(WPR/RC36/SR/l)
SUMMARY RECORD OF THE FIRST MEETING WHO Conference Hall, Manila Monday, 16 September 1985 at 9 a.m. CHAIRMAN: later: Dr T.M. Biumaiwai (Fiji) Dr Terepai Maoate (Cook Islands)
CONTENTS
l.
Formal opening of the session
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74
2. 3.
Address by the retiring Chairman ••••••••••• ~ •••••••..••••.••• Election of new officers: Chairman, Vice-Chairman and Rapporteurs ...........•••................................ Technical Discussions: Appointment of a Moderator •••••••••••
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74 74 74
4.
5. 6.
Address by the Director-Genera 1 •••••••••••••••••••••••••••••• Adoption of the agenda and the supplementary agenda
. ........ .
75
7.
Acknowledgement by the Chairman of brief reports received from governments on the progress of their health activities ....•....................................... Report of the Regional Director
75 75
8.
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73 -
]I..
REGIONAL COMMITTEE:
THIRTY-SIXTH SESSION
I.
FORMAL OPENING OF THE SESSION:
Item 1 of the Provisional Agenda
Dr BIUMI\IWAI, retiring Chai nnan, declared the thirty-sixth session of the WHO Regional Committee for the Western Pacific open. 2. ADDRESS BY THE RETIRING CHAIRMAN: Item 2 of the Provisional Agenda
Dr BIUMAIWAI made a statement to the Committee as retiring Chairman (see Annex 1 for a copy of his statement). 3. 3.1 ELECTION OF NEW OFFICERS: CHAIRMAN, Item 4 of the Provisional Agenda Election of Chairman VIC~-CHAIRMAN
AND RAPPORTEURS
Dr DE SOUZA (Australia) nominated Dr TEREPAI MAOATE (Cook Islands) as Chairman; this was seconded by Dr CHRISTMAS (New Zealand). Decision: Dr TEREPAI MAOATE was elected unanimously.
Dr TEREPAI MAOATE took the chair. 3.2 Election of Vice-Chairman
Dr PHAM SONG (Viet Nam) nominated Dr PONMEK DARALOY (Lao People's this was Democratic Republic) as Vice-Chairman; seconded by Mr NONUMALO FAIGA (Samoa). Decision: 3.3 Dr PONMEK DARALOY was elected unanimously.
Election of Rapporteurs
Dr KHALlD (Malaysia) nominated Dr BAY AN (Philippines) as Rapporteur for the English language; this was seconded by Dr NG KWOK CHOY (Singapore). Dr SILVA (Portugal) nominated Dr WONG FAT (France) as Rapporteur for the French language; this was seconded by Dr PONMEK DARALOY (Lao People's Democratic Republic). Decision: 4. Dr BAYAN and Dr WONG FAT were elected unanimously. APPOINTMENT OF A MODERATOR
TECHNICAL DISCUSSIONS:
The CHAIRMAN moved the appointment of a moderator for the Technical Discussions and proposed Dr LIU XIRONG (China). Decision: 5. The proposal was adopted unanimously. Item 3 of the Provis i onal Agenda
ADDRESS BY THE DIRECTOR-GENERAL:
The CHAIRMAN invited Dr H. Mahler to address the meeting (see Annex 2 f or a copy of his statement).
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6.
ADOPTION OF THE AGENDA AND THE SUPPLEMENTARY AGENDA_; Item 6 of the Provisional Agenda (Documents WPR/RC36/l and WPR/RC36/l Add.l)
The CHAIRMAN moved the adoption of the agenda and the supplementary agenda. Decision: In the absence of comments the agenda and the supplementary agenda were adopted. 7. ACKNOWLEDGEMENT BY THE CHAIRMAN OF BRIEF REPORTS RECEIVED FROM GOVERNMENTS ON THE PROGRESS OF THEIR HEALTH ACTIVITIES: Item 7 of the Agenda
The CHAIRMAN acknowledged reports on the progress of health activities received from the following countries or areas: American Samoa, Australia, China, Cook Islands, Guam, Hong Kong, Northern Mariana Islands, Philippines, Republic of Korea, Samoa, Singapore, Trust Territory of the Pacific Islands and Viet Nam, which were being distributed to the Committee. Dr CHRISTMAS (New Zealand) wondered whether it was necessary for governments to continue to provide reports on the progress of their health act~v1t1.es; New Zealand had not in fact submitted one on the present occasion. For countries which were short of key staff, preparation of the reports represented a considerable burden of work. He would welcome the views of other representatives on the matter. Dr KHALID (Malaysia) said his country also had prepared no report for the current session. It should be made clear what specific purpose the reports were intended to serve. If it was decided, for example, that a certain session of the Committee was to highlight a particular area, then the reports should be structured so as to give coverage to that area; if that were done, they would be much more useful. The REGIONAL DIRECTOR said the submission of brief country reports had long been the tradition in the regions. However, now that all Member States were submitting monitoring and evaluation reports every two or three years, they were no longer so useful. He himself and the Director-General were agreed that, for the future, it would be preferable for the progress reports to be integrated into the evaluation reports. He suggested that a formal decision on the matter should be taken when the Committee came to discuss item 12 (Review of regional evaluation reports). It was so decided. 8. REPORT OF THE REGIONAL DIRECTOR; (Document WPR/RC36/2) Item 8 of the Agenda
The REGIONAL DIRECTOR, introducing the report on the work of WHO in the Western Pacific Region for the period 1 July 1983 - 30 June 1985, said that it was gratifying to report that countries had made commendable efforts during the biennium to develop their health systems in the context of primary health care. The evaluation reports on the implementation of their health-for-all strategies, received from countries earlier in 1985,
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REGIONAL COMMITTEE:
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which formed the subject of the regional evaluation report under item 12 of the agenda, testified to the success of those efforts, particularly in such areas as community development, intersec toral coordination and development of the managerial process. Many countries were already reporting satisfactory coverage with the essential components of primary health care, such as immunization, safe water supply and provision of basic medical care. Nonetheless, with century, it was not relaxing of efforts. efforts were needed to of health delivery. only fifteen years to go before the turn of the the time for self-congratulation, complacency or Too much still remained to be done and sustained preserve the hard-won gains and improve the quality
