications and videotapes on safe deliveries; and midwifery tutor modules and accompanying student notes. In selected institutions, WHO also provides computer hardware, software and educational interactive CD-ROMs. Participants at the workshop on Clinical Teaching Strategies (see above) received a mini-library of textbooks and videotapes to help them to transfer skills and clinical teaching strategies learned at the workshop to their own countries.

HEALTH SECTOR DEVELOPMENT

RESULTS Provision of primary health care services to communities There are encouraging signs that training for midlevel providers is improving in the Region. Existing programmes are continuing to update and strengthen their curricula. Some countries, such as the Federated States of Micronesia and Vanuatu, have reinstituted nurse practitioner and health assistant training, using revised curricula. Plans have been developed to continue the newly established nurse practitioner training programme in Fiji. Several countries in the Region have expressed interest in sending qualified nurses to the Fiji nurse practitioner training programme. In all of the countries visited during the assessment study ofthe training and practice of midlevel practitioners, there was agreement that mid-level practitioners are needed and will continue to be needed to provide health care services, particularly in rural and isolated areas. Overall, governments of the Region are satisfied with the clinical practice ofthe mid-level providers, particularly in countries in which nurses have been trained as mid-level practitioners. In general, mid-level practitioners in the Region are a committed, motivated cadre of health workers.

ANALYSIS The review ofthe education and practice of mid-level and nurse practitioners in Pacific island countries carried out in 1999 emphasized the need to develop: • health and nursing practice legislation that reflects the services that mid-level practitioners provide; relevant job descriptions, performance evaluation systems and career paths which reward accomplishment, support increased responsibilities, permit continued growth and development, and facilitate career advancement for mid-level and nurse practitioners; • salaries which are commensurate with competencies, responsibilities, education and experience of mid-level practitioners; • ensured provision of essential drugs, medical supplies and facilities maintenance for an adequately stocked and safe and healthy working environment; • easy access to reliable communication equipment with which to contact referral centres; and • regularly scheduled clinical supervision and teaching.

The review also highlighted the continuing need to use multidisciplinary educational approaches which employ doctors and advanced practice mid-level and nurse practitioners as trainers. It is important that trainers should continue to practise in their area of clinical expertise while teaching. All training programmes should have formal curricula oriented towards the health care needs of the country in which students are to practise. The programmes require strong theoretical and clinical components, in both curative and preventive health care. Integrated curricula, which combine problem -based or case-based learning, and competencybased learning approaches, serve to develop high level diagnostic reasoning skills and evidence-based practice. Learning modules should be integrated A health worker distributing iodine pills in Tibet, China -providing so that new skills can be applied to related community-based education and preventive health care is an essential part cases or problems. of the modern health worker :S primary health care responsibilities

12.

HUMAN RESOURCES DEVELOPMENT

Strengthening primary health care services in Cambodia, the Lao People's Democratic Republic and Viet Nam

Cambodia As part of the Home Based Care Project in Cambodia, WHO sponsored workshops to revise and translate HIV/AIDS community-care and home-care guidelines for medical practitioners, nurses and other community health care workers into Khmer and French. The guidelines include algorithms and decision maps to guide health workers through the diagnosis and treatment of common presenting problems. The guidelines also address infection control measures and the nutritional needs ofHIV/AIDS patients.

Lao Peoples Democratic Republic WHO has supported the strengthening of nursing curricula and nursing practice in the Lao People's Democratic Republic, which included translating the WHO HIVI AIDS reference library for nurses into Laotian.

VietNam WHO-supported work in VietNam has included the development and planned translation of a continuing education programme and accompanying community nursing teaching manual, which focuses on the essential elements of primary health care and community nursing.

Primary health care in the Lao Peoples Democratic Republic

Resource shortages continue to limit the effectiveness of training programmes for mid-level practitioners in many countries. Most training programmes lack teaching and learning materials for use by faculty members and students, particularly in local languages. Computer hardware and software are often not available in the training programmes, and Internet access is usually limited.

FUTURE Technical support for trainers of mid-level practitioners, in particular support for instructional design, participatory and innovative teaching/

learning strategies and clinical teaching and evaluation, will remain an important part ofWHO's activities in the Western Pacific Region. Training needs, legislation, clinical practice guidelines and career development prospects for mid-level practitioners will be reviewed. There is a need for further efforts to ensure that mid-level practitioners are provided with essential drugs, supplies and equipment, clean and safe working environments and ongoing clinical supervision, and that their clinical skills are regularly upgraded. Alternative models of quality improvement will be examined. Structural guidelines to improve the effectiveness ofhealth interventions and to maximize patient satisfaction will also be designed.

liiii

13. Health information and evidence for policy

ISSUES Strategic plan The uncoordinated way in which information systems have developed has frequently led to duplicated data collection in the Region's health systems. Furthermore, priority health problems are often not addressed by existing systems. One reason for this is that there usually is no overall strategy to guide the support that information systems give to health planning and programme development. Most developing countries in the Region do not have strategic plans on health information systems within the Ministry of Health.

that data coverage is often poor. Many countries do not collect much data from the private sector. The data that are collected by the Region's health systems are often inaccurate because of poor diagnostic tools, inaccurate classification and coding of diseases, and inadequate validation procedures. Most countries still have not implemented the International statistical classification of diseases and related health problems, tenth revision (ICD-10) system (see Table 13.1).

Use of health information Although there has been a general improvement in the use of information, the capacity to analyse and use information effectively is usually inadequate at district and provincial levels. The information that is gathered is often not linked to health policy formulation and programme planning needs. Data presentation and status report preparation need to be improved in most developing countries.

Data coverage and data quality All countries have developed routine reporting systems for notifiable diseases and items of care, but underreporting and nonregistration of events mean

Health informatics All countries in the Region use information technology (IT) to collect, process and disseminate health information. E-mail and the Internet are widely used and networks have often been installed to improve disease surveillance and health reporting. The most common problem is hardware and system maintenance. Staff often need training in installation and use of different software and operating systems, and in database design and development.

WHO RESPONSE WHO works with Member States to strengthen health information support for the management and

Disease coding in progress

13.

HEALTH INFORMATION AND EVIDENCE FOR POLICY

implementation of public health interventions. WHO support takes the form of training, information exchange, technical support and supplying appropriate computers and other IT equipment.

Developing a strategic plan WHO presented a generic strategic plan for the development of information systems in the Region to the Regional Committee at its fiftieth session in September 1999. The plan incorporates methods of data collection, data harmonization, dissemination of information, data analysis and utilization and human resource assessment. The strategic plan was designed to be used as a guide by countries reviewing their information systems and to promote a more systematic approach, leading to better coordination among the various components of the information system.

Terminal digit filing system in practice

Improving data accuracy Strengthening the recording and reporting systems for health monitoring is a basic requirement for programme management. Following intercountry training courses on the International statistical classification of diseases and related health problems, tenth revision (ICD-10) held in Fiji and Guam in May 1999, training is being extended to other Pacific island countries through national training courses. China, Fiji, Malaysia and the Philippines, among others, have already started nationwide training on morbidity and mortality coding for coders and other staff working on medical records. For instance, China has so far trained more than 500 coders on morbidity coding and a new national standard for classification of diseases and codes was adopted by the Evaluation Committee in May 1999. Good classification and coding skills are vital for improving the accuracy ofdisease information. WHO has therefore provided support to countries for registration of vital statistics, human resources management, licensing and regulation, administration and prioritizing information systems in the context ofhealth system development.

Promoting data analysis and use of information While it is important to emphasize the collection of action-oriented data, the capacity for data analysis and use of information from district level upward must also be improved. WHO has been actively involved in supporting countries to integrate indicators into national health plans and has also provided common data definitions for selected indicators. WHO has worked with Cook Islands, Samoa and Vanuatu to develop country-specific indicators. To strengthen health information support for district health systems, key staff from six countries 1 participated in an interregional consultative meeting in Kuala Lumpur, Malaysia, in August 1999 to discuss strengthening health information system cooperation. WHO also supported participants from six countries and areas 2 to attend a training workshop on burden of disease and cost-effectiveness to define national control priorities and essential packages of care, in 1 Cambodia, Fiji, Malaysia, Mongolia, the Philippines and VietNam. 2 China, Hong Kong (China), Malaysia, the Philippines, Singapore and Viet Nam.

HEALTH SECTOR DEVELOPMENT

Table 13.1 Implementation status of ICD-10 as at December 1999

American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia ~1111m

X X X

X (2001) X X X

v (?nnn)

Hong Kong (China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands ·Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis & Futuna Total ()Target year specified

x X

X X X X X X X X X X X X· X X X X X X

X X

1191

Melbourne, Australia, in November 1999. The aim of the workshop was to train participants in the methods used to prioritize health sector resources and to analyse the cost-effectiveness of health interventions.

Following the publication of a training manual and a data dictionary and installation of computer systems in two pilot districts in VietNam, training in operating a recording and reporting system and in analysing and using health indicators to monitor

13.

HEALTH INFORMATION AND EVIDENCE FOR POLICY

health status was provided for district and provincial staff A project to promote the development and use of health indicators to support health management will be initiated in a county in China.

of information on hospital services, diagnostic systems, environmental health systems, disability, health care costs, traditional medicine, accessibility by gender and other socioeconomic indicators.

Supporting use of informatics The rapid introduction ofiT in the Region has led to increasing demands for computer training, particularly in systems maintenance and basic applications software. The Federated States of Micronesia, Niue and Tonga were provided with support ranging from the design of specific application software to transfer of technology for hardware maintenance and managing operating systems. WHO provided support to Mongolia for a network covering all aimags (provinces). Computer training courses have been conducted for aimag health and hospital statisticians.

