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The work of WHO in the South-East Asia Region: Biennial Report of the Regional Director 1 July 1997 - 30 June 1999

10 octobre 1999 Organisation mondiale de la santé

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Texte intégral

Contents Page

Preface .............................................................................................................. vii Executive Summary ........................................................................................... xi

Section 1 –

Governing Bodies World Health Assembly .......................................................................... 1 Executive Board ...................................................................................... 2 Regional Committee.............................................................................. 4

1. Governing Bodies

Section 2 –

Health Policy and Management Managerial process for WHO’s programme development ........................................................................................... 7 WHO response to global change ....................................................... 8 Staff development.................................................................................. 9 Renewing the Health-for-All strategy ................................................. 9 Management and support to information systems...................... 10 Regional Director’s Development Programme ............................. 11 Coordination with other organizations ............................................ 12 Mobilization of external health resources ....................................... 14 Health Ministers’ Meeting.................................................................... 16 Health Secretaries’ Meeting............................................................... 16

2. General Programme Development and Management.................................. 7

3. Health, Science and Public Policy.............................................................. 18 Leadership for health ........................................................................... 18 Women, health and development .................................................. 19

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Health legislation, ethical dimensions of health care and bio-ethics .................................................................................... 20 Research policy and strategy coordination .................................. 21 Page

4. National Health Policies and Programme Development and Management ....................................................................................... 24 Support to development, management and coordination of country programmes........................................................................ 24 Technical cooperation among countries....................................... 24 Collaboration with countries and peoples in greatest need........................................................................................ 25 Procurement services (excluding drugs, biologicals and contraceptives)................................................................................. 26 Emergency and humanitarian action; relief and rehabilitation operation and emergency preparedness programme............................................................................................ 26

5. Biomedical and Health Information and Trends ......................................... 28 Epidemiology, statistics, trend assessment and country health information ............................................................................. 28 Publishing, language and library services....................................... 29

Section 3 –

Health Services Development

6. Organization and Management of Health Systems based on Primary Health Care .................................................................................. 33 Health systems research and development .................................. 33 Policy reform and restructuring of national health systems..................................................................................................... 34 Health financing and economics, option appraisal, systems and skills development ..................................................... 35 District health systems .......................................................................... 36

7. Human Resources for Health..................................................................... 38

Human resources for health ............................................................... 38 Fellowships .............................................................................................. 42 Directory of training institutions .......................................................... 46 MIS allied system (Fellowships).............................................................. 46 Group educational activities ............................................................. 46

8. Essential Drugs .......................................................................................... 48 Action programme on essential drugs ............................................ 48 Procurement of drugs, biologicals and contraceptives ...................................................................................... 50

9. Quality of Care and Health Technology ..................................................... 51 Technology for health care................................................................ 51 Drugs and biologicals, quality, safety and efficacy..................... 54 Traditional medicine............................................................................. 56 Page

Section 4 –

Promotion and Protection of Health Care

10. Reproductive, Family and Community Health and Population Issues....................................................................................... 57 Reproductive health ............................................................................ 57 Child health ............................................................................................ 61 Adolescent health ................................................................................ 62 Women's health..................................................................................... 63 Ageing and health ............................................................................... 63 Special Programme of Research, Development and Research Training in Human Reproduction................................. 64 Occupational health ........................................................................... 65

11. Healthy Behaviour and Mental Health........................................................ 66 Mental health......................................................................................... 66 Substance abuse including alcohol and tobacco ...................... 68 Health promotion .................................................................................. 69 Communications and public relations............................................. 71 Rehabilitation ......................................................................................... 72

12. Nutrition, Food Security and Safety ........................................................... 73 Nutrition ................................................................................................... 73

Food safety............................................................................................. 75 Food aid.................................................................................................. 76

13. Environmental Health ................................................................................ 77 Water supply and sanitation in human settlements..................... 77 Environmental health in urban development .............................. 78 Assessment of environmental health hazards ............................... 79 Promotion of chemical safety ........................................................... 80 Incorporation of health concerns into environmental management ..................................................................................... 81

Section 5 –

Integrated Control of Diseases Guineaworm (Dracunculiasis)/Brucellosis....................................... 83 Leprosy .................................................................................................... 83 Poliomyelitis ............................................................................................ 84 Page Neonatal tetanus.................................................................................. 87 Measles.................................................................................................... 88

14. Eradication/Elimination of Specific Communicable Diseases .................... 83

15. Control of Other Communicable Diseases................................................. 90 Vaccine preventable diseases ......................................................... 90 Acute respiratory infections and diarrhoea ................................... 91 Integrated management of childhood illness (IMCI) ....................................................................................................... 91 Tuberculosis ............................................................................................ 93 Emerging diseases, including cholera and other epidemic diarrhoeas, zoonoses and antimicrobial resistance................................................................................................ 94 Other communicable diseases ......................................................... 96 Dengue/Dengue haemorrhagic fever (DHF) ................................ 97 AIDS and sexually transmitted diseases........................................... 99 Control of tropical diseases.............................................................. 101 Special Programme for Research and Training in Tropical Diseases (TDR) ................................................................... 104

16. Control of Noncommunicable Diseases ................................................... 105

Oral health............................................................................................ 106 Prevention of blindness and deafness ........................................... 106

Section 6 –

Administrative Services

17. Personnel ................................................................................................. 109 18. General Administration............................................................................. 111 19. Budget and Finance ................................................................................. 112 Annex – Organizational Chart................................................................................. 115

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Executiv e Sum m ary The Fifty-first and Fifty-second World Health Assemblies were held during the reporting period. The Fifty-first Health Assembly appointed Dr Gro Harlem Brundtland as Director-General of WHO for five years beginning 21 July 1998 and debated on the regional allocations of the WHO Regular budget resulting in a compromise approach which was substantially more favourable to the South-East Asia Region. The Fifty-second Health Assembly reviewed and approved the programme budget for 2000-2001. It also reviewed the World Health Report 1999, the DirectorGeneral's Report on the work of WHO and issues concerning smallpox, malaria, polio, tobacco, revised drug strategy, iodine deficiency disorders and cloning. The 101st session of the Executive Board considered the draft global health policy for the 21st century, and WHO reforms, and reviewed the issue of regional allocations, which was further reviewed by the 102nd session. The 103rd session, inter alia, discussed the Drug Strategy, Tobacco Free Initiative, and Polio Eradication. It reviewed the programme budget for 2000-2001 and suggested certain adjustments. The 104th session of the Executive Board reviewed research strategies and mechanisms for cooperation as well as administration and award of foundation prizes and fellowships. The fiftieth session of the Regional Committee considered the Regional Director’ s report and endorsed the Declaration on

Governing Bodies

The Work of WHO in SEA

Health Development in the South-East Asia Region in the 21st Century (Regional Health Declaration). The fifty-first session of the Regional Committee was preceded by WHO’ s 50th anniversary celebrations. Ministers of Health from most SEAR countries and the Director-General of WHO attended it. The Regional Committee nominated Dr Uton Muchtar Rafei as Regional Director of the South-East Region for a second term of five years with effect from 1 March 1999.