A number of constraints demanded urgent attention. Lack of rna intenance was often a major problem. Capability in the maintenance of health facilities and electromechanical equipment needed to be strengthened. Appropriate training programmes needed to be developed and implemented wherever necessary. In certain areas such as rural water supply, the community could be more fully and actively involved in the implementation of projects, particularly in the operation and maintenance of facilities. Some of the current difficulties could be alleviated by the greater use of technology that was more relevant to social and cui tura 1 traditions or more appropriate to local conditions, whether in the form of traditional medicine such as medicinal plants or village-based handpumps. Communities for their part should be encouraged to participate more actively in the selection of such technologies and in their subsequent maintenance. Much remained to be done in the area of urban primary health care. Increasingly heavy demands were being placed on the public health and sanitation services of the large cities as a result of the constant influx of unemployed persons from rural areas. The spread of pollution, the increasing incidence of cr1me and ot~er grim reminders of social disorder were all manifestations of the deteriorating situation in many countries, which called for research and development activities and other more practical and immediate interventions. One of the essential components of primary health care was the availability of safe and effective drugs at a reasonable price. Most countries in the Region were experiencing difficulties in ensuring a continuous supply of adequate quantities of the most essential drugs to the periphery where they were needed for primary health care. To stimulate further action in that area, and in pursuance of the resolution adopted by the Committee in Fiji, an ad hoc Sub-Committee of the Regional Committee had been convened in June 1985 to review the situation and to make recommendations to the Committee. The Regional Director recalled that, elsewhere in the report, in the context of primary health care, he had referred to the sustained effort that was needed to change the traditional health services concept of a provider-recipient relationship, with all that it implied - dependence on highly skilled professional health workers and emphasis on hospital-oriented curative activities to the detriment of promotive and preventive activities. That concept still persisted 1n a number of countries and a reorientation was needed.
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Another equally important and fundamental reorientation was called for in the preparation of health manpower in the context of primary health care. Future health personnel must become more responsive to the needs of countries and the requirements of the new health system reoriented to primary health care. This in turn implied fundamental changes in the training institutions themselves. A further significant step in that direction had been taken with the convening in April of the so-called Tokyo Conference. Increasing importance was being attached in the context of primary health care to the utilization of traditional medicine such as herbal medicine and acupuncture as a system of medical care in its own right. Traditional medicine had formed the subject of a study by the Sub-Committee on Technical Cooperation among Developing Countries at its meeting in July and would also be the topic of the Technical Discussions. The Regional Director 88 id that, in the context of communicable and noncommunicable diseases, evaluation summaries had been prepared of two programmes, the immunization programme and the diarrhoeal diseases programme, to which high priority was being given. Positive results were already discernible in the immunization programme in many developing countries with regard to diphtheria, poliomyelitis and tetanus. However, if a further reduction in morbidity and mortality was to be achieved, greater efforts would need to be applied to alleviating or solving some of the maJor problems that persisted in such areas as production of good quality vaccines, development of an effective cold-chain system and availability of transport facilities and minimum required supplies. Progress had also been made in the diarrhoeal disease control programme, particularly with regard to the promotion of oral rehydration therapy as a simple and efficient means of preventing mortality and controlling disease. However, training and promotional activities needed to be strengthened to overcome some of the operational constraints encountered. such 8S the still limited acceptance of the efficacy and safety of the therapy by physicians and health workers and the lack of oral rehydration salts in some areas. In particular. the implementation of primary prevention measures such as health education in good maternal and child health practices and personal hygiene, provision of proper sanitary facilities and of safe drinking water were essential if meaningful progress was to be achieved in the reduction of morbidity due to those diseases. Introduction (pages ix-xv) Dr SUNG WOO LEE (Republic of Korea) said he wished to extend a warm welcome to the representative of Brunei Darussalam. He congratulated the Regional Director and his staff on preparing such a clear and comprehensive · report, and noted with satisfaction the steady progress made in the development of programmes. He greatly appreciated the support and cooper at ion given by the Secretariat to his country's health programme over the past year.