Enhancing the use of information in decisionmaking The identification of health indic<ttors <tnd improvements in the links between infornution gathering and decision-making have enabled decisionmakers to rationalize the use of health resources and improve evaluation. Cook Islands, Cambodi<t, Fiji, Mongolia, Tonga, and Viet Nam arc among the countries in the Region where information is now used in a much more systematic way to support decisionmaking. The use of information has also been improved through training courses on statistical analysis and data presentation .

RESULTS Information system strategic plan One of WHO's objectives has been to increase awareness among policy-makers of the need to plan information systems systematically. There has been some progress in this regard and there is now a general acknowledgement of the need to draft a strategic plan for health information in line with more general health sector development. Cambodia and VietNam are now streamlining their information systems in order to reduce duplication in data generation and to make other improvements.

Informatics support Increased computerization has led to more rapid communication among district, provincial and national levels. In Mongolia, for example, e-mail and a new computer network have greatly improved the transfer of data between central and provincial levels. China has strengthened its biomedical information network through the provision of hardware and training in information network management and medical information retrieval. The health information system in the Philippines has been strengthened through training in electronic networking, data administration, data warehousing and mining and geographical information systems.

Data quality improvement Following extensive training by WHO to promote the use ofiCD-1 0 in the Region, 28 countries have either implemented or formulated plans to implement ICD10 in the next two years (see Table 13. 1). Data collection systems (recording and reporting) and data analysis capability have been improved. In Fiji, Mongolia and Viet Nam, analysis and use of statistics has been improved through training. New Caledonia has extended its epidemiological surveillance system to cover private practitioners. Generally, improvements can be seen in the collection

ANALYSIS Progress has been made in a number of countries. In general, epidemiological surveillance systems are more timely, medical documentation is better, health information systems are incorporated into national health plans, and information management practices have been improved. Most governments are now able to coordinate health information activities both within and outside the Ministry of Health. However, the recent Asian economic crisis has meant that upgrading health information

HEALTH SECTOR DEVELOPMENT

infrastructures has been slow and this has hindered the effective transfer of technology and skills. Rapid turnover of technical staff has also made improving health information systems difficult. The demand for training on information technology has increased in recent years and this trend seems likely to continue.

FUTURE WHO will continue to support countries to improve health information and evidence for policy and to collect more types of information to meet the decisionmaking needs of different parts of the health system. More attention will be given to such areas as costeffectiveness analysis of resource allocation and utilization, health care financing, quality of care improvements and measurement ofthe disease burden.

lCD-I 0 implementation will continue to be encouraged and WHO will coordinate training through its network of collaborating centres for the international classification of diseases and for the international classification of impairments, disabilities and handicaps (ICIDH). Technical support to develop strategic plans and to evaluate the information needs of the Ministry of Health will be provided in partnership with other agencies. Practice-based health indicators for the district level will be developed to improve evaluations ofhealth service performance. WHO will continue to work with countries to respond to growing demands for training, workforce development and information technology equipment. The regional health database will be regularly updated in close collaboration with countries.

14. Emergency and humanitarian action

ISSUES In July and August 1999, typhoons and torrential seasonal rainfall caused floods in Cambodia, China, the Philippines and the Republic of Korea. In November 1999, six coastal provinces of central Viet N am were inundated by the worst floods this century. One month later, even more severe rainfall devastated the same area, causing extensive flooding that resulted in nearly 700 deaths. On21 September 1999, Chi-chi, Taiwan, China, experienced an earthquake that measured 7.6 on the Richter scale and left 2405 dead and 8664 injured. The total economic loss from the earthquake was estimated at US$ 9.2 billion. A strong aftershock measuring 6.2 occurred on 26 September and another earthquake measuring 6.4 hit the Chiayi area on 22 October. Since March 2000 Mongolia has been suffering from a climatic disaster known as a "multiple dzud'' the cumulative result of the previous summer's drought, a winter which began in September and was the coldest for 30 years, and repetitive and heavy snowstorms. Years of pastoral degradation exacerbated the effect of these extreme climatic conditions. Out of a total of 15 million head of livestock, 1.4 million perished, directly affecting 500 000 people or 20% of the country' s population. A United Nations interagency appeal was launched in April 2000 to provide assistance to the following sectors: livestock, food security through agriculture, water supply and irrigation, nutrition, health, education and coordination and monitoring. In order to minimize the extent of the natural disasters that regularly affect the Region, countries need to improve their preparation for natural disasters. They need to update their health emergency plans and incorporate coordination mechanisms into the plans, especially when responding to large-scale disasters. Exercises and drills should be conducted to test the plans.

WHO RESPONSE The emergency and humanitarian action focus works with countries to increase their capacity to prepare for emergencies and mitigate their health consequences. In particular, it focuses on strengthening emergency response capacity at national, local and community levels by establishing national and local emergency focal points, particularly in disaster-prone countries. The focus also aims to link emergency action and sustainable development. WHO worked closely with international agencies, nongovernmental organizations (NGOs) and national governments during the International Decade for Natural Disaster Reduction (IDNDR) which covered the period 1990-1999. The objective of the Decade was to reduce the loss of life, property damage, and social and economic disruption caused by natural disasters. In July 1999, the Programme Forum of the IDNDR reviewed the natural disasters that had occurred during the decade, including the health impact ofthe 1995 earthquake in Kobe, Japan. During the reporting period, a review of natural disasters in the Western Pacific Region from 1990 to 1999 was carried out. This provided valuable data that will be used to strengthen the Regional Office's approach to disaster management. WHO provided technical and logistical support, including medical supplies, following floods in Cambodia, China and the Philippines from July to November 1999. Three tons of water purification powder were provided after severe floods in VietNam. Following the earthquakes in Taiwan, China, in September 1999, technical information and guidance on managing evacuation centres was translated into Chinese and distributed to public health workers. A Health Information Network covering public health workers in Taiwan, China, and their counterparts in Kobe, Japan, was established. In order to reinforce emergency preparedness in the most disaster-prone countries in the Region, 14

HEALTH SECTOR DEVELOPMENT

Mayan Volcano erupts in the Philippines In the Region's most disaster-prone country, the Philippines, Mayon Volcano erupted in February 2000. The volcano unleashed clouds of ash I 0 kilometres into the sky and pyroclastic materials reached temperatures of nearly I 000 degrees celsius.

It is estimated that 70 000 to 80 000 people were evacuated from the danger zone at the base of the volcano. Over 57 000 people were housed in 47 evacuation centres, managed by the Provincial Disaster Coordinating Centre, supported by national and regional government units. Damage to agricultural production, including loss of farm animals, was estimated at US$ 2.2 million. As part of its proactive emergency management programme supported by WHO, several months before the eruption the Government of the Philippines strengthened emergency preparedness within the area. As part of this process, WHO, in collaboration with the Government and the University of the Philippines, Manila, supported the training of 54 health emergency coordinators in August 1999. The postgraduate course covered public health issues in emergencies, emergency medical services, and emergency resource and logistics management. Some ofthe participants in this course actively participated in the management of the evacuation. In addition to supplying medical supplies for the evacuation centres, WHO provided technical and health logistics management support during the post-disaster phase.

national health emergency focal points participated in a regional training course for health emergency management in Manila and Subic, the Philippines, in October 1999. The course included basic health emergency techniques and guidelines and rapid health assessment/coordination and made extensive use of simulation exercises. Since earthquakes frequently cause substantial damage to big cities of the Region, WHO cosponsored a meeting with the international NGO, Earthquakes and Megacity Initiatives, in Makati City, the Philippines, in December 1999. The meeting recognized that concerted efforts involving seismologists, civil engineers, disaster management officers and public health experts were essential for earthquake preparedness. Coordination with other United Nations relief agencies is crucial during emergencies and WHO has played an active role in United Nations Disaster

Assessment and Coordination (UNDAC), sending staff on UNDAC training courses and participating in a UNDAC mission to Yunnan Province, China, in February 2000, following an earthquake and snow storm the previous month. WHO collaborated with the United Nations Disaster Management Team in launching an interagency appeal for international assistance for Mongolia following the "multiple dzud". A working group composed of representatives of the Regional Office and country offices met in July 1999 to improve WHO's response time to emergencies, particularly with regard to procurement of medical supplies by Member States.

RESULTS Adequate preparation is essential if the health impacts of natural disasters are to be mitigated. The regional

14.

EMERGENCY !WD HUM!WITARI!W ACTION

training course on health emergency management for national focal points that was held in October 1999 was an important step in this process. National focal points have started to develop country-specific proposals for 2000 in Cambodia, China, Malaysia and the Philippines. National health emergency focal points have been established in the Region since 1998 and have proved to be an effective way of promoting national and international disaster reliefwork in Cambodia, China, Fiji, Mongolia, the Philippines and Vanuatu. For example, following the very heavy snowfalls in February 2000, the focal point in Mongolia worked together with WHO's Mongolia Office and the Ministry of Health and Social Welfare to conduct a rapid health assessment. Regular participation in UNDAC training courses and missions has helped to reinforce WHO's contacts with focal points of other relief agencies. Following the meeting on earthquakes and megacities in December 1999, a model tri-cityhealth emergency project covering Kobe, Manila and Shanghai was launched in February 2000. As a result ofthe recommendations of the internal working group, mechanisms are now in place to expedite the procurement of medical supplies by Member States following disasters.

the need for proactive city-specific emergency preparedness plans more urgent than ever. Large numbers of people concentrated in huge urban areas such as Shanghai, China, or Manila, the Philippines, greatly increase the potential for largescale disasters. Human resources development and timely mobilization of emergency personnel will remain an essential part of disaster preparedness in vulnerable countries. As many of the disasters that hit the Region are a consequence of extreme weather, improved early meteorological warning systems will be needed to help to ensure that disaster preparedness begins before typhoons, cyclones and floods strike.

