WORLD HEALTH ORGANIZATION
ORGANISATION MONDIALE DE LA SANTE
REGIONAL OFFICE FOil THE WESTEI\N PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAl.
REGIONAL COMMITTEE Thirty-fourth session Manila
WPR/RC34/SR/4 6 September 1983 ORIGINAL: ENGLISH
PROVISIONAL SUMMARY RECORD OF THE FOURTH MEETING WHO Conference Hall, Manila Tuesday, 6 September 1983 at 2.30 p.m. CHAIRMAN: Datuk (Dr) Abdul Khalid Sahan (Malaysia)
CONTENTS
1.
Report of the Regional Director (continued) ••••••••••••••••••
3
Note: Corrections to this summary record should be given to the Programme and Reports Officer, Room 326, or handed to the Enquiry Desk in the lobby of the Conference Hall, within 24 hours of its distribution.
WPR/RC34/SR/4 page 2
For the List of Representatives at separately issued document WPR/RC34/DIV/l.
the
thirty-fourth
session,
see
WPR/RC34/SR/4 page 3
1.
REPORT OF THE REGIONAL DIRECTOR: the third meeting, section 3)
ITEM 9 OF THE AGENDA (continued from
PART II: 1.
Review of selected programmes (pages 113-128) (continued)
Malaria control (continued)
Dr CH'EN (Regional Adviser in Malaria) said that the malaria situation had worsened in two subregions - in Sabah State in Malaysia, in part of the Philippines and in the countries of the Indochinese peninsula, where Anopheles balabacensis was the main vector, and in the Solomon Islands, Papua New Guinea and Vanuatu, where the vectors belonged to the A. farauti complex. The disease, however, had been eradicated in Australia, Brunei, the Chinese province of Taiwan, the Ryuku Islands in Japan and Singapore. Drug resistance was a further problem in the countries where there had been a resurgence of malaria. There were 41 million people at risk in Viet Nam, mostly in the South. In the Philippines some 43 000 microscopically confirmed cases of malaria had been reported in 1981-1982, and obviously the total number of cases was very much higher. Roughly 3 million people were believed to be at risk in Democratic Kampuchea and parasite rates among children, as found in sporadic surveys, had ranged from 15 to 65% and averaged 24%, indicating the seriousness of the problem in that country. In Lao People's Democratic Republic 3. 8 million people were at risk and surveys had shown an uneven distribution of malaria, with parasite rates ranging from 5 to 60%. In the State of Sabah in Malaysia there had been 50 000 microscopically confirmed cases in 1981 among a total population of about 650 000 at risk. In the southern Philippines 16 million people were at risk and the malaria service reported 110 000 to 130 000 confirmed cases a year. In the Solomon Islands in 1982 there had been 69 680 microscopically confirmed cases among a total of 220 000 people at risk. The reported number of confirmed cases in Papua New Guinea was some 110 000 - 120 000 a year but that was certainly below the real figure and the problem was a very serious one. Malaria incidence had also been increasing of recent years in Vanuatu. In his op~n1on three factors were mainly responsible for the present sorry state of affairs. Firstly, the effectiveness of residual spraying with DDT, a major weapon in malaria control, had decreased. A. balabacensis and A. farauti had not developed physiological resistance to DDT but had adopted different patterns of behaviour to avoid its lethal effects, by not going indoors or resting on sprayed surfaces and by biting animals and human beings out of doors. Spraying was being badly done, particularly in areas where voluntary labour was being used for reasons of economy. A second factor was drug resistance, although it was impossible to say precisely how serious the problem was. Thirdly, the integration of the formerly vertically organized malaria services into the general health services had not run smoothly and during the past four or five years there had been in many places a kind of organizational vaccum.