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REGIONAL COMMITTEE;
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DR K~INUMA (Japan) was also pleased to note from the report the steady progress 1n t~e development of programmes, both at regional and country ~evel. He ~lshed to highlight certain aspects that were of special 1nterest to h1s delegation. On the subject of health system development, the Japanese Government was endeavouring to perfect a comprehensive health promotion system to meet the ~eeds of all stages of the human 1 i fe-cyc le. The system would focus part1cularly on the problems of the rapid aging of the population and of changes in disease. patterns. With the aim of eliminating hepatitis B, measures had been lntroduced to prevent vert ica 1 transmission from mother to child. A committee on the family physician had been established under the Ministry of Health and Welfare with the object of improving the primary health care system. The conference entitled 11 Towards future health and medical manpower~ New strategies in education for the }0Clst century 11 , which had been held in Tokyo in April 1985, represented an important first step towards tackling the vital issue of health manpower, which was a key element in the implementation of the health-for-all strategy. He wished to express his appreciation to the Regional Director for having initiated that endeavor. Despite the efforts of WHO and its Member States, the world health situation was still far from satisfactory. The greatest threat to health in many countries was still that of communicable diseases. Japan had succeeded in substantially reducing both morbidity and mortality from those diseases through its various health care programmes, and was eager to share the knowledge and experience it had gained with other countries of the Region. Dr LIU XIRONG (China) congratulated the Regional Director and his staff on a comprehensive report and on the progress achieved in all the main programmes. He was pleased to note the active support given to Member States in the area of in format ion resources management, which had greatly assisted in the completion of the first evaluation of national health-for-all strategies. He was also glad to see that priority had been given to the immunization programme and to the diarrhoeal disease programme. The reinforcement of the health manpower training programme had also helped to promote the primary health care work being carried out by Member States. The activities of the regional hepatitis programme had also been most valuable in supporting Member States, notably through the research being carried out on the production of an improved hepatitis B vacc1ne. In applied subject session, many countries of the Region, traditional medicine was widely as part of primary health care. He was pleased to see that the was to be included in the Technical Discussions at the current and hoped those discussions would facilitate an exchange of ideas.
He expressed his appreciation of the continued work being carried out on the preparation of a standard terminology for acupuncture. A number of Member States had submitted evaluation reports on the health-for-all strategies, on the basis of which a regional report had been drafted. He hoped that there would be a full discussion of that regional
SUMMARY RECORD OF THE FIRST MEETING
79
.on, so that the Committee could determine what report at t h e current Sessl was the best action to be taken to implement the strategies. Although great successes had been achieved, much still remained to be done, and competent staff would be needed. The report showed that ~here were still sixty vacant posts in the Region, and he hoped that the Reg1onal Director would take positive steps to fill those vacancies in order to improve the programmes in the future. Dr KHOO (United Kingdom of Great Britain and Northern Ireland) commended the Regional Director and his staff on the clear and comprehensive presentation of the report, which described the progress made towards health for all during the biennium 1983-1985. Noting the steady development of health programmes at the regional and country levels, he commended the work undertaken in the promotion of technical cooperation among Member States of the Region and the efforts made to improve people's health. He wished to record appreciation of the support given to his country by the Regional Office with respect to (l) medical library facilities; (3) training courses in laboratory (2) epidemiological investigations; techniques; and (4) remedial measures in malaria control. Dr TAPA (Tonga) welcomed the delegation of Brunei Darussalam, which was attending the Regional Committee for the first time. He congratulated the Regional Director on his excellent and comprehensive report. The increase in its size compared with the previous report reflected the increased achievement in the Region under the sound leadership of the Regional Director. He commended the Regional Director and all his staff, including those in the office of the WHO Programme Coordinator for the South Pacific in Suva, Fiji, for their dedicated hard work both within the Organization and in supporting Member States. While the report highlighted the achievements, it also pointed out the lack of achievement in some areas, which it was important to bear in mind for the future. With reference to the Introduction, he was pleased to note that the first evaluation of national and regional health-for-all strategies had revealed a marked improvement in evaluation data and materials compared with the situation in the previous year, when the first monitoring activity had been undertaken. He welcomed the Declaration of Tokyo issued by the historic conference held in Tokyo in April 1985 on the theme "Towards future health and medical manpower: New strategies in education for the XXIst century". Only fifteen years remained before the year 2000, so that such a forward-looking declaration was most welcome. He commended the Regional Director and his staff on the active work undertaken in the hepatitis B programme since the adoption of resolution WPR/RC3S.Rl4 at the thirty-fifth session of the Regional Committee.
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REGIONAL COMMITTEE:
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to g1ve dynam~c and 1nsp~r1ng leadership health for all by the year 2000.
D~re~tor-General, Dr Halfdan Mahler, was present and addressed the meet1~g. WHO ~as fort~nat~ .to have such a Director-General, who continued to global health work towards
.