General Programme Development and Management

WHO collaborative programmes were implemented with the active participation of Member Countries. The financial implementation rate for the 1998-1999 biennium was 61 per cent during the first twelve months. Management of programme budget was also facilitated through the implementation of supplementary intercountry programmes, which addressed common priority issues of countries. Country evaluation exercises, conducted in five countries, reaffirmed that WHO’ s technical support to countries was useful and productive. A new initiative called the Joint Programming Initiative, with the participation of government officials and WHO country staff, was organized to prepare plans of action for the 2000-2001 biennium. The Regional Office has started implementing the new reform measures, initiated by the Director-General, which are geared to improve efficiency, accountability and transparency in the work of the Organization. WHO worked closely with other UN agencies in areas of mutual concern. WHO also extended full cooperation to the UN’ s reform initiatives and participated in the pilot exercise on the UN Development Assistance Framework (UNDAF) in India. In view of the probable impact of the WTO Agreements on the health sector, WHO took initiatives to promote awareness among

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Member Countries about these developments so that timely measures could be undertaken to safeguard the health interests. WHO and ASEAN strengthened their collaborative activities within the framework of the MoU signed between the two organizations. Steps have been taken towards formalizing collaboration with SAARC. WHO continued its efforts to strengthen national capacity for aid negotiation and coordination in the health sector and provided support to Member Countries in the mobilization of external resources. It worked in close cooperation with the World Bank and the Asian Development Bank as well as with bilateral donors and NGOs that had actively supported national health programmes in Member Countries. A wide range of consultations from 1995 to 1997 resulted in Renewing the HFA Strategy in the form of the Regional Health Declaration. The fifteenth and sixteenth meetings of Ministers of Health and the third and fourth meetings of Health Secretaries were held during the reporting period. The third meeting of Health Secretaries decided to take a well-coordinated stand on the regional allocation of the WHO Regular budget to safeguard SEAR interests; the outcome was gratifying. At their fourth meeting, they reviewed the joint government/WHO programme during 1998-1999 and discussed TRIPS (Trade-related Aspects of Intellectual Property Rights) and the health sector in the SouthEast Asia Region. Major events, such as the Fourth International Conference on Health Promotion, International Conference on Intercountry Cooperation for Health Development in the 21st Century, and the International Conference on Global Health Law served to reinforce WHO’ s leadership role in health development.

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Health, Science and Public Policy

WHO activities on women, health and development have continued to support the use of a gender perspective in addressing women’ s health issues across their life span. Information dissemination and use has been promoted to facilitate relevant policy and programme measures. Particular attention was given to the role of the health sector in the prevention and management of domestic violence as an issue affecting women’ s health. In line with the Declaration on Global Health Law, six Member Countries were supported in the review and updating of their health legislations and regulations for the development of a national health policy based on HFA values and principles. The South-East Asia Advisory Committee on Health Research (SEA-ACHR) and the directors of Medical Research Councils (MRC) or analogous bodies met at a (first) joint session in April 1998. The 24th session of SEA-ACHR, held in April 1999, recommended an enhanced role for vaccine research in disease prevention and control, including HIV/AIDS, in the 21st century and underscored the contribution of health research to evidencebased policy and decision-making.

National Health Policies and Programme Development and Management

Technical cooperation among countries in addressing common health problems was further strengthened through border meetings to control malaria and kala-azar and by holding joint National Immunization Days. Development of the district health systems in Nepal, establishment of a health trust fund in Bhutan, formulation of a health and population sector programme in Bangladesh, development of a health policy in Myanmar, and health care financing in Maldives were supported. Five countries reported seven major natural disasters. WHO developed a multi-pronged approach to support the affected countries, including mobilization of extrabudgetary funds.

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The Work of WHO in SEA

The health situation and trend assessment programme continued to improve national health information systems. Results of the third evaluation of the HFA strategies and other sources of health data were analysed in the Health Situation in the South-East Asia Region, 1994-1997. The Regional Office Library continued to provide comprehensive technical information, including in the electronic format, and literature support. WHO supported further development of health policies in Nepal, Myanmar, Sri Lanka and Bangladesh. Support was also provided for capacity-building in developing national health plans. Six countries were supported in reforming their health sectors. Countries were also facilitated in preparing country profiles on health sector reforms to monitor the progress and minimise the adverse consequences of health sector reform, particularly on the poor and the vulnerable. Countries were supported in the study of various alternative financing mechanisms and national health insurance schemes. Focus on strengthening of the District Health System was continued. A set of 16 training modules on organization and management of district health systems and primary health care was developed and introduced. Health problems of indigenous, tribal or isolated populations received increasing attention. Human resources for health (HRH) activities continued to focus on qualitative aspects of health manpower development. Intensification of planned HRH programmes resulted in the development of appropriate mechanisms to address the issue of the paramedical workforce in the Region. Standards of midwifery practice for safe motherhood were field-tested and are being finalized. Guidelines for collaboration between nursing services and education to improve nursing care and education were developed.

Biomedical and Health Information and Trends

Organization and Management of Health Systems based on Primary Health Care

Human Resources for Health

The Work of WHO in SEA

Several Member Countries introduced new modalities for implementing fellowships. Indonesia instituted in-country fellowships. Bangladesh and Nepal changed their approaches to the planning and implementation of fellowships in an effort to match awards more closely with their national health priorities, making greater use of regional and in-country training facilities.

Essential Drugs

With WHO support, national essential drugs programmes have been developed by all Member Countries. The ASEAN pharmaceutical programme continued its successful and pivotal role in bi-regional technical cooperation in the area of essential drugs. WHO also focused on drug financing for making essential drugs available in some countries. At the same time, the attention of Member Countries was drawn to the public health issues related to the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS).

Quality of Care and Health Technology

Strengthening of quality assurance of laboratory services was continued. Some Member Countries are progressing towards the accreditation of all laboratories. With a view to developing a regional strategy for the prevention and control of antimicrobial resistance monitoring (ARM), technical support was extended to several countries. Vaccine Regulatory Authority (NCA) was established as an entity. Thus the regulatory authorities in Indonesia, India and Thailand are now working with all their control functions in place. Traditional medicine (TRM) practice continued to flourish in Member Countries. Bangladesh and Sri Lanka integrated TRM into the national health care systems. Bhutan is improving its TRM through training of personnel. TRM services are being introduced in remote areas of India to strengthen primary health care.

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The Work of WHO in SEA

WHO activities during this period were targeted towards supporting countries in the operationalization of the regional strategy for reproductive health, with special focus on reducing maternal mortality rates. WHO also continued its support to child health programmes, including breastfeeding and growth monitoring, immunization, control of diarrhoeal diseases and integrated management of childhood diseases. Effective linkages among the health and the health-related sectors, funding agencies and NGOs have also been achieved. Investment in women’ s health was one of the actions identified in the Regional Health Declaration. Efforts were initiated for developing strategies in this regard. Realizing the health problems among the ageing population, many Member Countries have included ‘ Elderly Health’ in their national programmes. Further impetus was provided in this regard by the theme of the World Health Day 1999 being devoted to “ Active Ageing Makes the Difference” . The Special Programme of Research, Development and Research Training in Human Reproduction has extended a longterm institutional development grant and resource maintenance grants to some institutes in India. Research training grants were given to Sri Lanka, Myanmar and Nepal. Several individual projects on emergency contraception, abortion and injectable contraceptive etc. were supported. As regards mental health care, coverage has been increasing in all countries of the Region. Regional consultations on the special needs of street and working children resulted in setting standards for good services for these highly vulnerable children. In order to increase the focus of psychiatric care and rehabilitation activities, the Burden Assessment Schedule (BAS) was developed and published. The WHO Cabinet project ‘ Tobacco Free Initiative’ received a favourable response from Member Countries. Considering the

Reproductive, Family and Community Health and Population Issues

Healthy Behaviour and Mental Health

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xvii

steady increase of tobacco use in the Region during the last five years, the regional focus is on reducing consumption levels and preventing initiation of tobacco use. The Jakarta Declaration, the outcome of the Fourth International Conference on Health Promotion, provided a crystallized vision for health promotion and development. The community empowerment process has been strengthened with the focus on vulnerable groups such as women. Within the larger context of the healthy settings approach, the development of health-promoting schools gained wider acceptance. Efforts continued to improve dissemination of information to enhance the goals of the Organization. WHO also supported the integration of community based rehabilitation into PHC services in Bangladesh, Bhutan and India.

Nutrition, Food Security and Safety

The focus of WHO’ s support was on improving the quality of national programmes covering protein energy malnutrition, iodine deficiency disorders, vitamin A deficiency and iron deficiency anaemia. WHO organized a regional consultation on nutritional status of adolescent girls and women of reproductive age, and also conducted a regional training course on research methodology for developing a database in maternal and adolescent nutrition. The nutrition research agenda was developed and technical support provided for improvement of case management of children with severe malnutrition. A tenpoint regional strategy for food safety was also developed. WHO's collaborative programme continued to focus on drinking water quality surveillance as well as operation and maintenance of water supply systems. A strategy for sanitation for high-risk communities has been introduced. Support continued to the National Arsenic Mitigation programme in Bangladesh. A Regional Consultation on Healthy City initiatives introduced a new implementation framework to address operational issues.