FUTURE WHO will continue work with countries to reduce the impact of natural disasters by: • carrying out fact-finding, including mapping ofvulnerable areas and identifYing populations at risk; • improving awareness of hazards through community education; • providing technical support to improve management ofhealth logistics; • strengthening self-help capacity in the first 48 hours of emergencies, including the involvement of the private sector; and • formulating rehabilitation and human resource development programmes. Efforts are being made to translate recent WHO publications such as Rapid health assessment protocols for emergencies and Community emergency: a manual for managers and policymakers into languages of the Region.

ANALYSIS Despite the numerous natural disasters that hit the Region during the last decade, most disaster-prone countries have not revised their national health emergency contingency plans. If the impacts of disasters are to be minimized, countries must shift from emergency response to proactive emergency preparedness. The continuing population movement from rural areas to huge cities in disaster-prone countries makes

Reaching out The aim of this theme is not only to develop and strengthen partnerships and alliances, but also to improve the way WHO disseminates information to the public. Information technology will be used to improve countries' capacity to access information and to share information with one another and with WHO, as well as to make greater use of the new technology for training and telemedicine. Information technology will also be used to continue the process of strengthening communication within WHO. The aim of the external relations focus is to strengthen partnerships, not only with WHO's traditional partners in the health sector, but also with new partners in other sectors whose activities have a bearing on health. Through such media as the Internet and newsletters, the public infonnation focus aims to improve knowledge of WHO's activities.

15. Information technology Information technology in and between countries Information technology within WHO

16. External relations 17. Public information

15. Information technology

Information technology in and between countries

ISSUES All ministries of health in the Western Pacific use information technology to some degree, but in several cow1tries the ministry has neither computer networks nor access to the Internet. Many communities in the Region are isolated, particularly in Pacific island countries. This is not a new issue, but for the first time information technology (IT) may offer a way of alleviating the health implications of geographical remoteness. This was recognized by the Meeting of Ministers of Health of Pacific Island Countries held in Palau in March 1999 which highlighted the potential of telehealth. 1

RESULTS Computer networks in the Lao People's Democratic Republic and Mongolia have been improved, particularly in Mongolia where the new system links all the aimags (provinces)- seep. 145. This has greatly assisted the transmission ofhealth information to and from the central and provincial levels.

ANALYSIS The challenges posed by the fast-moving world of information technology are often difficult to meet for health sectors in less developed countries, particularly those in geographically isolated areas. WHO's capacity to support such countries to upgrade their information systems is also limited by resource constraints, but it does have in-house expertise that can be brought to bear. Within these constraints, WHO will continue to support efforts of less developed countries in the Region to upgrade and improve their information systems. With regard to the telehealth initiative, further surveys and technical assessment need to be carried out. The subregional distance education and health promotion project needs to be further developed.

WHO RESPONSE The information technology capacities of the Ministries of Health ofthe Lao People's Democratic Republic and Mongolia were strengthened significantly through the installation ofnew local area networks. During the period, in collaboration with the Government of Japan, WHO sent consultants to several Pacific island countries to review existing systems for telehealth, assess needs and investigate the financial implications of telehealth. A proposal has been drafted for a subregional distance education and health promotion project for nurses and other health workers in the Pacific. Among other things, the project will provide communication equipment and establish linkages between island countries and training centres. 1

FUTURE WHO will improve the capacity of its staff to collaborate with countries in the Region and with WHO Headquarters. Web-based technologies will play an important role in such collaboration, particularly with regard to telehealth initiatives.

Palau Action Statement.

REACHING OUT

Information technology within WHO

ISSUES Although information technology, particularly Internet technology, has greatly assisted communications within WHO and from the Organization to the outside world, continuous efforts need to be made to improve the Organization's capacity to communicate its message, to allow Member States, partners and individuals to access up-to-date information and to improve WHO's internal efficiency. Information systems in the Regional Office must be made as compatible as possible with those at WHO Headquarters, other regional offices, WHO country offices and Member States.

conjunction with the installation of a global private network linking all WHO regional offices and WHO Headquarters (seep. 165).

RESULTS The updated plans of action system and related administrative systems have improved the information flow in the Region and increased the efficiency and timeliness of administrative processes. For example, information related to the plans of action and financial data is now exchanged daily between the Regional Office and country offices (instead of once a month as before). The Intranet version of the plans of action system has been enhanced to improve access to information kept in the Regional Office.

WHO RESPONSE A fully integrated suite of administrative and programme support systems covering plans of action, procurement, fellowships administration, personnel, local costs administration, imprest accounts, mission reports, and meetings and courses was launched. The imprest accounting system was rewritten to support all WHO country offices throughout WHO. The fellowships and procurement applications were shared with other regional offices. The Regional Office also collaborated with the Regional Office for the Americas to install and refine a common personnel system. Significant improvements to hardware and software were made in all offices in the Region to enable WHO to improve its response to requests from Member States. These included upgrading country office networks, replacing obsolete desktop computers, upgrading office software to Windows 2000/0ffice 2000 and installing common messaging software throughout the Region. These improvements to WHO in-house information technology capacity were carried out in

ANALYSIS Although communication systems have improved in most WHO country offices in the Region, work is still needed in some offices. Improvements to the Organization's communications and IT systems reflect the fact that the review period has been a period of change in the Region. Many reforms to administrative procedures have already been integrated into the information systems in the Region, but as procedures are further refined this will in turn need to be reflected in information systems.

FUTURE The global private network will provide the backbone for a range of enhanced services for voice, video and data, improving information links between the Regional Office, WHO Headquarters and other regional offices. Information systems in the Regional Office and country offices will be continuously improved to ensure that they are up to date and reflect current IT standards.

16. External relations

ISSUES Need for coordination and cooperation The increasing number of players involved in health issues offers great opportunities, but it also means that the activities of a growing number of agencies, both directly and indirectly associated with health, should be coordinated. Each agency has its own agenda and priorities and there is significant potential for duplication of activities, leading to reduced efficiency and effectiveness, as well as incoherent policy-making and technical support at country level. This has sometimes created an atmosphere ofhostility among different agencies and between agencies and national governments.

Declining resources from the WHO regular budget The WHO regular budget has declined in real terms for a number of years. Coupled with this overall decline, the allocation to the Western Pacific Region will be reduced by 18% spread over three biennia commencing in 2000-2001. 1 Meanwhile, demands

for support from Member States have continuously increased. The Region 's health needs cannot be met from the regular budget alone. Despite the decline in resources from the regular budget, WHO has managed to maintain its level of support to Member States because of the extrabudgetary funds it has received from various partners (Table 16 . 1) . These extrabudgetary funds are often the only means of translating new policy initiatives and technologies into support to Member States, thus enabling WHO to fulfil its mandate to offer technical cooperation to developing countries. Funds contributed by donor country governments, other UN agencies, nongovernmental organizations and the private sector now account for a significant portion of WHO's expenditure. Table 16.2 shows the major programmes supported by the extrabudgetary funds in the 1998-1999 biennium. If present funding trends continue, WHO will have to rely increasingly on extrabudgetary funds to carry out its activities in the Region .

WHO RESPONSE Strengthen and build new alliances through better communication and coordination As the lead agency in international public health, WHO recognizes that it can lead more effectively and

Resolution WHA51.31

Table 16.1. Regular and extra budgetary sources of funds in the Western Pacific Region, 1994-1995 to 1998-1999 (US$)

110-iOW

Regular Budget (RB) Extrabudgetary sources (EB)

74 558 000 40838652 35.38

76 709 000 38016020 33 .14

80 279 000 38234819 32.26

231 546 000 117089491 33 .6

o/o of EB resources to total funds (RB and EB)

REACHING OUT

Table 16.2. Major programmes funded by extrabudgetary sources, 1998-1999 (US$)

Technical cooperation with countries Vaccine-preventable diseases Other communicable diseases Reproductive health Global elimination of leprosy Control of tropical diseases Health systems development Emergency and humanitarian action Human resources for health Diarrhoeal and acute respiratory disease control

11575641 6 162 204 3 920 742 3 543 913 3193 209 2 214 514 2 209 366 1 757 209 1 468 680 1 447 262

can achieve more by strengthening ties with traditional partners and establishing new alliances. WHO actively promotes cooperation and joint efforts with Member States, the United Nations family, civil society, and the private sector. To improve communication and coordination with other agencies, in the review period WHO actively facilitated participation of different agencies in meetings of WHO's governing bodies, technical and programme review meetings and factfinding missions to countries. WHO also collaborated with other organizations in organizing technical meetings in important areas such as Roll Back Malaria. Information is regularly exchanged with other agencies and WHO has been actively involved in planning, designing and assessing health projects implemented by other agencies. WHO has also been actively involved in the Common Country Assessment (CCA) and the United Nations Development Assistance Framework (UNDAF) in the four participating countries that were part ofthe first and second phases ofthe CCAIUNDAF exercise. These countries were Cambodia, China, the Philippines and VietNam. In most cases, health has been identified as a key area under CCNUNDAF. Activities with the United Nations Development Programme (UNDP) were carried out on a

country-specific basis, in areas such as management development in Cambodia, control and prevention of HIV/ AIDS and nursing development in China and malaria control in Solomon Islands. Technical cooperation with the United Nations Population Fund (UNFPA) focused on strengthening of reproductive health services, health education outreach, and family planning in Cambodia, Cook Islands, Fiji, Kiribati, the Lao People's Democratic Republic, the Federated States ofMicronesia, Marshall Islands, Papua New Guinea, Solomon Islands, Tonga, Tuvalu and Vanuatu. WHO worked closely with the United Nations Children's Fund (UNICEF) to implement the programme for integrated management of childhood illness (IMCI), including control of acute respiratory infections, diarrhoeal diseases and malaria. This included a regional workshop on IMCI in VietNam and the planning of a regional training course on IMCI case management in the Pacific. UNICEF has continued to be a major partner in the expanded programme on immunization (EPI) and poliomyelitis eradication and in the elimination of neonatal tetanus in countries that have not yet reached the elimination target. Recognizing that both organizations work with national immunization programmes and national counterparts in all the countries and areas of their respective regions, in April 2000 the WHO Regional Office for the Western Pacific and the UNICEF Regional Office for East Asia and the Pacific adopted a joint strategic plan on immunization for the period 2000-2004. UNICEF and WHO also work closely together in the "Mekong Roll Back Malaria Initiative" (see pp. 17-21 ). WHO continues to play an active role in UN AIDS. In recent years the respective roles of the Organization and the other co-sponsors of UN AIDS have been clarified leading to improved collaboration and a more focused approach (see alsop. 39). To renew and intensify collaboration between WHO and the Association of South-East Asian Nations (ASEAN), a mid-term review of the memorandum of understanding signed by the two organizations in 1997 was undertaken in December 1999. The review examined progress achieved so far and laid the basis for future collaboration based on the comparative advantage oftwo organizations. WHO significantly increased its collaboration with the Asian Development Bank (ADB) during the

- -==--===

16.