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In response to the question of the representative of Viet Nam regarding chloroquine resistance, the monitoring techniques in use were not simple and required highly trained malaria technicians, who were not available in many of the countries in the Region. In addition, the number of tests for chloroquine resistance carried out had been too small to obtain any statistically significant results. In reply to the representative of Papua New Guinea, he said the effectiveness of residual spraying in interrupting transmission depended on the susceptibility of the vector species to the insecticide and the quality of the spraying coverage. Some malaria control programme had had little, or no, impact on transmission despite 20 years of operations due to poor spraying coverage, growing public resistance and the changes in vector behavioural patterns already described. The cost-effectiveness of residual spraying as the principal method of attack required reappraisal, particularly when results were unsatisfactory. Such operations could absorb 60-70% of the malaria control budget which in some countries represented 10% of the total health allocation. Moreover, free supplies of insecticides such as DDT were now diminishing. Nevertheless, residual indoor spraying remained the most effective preventive measure as well as the most suitable for use in epidemic outbreaks. The few alternatives larviciding, space spraying and antimalarial drugs - were effective only under particular conditions. Environmental management and community participation were not yet feasible as measures to eliminate breeding sources, particularly in A. farauti and A. balabacensis endemic areas. There was an urgent need to make diagnostic and treatment facilities accessible to populations in hyperendemic areas: early treatment and referral of severe cases to competent medical facilities would effectively prevent mortality. Vulnerable population groups, such as children and pregnant mothers, required special attention. The use of mosquito bed nets was being encouraged as a long-term effective personal preventive measure. The United States Army Research Group had, in fact, tested over 250 000 chemical compounds for antimalarial properties since 1963. However, the only new promising weapon, apart from Ching hao su, was mefloquin which was not yet available on the market. He doubted that immunization would become available in the foreseeable future. Dr MINNERS (United States of America), complimenting Dr Ch 'en on his excellent review, said that he considered the report had seriously underestimated the problem of drug resistance. In view of the extraordinary ability of the malaria parasite to adapt, new drugs would constantly be required which were extremely costly and time consuming to produce. He noted that epidemiological assessment and surveillance would assume far greater importance if a vaccine were available, and in this respect he believed that some optimism was justified in view of the results achieved using monoclonal antibodies and genetic engineering techniques. He stressed the need for better diagnostic tests to determine at an earlier stage the response of a patient to a drug.
W 'PR/RC34 /SR/ L! page 5
Dr CHRISTMAS (New Zealand) also commended Dr Ch'en's presentation which had stirred representatives from their complacency to recall the purpose and importance of the malaria programme. He :was heartened by the knowledge that the basis for present epidemiology as well as the mathematical study of diseases owed much to malariologists. He suggested that a task force approach should be adopted to deal with problematic situations until normal control could be resumed. Apart from the expanded programme on immunization and the water decade he ranked tuberculosis, leprosy and malaria as high priority issues. The CHAIRMAN felt that the concern expressed by representatives related to the resurgence of malaria and should not obscure the successes achieved in control, such as in areas of Malaysia, which were a direct result of collaboration between the national administration and WHO. Dr PAIK (Chief, Research Promotion and Development) thanked representatives for their comments and suggestions. Replying to the representative of the Republic of Korea he said that the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) was devoting considerable resources to the development of new tools for the control and treatment of malaria. The Walter and Eliza Hall Institute in Melbourne was also attempting to develop a vaccine through DNA recombinant techniques. However, such tools would require field testing to assess their effectiveness. Until new tools became available, the primary health care approach would be essential to reduce morbidity and prevent mortality, particularly in vulnerable groups. A number of facts - such as the incr,eased cost of insecticides and the growth of human resistance to spraying - had necessitated the reorientation of the traditional vertical malaria control programme. The new approach encompassed more effective case detection, reduction of mosquito breeding sources, and health education, together with limited indoor spraying. Retraining of health personnel at all levels was required in line with newly defined tasks. Specialized malaria workers would provide technical backstopping.
With regard to the difficulties being encountered 1n drug treatment regimens, the Regional Office planned to send consultants to investigate the clinical aspects of severe falciparum cases and develop a practical manual on case management. He clarified that the new drug Ching hao su was derived from a herb which had been used for therapy in China for a thousand years. The drug had proved highly effective against chloroquine resistant parasites. Further studies were being undertaken on the pharmacokinetics and toxicology of the drug in cooperation with TDR, following which it was hoped the drug would become available to other Member States. The REGIONAL DIRECTOR felt that there was undue anxiety regarding the diminished role of malariologists. He expressed concern at the costs involved in malaria control and surveillance, particularly for small areas such as Brunei which two years earlier had invested several million US dollars for maintenance alone. On the other hand, he noted that an improvement in the health situation generally often led to the disappearance of malaria.