Environmental Health

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Activities connected with the sound management of hospital wastes were implemented in most countries. Assistance was provided to Indonesia on the problem of haze from forest fires. Air pollution monitoring activities were supported in Nepal, Bangladesh and Sri Lanka. Hazardous waste management surveys have been initiated in some countries. Regional consultations on promotion of chemical safety, poison control and pesticide poisoning database were conducted. The incorporation of health concerns into environmental management continued to be stressed. National action plans were developed incorporating health and development strategies in Bangladesh, Bhutan, Myanmar and Nepal. Eight countries (Bangladesh, Bhutan, Indonesia, India, Maldives, Myanmar, Nepal and Sri Lanka) have been officially certified as free from dracunculiasis. Most children in the Region are now covered against the six major childhood diseases. With the continuance of the National Immunization Days, more than 185 million children under five years have been immunized against poliomyelitis with more than 95 per cent OPV coverage. All countries have taken steps to ensure that the immunization coverage exceeds 80 per cent. The goal of neonatal tetanus elimination is within reach. Measles control measures were directed at managing the existing outbreaks and steps were taken to bring it into the Integrated Management of Childhood Illness (IMCI) programme. Considerable progress was made towards the elimination of leprosy. The population coverage with DOTS in the treatment of TB expanded from 95 million to 370 million during the reporting period. Treatment success rates remained high at approximately 77 per cent compared with the global target of 85 per cent. Regional guidelines for the prevention and control of dengue/DHF were developed and published, including simplified

Eradication/ Elimination of Specific Communicable Diseases

Control of other Communicable Diseases

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guidelines for case management in small hospitals. WHO supported independent reviews of the dengue/DHF prevention and control programmes in the countries. HIV/AIDS remains a major public health problem. WHO has played a proactive role in control measures through strengthening of the capacity of health systems, integration of HIV/AIDS prevention and control into primary health care, improving clinical management of AIDS cases, ensuring blood transfusion safety and disease surveillance. These efforts are leading to a declining trend in AIDS cases in Thailand. In the surveillance of communicable diseases, case definitions for 10 communicable diseases were developed in Sri Lanka and fieldtested in Myanmar and Indonesia. WHO supported the two-year field epidemiology training courses in Indonesia and Thailand, and supported a three-month training programme at the National Institute of Communicable Diseases, Delhi. Malaria continues to affect health and socioeconomic development in the Region. All Member Countries are committed to Roll Back Malaria. Synchronization of activities across the borders is increasing. WHO developed training modules for the treatment of severe and complicated malaria. An integrated approach for comprehensive vector control of diseases, is being promoted. Research studies supported by TDR focused on drug resistance in Myanmar and Thailand. Drug efficacy was monitored in Indonesia, Myanmar and Sri Lanka. Studies on lymphatic filariasis included the evaluation of the impact of mass chemotherapy with DEC and ivermectin in India, Myanmar and Sri Lanka. In the control of noncommunicable diseases, such as cardiovascular diseases, diabetes mellitus and cancers, efforts were made to increase public awareness and to strengthen programme management capabilities of PHC personnel.

The Work of WHO in SEA

Following the restructuring of the programmes at HQ, the Regional Office was reorganized to facilitate smooth coordination with HQ and country levels. Efforts continued to increase the participation of women in the work of WHO. For the 1996-1997 biennium, 100 per cent implementation of the Regular budget was achieved. During the first 18 months of the current biennium, which began with a 3 per cent reduction in the working allocation, 80 per cent implementation had been achieved.

Administrative Services

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Governing Bodies

Section 1

Governing Bodies The Fifty-first World Health Assembly, held in Geneva from 11 to 15 May 1998, elected Dr Faisal Radhi Al-Mousawi (Bahrain) as President, Mr J.Y. Thinley (Bhutan) as one of the Vice-Presidents, and Dr Nimal Seripala de Silva (Sri Lanka) as Chairman of Committee B. Bangladesh was elected to designate a person to serve as a Member of the Executive Board for a term of three years, to fill the vacancy created by one of the outgoing Members (Bhutan) from the South-East Asia Region on completion of its term. The Assembly appointed Dr Gro Harlem Brundtland as the Director-General of the Organization for a five-year term beginning 21 July 1998. It also debated the issue of regional allocations and adopted resolution WHA51.31. This resulted in a consensus for a compromise approach, which is substantially more favourable to the South-East Asia Region when compared with the earlier Executive Board proposal. The Fifty-second World Health Assembly was held in Geneva from 17 to 25 May 1999. The Assembly elected Mrs Maria de Belem Roseira (Portugal) as President. Mr S.U. Yussuf (Bangladesh) was elected as one of the Vice-Presidents and Dasho Sangay Ngedup (Bhutan) as one of the Vice-Chairmen of

World Health Assembly

The Work of WHO in SEA

Committee B. In addition, delegates from Bangladesh and Myanmar from SEA Region were included in the Committee on Nominations. India was elected to designate a person to serve as a Member of the Executive Board for a term of three years, to fill the vacancy created by one of the outgoing Members (Indonesia) from the South-East Asia Region on completion of its term. Technical and health matters discussed at the Assembly included active ageing, smallpox eradication, roll back malaria, WHO framework convention on tobacco control, poliomyelitis eradication, prevention and control of iodine deficiency disorders and cloning in human health. The Fifty-second Health Assembly held, for the first time, roundtable discussions on lessons learned in world health in which Ministers of Health from Member States participated. It reviewed the World Health Report 1999, the Director-General’ s Report on the Work of WHO and the reports of the 102nd and 103rd sessions of the Executive Board. The Assembly approved travel expenses for attendance at Regional Committees for one representative each of Member States who are categorized as a ‘ least developing country’ ; reviewed and approved the programme budget for 2000-2001 on the basis of zero nominal growth, but with the additional allocation of $15 million of casual income to five priority programmes; and reappointed South Africa as External Auditor for the bienniums 2000-2001 and 2002-2003. It also decided not to pursue proposed amendments to the WHO Constitution.

Executive Board

The 101st session of the Executive Board was held in Geneva from 19 to 27 January 1998. Among the important items covered in its 22-point agenda, were: Consideration of the draft global health policy for the 21st century, WHO reform,

The Work of WHO in SEA

and Nomination of a new WHO Director-General. It reviewed the two separate reports of the special group on the review of the Constitution of WHO (Articles 2 and 73 of the Constitution), and passed 26 resolutions. The critical issue of regional allocations was also reviewed, and the Board recommended to the World Health Assembly adoption of an approach which, if not modified, would have resulted in substantial reductions in Regular budget funding for the South-East Asia Region, starting in 2000. The 102nd session of the Executive Board was held in Geneva on 18 and 19 May 1998. It considered a number of mostly procedural issues. This session also further reviewed the formula to be used as a factor in the allocation of resources among regions. The 103rd session of the Executive Board was held in Geneva from 25 January to 3 February 1999. Among the important items covered were: Revised drug strategy, Tobacco free Initiative, and Poliomyelitis eradication. It also reviewed the role of the Executive Board and the proposed programme budget for the financial period 2000-2001, and adopted 19 resolutions. In addition to establishing an Audit Committee, the Executive Board considered the reforms of the Health Assembly. It recommended (EB103.R19) that the Health Assembly evaluate the interim arrangement with a view to revising the arrangements for the conduct of its proceedings at subsequent Assemblies. The 104th session of the Executive Board, which was held in Geneva on 27 May 1999, considered a number of mostly procedural issues. This session also reviewed research strategies and mechanisms for cooperation, rules of procedure of EB on election of Chairman, financial regulations and rules, and administration and award of foundation prizes and fellowships.