ExTERNAL RELATIONS

period. WHO participated in a rural health project in Viet Nam and joined a fact-finding mission in January 2000. WHO staff attended various meetings organized by ADB such as the Greater Mekong Subregion Conference, the Manila Social Forum and other consultative meetings WHO and the Secretariat of the Pacific Community (SPC) collaborated in various activities, including a comprehensive review of the Pacific Community's health programme, a regional project on tuberculosis and a vectorborne diseases project for control of malaria, filariasis and dengue haemorrhagic fever in Fiji, Solomon Islands and Vanuatu. WHO, SPC and the International Diabetes Federation - Western Pacific Region cosponsored a meeting on the Western Pacific Declaration on Diabetes in Kuala Lumpur, Malaysia, in June 2000. A revised memorandum of understanding between WHO and the Secretariat of the Pacific Community was signed in February 2000. This superseded the previous agreement signed in 1996 and aims to strengthen collaboration between both parties. Cooperation was maintained with various nongovernmental organizations (NGOs) in official relations with WHO, such as the International Council of Nurses, the International Diabetes Federation, the International Society on Prosthetics and Orthotics, the International Union Against Tuberculosis and Lung Disease, Rotarians Against Malaria, Rotary International, Save the Children Fund (UK), Save the Children Fund (Australia) and World Vision International. WHO has also collaborated with regional NGOs, regional offices of global NGOs and national NGOs. In Cambodia, for example, the International Federation of Red Cross and Red Crescent Societies worked with WHO to prevent and control of dengue outbreaks through clean-up campaigns and provision ofmedical equipment and health education materials.

have attended technical and programme review meetings, field events at country level and internal meetings at the Regional Office. A study of resource mobilization in the Region and an evaluation of programmes/activities funded by extrabudgetary sources was undertaken by the Regional Office during the review period. This study provided a clear picture of the current situation on resource mobilization; a profile ofthe donors and the various programmes funded; trends in contributions; constraints experienced in relation to implementation; and the impact, outcome and effectiveness ofprojects. The findings will be used to further improve strategies for future resource mobilization.

RESULTS Effecting an improvement in resource mobilization and coordination with other UN agencies, multilateral and bilateral agencies, NGOs and other partners in health is a long-term and gradual process and is governed by the interplay of a number of factors, some ofwhich are beyond the control ofWHO. However, early progress can be seen at both regional and country levels. The extrabudgetary resource flow to the Region has been maintained; traditional donors are continuing or increasing their contributions and several new donors have shown an interest in joint undertakings, especially in tuberculosis control, Roll Back Malaria, the Tobacco Free Initiative, health sector development, iodine deficiency disorders (IDD) and sexually transmitted infections, including HIV/ AIDS. For example, the Australian Agency for International Development (AusAID) has pledged US$ I million through WHO for an IDD project in Tibet, China, as a result of a feasibility study prepared by WHO. Coordination and communication within the UN system has been further improved following WHO's active participation in the CCA and UNDAF exercises in four countries of the Region, and an increase in the number of visits by leading technical officials of WHO and other UN agencies at regional and country levels. The completion of the CCA/UNDAF health sector exercise in Cambodia, China and VietNam led to the preparation of comprehensive situation

Actively pursue r·esource mobilization with traditional and new partners WHO has taken all available opportunities to reach out to existing partners and establish ties with new ones. Staffhave attended meetings of other agencies, visited Member States, and met regularly with donors and potential donors. Representatives of major donors

REACHING OUT

Figure 16.1 Extrabudgetary contributions by major donor partners, 1994-1999

16~~

. - - ---------- -- -------------------- ------ -------------- ---------------,

~ 10~~ :;I

.5 .... 0

c :s

8000000 6000000 4000000 2000000

..i

..lafEn

G'MJNAJDS

UNFPA

UNDP

DFID/UK

Nippon

Rotary

USAD

CDC

Donor partners

analyses, identification of major issues and constraints, setting of priority areas, and development of strategies and plans of action. Outside the UN system, WHO's higher profile has been reflected in the number of requests for WHO involvement in planning, assessment, preparation and implementation of health projects from such organizations as the World Bank, ADB, SPC, AusAID, the Department for International Development ofthe United Kingdom (DFID) and the United States Agency for International Development (USAID) .

ANALYSIS Despite some progress in improving collaboration with parU1ers in the UN system, multilateral and bilateral agencies and other parmers, coordination remains a major issue. The CCAIUNDAF exercise was a good start, but it also revealed that there is still a long way

to go before all parts of the UN system can work together in a coordinated and coherent way according to a common framework. WHO's comparative advantage as the specialized technical agency in health has not yet been fully recognized by many multilateral and bilateral agencies. There are still cases where health projects are planned, formulated and implemented without any consultation with WHO. Better advocacy, communication and informationsharing on what WHO is and what it is capable of doing, its ability to provide sound and effective policy and technical inputs and its capacity to implement essential health projects, is critical. Despite recent successes in resource mobilization efforts, a number of factors may come into play as WHO tries to expand its efforts to attract increased extrabudgetaryresources in future. These include the worsening financial situation in the whole UN system and increasing demands for resources from Member States. There is substantial variation in the level of resources different focuses are able to mobilize.

16.

EXTERNAL RELATIONS

Collaboration with Rotary International The partnership between Rotary International and WHO has been a pillar of poliomyelitis eradication in the Region. Rotary International is WHO's major NGO partner in the poliomyelitis eradication initiative. Since 1992 the regional poliomyelitis eradication initiative has received sustained support from Rotary International as well as from Rotary Districts 2640 and 2650 in Japan. Rotary has provided essential financial support to countries in the Region for oral poliovirus vaccines for national and subnational immunization days and for acute flaccid paralysis surveillance and laboratory testing. Between 1992 and 2000, Rotary International contributed US$ 15.9 million to WHO's campaign to eradicate poliomyelitis in the Region. In addition Rotary members and clubs in several countries have actively participated in poliomyelitis eradication activities and have been instrumental in promoting public awareness of the importance of poliomyelitis eradication in their respective countries. The collaboration between Rotary and WHO in poliomyelitis eradication has been a successful model that may be followed by other donors and NGOs in the Region.

Focuses which are able to demonstrate measurable results (especially the eradication or elimination of a disease) are much more attractive to donors than those whose work leads to long-term capacity building. In order to improve the Organization's capacity to raise funds across all its areas of operation, fund-raising skills of staff need to be improved. Donors' profiles need to be developed so they can be used by staff to facilitate proposal development. Other requirements for the future include better coordination and communication, sharing of experiences on best practices and successful projects, as well as improved training on proposal development.

FUTURE WHO will continue to improve its relationships with all donor partners through better advocacy, dialogue and communication. It will continue to seek new partners, in order to maintain and increase the extrabudgetary resources available for priority

programmes in the Region and to ensure that health is always high in the development agenda. To achieve this, existing mechanisms with donor partners will be further improved. A profile of major donors, their current priorities and requirements, project and budget cycles will be developed. Staff at country and regional levels will be trained on effective resource mobilization, including communication skills and development of realistic and persuasive proposals. WHO will continue to strengthen partnerships and strategic alliances within the UN family, multilateral and bilateral agencies, the private sector, civil organizations, NGOs and other partners. It will continue to participate actively in CCNUNDAF exercises and will share information, experiences and best practices with implementing agencies and Member States. WHO's advocacy and visibility will be improved through frequent meetings and information exchange with other agencies. Special attention will be given to areas where WHO's comparative advantage as the lead agency in international public health can be can brought into full play.

17. Public information

ISSUES Governments and other agencies need to be persuaded of the importance of investments in health. In the same wav: members of the general public need to be well-inf;:rned about health issues if they are to make decisions that will enhance their own health. In both cases, WHO has an important advocacy role to pla? Coverage of public health issues in the med1a ranges from highly objective and analytical reports to ill-informed and sensationalist tabloid journalism. Health rarely makes the headlines, unless it is related to disasters and emergencies. WHO must find a way to ensure that print, radio and television media cover public health more frequently and more accurately.

WHO RESPONSE High priority has been given to improving the media skills of staff at the Regional Office and country offices. For example, all WHO Representatives and Country Liaison Officers attended a two-day media seminar in August 1999. A digital image library accessible through the Intranet and the Internet has been established. Advocacy materials and press kits emphasizing priority programmes, such as Stop TB and the Tobacco Free Initiative (TFI), have been produced. Efforts have also been made to improve monitoring ofWHO 's media exposure, through media coverage assessments . This has resulted in an improved understanding ofissues that are ofparticular interest to the media and how they should be packaged and presented.

example, WHO organized a media forum for a dozen journalists entitled Journalists' encounter: From Manila to Kobe in November 1999 (see box). WHO works with countries to improve coverage of priority or sensitive issues. In Mongolia, for example, following a request from the Ministry of Health and Social Welfare, WHO collaborated in a media seminar on adolescent health issues in November 1999. The seminar focused on substance abuse, especially alcohol and tobacco, mental health and sexually transmitted infections, especially HIV/ AIDS. Participants included journalists from the radio, television and print media. A similar media seminar was conducted in Cavite, the Philippines, in October 1999. The seminar, entitled The Young, The Young Once and The Media, brought together radio, television and print journalists to discuss health issues related to adolescence and ageing.