It was a particular pleasure to attend the Regional Committee when the
Dr PHAM SONG (Viet Nam) congratulated the Regional Director on an excellent report that was full of information. He expressed his Government's grati~ude to the international and national organizations, specialized agenc1es and Member States of the Region for their cooperation. Particular thanks were due to WHO, the Director-General and the Regional Director for their support over the past year. Viet Nam had submitted a report on the activities undertaken in the country. He expressed his country's willingness to cooperate in working towards the common goal. Dr CHRISTMAS (New Zealand) congratulated the Regional Director and his staff on the presentation of the report. It was a pleas ant change to receive such an eminently readable report free of jargon that was not always understood by readers. He commended the series of important points made by the Regiona 1 Director, in particular that concerning the primary health care approach in relation to present health systems. Member States such as his own with complex and costly health systems were conscious of the need to review those systems. The health system in New Zealand had been reviewed and reoriented in an attempt to decentralize services, with one and, possibly in the near future three, area health boards. Over the next twenty years, many Member States would need to review and reorient their health systems, a matter that would be discussed later in the meeting. He agreed with the Regional Director on the need for training of manpower for the implementation of primary health care, which had been discussed at the recent conference in Japan. It was an issue to which Member States with established health systems would have to pay particular attention. He was pleased to report that New Zealand had introduced the iuununization of neonates with hepatitis B vaccine. In the International Youth Year, health services were focusing on adolescent health. The prevention of cardiovascular diseases had been adopted as a public health priority for the coming year.
Dr KHALID (Malaysia) welcomed the delegation of Brunei Darussalam, which was attending the Regional Committee as a full member for the first time. He congratulated the Regional Director and his staff on another year of achievement in the implementation of programmes, which had been clearly documented in the Regional Director's report. He was pleased to note the progress made, and welcomed the continued support of WHO, particularly to his own country. Dr DEL ROSARIO (United States of America) expressed his belief that attending the Regional Committee could provide the leadership
those
SUMMARY RECORD OF THE FIRST MEETING
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necessary to achieve primary health care for all by the year 2000 in the Western Pacific Region. The United States of America fully supported the goal established at Alma-Ata. He was particularly impressed by the way in which WHO, especially in the Western Pacific Region, gave equal attention to both small and large countries. The health of the people was of importance, whether a small island population or a country with a population of millions was concerned. He hoped that that attitude would continue in the future. Mr LECLERC (France) said that his delegation had been most interested to read the Regional Director's report, which contained a realistic analysis both of the progress made and of what still remained to be done. France was prepared to contribute to any regional cooperation in the health field. Chapter 1: General programme development (pages 1-5)
Dr DURAYAPPAH (Brunei Darussalam) expressed her delegat1on's appreciation of the warm words of welcome extended by other representatives. As this was the first time Brunei Darussalam had attended the Regional Committee, it was a special occasion for the delegation. She commended the Regional Director for his excellent and comprehensive report. Chapter 2: External coordination for health and social development (pages 7-13)
There were no comments. Chapter 3: Health system development (pages 15-23)
Dr CHRISTMAS (New Zealand) said that the chapter, one of the most important in the report, dealt with a subject of considerable concern to most Member States of the Region. It made the relevant point that the programme for achieving the objective of health for all by the year 2000 entailed a shift away from a problem-oriented approach and towards the development of effective and comprehensive health systems. Many Member States were facing considerable changes in preparing for that shift. The Director-General had highlighted the importance of the managerial process and of setting targets. He himself hoped that the Regional Committee and the Sub-Committee on the General Programme of Work would look closely at the changes taking place in different countries so that those faced with changes could learn from one another. The issue provided an admirable opportunity for technical cooperation between developing and developed countries. Dr DE SOUZA (Australia) agreed with the points made by the previous speaker. The chapter stressed the need for a change in curriculum philosophy, with a more comprehensive approach to health manpower development. In past years, his delegation had drawn attention to the need to make better use of the fellowship programme. Close attention should be paid to the selection of applicants for the fellowship programme in order to improve the programme, particularly in the area of health manpower development.
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. Dr CATI (Kiribati) . expressed his country's appreciation of the gu1dance and support p~ov1ded ~y WHO during the undertaking of changes in ~tructure an? systemat1c plann1ng and management in Kiribati. Without WHO 1~vo~vement ~n s~ch are~s, Kiribati would not have achieved the progress it d1d 1n plann1ng 1ts nat1onal health and family planning programme. He was also grateful for WHO's support in indicating the appropriate action needed for effective implementation of health-for~all tasks. Dr TAPA (Tonga) welcomed the emphasis given to section 3.1 (Health situation and trend assessment). The present era was one of rapid change. In order to direct that change so that it was beneficial, a thorough assessment of the present and 1 ike ly future situation was necessary. As pages 15-17 of the report showed, many training courses had been arranged in Tonga and other parts of the South Pacific on the use of the epidemiological approach in the assessment of available data. Dr KHALID (Malaysia) said that the chapter was important, as health system development formed the basis of the health-for-all strategy. Such issues as the utilization and equitable distribution of resources in order to improve effectiveness were relevant to all countries. The national study on financing of health care in Malaysia, referred to on page 20 of the Regional Director's report, had covered both public and private sectors and all agencies with activities relating to health. The report on the study, which would be submitted to the Government shortly, showed how much was being spent on health in each sector and by each agency. In his view, greater emphasis should be placed on health system development, with a corresponding increase in activities in the Region. Chapter 4: Organization of health systems based on primary health care (pages 25-31)
Dr SUNG WOO LEE (Republic of Korea) agreed with the report that existing health care delivery systems, if they were to effectively lead in the introduction of change, must themselves undergo a process of reorientation. However, as the second paragraph on page 30 showed, shortcomings in the delivery of programmes to the whole population and traditional concepts of health services persisted in a number of countries, his own included. He favoured greater emphasis on the exchange of information and staff so that countries could see what others were doing to achieve health for all. Dr CHRISTMAS (New Zealand) was glad to see the reference on page 28 to studies being undertaken in the Philippines and the Republic of Korea on the input of nursing in primary health care. New Zealand had long recognized the important role of nurses in that field, and he looked forward to seeing the results of the studies when they were ready. Dr SUNG WOO LEE (Republic of Korea), responding to the New Zealand representatives's comments, said that his country was reorienting the role of nurses as part of the development of primary health care at the grassroots level. Under the 1980 act on health care in rural areas, some 1300 community health posts had been established by 1984; that total would
SUMMARY RECORD OF THE FIRST MEETING
83/84
reach 2000 by 1988. The use of coununity health practice nurses would be extended to urban areas in order to cover the whole country well before the year 2000. Dr CATI (Kiribati) said that his country had found the organization of the actual health system particularly difficult, as all staff had to be reoriented to follow the new approach highlighted in the Regional Director's report. WHO technical staff had given essential help in showing how to tackle the problem, through such means as basic and post-basic training in primary health care. Chapter 5: Health manpower (pages 33-59)
Ms TORRES (Philippines) stressed the importance of Chapter 5, since health manpower development was critical to the success of primary health care. She was heartened to see that attention had been given to monitoring, coordination and research, and suggested that those activities should be further strengthened. She took the opportunity to wish all participants a warm welcome to her country.