The Work of WHO in SEA

Regional Committee

Two meetings of the Regional Committee of the WHO SouthEast Asia Region were held in the period under review: the fiftieth session was held in Thimphu, Bhutan, from 8-12 September 1997, and the fifty-first session in New Delhi, from 7-11 September 1998. At the fiftieth session, the Regional Committee reviewed the report of the Regional Director covering the period from 1 July 1995 to 30 June 1997. It noted the progress made in the implementation of the WHO collaborative programmes in the Region. The report reflected a steady improvement in the health status of the people in the countries of the Region. A declaration on Health Development in the South-East Asia Region in the 21 st Century was endorsed by the Committee. The Committee endorsed the recommendations made during the Technical Discussions on Health Sector Reform. The Committee urged the Member States to explore effective strategies for political and administrative management of the process and content of the health sector reform through involvement of policy-makers, providers of health services and the public. The fifty-first session of the Regional Committee was preceded by a function to celebrate WHO’ s fiftieth anniversary in which, apart from the Director-General of WHO, Ministers of Health of Bhutan, DPR Korea, India, Indonesia, Myanmar, Nepal and Sri Lanka participated. They felicitated WHO on its achievements in the promotion of health, prevention and control of diseases and for its continued technical support and cooperation to the Member States. The Director-General, Dr Gro Harlem Brundtland, in her address, asserted WHO’ s continued role as the centre of excellence for providing norms and standards, supporting national capacity building and innovative approaches for health development. A well-organized cultural programme, presented by the Member Countries of the Region, formed part of the celebration.

The Work of WHO in SEA

The Regional Committee nominated Dr Uton Muchtar Rafei as Regional Director of the South-East Region of WHO for a second term of five years with effect from 1 March 1999. On her first visit to the Region as Director-General, Dr Brundtland informed the Committee of the Organization’ s commitment to Health for All. She stressed the need for intersectoral collaboration, involvement of other UN agencies, international financial institutions, civil societies and private sectors for coordinated efforts in health development. The Committee considered the report of the Regional Director covering the period 1 July 1997 to 30 June 1998 and expressed its appreciation of the progress made. It acknowledged the new reforms undertaken by the DirectorGeneral concerning new concepts of programme clustering and budget preparation and noted the proposed programme budget for 2000-2001. Recognizing the need for intensifying action on priority health challenges brought out in the Director-General’ s statement, among others, Roll Back Malaria and Tobacco Free Initiative, the Committee urged Member States to intensify timebound action on priority health issues affecting the Region. The Committee adopted an important resolution on the method of work of the Regional Committee. It decided that, starting with the fifty-second session of the Regional Committee, the Consultative Committee on Programme Development and Management (CCPDM) will review the programme budget, including biennial country and intercountry programme proposals, and periodic programme implementation, at its meeting preceding the Regional Committee session. CCPDM will also review reports by country representatives attending meetings of the coordinating bodies of global programmes, and hold Technical Discussions.

The Technical Discussions were devoted to “ Partnerships for health development with the focus on women’ s health and

The Work of WHO in SEA

development” . The Committee adopted a resolution urging Member States to integrate a gender perspective into health policies and programmes in order to effectively address women’ s health issues and women’ s access to quality health care throughout their life span. They were also requested to make optimal use of national and international institutions, WHO collaborating centres and nongovernmental organizations to foster gender-sensitive advocacy and development, and to ensure increased participation of women in national health development, especially at policy formulation and decision-making levels.

The Work of WHO in SEA

Health Policy and Management

Section 2

General Programme Development and Management The WHO collaborative programme at country, intercountry and regional levels was implemented through active participation of the national authorities, WHO country offices and the technical units in the Regional Office. The programme for 1998-1999 achieved a financial implementation rate of 61 per cent during the first twelve months of the biennium. Management of programme budget was also facilitated through the implementation of supplementary intercountry programmes which addressed common priority issues of the countries. As part of the WHO reform process, the Regional Office reorganized the programme planning and management areas under a separate unit named as Managerial Process for WHO’ s Programme Development (MPW) Unit. The Unit provided support to the technical units and the country offices in the development, implementation and evaluation of the WHO collaborative programmes. A series of briefings on the WHO managerial process was initiated. A Regional Workshop on Programme Development and Management was held for nationals and staff of the WHO

Managerial process for WHO’ s programme development

The Work of WHO in SEA

country offices and the Regional Office. Meetings of the Consultative Committee on Programme Development and Management (CCPDM), the Regional Committee and the meetings of the Regional Director with the WHO Representatives provided guidance and direction for improving programme formulation and their implementation. The collaborative programmes were also reviewed in erms t of their relevance, quality and effectiveness. It was noted that adequate designing of the expected result and activity, close follow-up of implementation and frequent dialogues with the nationals were necessary for improving the qualitative aspects o f programme implementation. The Regional Office is closely monitoring these aspects of programme preparation and delivery. Country evaluation exercises were conducted in five countries. They reflected WHO’ s technical support to countries and proved to be very useful. A new initiative called Joint Programming Initiative (JPI), with the participation of concerned government officials and WHO country staff, was launched to prepare plans of action for 2000 2001. Country and intercountry programmes were develope d through consultative and participatory approaches.

WHO response to global change

The reform measures arising out of WHO’ s response to global change were geared to improving the efficiency, accountability and transparency in the work of the Organization. The programme budget for 2000 -2001, noted by the Regional Committee at its fifty-first session, was submitted to the Executive Board at its 103rd session and approved subject to modifications in format. The document has now been adjusted. In so doing, the objectives, targets and expec ted results were sharpened to reflect an integrated programme approach. As part of the reform process and in accordance with the decision of the fifty-first session of the Regional Committee, a

The Work of WHO in SEA

working group on internal efficiency of the regional and country offices was established. A progress report on the work of the working group is expected to be submitted to the fifty -second session of the Regional Committee. Staff development and training continued to be an integral part of General Programme Developm ent and Management. This helped to ensure enhancement of the skills of staff through education and training programmes. A major policy decision was taken to limit the number of extra-regional individual training proposals. It was decided, instead, to concentrate on broad-based group training programmes which would benefit a larger number of staff members and ensure optimum utilization of scarce resources. As a result of a training needs assessment exercise, Department Directors and other staff attended trai ning programmes to strengthen drafting and writing skills, communication skills, presentation skills, speed-reading, speechwriting etc. With the filling of the post of Briefing/Training Assistant, briefing of staff members has been streamlined. Attentionwill be paid to developing briefing and training programmes for both Professional and General Service staff. The Regional Health Declaration (RHD), adopted by the fifteenth meeting of Ministers of Health, was subsequently endorsed by the Regional Committee. The Committee urged the Member States to further adapt and integrate the policy guidance provided by it in their national health policies and plans. On the basis of the recommendations relating, inter alia, to advocacy for health, and the ownership of R HD, made by a

Staff development

Renewing the Health-for-All strategy

The Work of WHO in SEA

Regional Consultation and the Third Meeting of Health Secretaries, a plan of action for implementing the Regional Health Declaration was prepared. It was considered and endorsed by the 33rd meeting of CCPDM. The Health Ministers, at their sixteenth meeting in September 1998, recommended that a time-bound action programme for accelerating the process of incorporation/adaptation of the principles and policy guidance of RHD in national health policies and plans be developed.

Management and support to information systems

The Regional Office standardized its common operating software for Server and Desktop environments. The Informatics infrastructure at most of the WRs’ offices in the Region was upgraded according to a standardized Network Design.Regular training programmes were conducted forRegional Office staff on the use of the new software. Reorganization of the group of servers in SEARO was initiated and the transition from Novell Netware Server to Windows NT 4.0 platform completed. The SEARO Local Area Network (LAN) was upgraded in the first of two phases, substantially boosting the speed of accessing selected servers. Phase II will concentrate on a general redesign to meet increased infrastructure requirements envisaged in the 21st century. The possible repercussions of the Year 2000 (Y 2K) problem in the Regional Office were studied. Steps were initiated to ensure Y2K compliance of in-house computer applications and systems, as well as other computer -influenced equipment. Internet access was enhanced, and migration to an improved E-mail system initiated. As a first step towards establishing Regional Office presence on the Internet, an experimental web site was developed and launched within the office in September 1998.