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As suggested by the representative of New Zealand, WHO was trying to develop a task force, or a more pragmatic "area oriented" management approach to policy planning and implementation, applying health systems research. He had been following developments 1n the Region closely and would continue to keep a close watch on them. A major obstacle to the development of the DNA recombinant vaccine was the need for human blood; another medium was sought. However, he was hopeful that a breakthrough was fairly imminent. Regarding drug resistance and therapy, he felt that there was insufficient understanding of the reaction of the drug in vitro to different It was possible that stages of development of, for example, plasmodium. treatment with primaquine might be effective for falciparum resistant carriers. He had observed that new developments in the medical system, if improperly understood, sometimes led to an increase in mortality due to poor case management. He was convinced that a concerted effort would enable the malaria problem to be overcome, and that a new generation of malariologists would take the place of those who had disappeared. In this connexion he drew attention to the new Regional Centre for Training and Research located in Kuala Lumpur. 2. Health services research (pages 121-127)
Dr DE SOUZA (Australia) said that section 4. 2 of the programme review referred to a regional strategy for the development of manpower in health services research and outlined various related activities. However, there was little mention of the fellowships programme or of other mechanisms for research tra1n1ng grants. A major problem was the lack of trained personnel. Workshops and training courses might be useful for general information, but were no substitute for training in epidemiology, biostatistics and health economics, the basic sciences used 1n health services research. He noted from the figure on page 79 of the report that only 0.4% of WHO fellows during the biennium had been statisticians. He wondered what efforts were being made, for example, to find statisticians to undertake research training in biostatistics or doctors in epidemiology so that countries had people capable of designing projects in health services research in order to solve health problems. Dr CHRISTMAS (New Zealand) took issue with the definition of health services research in the first sentence of section 1 of the programme review. The word "means" was so broad that it might include any form of biomedical research and its application. The next sentence rightly referred to the potential of health services research as an agent for change in health systems operations and management. The definition might read "health
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services research is the systematic study of mechanisms, systems, organizations, operations or approaches whereby ••• ", since it was the system, organization or management approach, and not the means that was being assessed. Dr SUNG WOO LEE (Republic of Korea) shared the Government of Australia's concern at the lack of expertise on health services research. He hoped that WHO would award more fellowships for postgraduate training in that field. Referring to the last paragraph in section 4.2, he welcomed the designation of the Korea Institute for Population and Health in Seoul as a WHO Collaborating Centre for Research and Health Development. Dr MINNERS (United States of America) associated himself with the comments of the previous speakers. The attempt to define health services research was worthwhile, as a better understanding was needed of what was meant by health services research, and what it could do. Of the six inhibiting factors listed in the second paragraph of Section 1, the fifth the lack of expertise and skills - was particularly important, and was related to the second objective in section 2, the strengthening of national capability to carry out health services research. Similarly important was the last paragraph in section 5, which referred to inadequate manpower resources at the regional level. He agreed that the active coordination among WHO programmes mentioned in section 4.6 was valuable, and suggested that a linkage might also be made between the activities of countries; health services research appeared to provide a prime opportunity for technical cooperation among developing countries. Dr GALVEZ (Philippines) said that his country had adopted operational research to find ways of improving health care. To what extent had WHO propagated that methodology in the Region, and did countries need bilateral programmes to initiate activities? The CHAIRMAN, speaking as the representative of Malaysia, said that his country, which lacked expertise in health systems research, had drawn on staff from a number of fields in undertaking a study of hospital bed utilization with WHO's help; the problem had been that people were by-passing the district hospitals, which were under-utilized, and overcrowding the urban specialist hospitals. The authorities had been sufficiently impressed by the practical usefulness of the findings to set up a permanent research unit. He asked the Secretariat to connnent on the use of the two terms "health services research" and "health systems research". Mr SUBRAMANIAN (Regional Adviser in Health Information), responding to the representative of Australia, pointed out that the figure on page 79 showed fellows' professions; their fields of study were shown on page 80, where health services research training came under several of the headings. Health services research should be treated not as an independent subject, but as an integral part of programme development and management. As stated in section 4.2, the best way to develop capability in health services research was to involve health workers in actual studies. They
WPR/RC34/SR/4 page 8