The meeting rose at 11.45 a.m.
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ANNEX 1
ADDRESS BY THE RETIRING CHAIRMAN
Distinguished Representatives to the Regional Committee, the Director-General of the World Health Organization, the Regional Director of the Regional Office for the Western Pacific, Representatives of Nongovernmental Organizations and Specialized Agencies of the United Nations, the World Health Organization Secretariat, Ladies and Gentlemen, It hardly seems that an entire year has passed, but it is now time for me to retire as Chairman of this distinguished Committee. I was honoured first by being elected Chairman of the thirty-fifth session, and I am honoured again by this chance to address you now. I would like to thank each of you for your participation and cooperation in making this year a time of learning and understanding for me and, I hope, for the Committee as a whole. Once again, we have assembled to deliberate on the health problems of our Region and, t01e hope, to share experiences and knowledge in order to erase these problems. It is this Committee's tradition to have among its members some of the most respected and cooperative representatives of each Member State. I am certain that the representatives here today continue this tradition and will create the atmosphere of comradery that we need to make this Committee effective. At the last meeting of the Western Pacific Region in Fiji, we had the pleasure of having the representatives of Brunei Darussalam as observers. It is with great pleasure that I welcome the honourable representatives of that Member State in joining our Organization. On behalf of this Committee, I would like to offer our appreciation and greetings to the Government and people of the Philippines, who once again accept us into their country. I am sure that we have all experienced already the warm and friendly nature of our Filipino hosts and know we can look forward to an enjoyable and comfortable stay here. And for that we are very thankful. I would li~e to take a moment now to thank a group that continues to make these sessions run smoothly and effectively our Secretariat. We will discuss some time later the report of the Regional Director, Dr Hiroshi Nakajima, but I want to take this time to of fer our thanks for his past hard work and leadership. Now, if I may, I will briefly point out some of the important topics and activities of this past year, which, I hope, will prove interesting to the distinguished meabers of this Co111111ittee.
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Annex 1
During the last session of this Committee, we were honoured by the presence of the Director-General of the World Health Organization, Dr Halfdan Mahler. In his address, Dr Mahler raised hard questions to us about our progress in achieving the goals of health for all by the year 2000. He also encouraged us to better utilize the resources of the World Health Organization, both its manpower and its funds. In short, Dr Mahler sparked us to remember the goals, not only of this session, but of the World Health Organization itself. On your behalf; I would like to thank the Honourable Dr Mahler for the encouragement and the admonishments of his address. Also during the last session, seventeen resolutions were adopted. They ranged in topic from World Health Organization guidelines for drinking water quality to the subject of women, health and development. These resolutions offered a working programme for the further discussion and implementation of issues important to our Region. During this past year as Chairman of this Committee, I was invited to a number of forums organized by the World Health Organization. Several of these forums addressed topics which the members of this Committee have adopted as resolutions. These forums are extremely useful for bringing specific information and areas needing examination to light. They are also yet another arena for developing good relationships among our nations. att~nd
In April of this year, I attended one such forum in Tokyo, which dealt with health manpower development. The approach of the meeting was to examine ways of implementing changes in health personnel education to solve a common problem among the Member States in our Region the need for improvement of the local educational institutions in regard to health training. In a report by Dr Fulop, the Director of Health Manpower Development from the World Health Organization, Geneva, he stated that "the key to further progress in the health manpower development field is the promotion of national political will to seek out and apply the right solutions to well-diagnosed priority problems. The k e y word in the future is relevance". The training a nation develops must be relevant to its needs and its means. The primary health care approach was seen as the key to providing the health-for-all goal we strive for. It was noted that a primary health care-oriented system needs an educational network which wi 11 provide it with manpower in appropriate quantities and with appropriate skills. It is this manpower which will continue our push for primary health care for all. Another forum I attended was the tenth session of the Western Pacific Advisory Committee on Medical Research. During this forum, the Member States of our Region were commended for the progress they have made in several areas:
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Annex 1
(1)
development of a national system for the management and coordination of health research and strengthening of national research capability; strengthening of the institutional capabilities of the Institute for Medical Research in Malaysia; and the Special Programme for Research and Training in Tropical Diseases and the Special Programme of Research, Development and Research Training in Human Reproduction. the the this some Advisory means of research specific
(2) (3)
In addition, fourteen recommendations were made by Committee on a variety of concerns of our Region regarding research, the sharing of this research and the direction should take. The Ca.mittee's recommendations identified areas for research. Some of the recommendations were: (1)
to expand the use of health system research; to make oral rehydration therapy a main thrust; to encourage certain countries to examine the impact of primary preventive measures on diarrhoeal diseases; to concentrate research efforts on health manpower development; and to initiate studies on the high incidence of hepatitis B virus infection.
