(WPR/RC37/SR/2)
SUMMARY RECORD OF THE SECOND MEETING WHO Conference Hall, Manila Monday, 15 September 1986 at 2.30 p.m. CHAIRMAN: Dr B.W. Christmas (New Zealand)
CONTENTS
1. 2.
Report of the Regional Director (continued) Regional programme budget policy: of the Sub-Committee, Part I I
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1.
REPORT OF THE REGIONAL DIRECTOR: Item 7 of the Agenda (Documents WPR/RC37/2 and WPR/RC37/INF.DOC./l) (continued first meeting, section 7)
from
the
Dr REILLY (Papua New Guinea) felt that the strong bonds of friendship that had been forged over the years between the representatives attending the Regional Committee and the elimination of all stiff formality from the Committee's deliberations would provide a solid basis for the teamwork and partnership of which the Director-General had spoken that morning. His Government shared the concern expressed by the representative of Tonga in regard to the large number of unfilled vacancies at various levels in the Organization and he hoped that the situation would be improved before long. Papua New Guinea had greatly appreciated WHO's cooperation in the development of its national information service. A health plan for the period 1986-1990 had been drawn up with the main emphasis on primary health care and it was hoped to receive support in achieving its goals of improving the health services through increased community participation and the delegation of greater responsibility to the districts. WHO fellowships had been successfully used to improve provincial hea.lth management. WHO might usefully play a stronger role in coordinating health manpower development in the South Pacific is lands and helping them formulate an overall manpower development plan. His country was proposing to introduce acupuncture and hypnotherapy into the health workers' curricula and was most grateful to China and WHO for their cooperation in that respect. WHO was also cooperating in the reorientation of malaria control programmes and the introduction of short-term chemotherapy regimens for controlling tuberculosis and leprosy. He agreed with the representative of Malaysia that malaria was one of the most serious problems in the Region and hoped that their spirit of partnership would enable them to bring it under control. Mr TOEOLESULUSULU (Samoa) considered that the Director-General's address would give much food for thought to those responsible for health in their various countries. Evaluation was indeed a springboard for action. In his country it was providing guidance on what had been achieved and what remained to be done. Immunization coverage of infants had risen to 86% and it was hoped to extend measles vaccine coverage to 95% of the ta r get population with a view to possibly eliminating the disease in their area. WHO and the Government of Japan had cooperated in making a vaccine against hepatitis B available for administration to infants in Samoa. Over the previous fourteen months, 98% of leprosy patients had been continuously covered by a multidrug therapy programme carried out by members of the local communities chosen by the patients concerned and it was hoped that by 1987 the majority of those with the disease would have completed their prescribed regimen. In May 1986 10 000 temporary health aides had carried out mass filariasis treatment based on the annual administration of a single dose of an antifilariasis drug. The campaign had covered 92% of the Samoan population. No adverse reactions had been reported. It should be possible in the coming ye ars to elimi nate filariasis as a publ i c health problem in Samoa. The Government had ordered a review of all ex i sting health legislation with a view to bringing it into line with the principles enunciated in the Alma-Ata Declaration. It also had plans for streamlining the supply of essential drugs and ensuri ng by the i r prompt distribution tha t peripheral health units had adequate amounts of them available at all times. He wished to put on record also his Government's appreciation of the WHO/UNDP health management development network, aimed at strengthening
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middle-level management skills, thereby helping to alleviate manpower problems which continually beset countries like Samoa.