could be given further training in research methodology later. WHO was using two approaches: (1) workshops on health services research methodology; (2) training courses covering both biomedical and health services research, in which the scientific approach used in the biomedical research was followed, but with the emphasis on work that was relevant to health programme management. The definition shown in section 1 had been drawn up in 1976 by a task force on health services research set up by the WPACMR. The word "means" meant the various ways existing knowledge could be applied. The problem in meeting the need for staff trained in health services research was to find an institution, within or outside the Region, that could provide the training. The learning-by-doing approach had been tried in various countries. Studies had been carried out first in Malaysia on the methodology of health services research; the findings had been tested in further research in the Philippines, and it had in both cases been found possible to apply the findings for a reorientation of basic health services. While the initial experience in development of methodology in Malaysia had taken three years, in the Philippines it had been possible to complete that operation in 18 months, and it was expected that in the Republic of Korea it would be possible to do the same on a smaller scale in only eight months. With regard to the development of manpower for health services research in accordance with the recommendations of the Working Group on Health Services Research in 1978, he described a number of activities including a recent workshop in Fiji for participants from the South Pacific, to give training in health services research methodology. The studies in the three countries mentioned and a tuberculosis project in Japan had demonstrated that it was possible to improve services two- or three-fold without an increase in manpower or resources. The next step was to study ways of improving the efficiency of hospital services, first developing methodology for the evaluation of hospital use. After testing it in 1984 it was · hoped to make available the tried methodology for application in countries. Explaining the historical development of health services research from earlier operational research to health systems research, he described the epidemiological, social and technological approaches by which, through influencing the environment, adopting techniques and changing attitudes it became possible to provide better services to a more receptive population in better circumstances before even broaching the question of increased resources. Health systems research then introduced considerations of policy change and intersectoral cooperation to ensure the best use of all the components influencing health and health service delivery in a given country. Dr DE SOUZA (Australia) said that when asking his question he had referred to the diagram on "fellows by profession" on page 79 of the report in order to illustrate his concern that, as not all those trained to serve
WPR/RC34/SR/4 page 9
were capable of research, there should be careful selection of those in any profession who would be most suitable for training for the research. That would save a lot of time that would be lost if all health professionals were expected to be equally apt for research. Mr SUBRAMANIAN (Regional Adviser in Health Information) replied that the aim was indeed to develop research capability in certain priority areas, starting with health administrators and planners, then epidemiologists, health economists, etc. There had also been some selection in the sense that statisticians, clinicians and epidemiologists constituted a team which could be brought together as a core group to direct and conduct health research studies in a country. The REGIONAL DIRECTOR said that it was natural that there should be some confusion about terminology in definitions in such a new area. He had selected health services research for the report precisely with the intention of having a review that would help develop the concepts and clarify the aims of the programme. On the point raised by the representative of Australia, he said he had asked the Dean of a medical school concerned with the community-oriented problem-solving approach what new emphasis in curricula for basic medical education could be considered to represent a breakthrough in preparing students for the new approaches to problem-solving; the reply had been that they now received training in statistical skills and health economics as well as epidemiology. That approach . had been introduced not only in Newcastle University in New South Wales, Australia but also in McMaster University in Canada, and many other countries were preparing for health service research along similar lines. Dr CHRISTMAS (New Zealand) wondered what subjects such universities might be considering dropping from their curricula in order to make way for the new approach. Dr REYNES (France), taking the opportunity to congratulate the Regional Director on his nomination for a further term and to thank him for his Report to the Regional Committee, expressed support for the plan of action for the regional strategy and pledged her Government 1 s assistance through cooperation with countries of the Region in their coordinated efforts to determine national policies and make health for all a reality. Mr BOYER (United States of America) said that on completion of the review of the report of the Regional Director and looking back to Chapter 7, it might seem that its coverage of general programme development and management was rather scant; the Director-General himself had stressed planning and the use of resources. That was not intended as a criticism of the Report; rather he hoped that activities in that field in countries of the Region would be increased so that in the next biennial report there might be material for a more detailed chapter giving managerial aspects the attention they deserved. Dr XU SHOUREN (China) said that the Report provided a broad review of extensive activities, and the achievements of the Regional Director and his
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staff in support of the work to promote health in the countries of the Region could be seen to be considerable. The strategy and plan of action for health for all had been formulated and tasks determined in accordance with the Seventh General Programme of Work. Emphasis had rightly been placed on management aspects, and international and regional cooperation had been seen to have improved. Increased attention had been given to the role of subcommittees and health committees, which was a trend to be welcomed. The CHAIRMAN asked the Rapporteurs to prepare a draft resolution on the biennial report as a whole.
The meeting rose at 5.00 p.m.