(2) ( 3) (4) (5)
This last recommendation on hepatitis B was also the subject of discussion at the last meeting of this Committee. We recognized hepatitis B as being a serious public health problem, and it continues to be so. It was noted that, of an estimated 215 million chronic carriers of this disease throughout the world, approximately 168 million resided 1n the Western Pacific Region and other countries in Asia. We endorsed a year ago the efforts being made by the World Health Organization to prevent and control hepatitia B and adopted a resolution on this topic to reflect the various preoccupations of Member States. In that resolution, the Regional Committee urged Member States: {1)
to formulate programmes for the prevention and control of viral hepatitis 8 and to initiate these programmes in a phased manner; and capability to ensure that to strengthen laboratory aero-epidemiological surveys of the popul~tion are effectively carried out.
(2)
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Annex 1
It is rewarding to me to see the progress already being made on this resolution such as the work of the Task Force on Hepatitis B and the research on new vaccines being conducted by several of our Member States. It is through cooperation and problem-solving of this kind that we may soon be able to drastically reduce the high incidence of this disease in our Region. For the current session of this Committee, I offer my sincere hope that these meetings will continue to provide this kind of shared knowledge and spirit of unity that will yield the results we desire. It is only through the work and understanding of you, the esteemed members of this Committee, that this is possible. But I am secure in the knowledge that we shall all rise to the task at hand and progress towards our common goal, that of health for all by the year 2000. In conclusion, let me thank you again for this rewarding experience as Chairman of this distinguished CoDDDittee, and allow me to wish you all great success in the deliberations of this session.
SUMMARY RECORD
OF THE FIRST MEETING
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ANNEX 2
ADDRESS BY DR H. MAHLER DIRECTOR-GENERAL OF THE WORLD HEALTH ORGANIZATION to the
THIRTY-SIXTH SESSION OF THE REGIONAL COMMITTEE FOR THE WESTERN PACIFIC Manila, 16-20 September 1985
TARGETING ON HEALTH FOR ALL
Mr Chairman, Excellencies, Honourable Representatives, Friends, may I be permitted to ask you to listen to me for a few moments as to how 1 see some of the priorities for your organization. Targeting for health 1. A senior health executive in a North-European country stated recently that the most novel and exciting idea that health for all by the year 2000 has inspired in him is that you can target for health. Perhaps we who have been so deeply involved in the health-for-all movement have taken the very concept of targeting more or less for granted. It surely was at the very basis of our new health policy; but have we not lost sight of that in practice?
2. I shall be more explicit. To be sure, we have defined the very broad target of health for all. We have also identified indicators to help us realize if we are getting there. We have also defined a couple of specific targets - safe drinking water for all and immunization of all the world's children against the most common infectious diseases of childhood by 1990. We realized full well that such targets are only meaningful if each and every Member State adopts them as its own. But have national targets been defined for the very vehicle that will make or break the realization of all other targets, and by that I mean primary health care rightfully placed in the health system? I think not. I realize that there may have been very good reasons for not doing so in the past, but I certainly believe that there are equally good reasons for starting to do so now. Your evaluation of your health strategies leads me to that conclusion, and so does the progress achieved in defining appropriate technology 1n a number of specific programme areas. 3. What aspects of your strategies am I referring to? First of all, I am very impressed by the statement that national socioeconomic strategies have been worked out by consensus rather than confrontation, and that this has helped to ensure economic progress without accompanying negative social repercussions. That, I think, is very encouraging. Some of your health indicators too are very encouraging. I refer in particular to the satisfactory food supply for most of your countries, at least in terms of calories, infant mortality rates of less than 50 per thousand live births,
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life expectancy of more than 60 years and an adult literacy rate of more than 70 percent. If that is the case, you would seem to have the critical energy required to leap forward towards the health-for-all goal. 4. What obstacles are you facing? You have spelt out some of them. You appear to be experiencing considerable difficulty in combining your efforts with those of other sectors in favour of people's health and socioeconomic wellbeing - much more difficult than in extending the coverage of health services. You are also trying to decentralize the implementation of your strategies with varying degrees of success because of inadequate national policy and not enough people with the required managerial skills. And you are facing the inevitable reality that health resources and economic resources are closely interlinked. National action programmes for primary health care
5. Why then am I encouraged that you are in a position to do better? First of all, because the very fact that you have identified the problems is an important first step in resolving them. Intersectoral action , decentralization to ensure that people become deeply involved, making the most of limited resources - these are the very stuff of strategies for health for all based on primary health care. So there would seem to be nothing more logical than intensifying your primary health care efforts and widening access to it until all people are covered. At Alma-Ata everyone agreed that primary health care is the key to attaining health for all but that message seems to be getting lost by the wayside. I think the time has come to shout once more the clarion call for national action programmes for primary health care and not only national talk programmes for primary health care. You can target for that; and you can redouble your efforts to attain your targets. 6. I think we can look back with some satisfaction on the way we have been reshaping health pol icy at central government level. Now we must concentrate on implementing that policy where it matters most - close to people, in communities and in geographical districts. In most countries these districts are usually small enough to be managed without becoming submerged in excessive government bureaucracy, and yet large enough to permit the country to be subdivided into limited numbers and therefore avoid overdispersal of skills. 7. What can we do about the limited resources for health? I am afraid a hard look at the money side of health for all is essential if we are to avoid unrealized dreams and discredited promises. First of all, it is necessary to identify clearly what is being spent on health and where it is being spent - information that is sorely lacking in most countries, not only in this Region but throughout the world. Then it is necessary to focus resources more sharply; picking up the slack and putting it to good use could make a tremendous difference in most countries. Health for all is not necessarily only a matter of spending more. Much more could be achieved by making sure that existing resources are squeezed to the maximum and used for tomorrow's defined targets, not yesterday's undefined services.