The Work of WHO in SEA

Development of the regional Activity Management System (AMS) software continued to extend its application beyond financial monitoring to activity monitoring. A Technical Working Group was formed to develop: Guidelines for Activity Monitoring; a Glossary of AMS terms; Business Rules for use of AMS for Monitoring, and a limited number of reports satisfying office-wide needs. A Help Desk Management System was developed to monitor responses to calls and thereby improve efficiency and quality of help desk services. In collaboration with WHO headquarters, enhancements were made to the RO/AFI system (payments). A Catalogue Management System, Vacancy Tracking System, and Library Information Management System were the other applications developed in the Regional Office. Pilot implementation of a Document Management System (DMS) was initiated in one department for workflow management and, in another, for document archiving.

The aim of this programme is to respond to urgent requests for help from countries of the Region in emergency situations. In addition, this programme also provides e s ed funding for innovative health initiatives at both country and intercountry levels. During the reporting period, support was provided to: Bangladesh and Myanmar in the form of medical supplies for tackling emergency situations due to floods and disaster s; Bhutan for partial support for the Health Telematics Project (with contribution also from the Director-General); DPR Korea for supplying essential drugs to meet the shortage caused by natural disasters; India for supplying emergency drugs for implementi ng the revised National Tuberculosis Programme; Indonesia for emergency supply of portable monitoring equipment to deal with the consequences of forest fires, and strengthening of a polio laboratory in Surabaya; Maldives to cover activities relating to thalassaemia and health awareness campaign by the Society for Health Education; Myanmar to strengthen the infrastructure of

Regional Director’ s Development Programme

The Work of WHO in SEA

the Institute of Community Health, Aungsan; Nepal to strengthen the activities of the Nepal Nursing Council; and Thailand to promote activities of Mae Chan Hospital, Chiang Rai, in combating HIV/AIDS.

Coordination with other organizations

WHO continued its initiative on strengthening collaboration and partnership with United Nations agencies. It participated in the pilot exercise to test the UN Development Assistance Framewo rk (UNDAF), which is being designed to promote a coherent programmatic response by the UN system to national development priorities. The Regional Office took part in the UNDAF pilot exercise in India and provided technical inputs to its formulation process within the framework of the Resident Coordinator System. WHO continued to execute UNDP -funded projects in Bangladesh, Myanmar, Nepal and Sri Lanka. National programmes in Primary Health Care, Prevention and Control of HIV/AIDS and Human Resources Developm ent for Water and Sanitation were supported through these projects. WHO also closely collaborated with UNICEF and UNFPA. The WHO/ UNICEF/UNFPA Coordination Committee on Health (CCH) provided the policy guidelines for joint action among these three agencies. WHO participated in the meeting on Safe Motherhood and Maternal Mortality Reduction, organized in March 1999 by the UNICEF Regional Office for South Asia. The Regional Office conducted studies on the probable implications of the Agreement on Trade -Related Aspects of Intellectual Property Rights (TRIPS) and the General Agreement on Trade in Services (GATS), on the Health Sector. These subjects were discussed at the Fourth Meeting of Health Secretaries, held in New Delhi in February 1999. The meeting recommended the establishment of a Focal Point or a Working Group in the ministries of health to deal with matters relating to

The Work of WHO in SEA

the WTO Agreements and convening of an intercountry meeting by the Regional Office to consider possible measures to safeguard health interests. WHO continued its collaboration with ASEAN in the areas of health and nutrition, STD/AIDS, tuberculosis control, pharmaceuticals and disease surveillance. WHO supported the participation of Myanmar as a member of ASEAN at the Planning Meeting for the Implementation of Roll Back Malaria in six Mekong countries, held in Vietnam in March 1999. WHO participated in the 16th Meeting of the ASEAN Sub-Committee on Health and Nutrition at Brunei, in September 1998. While a MoU between SAARC and WHO for mutual cooperation was under process, WHO continued to collaborate with the SAARC Regional Tuberculosis Centre in Nepal. WHO supported the SAARC Parliamentarians Meeting on Reproductive Health and HIV/AIDS, held in Kathmandu, in May 1998. An International Conference on Intercountry Cooperation for Health Development (ICHD) in the 21 st Century was jointly organized by the Governments of Indonesia and Thailand in Chiang Mai, Thailand, in December 1997 with technical and financial support from WHO. The Organizatio n also supported the follow-up Country Process Coordinators’Meeting in Bali in November 1998. The priority subject areas chosen to start the ICHD process were: women and reproductive health; early childhood development; emerging and re -emerging infectious diseases; health policy systems research; pharmaceuticals; traditional medicine; nutrition and general child health. WHO continued its collaboration with the Asian Development Bank in various national health development programmes. WHO also had a fruitfulpartnership with ADB in Indonesia which intensified further in the wake of the economic crisis.

The Work of WHO in SEA

WHO participated in the ESCAP meeting of the Expert Group on Regional Implementation of the Beijing Platform for Action as well as the Fifty-fifth Session of ESCAP, held in Bangkok in April 1999. WHO continued to participate in meetings of the Regional Interagency Committee for Asia and the Pacific (RICAP), RICAP sub-committees and in other high-level meetings of ESCAP. The Regional Office took part in the ESCAP Regional Meeting on Social Issues Arising from the East Asia Crisis and Policy implications for the Future, held in Bangkok in January 1999. WHO contributed to the Fifth Compendium of the United Nations Programme on Rural Poverty Alleviation, 1998-1999, and also organized a meeting on Health and Poverty in Bangladesh in April 1999. The meeting was attended by representatives of the ministries concerned, a cross -section of NGOs and development-related institutions. WHO had fruitful collaboration with a number of NGOs in the Region, such as Rotary International, Nippon Foundation and Lions International. In addition, WHO worked closely with AMDA International, Japan, to strengthen the professional capacity of the grassroot -level health care providers and heal th institutions in some areas in Myanmar. WHO also collaborated with Medecins du Monde (MDM) in the HIV/AIDS prevention and control programme in Myanmar. The Organization is now formulating a strategy on renewed relations with NGOs to broaden the scope of its collaboration in support of health development.

Mobilization of external health resources

WHO executed 22 components of the World Bank Consortiumfunded Fourth Population and Health Project in Bangladesh, which was completed in June 1998. WHO collaborated with the World Bank and the Government of Bangladesh in the formulation of the Health and Population Sector Programme

The Work of WHO in SEA

(HPSP), which became operational from July 1998. A Memorandum of Understanding (MoU) was signed between the Government of Bangladesh and WHO for technical cooperation in the implementation of this programme. The Government of Japan supported National Immunization Days in the Region, as well as activities aimed at the control of Iodine Deficiency Disorders (IDD) in Bhutan and Myanmar. The Norwegian Agency for Development Coopera tion (NORAD) supported the polio eradication and the national TB Control programmes in Nepal. WHO also worked closely with Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ) and DANIDA in various health development programmes. Through WHO, AusAID made a significant financial contribution to the TB Control Programme in Indonesia. WHO facilitated the visit of the Health Minister of Bhutan to various donor countries and funding institutions to mobilize financial support to the Bhutan Trust Fund. WHO participated in the Pre-Round Table Consultations, held in Colombo in March 1999, for the Sixth Round Table Meeting between Maldives and its Development Partners, to be held in Geneva.

A National Workshop on Aid Coordination was organized in Myanmar as part of WHO’ s efforts to strengthen national capacity for aid negotiation, coordination and management in the health sector. WHO’ s other initiatives in this area include intercountry workshops on different aspects of mobilization of external resources for health , which are planned to be organized during 1999. In support of innovative activities, WHO co-financed with the UK Department for International Development (DFID) and GTZ,

The Work of WHO in SEA

a National Workshop for Sectorwide Approach to Health Sector Development in Nepal. The Regional Office has developed a database on Donors’ Profile to assist the ministries of health in mobilizing external resources. Copies of the profile have been provided to the WRs and concerned national authorities.