Increasing access to health information A new quarterly newsletter, entitled WHO in action, was launched during the fiftieth session of the Regional Committee in September 1999. The newsletter aims to provide information on innovative programmes at country level and to update readers on key issues related to health, policy and development in the Region. The Internet is a cost-effective way ofimproving access of government officials, health workers and the general public to health information. The Regional Office therefore completed an extensive revision of its website during the review period. The revised website reflects the recently reorganized structure of the Regional Office and provides more detailed and updated statistical data and technical information. A number of new databases, a digital version of the newsletter WHO in action and a digital photo gallery have been added. Links to other public health related websites have been expanded.

Working with the media Considerable attention has also been given to building trust and fostering partnerships with the media. For

17. Public information

"Journalists' Encounter: From Manila to Kobe" To send a message, you need a reliable messenger. That was the principle behind a recent media forum organized by WHO's Western Pacific Regional Office- to raise public awareness on major health issues, WHO needs to work together with journalists and make them their partners. A dozen journalists from across the Western Pacific Region and reporters from Thailand and India attended an eight-day forum, hosted by WHO and the Philippine Center for Investigative Journalism (PCU), entitled Journalists' encounter: From Manila to Kobe, in November 1999. The encounter exposed the journalists to the major public health issues facing the Western Pacific Region: tuberculosis; HIV/ AIDS and sexually-transmitted infections; and tobacco use. The first part ofthe forum consisted of interactive sessions held with the staffofthe Department ofHealth, the Philippines, and WHO. Field visits were carried out to enable "one-on-one" interviews with tuberculosis and HIVI AIDS patients. In the second part, the journalists attended the International Conference on Tobacco and Health: Avoiding the Epidemic in Women and Youth, in Kobe, Japan. As a result of the encounter, participating journalists filed more than 50 articles to newspapers, wire services, magazines as well as reports for radio in China, Fiji, India, Japan, Mongolia, Papua New Guinea, the Philippines, Singapore and Thailand.

"Despite medical advancements and the discovery of medications and inoculations, diseases will still ravage the Asia Pacific unless the respective governments get their act together. The biggest killer is still political will, or lack thereof" Ms Joanne Lee, journalist/formerly with Singapore StraitsTimes, a member of the Encounter

Advocating health issues Increased emphasis has been given to commemorating WHO's special annual events, such as World Health Day, World Tuberculosis Day, World No-Tobacco Day and World AIDS Day. In collaboration with WHO Headquarters and other focuses in the Regional Office, advocacy and media packages have been developed and widely distributed throughout the Region. For example, during World Health Day on 7 April 2000, which focused on blood safety (seep. 130), many awareness-raising activities

were undertaken and voluntary blood donations were promoted in collaboration with national health authorities and Red Cross officials.

RESULTS The public information focus has increased its capacity to carry out advocacy, to provide support for other focuses and to country offices, and to work in a more proactive and timely manner with the Region's journalists.

REACHING OUT

Publications To support the work of technical programmes and to provide health information at the regional level, WHO published the following titles in the Region during the period: Food-based dietary guidelines for the Western Pacific; Cancer Data Base for the Western Pacific Region; Immunization Safety Surveillance; Towards healthier families: A guide for community nutrition workers; Training Package for Traditional Healers; and Promoting the health of communities - Guidelines for health professional education. Publications under preparation include: Grandmothers can learn: Reinforcing the role of grandmothers in homecare of diarrhoea and acute respiratory infections; Regional guidelines for the development of health-promoting workplaces; Medicinal plants in Japan; Vector Control (Asian and Vietnamese editions); Prevention of noncommunicable diseases through health promotion; and Nutrition in the Western Pacific. WHO encourages translation into local languages and reprinting of WHO publications. Other activities included the following: • Collaboration with People's Medical Publishing House in China, a WHO collaborating centre for promotion and translation of WHO publications, was strengthened by providing support for the translation of more regional titles. • A comprehensive list of WHO titles available for sale was added to the WPR website. In addition, it is now possible to download documents and information materials that are distributed free of charge from the site. • WHO publications were displayed and made available at 24 WHO-sponsored regional and intercountry meetings and workshops. WHO publications continue to be promoted through mailings to ministries of health, depository libraries, national focal point libraries, medical associations and medical schools.

Improved access to information about WHO's work in the Region has been achieved through WHO in action and a wide variety of printed advocacy materials. The relaunching of the website increased access to information on WHO's work. The knowledge of public health issues of some of the Region's journalists has been enhanced through interactive media seminars. Closer ties with the media were established through the Journalists' Encounter and regular dissemination of press materials.

ANALYSIS Despite the success of the media workshops, there is a need to increase training for journalists in the Region. As the new website, the newsletter and other print products reach only limited numbers of people, WHO needs to explore ways of working with other media, such as radio and television.

17. Public information

FUTURE The public information focus will continue to support other focuses and country offices to improve their advocacy, media and communications skills, primarily through training. More emphasis will be given to improving WHO's use of mass media, particularly radio and television. Public service announcements, video news releases and short documentaries will be produced for both radio and television.

Updated information and data on health and the work of the organization will be maintained through a frequently updated website, the newsletter WHO in action, technical publications, and other print products. Annual encounters with the media will be organized and interactive media sen1inars will be held in selected countries. Close collaboration will be established with the external relations focus, to enhance the Organization's capacity for resource mobilization.

lfUI

ADMINISTRATIVE SERVICES

Administration During the period, significant strengthening of WHO's communications capacity in the Region was achieved by ( 1) linking the Regional Office in Manila with the other WHO regional offices and WHO Headquarters through a satellite-based global private network, (2) installing a new PBX telephone system in the Regional Office, (3) installing leased lines or fixed links in the WHO country offices for Cambodia, China, the Lao People's Democratic Republic, Mongolia, Papua New Guinea, the Republic ofKorea, Samoa and VietNam. To improve space utilization and the working environment at the Regional Office, an architect is working on a comprehensive and unified plan for the office. The plan will be submitted to Headquarters for funding from the Real Estate fund. The plan can be implemented in stages over a number of years.

Personnel A new organizational structure formally took effect in January 2000 (see p.x). This new structure encourages a more focused approach to achieving health outcomes and fosters a greater sense of teamwork and unity among both professional and general service staff A monitoring system for short-term recruitment has recently been implemented and full computerization of the entire personnel system is planned. WHO has recently renewed emphasis on staff development and training, and management training was carried out in the Regional Office in February and March 2000. The Western Pacific Region supports the aim of achieving parity in the number of male and female professional staffby 2010. Participation by women in

the work ofWHO in the Region is strongly encouraged and WHO is taking positive steps to select female candidates for both fixed and short-term professional posts. The representation of women among the senior management in the Region increased significantly during the period. Two female directors (heading the themes "Building healthy communities and populations" and "Health sector development") and two female WHO Representatives (for Papua New Guinea and VietNam) were appointed. The two WHO Representatives were the first women to be appointed to this position in the Region. Considerable efforts are being made to increase the selection of women for both fixed-term and short-term professional appointments. However, although 11 women were selected for fixed-term appointments in 1999 (more than the combined total for 1997 and 1998) the percentage of women selected for fixed-term (32%) and short-term (36%) professional positions needs to be improved . This relatively low percentage of selections is in large part due to the correspondingly low percentage of female applicants for advertised positions. Nevertheless, the Region intends to build on its successes in attracting high-quality women to senior management positions and to continue to increase the number of women employed in both fixed term and short-term professional positions.

Supplies and equipment The aim of the supply unit of the Regional Office is to ensure timely procurement and delivery of supplies and equipment at the lowest possible prices to support WHO's programme implementation. Supplies and equipment, principally for country projects, valued at approximately US$ 14 000 000 were procured during the period under review. They included local and direct purchases amounting to US$ 8 000 000, the

'"'"•

ADMINISTRATIVE SERVICES

remainder being procured with the help of the purchasing services at WHO Headquarters. Supplies and equipment procured on behalf of Member States through the reimbursable procurement scheme are also included in this figure. These amounted to US$ 900 000 and consisted mainly of anti-tuberculosis drugs and rabies vaccine for the Philippines and mosquito nets and pesticides for the Solomon Islands. As part of the streamlining of regional procurement procedures, the delegation of authority for WHO Representatives and Country Liaison Officers to

purchase project supplies locally was increased from US$ 5000 to US$ 10 000. This has enabled country programmes to quicken their access to goods available locally. The documents reproduction unit duplicates and prints most of the documents and health promotion materials prepared in the Region. New pre-press digital equipment, which enables in-house colour separation, was purchased during the period. This will increase the quality and capacity ofthe unit to prepare printed materials.