the
acute
Dr TAPA (Tonga) asked for information on the Hantaan and Hantaan-like viruses mentioned in connection with viral haemorrhagic fever with renal syndrome. . His country greatly appreciated WHO 1 s cooperation in regard to the intensified programme of action for the prevention of rheumatic fever and rheumatic heart disease and to the development of an integrated noncommunicable disease control programme. Dr DE SOUZA (Australia) said that, in addition to the nutritional deficiencies mentioned 1n the Regional Director's report, developing countries in the Region were increasingly exposed to nutrition-related disorders typical of the developed countries, such as adult-onset diabetes, hypertension and cardiovascular diseases, thus making it essential to strengthen nutritional guidelines and national nutrition policies. Mention should also be made of the considerable technical and consultative efforts made in the Region for the control of iodine-deficiency diseases. He strongly supported the stress put on prevention· in oral health programmes. In Australia a threefold decrease in the DMF index had been achieved in twelve years by means of preventive measures and a further decrease could be anticipated. Treatment could never have achieved such striking results. WHO should continue to give visible support to water fluoridation. Australia was establishing a National Institute of Occupational Health and Safety, which could provide valuable future support for WHO occupational health activities in the Region. He fully supported the Malaysian representative's remarks on the control of alcohol abuse. In regard to the figures given concerning the increases since 1981 in the number of people with access to safe water and proper sanitation, perhaps the Secretariat could also give the magnitude of population increases in the same period, so that percentage coverage could be better assessed. Measures were needed to train medical and allied personnel in the effective control of malaria and vector-borne arbovirus diseases endemic in the Region. The vector control course run in the State of Victoria had included two or three participants a year from the Pacific island countries and it was hoped to continue the activity. Continuing emphasis was needed on the training of health workers in diarrhoeal disease control. Access to oral rehydration salts and home solutions should be assured down to village level. Information on methods of preparing home solution was also essential. Australia hoped to be able to continue to provide assistance in regard to sexually transmitted diseases, including AIDS. The Regional Director was to be congratulated on the steps taken to exclude smoking in the Regional Office. Similar steps were being taken in his own office in Canberra. Dr VILLAROSA (Philippines) expressed her Government's appreciation of WHO's cooperative efforts towards health for all in the Philippines, particularly in the areas of primary ,health care, health manpower development, management information system, the disease control programmes and research and evaluation. Through WHO the Philippines had been instrumental in the development of in vitro diagnostic tests, and basic radiological service units had been establ1shed in the country. Another important development was in the managerial process at provincial and district levels, where the improvement of managerial capabilities was
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particularly relevant to increased efficiency in hospital and other care services. Those advances brought the Philippines closer to a realistic, attainable national health plan. Mr LAVIGNE (France) supported the remarks of the Director-General concerning the abandoning of paternalism in WHO and the need to limit spending of its resources to properly planned activities. Those remarks deserved to be reflected upon. He had also noted the remark on links between prolonged assistance and reduced responsibility in the Region. He connnended the report of the Regional Director, in which three points had seemed to predominate: first, the evaluation of the health situation in a global perspective using epidemiological and statistical methods was essential for the determination of priority goals; second, the managerial process for national health development seemed necessary to ensure effective action; and third, there was a need to insist on the preponderant role of WHO in health manpower tra1n1ng and its planning, oriented especially to public health activities. French Polynesia was very sensitive to the ·issues of concern in the Region, and the French Government would continue to support WHO's efforts. Dr KHALID (Malaysia) expressed gratitude for the holding of the malaria workshop in Kuala Lumpur in 1986. He hoped that the proposed change in status of the Interregional Malaria Training Programme for Asia to reflect the fact that it no longer served South-East Asia would not result in a downgrading of its activities, as the seriousness of the problem in the Western Pacific Region called on the contrary for increased concern. Dr MAOATE (Cook Islands) pledged his Government's full support for the establishment of an office 1n Samoa to cover certain is land countries, including his own. The REGIONAL DIRECTOR expressed his gratitude for the appreciative ·remarks of representatives, which should go principally to collaborators in countries, where the WHO offices were not intended for bureaucracy but for real cooperation. The new office in Samoa was to be a new example of that. Regarding the linking of programme implementation with its financial counterpart, the exercise was not as easy as it might appear; for example, when a consultant could be recruited close to the place of service, the financial implementation would appear to be perhaps only 50% when in fact no low-cost solution was possible. Regarding the filling of a post of regional adviser, rione of the first batch of candidates had proved suitable, even though temporary filling of the vacancy had been considered, but a new batch now under consideration was expected to yield a successful selection. With regard to the three recruitment categories used in the Region, the policy had produced good results: the staff were of good quality, which was borne out by the "loss" of five senior staff members to other WHO regions or headquarters, a record of which he was proud. It was better to fill vacant posts with good temporary replacements than to rush into the recruitment of permanent staff below that standard.