Health Ministers’ Meeting

The Fifteenth and Sixteenth Meetings of Ministers of Health of SEAR countries were held in August 1997 and September 1998 in Bangkok and New Delhi respectively. The Fifteenth Meeting adopted the Regional Health Declaration, which would serve as the basis of future health development in the Region. At their Sixteenth Meeting, the Ministers deliberated upon national capacity-building for primary health care; strengthening school health programmes, and promotion and participation of traditional medicine in primary health care. They made far reaching recommendations for health development in these areas. The Ministers also reviewed the progress in the implementation of the Regional Health Declaration; prevention and control of communicable diseases, particularly in the border areas; and intercountry cooperation in the field of drugs and pharmaceuticals, particularly in the wake of the economic crisis. The Third and Fourth Meetings of Health Secretaries were held in February 1998 and February 1999 in Bangkok and New Delhi respectively. At the Third Meeting, the Secretaries reviewed the actions taken on the conclusions and recommendations of their Second Meeting and the Fifteenth Meeting of Ministers of Health. Among other issues, they deliberated on WHO collaboration with

Health Secretaries’ Meeting

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Member States in the Region and the regional implications of the important decisions/resolutions of the 101st session of the WHO Executive Board, particularly the regional allocation of the WHO Regular budget. They expressed grave concern over the formula presented at the 101st session of the WHO Executive Board, and, inter alia, decided to take a well-coordinated stand on it at the Fifty -first World Health Assembly. The outcome has been very gratifying: the cut for the three bienniums beginning 2000 -2001 for SEAR would be about US $10.9 million as against US $48 million on the basis of the Executive Board model. Further, the five least developed countries of the Region and DPR Korea (the country in greatest need) would not suffer any decrease in their budget over the1998-1999 level. At their Fourth meeting, the Health Secretaries reviewed the actions taken on the recommendations of their Third Meeting and the Sixteenth Meeting of Ministers of Health. They also reviewed the joint government/WHO collaborative programme during 1998 -1999, and discussed the implications of Trade related Aspects of Intellectual Property Rights (TRIPS) on the health sector in the Region.

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3 Leadership for health

Health, Science and Public Policy To further strengthen leadership for health, the Regional Office, in cooperation with Member countries, organized a series of consultative meetings on health development in the Region. These meetings involved senior gov ernment officials and a wide range of experts for the health and health -related sectors, including NGOs. These meetings culminated in the adoption, at the Fifteenth Meeting of Ministers of Health, of the Regional Health Declaration, which is based upon the principles of basic human rights, equity and social justice and the centrality of health in sustainable development. The Declaration identifies the major future health challenges and commends policy actions in support of health development. A plan of action, adopted by the 34th meeting of CCPDM, held in September 1998, called for endorsement of the Declaration at the highest level of the government. It also called for integration of its principles and policy guidance in health policies and plans and their operationalization through national plans of action. The Health Ministers, at their sixteenth meeting, emphasized the need to develop a time -based action programme for accelerating the process of implementing the Declaration. Annual meetings of Health Ministers and Health Secretaries of SEAR countries have greatly contributed to enhancing

The Work of WHO in SEA

leadership for health. Institutionalization of the annual meetings of Health Ministers into a Health Ministers’ Forum, with a chairman for the whole year, has great potent ial for enhancing leadership for health. The WHO programme on Women, Health And Development (WHD) intensified its efforts over the past two years to promote approaches that address specific women’ s health issues across the life span, not in isolation but linked to the context of women’ s lives and their vital role in development. As a result, greater attention has been focused on gender issues and inequalities that adversely affect women’ s health and their access to health care. Such advocacy efforts have n i cluded wide dissemination of information materials and the production of a video presentation: “ Women’ s Health in South-East Asia: A Time for Action” . The preparation of WHD country profiles, in collaboration with multidisciplinary and multisectoral teams in countries under the coordination of national focal points, has provided a means to address WHD information needs and the importance of disaggregating data by sex, age and other relevant factors. These country profiles were used in the Regional Health Report 1998: Focus on Women. They are also the basis for a comparative analysis of women’ s health and development in the Region, to be published later in 1999. Attention has also been focused on previously neglected issues affecting women’ s health. A Region al Consultation on Violence Against Women and the Role of the Health Sector was held in Yangon, in January 1999. The Consultation provided an opportunity for participants from governments, NGOs and UN agencies to discuss the situation in countries and to propose priority areas for health sector action in the prevention and management of violence against women.

Women, health and development

The Work of WHO in SEA

A significant highlight of WHO’ s collaborative programme on WHD has been the establishment of a separate technical unit in the Regional Office. The unit will help enhance technical support to country and regional initiatives related to women’ s health and development and to gender mainstreaming in WHO and national health policies and programmes. This new thrust on gender mainstreaming was endorsed by th e Regional Committee at its fifty-first session in 1998 when it adopted a resolution on “ Partnerships for Health Development with the Focus on Women, Health and Development.” Follow-up action is already under way for the development of a resource package o n gender mainstreaming specific to health and relevant to the SEAR context. Steps have been taken in countries to give more attention to women’ s health issues and to incorporate a gender perspective in national health programmes. Actions have included the development of a gender strategy for the health sector in Bangladesh, training of women leaders and women’ s groups in India and Myanmar, and the use of gender analysis in health interventions in Indonesia. However, national capacity for integrating gender and WHD perspectives and for continued collection, analysis and use of sex-disaggregated data needs to be strengthened in order to ensure that gender concerns and WHD issues, especially emerging ones, are identified and addressed.

Health legislation, ethical dimensions of health care and bio-ethics

WHO, in collaboration with the Indian Law Institute, organized an International Conference on Global Health Law in New Delhi from 5-7 December 1997. The Conference endorsed the Declaration on Global Health Law, which explicitly spells out the role of Member States and WHO in prom oting health legislation for the development of a national health policy in line with the principles of Health for All and national values.

The Work of WHO in SEA

The Declaration on Global Health Law and the Conference proceedings were widely distributed to all Member States, al l regional offices and headquarters for their information and further action.

The regional research programme focused on three interlinked areas, namely research promotion and development, research capability strengthening, and health systems research pro motion. Improvement of health research management in SEAR countries remains the overall goal. Following the Regional Workshop on Research Management in South-East Asia, held in Surabaya in August 1997, some countries organized, in 1998 and 1999, national w orkshops on health research management (Sri Lanka and Myanmar) and on health research prioritization (Nepal and Indonesia). Greater emphasis was placed on bringing WHO collaborating centres and national centres of expertise into the mainstream of WHO progr amme implementation. Another important strategy was bringing research scientists and research policy advisers together. The South -East Asia Advisory Committee on Health Research (SEA -ACHR) and the Directors of Medical Research Councils (MRC) or analogous bodies met at their first joint session in Colombo in April 1998. Greater collaboration between these two important bodies was fostered and coordination of research activities supported by countries and WHO strengthened. At this meeting, separate working groups deliberated on: (1) formulation of national health research policies and strategies; (2) management of health research information; (3) criteria for setting health research priorities; and (4) mechanisms for coordination of health research activities in the countries.