Statistical annex

STATISTICAL ANNEX

Table 1 Demographic indicators Population Country/area Area (in 1000 sq. km.) 0.20 7 692.03

Year

Total fOODs) 62.90 18 966.79 323.00 11437.66 1 236 260.00 19.10 838.00 226.08 151 .96 6843.00 125252.00 77.80 4 581 .26 437.46 22179.50 50.84 115.14 2420.50 11.00 200.89 3803.90 2.30 66.60 18.10 4 356.37 74 745.76 0.04 47 275.00 165.50 3163.50 427.76 1.50 98.10 9.70 200.00 77 263.00 14.40

Year

Urban (%) 48.00 89.10 66.60 15.70 29.92 58.76 46.00 55.00 38.00 94.76 78.10 36.51 17.00 100.00 57.30 65.20 27.50 51.10 100.00 71.00 85.00 32.00 80.00 71.40 15.40 47.00 75.60 21.00 100.00 20.00 0.00 36.00 42.50 21.19 23.60 0.00

Year

Growth rate (%) 2.78 1.26 2.90 2.49 1.01 0.50 0.80 2.06 1.39 2.33 0.23 1.42 2.40 1.60 2.30 1.50 1.90 1.40 2.70

American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna WESTERN PACIFIC REGION

1999 mid-1999 1998 1998 1997 1996 1998 1998 1999 1999 1998 1995 1995 1999 1998 1999 1999 1998 1998 1997 1998 1996 1998 1998 1998 1999 1997 2000 1996 1998 1996 1996 1997 1997 1999 1999 ~994

1994 mid-1996 1991 1998 1997 1996 1996 1995 1999 1999 1995 1995 1995 1999 1998 1999 1995 1998 1995 1995 1998 1996 1995 1995 1995 1998 1995 1991 1998 1996 2000 1997 1997 1999 1999 1994

1999 1998-1999 1997 1998 1997 1996 1996 1995 1990-1999 1999 1998 1995 1995 1999 1998 1988-1999 1997 1998 1994 1997 1998 1996 1995 1998 1998 1999 2000 1991 1998 1996 1996 1997 1991 Census 1997 1998 1994

5.77 181 .04 9 600.00 0.24 18.33 4.17 0.55 1.10 377.83 0.81 236.80 0.02 329.76 0.18 0.70 1566.60 0.02 19.10 268.02 0.26 0.46 0.49 463.84 300 99.40 2.94 0.65 28.37 0.01 0.75 0.03 12.19 330.99 0.26

2.06 0.60 0.00 5.80 2.30 2.42 2.13 0.77 0.52 1.93 8.61 -D.90 0.30 1.70 2.40 1.75 1.30

1998

1649 930.00

1998

1.00

... Data not available.

STATISTICAL ANNEX

Year

< 15 years > 65 years (o/~) (%)

Year

Crude birth rate (per1000 population)

Crude death rate (per1000 population)

Dependencl ratio 1997 (%)

Year

Tota.l fertility rate (women 15-49 yrs)

1999 mid-1999 1998 1998 1997 1996 1996 1998 1999 1999 1997 1995 1995 1999 1998 1999 1997 1998 1992 1996 1998 1996 1999 1998 1998 1998 2000 1991 1998 1996 1996 1997 1997 1996 1994 1994 1998

38.10 20.68 32.70 43.90 24.98 34.56 33.80 32.76 34.60 16.92 15.35 41.15 44.00 23.20 34.00 42.90 44.00 35.40 41.80 31.00 23.00 34.90 23.92 24.75 41.83 36.10 21.70 41.00 22.50 43.68 41.10 39.00 34.70 43.10 36.80 41.90 26.06

3.45 12.24 3.60 3.50 7.04 5.37 4.00 3.92 8.60 10.73 15.66 5.09 4.00 7.70 3.80 2.20 3.50 3.80 14.00 8.00 12.00 7.20 5.41 3.70 7.10 4.00 10.20 4.00 (1994) 5.20 5.90 2.30 5.80 4.10 6.97

1998 1998 1998 1998 1997 1998 1998 1998 1998 1999 1998 1995 1995 1999 1998 1999 1997 1998 1994 1997 1998 1996 1998 1998 1998 1999 1998 1995 1998 1996 1991-1996 1997 1997 1991 1995 1990 1998

27.60 13.33 22.90 38.00 16.57 20.40 21.88 20.30 29.00 7.50 9.61 33.20 41.30 9.60 25.00 29.07 23.50 21.14 13.40 22.40 15.25 11.70 21.60 15.46 33.99 27.30 13.80 24.00 13.20 37.60 33.10 24.70 23.70 37.00 25.30 31.00 16.90

4.00 6.79 2.90 12.00 6.51 6.00 6.25 4.90 4.36 4.80 7.48 8.30 15.10 3.20 4.50 4.47 (1998) 4.20 6.08 5.00 5.10 6.91 4.80 2.30 6.96 11.80(1996) 6.00 5.30 4.60 4.60 6.50 8.20 4.10 10.30 9.00 6.70 6.00 7.10 85.90 68.30 73.00 70.00 40.00 76.70 40.80 87.60 52.90 69.60 64.60 90.90 40.20 44.80 60.20 50.10 57.80 83.10 47.80

1995 1998 1998 1998 1997 1996 1995-1996 1998 1998 1998 1995 1995 1998 1998 1999 1997 1998 1991 1997 1998 1991 1998 1998 1996 1999 1998 1991 1998 1995 1991-1996 1997 1997 1997 1996 1990 1998

4.50 1.76 2.70 5.20 1.80 3.26 2.71 4.20 0.98 1.38 4.50 5.60 1.40 3.10 5.70 4.70 2.30 4.90 2.70 2.00 3.50 2.44 2.60 4.70 3.46 1.50 4.76 1.49 5.40 5.67 3.80 3.20 4.40 2.78 4.60 2.00

a Source: The Human Development Report, 1999. Definition: The ratio of the population defined as dependent· those under 15 and over 65- to the working-age population, aged 15-S4.

STATISTICAL ANNEX

::::::=.::..=:.:.:..::::-::.:=.::...::==.:::==-..:::.=.::.... -:-_-=-===::::=...:._ -~.:-:...--:.=====-====.-=

-------

Table 2 Socioeconomic indicators Adult literacy rate Country/area American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore 1995 1991 1998 1991 1991 1996 1991 Census 1991 1998 91.16 95.90 99.50 33.00 97.00 91 .00 96.30 95.60 98.00 98.20 93.10 27.00 17.00 99.30 98.60 96.70 97.80 1999 1996 1998 1996 1998-1999 1995 1996 1994 1999 1992 US$ GDPatUS$ US$ Sl$ US$ US$ GDPatUS$ US$ US$ 8581.00 890.00 21 094.01 2 060.00 890.00 2058.66 1993.00 1150.00 2 500.00 1995 1990 1993 1990 1995 100.00 99.10 78.00 45.10 94.30 49.50 92.30 40.30 96.00 99.50 99.30 99.50 98.80 1995 91.00 92.00 90.00 1990-1995 1996 1996 1995 1995 1991 Census 1996 1999 1995 1996 96.40 90.51 99.00 92.20 60.00 89.47 91.00 97.00 90.00 96.90 97.50 96.30 96.80 97.20 93.80 74.00 94.08 90.70 48.00 85.29 94.90 86.20 1992 1998 1996 1996 1997 1998 1998 April1995 1996 1998 1985 1992 1998 1996 1998 1999 1996 1997 US$ HK$ US$ US$ US$ GDPatUS$ RM US$ US$ US$ US$ US$ US$ US$ US$ GDPatUS$ US$ US$ 10800.00 192960.00 40 940.00 872.00 400.00 15 854.47 11 835.00 1 850.00 1195.00 439.50 8 070.00 12 381 .00 14400.00 3 002.00 28 734.49 7137.00 1228.00 1220.00 1991 1998 1997 1998 1996 63.30 83.85 100.00 92.90 93.70 79.50 90.82 100.00 94.50 84.70 57.00 76.80 100.00 91.40

Year 1990

Both sexes (%) 99.50

Male ("/o) 99.50

Female (%) 99.50

Year FY 1996 1998-1999 1997 1999 1998 1997 1998

Per capita GNP (US$/Iocal currency) US$ GDPat$Aus GOP atBru$ Nominal GOP at US$ GDPatUS$ GDPatNZ$ GOP at FJ$ 2179.00 31363.00 25600.00 268.00 768.00 6 094.00 4 023.00

Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna

GOP atVND 5176 371 .61

... Data not available.

STATISTICAL ANNEX

Health expenditure Year FY 1996 1997-1998 1997 1999 1997 1997 1998 1995 2000 1998-1999 1997 1998 1996 1999 1998 1999 1997 1998 1995-1996 1998 1995-1996 1999 1997 1997 1997 1998-1997 1998 1996 1999-2000 1997 1998 1994 1998 US$ US$ US$ US$ PHP Won $WST 945.00 357.00 600.00 31.00 150.00 61994.74 119.00 1292.00 28.00 341.07 84.00 141.48 3 659.00 57 806.00 11 .91 8.20 13.10 1.30 11.00 5.59 1.22(GDP) 7.10 0.63 0.66 8.10 2.54 4.27 9.38 2.00 (1996) 0.43 0.69 13.30(GDP) 2.89 4.90 (GOP) 0.57 0.74 0.85 0.75 0.89 0.62

Per capita (US$/Iocal currency) US$ Aus$ Bru$ US$ Yuan NZ$ FJ$ US$ US$ HK$ US$ Aus$ US$ US$ RM

As%of total budget 10.00 (1998)

As%of GNP 8.40 (GOP)

Human development index (HOI) valueb 1997 0.92 0.88 0.51 0.70 0.76

435.00 2536.00 586.00 1.17 272.82 approx. 252.77 100.38 361.00 1144.00 4 695.54 973.40 98.93 < 9.00

5.39 7.30 2.98 (1994) 10.70 (1997-1998) 7.00 13.46 34.80 11.79a 19.00 15.70 7.60 9.57 (1998) 6.61 25.00 11 .30 10.00 8.90 17.20 7.80

2.21 (GOP) 0.63 (GOP) 3.84 (1994) 3.20 3.00 10.00 (1997) 2.43

0.88 0.92

1.50 1.99 (1998) 1.62 4.00 4.00

0.49 0.77

approx. 351.93 191.00 248.00 117.20 13 328.60

US$ US$ Tughriks

0.62

6.10

0.90

S$ Sl$ NZ$ Paanga AUD Vt VND

IWM

• %of public expenditure on health. Source: The Human Development Reporl. 1999. Definition: The human development index (HOI) measures the average achievements in a country in three basic dimensions of human development: longevity, knowledge and a decent standard of living. A composite index, the HOI thus contains three variables: life expectancy, educational attainment (adult literacy and combined primary, secondary and tertiary enrolment) and real GOP per capita in purchasing power parity (PPP$). The worldwide HOI value for 1997 was 0.69. b