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He referred further to the increase in the number of women among the Regional Office staff, and to the special difficulties of service in a region where a maximum of travel was expected. That also had a bearing on the answer to the question of the representative of Tonga. On the question of the health manpower development centre for medical education and with reference to the Tokyo Declaration on that subject, efforts had been made since its adoption to convene meetings in countries as a preliminary to the proposed regional meeting, at which the cooperative role of the World Federation for Medical Education would also be considered. He agreed with the representative of Malaysia about the importance of malaria in the Region, where the programme was more specific than in other regions, being divided into two subregional programmes. He referred to the plan to establish a primary health care and malaria training centre for certain island countries. Dr HAN (Director, Programme Management) agreed that health systems research was very important to the achievement of health for all, as the representative of Malaysia had said, and that the strengthening of national capabilities to that end should have high priority. Health systems research should be made an integral part of efforts in all areas and programmes. He confirmed that the Government of Malaysia and WHO were negotiating a combined malaria interregional and intercountry training programme; it had been considered that the time had come for a review of the activities. The development of teaching/learning modules could be continued as a global activity centred on WHO headquarters while other aspects, particularly the training of malariologists - which would not receive lower priority - would continue on an intercountry basis. In reply to a question by the representative of Solomon Islands, he said that the flexibility of action in countries would be ensured by the authority given by the Regional Director to country liaison officers to deal with programme matters at the country level. He confirmed that malaria would be treated as the most important health problem in the Region, to be dealt with in activities integrated with other programmes. He noted that the tripartite arrangements between Japan, Tonga and WHO would be the subject of a study mission in October. Tonga would also be represented at the meeting on acute respiratory diseases, to be held 1n Manila in November. In reply to a question by the representative of Tonga, he explained that the Hantaan virus owed its name to the area in the Republic of Korea in which it had been found by a Dr Lee of that country to cause haemorrhagic fever with renal syndrome. There were two other "Hantaan-like" viruses. On the question of estimated population increase in connection with community water supply and sanitation coverage, the figures would be provided at a later session.
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Mr FUNIFAKA (Solomon Islands) said that negotiations with the Japanese Government on the establishment of the training centre to which the Regional Director had referred were nearing completion and, following a mission to finalize the arrangements at the end of 1986, it was proposed to hold a meeting in 1987. Dr DE SOUZA (Australia) reported that Australia hoped to establish a training programme in tropical public health at the University of Queensland in 1987. The courses, which would be at masters' and diploma level, would be in two parts. The first part would consist of core subjects, to be taught at the University of Queensland, and the second part of supervised, problem-oriented work in the student's own country. Discussions were proceeding with the University of Queensland and inquiries concerning the proposed courses should be addressed to the Dean of Medicine at the University. Dr HAN (Director, Programme Management) stated that only twenty out of thirty countries had so far reported on the urban water supply situation and only nineteen countries on the situation in rural areas. In urban areas, there had been a 4.96% population increase and a water supply coverage of 7.8%. The population increase in rural areas had been 5.32% and the water coverage 5.74%. Water supply coverage overall for rural and urban areas had thus well exceeded population growth. In the absence of any further comments, the Chairman, on the proposal of the representative of Malaysia, asked the Rapporteurs to prepare an appropriate draft resolution. (For consideration of the draft resolution, see the third meeting, section 1.1). 2. REGIONAL PROGRAMME BUDGET POLICY: REPORT OF THE SUB-COMMITTEE, PART II: Item 11 of the Agenda (Document WPR/RC37/7)
The REGIONAL DIRECTOR explained that the report of the Sub-Committee on Programmes and Technical Cooperation, which was a newly established unified sub-committee, was in four parts, only Part II of which related to item 11 of the agenda. Parts I, III and IV would be discussed respectively under items 10.1, 12 and 13. Part II was of particular relevance to item 9 of the agenda, and it was therefore proposed to consider it prior to the discussion on that item. The CHAIRMAN said that the Committee would accordingly proceed with its consideration of Part II of the report and would then go on to consider Part I followed by the question of membership of the Sub-Committee. Dr VERMEULEN (Samoa), Rapporteur of the Sub-Committee, introducing Part II of the Sub-Committee's report, said that the regional prograrnrne budget policy had been prepared to address two interrelated management issues facing the Organization. First, the policy outlined a process which would enable Member States to make the best possible use of WHO's resources in furthering their health development and, in particular, in implementing their national health-for-all policies and strategies. The process included guidelines for planning, programming and evaluating WHO's resources to effectively carry out the collective policies of the Organization at country and regional