Research policy and strategy coordination

The Work of WHO in SEA

As a follow-up, a meeting of chairpersons of scientific working groups in these four areas was convened in the Regional Office in December 1998. This meeting charted the way for the development of guidelines in these areas suitable for th is Region, in effect aiming to balance regional specificity with normative work. The Research Development Committee of the Regional Office recommended that different WHO collaborating centres and national centres of expertise be given the task of managing three (of the four) research management areas deliberated on at the joint session with WHO support. The Collaborating Centres identified are: the Centre for Health Systems Research and Development, Surabaya, (Formulation of national health research policies and strategies); the Indian Council for Medical Research, New Delhi (Criteria for setting health research priorities); and the College of Public Health, Chulalongkorn University, Bangkok (Mechanisms for coordination of health research activities in the countries). The 24 th session of SEA-ACHR, organized in Yangon in April 1999, carried these developments further. Important recommendations relevant to this Region were made in the areas of research on HIV-AIDS, the role of vaccine research in disease prevention and control in the 21 st century and the contribution of health research to evidence-based policy and decision-making. The SEA-ACHR also noted the recommendations made by the Committee since its inception in 1976. Results of an evaluation of the region al research programme, carried out in the latter part of 1998, were reported to the 24th session of SEA-ACHR. Consisting of desk review and analysis, the evaluation covered health research promotion and development, research capability strengthening and he alth systems research promotion. Furthermore, a strategic review of policies and strategies to support WHO in health research, initiated by WHO headquarters in 1999, was provided with regional insight, by the 24 th SEA-ACHR and through the

The Work of WHO in SEA

deliberations of the external expert (as well as internal) working group formed for that purpose by the Regional Office. The evaluation of the regional research programme as well as this comprehensive research policy review, currently under way, will form an important basi s for future activities. The fifth volume of Research Abstracts – South-East Asia Region was published and disseminated to a wide range of health professionals. The publication covers 45 WHO -supported research projects completed since the publication of Vo lume 4 in 1993. The areas covered are: malaria and other vector -borne diseases; human resources for health; health systems research; nutrition; health laboratory technology in noncommunicable diseases; information, education and communication; communicable diseases; maternal and child health; health systems development; health of the elderly; noncommunicable diseases; traditional medicine; mental health; expanded programme on immunization and environmental health. In addition, a number of commissioned resea rch studies have been undertaken.

The Work of WHO in SEA

National Health Policies and Programme Development and Management Support to development, management and coordination of country programmes Support was provided to the countries in the formulation of national medium and long-term health plans and in the formulation of national health policies and strategies. Bangladesh, Bhutan and Nepal, for instance, were assisted in formulating their respective health components of the medium term and long-term plans. Likewise, support was also provided in the formulation and development of projects funded by bilateral and multilateral agencies in various countries. Subsequent to the International Conference on Intercountry Cooperation in Health Development, held in December 1997, efforts have been made to strengthen the existing mechanisms for controlling emerging and re -emerging infections and to identify new mechanisms and networks for health policy, health care reforms, environmental health and disaster preparedness and management. A Regional Consultation on International Health Development was organized in November 1998 in Bangko k to,

Technical cooperation among countries

The Work of WHO in SEA

among other things, develop capacity building on international health development to optimally contribute to and gain from international cooperation. Based on the recommendations of the meeting, a curriculum for the training of health professionals responsible for international health is being developed by the College of Public Health, Chulalongkorn University, Bangkok. This will be a regional training programme to be utilized by all Member States. A Regional Training Programme on Health Planning and Management is being developed in collaboration with the Faculty of Public Health, University of Indonesia. Mid-level and senior health professionals from public and private sectors are expected to benefit from this training programme. In addition, in the spirit of TCAC (Technical Cooperation among Countries), countries in the Region have been providing seats for training in public health, economics, medicine, nursing and paramedical training institutes. They are also collaborating in building, equipping and even running of referral hospitals; jointly controlling diseases, such as malaria and polio , and working for general health development. A National Seminar on Meeting the Health Needs of the Poorest and the Most Vulnerable was organized in April 1999 with support from the Government of Bangladesh. The Seminar covered viable experiences involving local authorities and communities in protecting the health of the poor. Successful strategies for using health as an entry point for reducing poverty and the best ways to provide health services to the poorer sections of the population were identified. In addition, under intensified cooperation with countries and peoples in greatest need, support was provided to Bangladesh in the preparation and finalization of the Fifth Health and Population Programme. Myanmar was supported in the area of health care financing. A revised work plan, based on discussions between the Director -

Collaboration with countries and peoples in greatest need

The Work of WHO in SEA

General, Ministry of Health, Myanmar, and WHO headquarters, is being finalized. Support was pr ovided to the Royal Institute of Health sciences, Thimphu, for strengthening the production of an appropriate mix of health manpower. An additional support of US $ 141 000 within the plan of action for the 1998 -99 biennium, is being sought. Further, with f inancial support from WHO headquarters, the booklet on Bhutan Trust Fund was translated into Japanese to facilitate resource mobilization.

Procurement services (excluding drugs, biologicals and contraceptives)

The Medical Supply Unit in the Regional Office provided equipment and essential supplies in support of WHO collaborative programmes, funded from the Regular budget as well as other sources. As part of WHO’ s Global Programme on Eradication of Poliomyelitis, laboratory equipment and supplies were provided to all countries of the Region. The Medical Supply Unit undertook reimbursable procurement for Member States, UN agencies and organizations in official relations with WHO under several programmes .

Emergency and humanitarian action; relief and rehabilitation operation and emergency preparedness programme

During 1997 and 1998, five countries of the Region reported seven major emergencies and disasters, besides a number of minor events. In 1998, 4 606 000 persons were affected due to cyclones in India, with approximately 10 000 dead and a very large number injured. In the same year in Bangladesh, approximately 30.6 million people (38 per cent of the total population) were affected due to floods, which claimed 918 lives. In DPR Korea, economic constraints, further precipitated by a series of natural disasters since 1995, affected 60.4 per cent of children with moderate and severe malnutrition amongst the surveyed group. Approximatel y 200 per 100 000 population are estimated to be suffering from TB. In addition to the WHO

The Work of WHO in SEA

0Regular budget, extra funds were mobil .ized to meet public health needs. During 1997, US $ 563 000 was mobilized from the Government of Sweden in response to the UN a ppeal for 1997 , and during 1998, a total of US $ 1 224 000 came from the Government of Norway and Sweden. The funds are being used for strengthening surveillance systems, control of communicable diseases, including TB and the EPI Programme, and for strengthening laboratories, including polio laboratory. A WHO-EHA office has been opened in Pyongyang in order to provide technical advice to the national authorities, nongovernmental organizations, other UN agencies and to strengthen linkages with the different agencies. The haze from the forest fires in Indonesia had significant social and economic effects on the people living in the affected areas, not only in Indonesia but also in the neighbouring countries. In order to support the Member Countries, in the area of emergency and humanitarian action, a multi-pronged approach was developed. This included building regional consensus; developing a forum for sharing of knowledge and experiences among institutions within and between Member Countries; supporting the Member Countries through the WHO Regular budget and mobilizing extrabudgetary resources.

The Work of WHO in SEA

Biomedical and Health Information and Trends Epidemiology, statistics, trend assessment and country health information Countries in the Region, supported by the intercountry Health Situation and Trend Assessment (HST) programme, continued their efforts to improve national health information systems H ( ISs). To strengthen morbidity and mortality data, a training course on the Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems (ICD -10) was developed by the National Centre for Classification in Health, a WHO Collaborating Centre in Australia. The institutionalization of this English-language course is being supported in a few countries. The pilot testing of the course was completed in November 1997 in Thailand. In early 1999, an intercountry course was also held in Myanmar. Activities were also initiated to extend the course to Sri Lanka. This course has been very well received although its institutionalization has not yet been fully realized. To further strengthen morbidity data, a short course in basic medical records practice has been designed, also with the assistance of the WHO Collaborating Centre in Australia, for countries of the Region which have little or no formal training for medical records staff. The first such course was conducted in Myanmar in 1998. It is anticipated that this training will be institutionalized in a few SEAR countries.