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8. I realize the difficulty of reducing ongoing activities in order to release resources for new ones when additional funds are not forthcoming. But it is not impossible. WHO has done just that. If 70 percent of the regular programme budget is now devoted to direct support to its Member States as compared with 50 percent ten years ago, if in 1986 and in 1987 activities in your countries will benefit from a real increase of some 4 percent in spite of a standstill global budget, if that can be done internationally, then I am convinced that it can be done nationally. Yes, but only if you are determined that it shall be done - you, the health leaders of your countries. 9. Your determination could lead your governments to target for primary health care. Each one of you could do that by incorporat i ng in your action programme for primary health care those elements that are of high priority to you. You could start with a few and set realistic targets, adding elements progressively until all are covered. Strengthening your infrastructure will enable it to deliver more programmes, and sustained delivery of more and more programmes will in turn strengthen your infrastructure. We are gaining experience slowly but surely with the kind of research and development required to build up health systems in just that way. You can use that experience in your countries and thereby add to the general pool of knowledge in the process. We understand sufficiently the social fabric of primary health care, and we have adequate experience of the managerial process required to set it up and manage it. Add to that the fact that we either have sufficient appropriate technology at our disposal, or could get it quickly by investing energies in intensive research and development, so there is no reason why each and every country should not embark on a primary health care action programme with well-defined targets for its infrastructure and for its content. 10. For what programmes could you define targets within primary hea l th care? I have already mentioned community water supply, with its related sanitation, and I have mentioned immuni~ation. Does appropriate technology exist for these? At the risk of repetition I would remind you that to be appropriate technology has to be not only scientifically sound, but also socially sound - that is sound to those on whom it is used and to those who use it. And it has to be economically sound that is it has to be affordable for the communities and the countries concerned. Wherever water exists, it can be exploited for human use in that kind of appropriate way. Experience has shown that even rural water supply can be made eminently "bankable" - by that I mean that the conununity itself can repay loans over a reasonable period, in part thanks to the economic gains of having water available. In my humble opinion, by far the best way to motivate people to share the costs of health development is to get them invo l ved in attaining tangible targets that relate directly to their own social preference val ues and to make them so enthusiastic about their health and t he health of their children that they will willingly agree even to help solve the financial problems involved. And as a digression let me add once more that people's social preference values do not necessarily correspond to technocrats either in national government or in international organizations.
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11. The technology and related managerial know-how are certainly available for immunization. This applies equally well to diarrhoeal disease control, So both these can be targeted for too. The problem of improved maternal and child health is not lack of knowledge, but lack of application. Proper application can be targeted for. There are no real mysteries about nutrition, so it too can be targeted for. At the same time, a great deal of social, economi.c and cultural research and development remains to be done to ensure that people have access to the right kind of food and that they actually consume it. We have also demystified the whole issue of drugs and know enough about how to set up and manage essential drugs progrananes to make it possible to provide care in the community for all common diseases. So medical care and related drug use can also be targeted for. 12. For the more developed countries in the Region, and also towns in some less developed countries, we know how to prevent and control cardiovascular disease at a fraction of the existing costs of waiting for disease to strike before taking action. That implies modifying lifestyles, and I admit we know less about that than we should - so here is another area for intensive research and development. But you could nevertheless target for reducing cardiovascular disease with existing knowledge, by setting targets, for example, for increase in popular sports and exercise, and reduction in the consumption of salt, eggs, food containing animal and dairy fat and, of course, tobacco. You could certainly target for reducing lung cancer by the appropriate technology of eliminating smoking, or at the very least drastically reducing its prevalence. 13. You could target for decentralization too. Each of your governments could make sure that every district reviews what is happening to the national health strategy in its communities; that it identifies priorities for implementation in every district through primary health care; that it targets for them one by one until all are progressively covered; that it builds up its health manpower to carry out first and foremost those priority activities; and that it ensures that its health facilities are geared to the same priorities. 14. Each of your governments could also make sure that every district does its best to take up the great slack in the existing health system and to focus all resources on targeted priorities. As part of that, the very least you could do, but certainly not the least important in many countries, is to rehabilitate your health institutions. I am referring in particular to the rehabilitation of your health centres and district hospitals so that they become capnble functionally and physically of supporting primary health care. To be capable of doing that, they must at least inspire confidence as focal points for health by their appearance and by the way they deal with people; and they should certainly not give the impression from their dilapidated state and inefficient management of being focal points for disease. That kind of institutional rehabilitation is certainly eminently suitable for targeted implementation.