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level. The unique feature of the process was the emphasis on the strengthening of interaction between Member States and WHO in managing programme budgeting activities. The regional programme budget policy was thus a specific measure for strengthening the partnership between governments and WHO, which, he believed, would result in more effective use of their limited resources. In addition, since WHO and its Members were accountable for the use of WHO resources, they had also the responsibility, technically and politically, to report on what they had done with them, indicating how that complied with their national health-for-all policies. There was increasing pressure on WHO to show judicious accountability for its technical and financial activities. Through improved financial management practices, they would also be in a better position to demonstrate to others that their collaborative actions met their mandated responsibilities. He believed therefore that the regional programme budget policy, as outlined, would achieve those needs of good management. During their discussions, representatives should note the implications of the policy in terms of the measures needed at country level to make their effort a truly collaborative activity between Member States and WHO. Dr KHALID (Malaysia) welcomed the Sub-Committee's clear and comprehensive report on the complex subject under consideration, and shared its views as to the health development issues that would provide a policy base for the programme budget at all levels. He also agreed with the criteria for making allocations to regional, intercountry and country programmes and activities, and strongly endorsed the emphasis on relevance, appropriateness and flexibility of programmes and activities at all levels. The programme budgeting mechanism described would enable countries to provide budget proposal inputs at Regional Committee meetings and through WHO representatives. A number of conditions had to be fulfilled to enable such an arrangement to work effectively. First, there must be a full understanding of and commitment to the mechanism for programme budgeting, policy base issues and allocation criteria. Second, WHO representatives had a critical role to play in interacting with national officials: their role was not only to react but also to promote understanding of the various issues covered by the programme budget. Third, a single central clearing house or contact point at country level was needed to deal with matters of country collaboration. That must be the channel of communication when proposals were made or decisions requested: multiple channels of communication or direct contact with individuals or national institutions could only result in confusion. Fourth, the activities of other health-related international organizations must be effectively coordinated so as to complement and supplement those of WHO. Fifth, there should be adequate two-way communication between national administrations and WHO through the WHO representatives. Lastly, the procedures should be as simple as possible; arrangements should be flexible, particularly at the country level, since circumstances and situations changed, but the instrument of such flexibility should be simple in order to avoid excessive documentation. His delegation agreed on the need evaluation at all levels of implementation. for effective monitoring and
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Dr BROYELLE (France) welcomed the information provided 1n the Sub-Committee 1 s report. Regional programme budget pol icy was an essential feature for the Organization, s1nce it was the basis of all WHO's activities. Programme budgeting was a very concrete action and general principles were only prerequisites. Planning must take account of the problems and activities particular to each country. It was necessary to determine a sequence in the analysis of those aspects. Objectives should be highlighted on the basis of priority health needs, determined using current epidemiological data, and in a sequence of priorities rather than by defining objectives and identifying means. It should be determined which diseases were present, which should be controlled and to what extent, thus providing a basis for the determination of actions and resources needed in quantitative terms. Such an approach was valid at all levels. Financial constraints made it imperative to set limits but, unless such an approach was followed strictly, programming would be of little use. It was important to establish the sequence of priorities in each country first before agreeing an allocation, rather than the other way around. The report appeared to indicate that programmes would be defined on the basis of predetermined allocations, and she requested clarification on that point. There were several ways of undertaking evaluation. As the Director-General had said, there would be an evaluation of the utilization and adequacy of the funds available for programmes. However, the best evaluation was one made on the basis of the results achieved, that is, the impact of a programme on morbidity and mortality. It was also important to evaluate the relationship of costs to those results. Mr HANDLEY (United States of America) supported the report and the representative of Malaysia 1 s proposals, which would make the po 1 icy more useful to the Region. In his address to the Regional Committee, the Director-General had made it clear that greater accountablity was needed in all the regions. Another region he knew well had begun to document, within the programme budgeting process, how resources were being expended. The exercise was most useful, providing a tool in evaluating the use of resources. The Director-General had also made clear the need for everyone to pay careful attention as to how resources were spent in order to achieve the collectively agreed goal of health for all. It would perhaps be appropriate to include that commendable call in the policy. Dr REILLY (Papua New Guinea) said that the concept of programme budgeting was fully supported by his Government and had been used as the basis of the national health plan for 1986-1990. He supported the representative of Malaysia's call for full and proper coordination of such budgeting. The process of monitoring required greater emphasis, and that related to the comments of the Director-General on partnership and participation among Member States. A regional programme budget audit unit should be set up to assess what each Member State was doing, to make comparisons and to encourage Member States, WHO and other agencies to follow such a procedure. The unit would be an important addition in improving the effectiveness of the programme budgeting process; without such a unit, monitoring of the programme buget would be difficult.