STATISTICAL ANNEX

Table 2 Socioeconomic indicators (continued) Country/area Year

% of population with Access to Adequate excreta disposal facilities safe water Year (%) (%)

Estimated smoking prevalence among adultsd Year Male (%) 41 .00 29.90 66.00C 66.90 34.40 50.50 36.00 37.70 27.10 51 .20 56.50 41 .00 31 .58 41.00

Female (%) 16.20 24.20 8.ooc 4.20 71.10 13.90 36.00 26.90 2.90 9.80 32.30 15.00 4.18 4.00

American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong {China) Japan Kiribati Lao People's Democratic Republic Macao {China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna 1998 1995 1998 1996 1998--1999 1997 1998 1991 1998 1990 85.20 85.00 100.00 64.00 100.00 100.00 100.00 87.00 50.00 100.00 1999 1995--1996 1998 1996 1996 1997 1999 1991 1995 1990 100.00 98.00 100.00 9.00 48.40 85.00 78.90 91 .00 16.30 47.50 1998 1999 1997 1999 1996 1999 1998 1995 1998 1998 1994 1990 1997 1996 1999 1995 1994 1997 100.00 99.80 96.00 75.00c 29.00 100.00 94.10 82.00 22.00 73.40 100.00 76.00 85.00 100.00 100.00 100.00 31.00 75.60 1996 1996 1995 1994 1997 98.00 80.00 57.00 25.00 66.60 1990 72.00 1997 1998 41 .00 54.20 1998 98.00 1998 1999 1994 1999 1996 100.00 > 99.00

1985 1994 1996 1998 1998 1997 est. 99.00 98.00 29.00 100.00 85.00 1990 1996 1998 1998 1997 est. 90.00 79.00 14.50 100.00 85.00 1999 1996 1998 1988 1995 1999 1998 1996-1997 1999 1995 1997 1986 1998

97.20 5o.ooc 15.00

1997 1975 1992 1999 1980

55.00 53.00 28.00 26.00 58.00

19.00 59.00 34.00 22.00 17.00

1990 1999 1997 1994 1998 1989 1991 1991 1976 1998 1997 1996

46.00 53.80 65.00 33.90 26.90 67.60 64.80 51 .00 49.00 50.00 42.00

28.00 11.00 4.40 12.70 3.10 23.00 42.00 13.00 31.00 5.00 3.40 18.00

•u•

curban. dThese estimates were derived from questionnaires, reports from countries, published data, local research, and in cases where no specific data exists, related information. e1998 overall smoking prevalence= 20% {no gender breakdown available). 1 1997 overall smoking prevalence= 18.1% (no gender breakdown available).

STATISTICAL ANNEX

Table 3 Health workforce and infrastructure indicators Health workforce (rate per 10 000 population) Country/area Year Physicians Dentists Nurses Year Health infrastructure Hospital beds 140 218 743 899 10890 2 616 280 138 1881 994b 225 52868 1660 766 6 140d 5 217 1068 42301 105 303

Rate per 1000 populatione 2.23 11.53 2.78 0.95 2.12 7.23 2.24 4.40 1.48 7.73 13.29 1.80 1.14 2.44 1.91 2.07 2.63

American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong {China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna

1999 Aug 1999 1998 1998 1998 1998 1998 1998 1999 1999 1996 1998 1996 1999 1998 1999 1999 1998 1995 1997 1999 1996 1999 1998 1998 1996 1998 1996 1998 1995 1996 1997 1999 1997 1998 1996

7.00 26.00 10.60 2.97 16.17 7.00 3.57 17.90 11.10 14.40 19.32 2.96 6.14 20.50 6.77 3.93 5.73 24.33 15.70 18.52 22.60 13.04 4.47 11.04 0.73 12.30 16.22 3.44 16.27 1.40 20.00 4.40 3.00 1.20 4.80 9.03

1.75 4.00 1.60 0.18 6.00 0.33 4.50(1999) 2.05 (1996) 2.60 6.86 0.49 0.43 0.95 0.79 1.22 1.35 5.18 5.50 8.70 0.57 1.10 0.27 5.20 3.47 0.40 2.89 0.70 0.00 0.92 1.00

20.19 82.00 43.30 7.38 9.86 20.00 19.35 28.70 43.40 (1997)a 37.00 74.49c 23.58 10.77 20.50a 10.67 14.36 27.90c 30.73 58.80 84.50a 47.83 17.88 14.40 6.70 41 .80 30.38 15.50 49.21a 11.90 73.00 31.51 30.00 26.00a 5.60

1999 1997-1998 1998 1998 1998 1997 1998 1999 2000 1999 1997 1998 1996 1999 1998 1999 1998

1998 1996 1999 1998 1997 1998 1996 1998 1995 1997 1999 1999 1998

23454 30 82

6.17 13.04 1.23 4.42 0.31 5.09 2.33 3.60 1.28 3.13 4.12 1.90 1.71

80 22080 236 387 386 11389 503 307 40 380 133190

...Data not available. aRefers to nurses/ midwives. bFigure applies only to general/specialized hospitals.

clncludes assistant nurses . dFigure applies only to one hospital. eRates computed using latest available population size.

STATISTICAL ANNEX

Table 4 Health status and coverage indicators Life expectancy at birth (years) Country/ Area Year Both sexes Male Female Year Mortality rates Infant Under-5

American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna

1995 1996-1998 1994-1996 1998 1997 1991-1995 1996 1996 1999 1999 1997 1995 1998 1993-1996 1998 1998 1997 1997 1992 1997 1995-1997 1999 1998 1998 1995 1999 1999 1992 1998 1995 1996 1997 1991 census 1997 1998 1990 1995-2000

72.00 75.86 75.40 54.40 70.80 70.00 66.60 71.50 77.75 80.00 60.20 53.00 76.57 73.60 68.00 64.25 72.50 70.00 75.79 56.00 67.30 72.73 64.50 56.00 65.70 70.60 64.00 77.30 65.00 68.00 68.00 67.00 %00 68.00 70.50

1998 81.52 77.70 58.62 73.04 72.00 68.70 74.20 81.30 82.60 83.82 64.70 54.00 79.98 74.60 67.90 71.00 67.60 64.00 76.50 79.60 79.03 70.80 58.00 68.90 78.10 65.00 79.30 70.00 70.00 69.00 69.60 70.00 72.50

16.00 5.02 6.50 89.00 33.10 18.00 17.83 7.00 7.87 3.22 3.64 62.00 104.00 4.10 8.30 25.85 19.30 35.38 14.50 5.30 6.80 10.00 8.40 10.71 77.00 45.00 7.70 10.50 4.10 44.00 0.00 10.10 26.10 41.00 37.00 15.00 35.00

19.50 6.41 8.50 115.00 42.30 20.60 23.66 10.64 4.69 5.12 (1997) 170.00 4.80 31.00 37.82 47.80 14.50 8.60 9.40 (1996) 100.00 66.80 (1995) 11.00 (1995) 27.00 (1994)

1998 1998 1998 1997 1998 1998 1998 1998 1998 1998 1995 1995 1999 1998 1998 1997 1998 1994 1997 1997 1993-1998 1998 1998 1987-1996 1998 1996 1995 1998 1995 1999 1997 1997 1996 1998 1993-1995 1998

50.34 68.71 68.00 64.50 69.10 74.56 77.20 77.19 58.50 52.00 75.11 69.60 64.40 66.00 61.02 55.00 68.80 74.30

63.00 75.20

IWI

0.00

64.00 65.00 64.90 67.00 68.60

52.00 (1995)

WESTERN PACIFIC REGION

... Data not available.

ST ATISTICAL ANNEX

Year

Maternal mortality ratio (per 100 000 live births)

Year

Newborn infants with birth weight at least2.5 kg. (%)

Year

%of women of reproductive age (15-49 yrs.) using contraceptive methods (%)

1998 1998 1998 1998 1997 1998 1998 1998 1998 1998 1997 1998 1998 1998 1998 1996 1997 1998 1994 1991-1997 1997 1996 1998 1998 1996 1998 1996 1994 1997 1992 1999 1997 1997 1993 1996 1996

118.50 2.80 40.00 473.00 63.60 0.00 38.17 0.00 23.10 1.87 6.50 0.00 650.00 0.00 20.00 0.00 122.00 158.00 0.00 39.00 5.20 0.00 0.00 0.00 370.00 172.00 20.00 70.00 4.22 549.00 0.00 0.00 0.00 68.00 120.00 0.00

1998 1997 1998 1995 1997 1998 1998 1995 1998 1998 1997 1998 1998 1999 1997 1998 1997 1998 1997 1997 1996 1998 1998 1997 1998 1996 1996 1997 1994 1998-1999 1992 1997 1991 1998 1990

97.00 93.40 89.60 88.00 97.69 99.00 90.46 94.70 91.78 95.01 92.11 94.96 82.00 94.60 90.80 85.80 71.00 94.80 92.20 93.80 100.00 81.42 91.00 89.00 49.80 71.40 96.10 92.00 87.20 100.00 97.00 94.30 92.60 93.00 97.00

1998 1995 1998 1997 1998

32.00 76.00 16.10 53.00 40.45

1990-1998 1998 1997 1998 1997 1998 1998

59.00 20.89 19.00 8.60 3 16.00 45.00 43.20

1996 1998 1998 1997 1998 1997 1998 1997 1996 1999 1997 1997 1998 1997-1998

39.10 54.00 28.94 5.00 28.00 80.50 35.00 62.00 11.00 13.40 40.90 41 .20 28.80 75.82

li~

At health centre level.