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15. It goes without saying that manpower rehabilitation is at the very core of institutional rehabilitation. Health personnel can breathe life into bricks and mortar and can convert them into useful health institutions; bricks and mortar alone cannot breathe life into health personnel. They have to be motivated socially so that they want to care for people; and they have to be provided with the right kind of incentives to work in health centres and district hospitals that are often far away from their homes, such as bestowing honour and careers on them, providing financial attractions or ensuring adequate educational facilities for their children. All that costs money. So financial rehabilitation of health centres and district hospitals is no less important than physical, managerial and human rehabilitation. In this context I should like to remind you once more of the many untapped resources that could be generated by involving people much more deeply in their own health development. Decisions by governments and people 16. Please note that, when 1 talk of taking decisions, 1 am referring to decisions by governments, by district authorities, and by people in their communities, not by WHO. It is not for WHO, nor for any external agent for that matter, to decide on behalf of people or governments. It is for them to decide. WHO can help by providing them with information and generating the skills required to make reasoned decisions, and I think your Organization is now in a very sound position to do that. WHO can cooperate with you in applying that information and using those ski·lls. But it cannot decide for you what your priorities will be. To do that would be frank United Nations colonialism. Nevertheless, when WHO's Member States have taken collective decisions, a~ you did with respect to the target of health for all by the year 2000 and ways of attaining it - when that has happened you have moral obligations individually and collectively to invest your resources first and foremost in realizing that target. The least you can expect of your Organization is that it should invest its resources in supporting you to do so. Regional programme budget policy 17. That is precisely what the new regional programme budget policy is all about - a policy of targeting resources on health for all. I hope I have been able to get that message across in the guidelines I sent you through your Regional Director. They emphasize investing the Organization's collective resources to trigger off your own resources as well as those of nongovernmental organizations and all external partners in support of your strategies for health for all. If the collective strategy has given rise to national strategies. then surely resources available to the collective strategy should give rise to resources for national strategies. If collective programmes aim at strengthening national ones, then surely the resources of collective programmes should reinforce national programme resources. And if there are collectively agreed principles for ensuring primary health care that deliver programmes whose technology is appropriate, surely the collective resources for infrastructure development
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should strengthen nat iona 1 infrastructures based on pr lmary health care. Targeted action programmes for primary health care can concentrate all these resources where they are most needed. 18. I have heard criticism - sometimes noisy, sometimes subdued - that the new programine budget policy is a return to centralization. Well, if the critics mean centralization in WHO headquarters, they are totally wrong. But if centralization means concentrating resources to focus on people everywhere - so that they can benefit from concerted worldwide efforts to attain defined national targets that reflect the worldwide target of health for all, if that is what it means, then let it be called centralization. Leadership for health for all 19. Honourable Representatives, to set up the kind of primary health care action programmes 1 have outlined requires leadership and determination. I Leadership can give rise to widespread am not sure which to put first. determination, but widespread determination can also generate leadership. Of one thing I am sure. Leadership is sorely lacking everywhere, not the least in the field of health. I include in leadership the ability to judge wisely, decide firmly and implement vigorously. I started by the need to judge wisely. Otherwise leadership can be very dangerous; it can lead in wrong or devious directions. I am convinced that we have provided the world with all the ingredients required to make decisions about sound health development. We are a unique international organization in that respect. These facts alone should excite us to firm decisions and equally firm resolve to carry them out vigorously despite all the obstacles. 20. What are the ingredients I have just mentioned? One is the ethical challenge and philosophy of health for all based on social justice and social equity. Another is the policy and strategy for getting there. Then there is the social contract for health between governments, people and WHO. There is the clear direction of building up infrastructures based on primary health care to deliver programmes that use appropriate technology. And there is the managerial process with its inherent financial planning to create the framework for moulding these ingredients into a variety of coherent national wholes. 21. All that makes WHO the leader in world health. By the same token, by applying all that, each and every one of you in your own country, you will become undisputed health leaders there and you will be able to inspire others to follow in your footsteps. I hope you will pressure your WHO to help you to develop your leadership qualities for the attainment of health for all. I hope you will clamour for part of WHO's resources in your country to be devoted to that. I hope that you as a Regional Committee will encourage countries in the Region to devote part of their resources to health-for-a 11 leadership development and that you wi 11 make sure that regional resources too are invested in the effort. I shall certainly invest global resources in this initiative.
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22. Mr Chairaaan, Honourable Representatives, lead your countries towards better health. You can do that very largely by targeting on health for all by the year 2000. And in all of this, let us never forget that all great things in human history have been carried out by women and men who refused to accept how badly they were doing. If you can live with the moral implications of that contradiction, I still think health for all is worth wl1ile fighting for. Thank you very much.