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Dr CHEN MINZHANG (China) joined previous speakers in supporting the Sub-Committee's report, which gave a clear explanation of the purposes of the programme budget policy, its principles and components, and areas of cooperation. The underlying principles should help Member States to make optimum use of WHO's limited resources in developing their health systems for the attainment of the goal of health for all by the year 2000. It should also ensure a more rational distribution of those resources based on regular evaluation. Many countries were currently facing economic constraints, resulting in a serious shortage of resources needed to meet the challenge of the health-for-all strategies. It was therefore most timely to have a well-defined programme budget policy. Morever, the measurements outlined should not be applied in a stereotyped manner; countries should take account of their own often widely differing circumstances. Flexibility was the key to deriving optimum benefit commensurate with each country's needs. A built-in monitoring mechanism was necessary for efficient management. Dr TAPA (Tonga) also welcomed the Sub-Committee's report. His Government fully supported the introduction of the· regional programme budget policy. It contained much material that was familiar regarding the process involved, while emphasizing the new method of monitoring the use of resources through financial audit in policy and programme terms. He concurred with the criteria recommended and the flexibility given to meet changes over a four-year period. The introduction of a regional programme budget policy was most timely for the preparation of future biennial budgets. Representatives would recall that, as a result of the current financial cr1s1s, the Director-General had had to withdraw some US$35 million from the global budget for the biennium 1986-1987. He understood that for the biennium 1988-1989 the figure was even higher at some US$50 million. He was convinced of the need to make optimum use of WHO's resources in order to achieve the health-for-all strategies. He supported the representative of Malaysia's proposals and the adoption of the proposed regional programme budget policy, together with those proposals, by the Regional Committee. He requested clarification concerning the Programme Committee mentioned on pages 25 and 26 of Annex 1. Mr KATO (Japan) said that his delegation supported the report, endorsing the principles outlined, especially the optimum use of resources, the improvement of the partnership between WHO and Member States, and the establishment of innovative monitoring and evaluation procedures. Dr RHIE (Republic of Korea) commended the Sub-Committee for its report and supported the proposals. He asked when, provided that the policy was accepted, the first financial audit in the Region would be implemented. Dr MAOATE (Cook Islands) said that his Government fully supported the report and the criteria recommended. He strongly believed in the maintenance of close cooperation with WHO in implementing the policy. He expressed his appreciation to those developed countries which had repeatedly given way to those who were less fortunate and hoped that such generous support would continue.