S TATISTiCAL ANNEX

Table 4 Health status and coverage indicators (continued) %of pregnant women attended by trained personnel MCH coverage %of deliveries attended by trained personnel %of wom~ngiven

Country/area American Samoa Australia Brunei Darussalamb Cambodia China Cook lslandsb Fiji French Polynesia Guam Hong Kong (China) Japan Kiribatib Lao People's Democratic Republic Macao {China) Malaysiab Marshall Islands Micronesia, Federated States of Mongoliab Nauru New Caledonia New Zealand Niueb Northern Mariana Islands Palau Papua New Guinea Philippinesb Pitcairn Islands Republic of Korea Samoa Singaporeb Solomon lslandsb Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna WESTERN PACIFIC REGION

Year

2 doses of tetanus toxoid TT2

1997 1996 1998 1995 1998 1998 1998 1999

> 90.00 100.00 34.30 78.65 100.00 100.00 95.20 100.00

1997 1998 1998 1995 1998 1998 1998 1998 1996 1998

>99.00 99.00 34.00 89.31 100.00 98.96 99.60 99.69 99.97 84.98 100.00 97.30 94.85 90.00 99.30 1998 1996 1996 1997 49.39 31 .00 55.70 84.00 1998 1998 99.00 77.92 1998 1997 52.20 30.51

1994 1998 1998 1997 1998

8.00 79.50" 96.10 79.00 98.80 1999 1998 1998 1997 1998

1995 1998 1998 1996 1998 1997 1995 1998 1995 1998-1999 1997 1997 1996

95.00

1995 1996 1998 1998 1997 1998 1997 1994 1998 1994 1998-1999 1997 1997 1995 1998

100.00 100.00 99.40 100.00 47.00 56.00 99.70 75.00-80.00 100.00 83.50 100.00 94.90 99.00 89.10 95.80 1998 1993 1997 1996 1998 1996 1998 1996

NA 100.00 18.50 68.80 38.00

84.40 99.64 77.50 86.00 99.60 90.00 100.00 70.00 100.00 92.20 99.00 75.00

99.00

0.00 91.60

82.80

... Data not available NA Not applicable "At health centre level. bFigures for Immunization coverage of infants are computed using the administrative method (number of doses given divided by number of children in target group times 100).

-===========-============

STATISTICAL ANNEX

Year

BCG ("lo)

Immunization coverage of infants DPT3 OPV3 (%) (%)

MV (%)

HB3 (%)

1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999 1999

NA NA 98.00 78.00 85.00 74.00 98.00

91.00 88.00 92.00 64.00 85.00 70.00 98.00 90.00 90.00 78.00 56.00 92.00 89.00 66.00 76.00 94.00 64.00 88.00 100.00 99.00 96.00 56.00

90.00 88.00 97.00 65.00 90.00 70.00 98.00 93.00 84.00 77.00 64.00 92.00 89.00 86.00 76.00 94.00 64.00 85.00 100.00 99.00 96.00 45.00

NA 89.00 94.00 63.00 85.00 63.00 98.00 93.00 87.00 62.00 71.00 92.00 88.00 93.00 79.00 93.00

98.00 93.00 70.00 67.00 94.00 99.00 89.00 82.00 92.00 86.00 80.00 77.00 92.00 62.00 89.00 100.00 96.00 96.00 50.00

NA 100.00 70.00 63.00 99.00 98.00 81.00

NA 97.00 95.00

NA 82.00 100.00 93.00 96.00 57.00

NA 100.00

NA NA 70.00

1999 1999 1999 1999 1999 1999 1999

99.00 98.00 100.00 100.00 100.00 95.00 86.00

98.00 94.00 100.00 94.00 84.00 93.00 85.00

98.00 95.00 100.00 94.00 85.00 93.00 90.00

91.00 86.00 100.00 97.00 94.00 93.00 85.00

99.00 95.00 100.00 93.00

NA 82.00 71.00

Table 5 Selected morbidity and mortality indicators Country/area Year Cases American Samoa Australia Brunei Darussalam Cambodia China Cook islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna 1999 Jan-Jun 1999 1998 0 169 0 5771

Cholera Deaths

Year Casesb 1998 1998 1998 1998 1998 0 0 0 0 1998 1998 1998 1998 1998 1998 0 0 1998 1998 1998 1998 1998 1998 1998 1998 0

Malaria Deaths 0 0 0 621 24 0 0 0 0 0 0 0 485 0 27 0 0 0 0 0 0 0 0 0 651

1998 1999 1999 1999 1998 1999 1999 1999 1999 1999 1999 1999 Jan-Nov 1999 1999 1999

0 4 93 4570

0 (i=705) 0 66140 27090 0 0 0 0 0 0 0 (i=O) 41623 0 13491 (i=513) 0 0 0 0 0 0 0 0 0 20 900 50 709 3 992 (i = 60) 0 0 (i=369) 72808 0 0 (i=2) 0 6181 72091 0

0 0 0 0 18 40 0 0 535 0 0

0 0

1998 1999 1998 1999 1999 1999

0 1 0 0 0 330

0 0 0 0

1998 1998 1998 1998 1998 1998 1998 1998

0 0 0 33 0 0 0 0 183 0

1998 1999 1998 1999 1998

0 11 0 0 0

0 0 0 0 0 0

1998 1998 1998 1998 1998 1998 1998 1998 1998

lml

WESTERN PACIFIC REGION 8

1998

376674 3

2024

... Data not available. (i) = Imported cases . Total for the Region is the sum of all cases including imported cases. bNo information on imported cases for those countries with 0 cases.

STATISTICAL ANNEX

Year

Meningococcal meningitis Cases Deaths

Year

Dengue fever Cases Deaths

1998 1999 1999 1999 1998 1999 1996 1999 1999 1999 1999 1999 1999 1999 1999 1999 1997 1997 1999 1997 1999 1999 1999 1999 58 242c 0 8 504c 0 0 1d 2538 0 0 0 558c 10 2852 2 98 26 1c 3c 1Dc 45

1998 1999 1999 1999 1998 1999 1999 1999 1999 1999 1999 1999 0 1999 Jan-Nov 1999 1999 1999

205 181 7 1306 0 430 33 1 5 9 0 2507 0 9312 0 0 0 0 0 0 0

84 oc

1998 1999 1997 1999 1999 1999

2618 9 0 0 0 9221 0 0 0

1998 1997 1999 1998 1997 1999 1997

13 0 1c

1998 1999

54 1355 0 0 205 0 110 20861 395 0

1997 1999 1998

0 0

lfi'W

0 4 0

1997 1999 1999

1998

7149

48824

ccountries and areas that have reported meningococcal infections (Australia, Hong Kong, Mongolia), and meningococcal meningitis (Japan, Macao (China) and Tokelau) and meningococcal disease (Guam, New Zealand). dBacterial encephalitis.

STATISTICAL ANNEX

Table 5 Selected morbidity and mortality indicators (continued) Country/ Area Poliomyelitis 1999 cases Measles 1999 cases Diphtheria 1999 cases Pertussis 1999 cases

American Samoa Australia Brunei Darussalam Cambodia China Cook Islands Fiji French Polynesia Guam Hong Kong (China) Japan Kiribati Lao People's Democratic Republic Macao (China) Malaysia Marshall Islands Micronesia, Federated States of Mongolia Nauru New Caledonia New Zealand Niue Northern Mariana Islands Palau Papua New Guinea Philippines Pitcairn Islands Republic of Korea Samoa Singapore Solomon Islands Tokelau Tonga Tuvalu Vanuatu VietNam Wallis and Futuna WESTERN PACIFIC REGION

0 0 0 0 0 (i = 1)

0 235 23 13827 61840

0 0 0 16

0 4403 7 618 5974 0 2 3 5 11 133 0 17 0 49 2 0

0 0 0 0 0 0 0 0 0 0

0 13 32 2 2302 1

0 0 0 0 0 6 0 6 0 0 11 0

2576 0 0 10

0 0 0 0 0 0 0 106

0 0 0 0 0

104-6 0 0 0 4773 4

0 0 0 6304 2981

0 0 0 0 0 0 (i=1)

65 0 6 0 14134 104459

0 0 0 0 81 0 0 0 903 17951

lml

184

(n=

Data not available Imported cases

NA Notapplicable.

STATISTICAL ANNEX

Number of cases of selected diseases Neonataltetanus 1999 Leprosy 1998 Tuberculosis 1998

AIDS1998

NA 0 173 3616 0

6 9 (1995) 2 (1997) 1609 2051 0 7 7 16 11 (1997) 15 (1996) 26 236 0 148 126 39 0 2 (1997) 5 10 (1996) 0 (1997) 7 3 572 3490 0 39 19

6 (1997) 899 160 (1993) 16946 457 349 2 166 105 94 (1994) 7673 44 016 276 2165 463 14 115 49 138 29.15 4 (1994) 102 367

0 273 0 1494 136 0 0 (1997) 2 7 63 231 2 27 4 875 0 (1997) 0 (1997) 0 0 3 26 0 1 (1997) 0 (1997) 220 41 37 0 125 0 0 1 0 (1996)

0 0 0 18 0 10 0

·o 0 0 0 0 0 52 332

1 97 15 {1997) 11291 159 866 30008 22

0 0 0 0 219 4421

7 21 0 1 (1996) 2162 0 10648

2120 295 1 (1996) 30 18 178 87449 14 1997 839121°

.1:1•

0 935 0 4503

"Total for Region applies only to 1998 figures.

Acknowledgement is made to PHIVOLCS for the photograph which appears on p.l48 and to Thierry Renavand for the cover photograph.

Key facts

Organisation World Health Organization (WHO)

Document type Governing Bodies documents

Adoption date December 31, 2000

Source World Health Organization