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Dr VERMEULEN (Samoa), speaking on behalf of the Sub-Committee, thanked representatives for their kind comments. The Sub-Committee had received considerable help from the Secretariat during its deliberations. He stressed that the policy outlined would have to be developed further. As indicated in the final paragraph of the executive summary of the report, the proposals were but a first step in an evolutionary process, providing guidelines for subsequent development at both country and regional levels. The representative of France had highlighted the need to start at the country level. However, the process was cyclical, being repeated every two years, but beginning in the countries. Clear guidelines were provided in that respect, based on the global indicators that each country was carefully monitoring. The REGIONAL DIRECTOR also welcomed representatives' comments. The regional programme budget policy would be translated into allocations to priority programmes to solve the major problems that needed to be tackled at country level if health for all was to be achieved. The policy would therefore have to be based on a concrete situation analysis which, in the case of the Western Pacific Region, would be provided by the regional evaluation and situation report on strategies for health for all by the year 2000, to be undertaken every two years. Thus policy would be formulated continuously at regional level based on the monitoring of the health situation at country level. Such a process would make better use of the resources of WHO, other agencies and organizations, and of the countries themselves. He welcomed the suggestions made by the representative of Malaysia to establish conditions and to set up coordinating mechanisms with other related agencies such as UNICEF and UNDP. However, in practice there might be some difficulties. Whereas WHO tended to have a single "clearing house .. within countries, usually the Ministry of Health, that did not necessarily apply to other organizations, which operated through various channels. Experience had shown that, even with a programme budget based on the country situation, the most difficult problems encountered during collaboration with countries and in the countries themselves were problems of implementation. The Region, therefore, hoped to establish not only a concrete regional programme budget policy but also strong mechanisms to monitor programme implementation, which combined to give a policy framework reflecting the reality in countries. Such an arrangement would provide sufficient flexibility to take account of the different conditions prevailing in each country. Dr HAN (Director, Programme Management) said that the Secretariat was ready to revise the document in the light of comments and suggestions made during the Committee's discussion. The representative of Malaysia had referred to the need for a full understanding of the allocation process; an attempt had been made to clarify that aspect in the document, but it could perhaps be further elaborated if it was felt necessary. Reference to the critical role of the WHO representative had been included on page 27 of the document, but further details could be given,
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citing the four major functions of WHO representatives vis-~-vis Member States. Further details could also . be included concerning communi¢.ation between WHO and Member States throughWHdrepresentatives. Details could also be included in the revised text concerning other health-related international organizations or funding agencies whose work should be coordinated with WHO to supplement WHO's activities. Reference had been made by the representatives of China and France to the need for procedures at country level to be as simple and flexible as possible. A brief reference to that aspect had been made on page 23, but further details could be given. Several speakers had emphasized the importance of monitoring and evaluation. An attempt had been made in the document to stress not only policy guidelines but also the management aspect, which would include monitoring and evaluation; in fact it had been felt that the emphasis on that element was great.e r than in the counterpart documents prepared in the other regions. Apart from the monitoring of prJJgress, evaluation referred to the relevance and adequacy of · certain activities, as well as their efficiency, effectiveness and impact in terms of reduction of morbidity and mortality. Further details could of course be included in the document, but it would become voluminous. Replying to the question . . raised by < the representative of Tonga about the Programme Committee, he apologized that no explanation had been given concerning the Committee, which was an internal secretariat mechanism. The Regional Programme Committee was composed of himself (as Director of Programme Management, he was the Chairman), the Directors and Chiefs of programmes, the Director of the Support Programme, the Budget and Finance Officer, the Programme Officer, and the Externa 1 Relations Officer (when extrabudgetary funds were involved). Any other staff member could be co-opted as deemed necessary, and of course the Regional Director could deliberate in the discussions. He read out the terms of reference of the Committee, which normally met once a month; its reports were sent to the WHO representatives and country liaison officers, who used them as a basis for dialogue with Member States. The Director-General had instituted a financial audit in policy and programme terms; programme auditing was to be carried out to assess the accountability of WHO 1 s collaboration at country level. On a trial basis such audit was to be carried out in Samoa. Dr DE SOUZA (Australia) suggested that the clear definition of the Committee given by Dr Han be included in the document (maybe as an annex), and that the reference should be amended to "Regional Programme Committee", to avoid confusion with the Programme Committee of the Executive Board. Dr TAPA (Tonga) supported the sugges.tion made by the representative of Australia. Dr KHALID (Malaysia) said that his reference to the need for a full understanding of the allocation process was not intended to imply that the document was not clear. The subject was very complex, and called for a full explanation at the country level.
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He had noted the reference to WHO representatives on page 27, and had merely intended to reiterate the importance and onerousnes~ of the work of WHO representatives if the programme budget policy was to be effective. In the absence of any further comments, the CHAIRMAN proposed that the Rapporteurs prepare an appropriate draft resolution. (For consideration of the draft resolution, see the third meeting, section 1.2, and the fifth meeting, section 1.1).
The meeting rose at 5 p.m.