The Work of WHO in SEA

The application of health futures methodologies is being used to strengthen HISs and their contribution to national planning processes. Another innovative appr oach recently promoted in South-East Asia is the DALY methodology, for measuring the burden of disease. The results of the third evaluation and other sources of health data were compiled and analysed in the Health Situation in South-East Asia, 1994-1997, which was completed in the first half of 1999. The global HST programme was reviewed by the Management Development Committee in WHO headquarters in October 1997; this was followed by an in-depth assessment at global, regional and country levels during the first half of 1998. At the same time, the intercountry HST programme in the Region was evaluated by the Regional Office. Specific HST products included for review were the English-language ICD-10 training courses and the HFA monitoring and evaluation exercises. These products were assessed for their relevance to WHO and national programmes, as well as their effectiveness in strengthening HISs at the country level. The findings from these evaluation exercises were used as inputs for the intercountry and country HST programmes for 2000 -2001. Improvement of scientific communication, production of documents and publications, translation of WHO publications into national/local languages and promotion of the sale of WHO publications continued to be the main activities during the period under review . Production of books and publications continued. Eleven new titles were issued under the SEARO Publications series. Two issues of the Regional Health Forum were brought out. Among the non-serial publications, Volume 21 of the Dengue Bulletin and the Regional Health Reports, 1997 and 1998 were issued. Non-priced documents, including reports of various kinds, were

Publishing, language and library services

The Work of WHO in SEA

produced and distributed. Documentation of the Regional Committee, including the report of the meeting and of the Technical Discussions was issued. The second volume of the Handbook of Resolutions of the Regional Committee was updated in November 1998. The loose-leaf list of technical documents issued since 1979 was periodically updated. Lists of documents received from WHO headquarters and other regions and distributed by the Regional Office were issued. World Health Assembly and Executive Board documents were received and distributed to the staff and the general public. Selected staff of the Regional Office were g iven training on report-writing at a workshop organized in August 1998. Translation of WHO publications into regional/local languages helped to make them easily available to health workers and the general public. The languages included Bahasa Indonesia, Bengali, Korean and Thai as well as several major Indian languages. The Regional Office participated in four book fairs. Reprint rights were granted to commercial publishers for low -cost local editions of 28 titles, including four SEARO publications totalling 20 000 copies. Permissions were granted to pharmaceutical firms to print and distribute for free 136500 copies of eight WHO publications (including one Regional Office publication) to doctors in India. Table 1 gives the sales figures for WHO publications for 1997 and 1998: Table 1. Sales of WHO publications, 1997 and 1998 1997 US$ 258,091.59 1998 US$ 110,230.22 July 1997– May 1999 US$ 256,356.12

Item Subscriptions and sales of publications

Note: The above figures represent actual receipts after deduction of all discounts and application of the concessional conversion rate of Geneva cover prices to Indian Rupees.

The Work of WHO in SEA

Work on the development of the electronic document database continued. Under this activity, important WHO policy papers, such as World Health A ssembly, Executive Board and Regional Committee documents, as well as reports of consultants and regional meetings are placed on LAN for users in the Regional Office. The Regional Office Library continued to provide comprehensive technical information and literature support to WHO staff members, WRs’ offices and Member States. More information in electronic format as well as additional bibliographic and full-text databases have been added to the collection. Library news and newsletter have been distributed in electronic format to WHO staff members, WRs’offices, HELLIS (Health Literature, Library and Information Service) network libraries and Member States in order to promote the most cost-effective utilization. Special attention was given for optimal utilization in sharing resources among HELLIS network libraries. Index Medicus for South-East Asia (IMSEAR) on CD-ROM for both Windows NT and UNIX operating system was developed. The Library has also been providing its Web-based information services through library Intranet and Internet servers. To facilitate the exchange of information, ideas and experiences at the regional level, development of a HELLIS forum or e -mail discussion groups was initiated among network members.

The Work of WHO in SEA

Health Services Development

Section 3

Organization and Management of Health Systems based on Primary Health Care The partnership with the Council for Health Research and Development (COHRED) was strengthened through joint activities. The countries of this Region have been sensitized to the need for health systems research. Health systems research activities and capabilities are closely linked to COHRED’ s concept of essential national health research. Nepal, for instance, conducted a national exercise in research prioritization to conduct essential health research, in 1998 . Indonesia has undertaken a similar exercise in 1999 . The first joint session of SEA-ACHR and MRC recommended that the main health challenges outlined in the Regional Health Declaration (RHD) be considered as the basis or f developing a regional health research agenda for the 21 st century. In this context, WHO-funded research projects completed during the period 1993 -1998 , were analysed in terms of priority challenges outlined in RHD. Most projects were found to address ex isting or anticipated health challenges. Also, the number of completed projects was observed to be broadly balanced between biomedical and programmatic objectives. However, the policy research area had not received due attention.

Health systems research and development

The Work of WHO in SEA

Inter-programme linkages o f r health systems research were strengthened by frequent meetings of the Research Review Committee, which assesses research proposals from an inter disciplinary point of view. Also, the Committee recently assessed reports of completed projects and provided valuable feedback. An evaluation of the regional research programme, conducted in an integrated way in the latter part of 1998 , included health systems research activities. This analysis - as well as the comprehensive research policy review currently bein g conducted by headquarters –will provide an important basis for future activities. An informal working group on health sector reform was established to review and monitor the progress made on reforms by the Member States. Subsequent to the development o f a common framework on country profiles for health sector reforms, six countries have prepared draft profiles while three others are in the process of preparing the same. Once the profiles are finalized, a regional analysis would be carried out and a synthesis put on the Web site. Under the Fifth Health and Population Programme in Bangladesh, efforts are being made to reorganize the Ministry of Health and Family Welfare. The focus is on integrating health and family planning programmes to provide “ one stop ” health and family planning services to the people at the outreach level. Similarly, with support from the World Bank and WHO, India has been implementing the State Health Systems Development Project in six states. This is aimed primarily at strengthening their capabilities in strategic planning and management and in improving overall health care delivery system to reach all, particularly the poor and other vulnerable groups. Major reforms are taking place in Indonesia and Thailand in the wake of the economic crisis. The Asian Development Bank

Policy reform and restructuring of national health systems

The Work of WHO in SEA

has provided technical and financial assistance to Thailand in restructuring its health care system and introducing a hospital corporatization system. Funds are being diverted to priority programmes to ensure that bas ic health care is accessible and available to all. Thailand has developed a strategy called “ good health at low cost” . Indonesia has formed a Special Task Force on Health Care Reform for the Minister of Health. Initiatives such as decentralization, managed care and “ health safety net” are under way to better target the rural poor and other vulnerable groups, such as women and children. In addition, the Government has recently announced its vision for a “ healthy Indonesia” by 2010 . The country is also introducing hospital autonomy in phases to ensure equity and access to health care, particularly by the poor and vulnerable. His Majesty’ s Government of Nepal has undertaken a study on the reorganization and management of the Ministry of Health and is in the process of reviewing the management and efficiency of large public hospitals. Sri Lanka is also going through a major health sector reform. A Presidential Task Force has been set up to facilitate the reform process and to help make the health sector more resp onsive to people’ s health needs. Support was extended to Thailand for reviewing various insurance and pre-paid schemes and recommending a common scheme that would not only be cost-effective and easy to administer, but also ensure access to health care of the poor and other marginalized groups. The Centre for Health Economics, Chulalongkorn University (WHO Collaborating Centre), with support from the Regional Office, facilitated in the establishment of the Regional Health Economics Network. The network is regarded as a means of strengthening national capability and capacity in the area of health economics, especially in formulating policy action, health care financing reform, and enhancing knowledge and skills for conducting economic analysis of health systems development.

Health financing and economics, option appraisal, systems and skills development

The Work of WHO in SEA

Indonesia is gradually introducing managed care (JPKM) as an alternative financing mechanism, to ultimately improve access to health care. This is a long-term measure which needs to be institutionalized in order to be fully operational. The Regional Office organized a Regional Consultation on Health Implications of Economic Crisis in the South-East Asia Region in Bangkok in March 1998 . The participants included eminent economists from Latin American and East European countries, representativ es from the World Bank, Asian Development Bank, RAND Corporation, UN agencies and representatives from ministries of health from the countries of the Region as well as from Japan. Subsequently, a Regional Meeting of Parliamentarians on Economic Crisis and its Impact on Health was organized in collaboration with the House of Representatives, Republic of Indonesia, and the International Medical Parliamentarians Organization in Jakarta, in December 1998 . A Parliamentarians’Call for Action was developed and unanimously adopted by the Jakarta meeting. Recommendations were made on urgent action by the parliamentarians, governments and international agencies to mitigate the adverse consequences of the economic crisis on health. Meanwhile, the Ministry of Public Health, Thailand, with support from WHO and other donors, has established a Health Intelligence Unit to develop indicators and monitor the effects of the economic crisis on health care and health status. Similarly, Indonesia has established an Economic Crisis Centre to closely monitor the effects of the economic crisis on health.

District health systems

Efforts to strengthen district health systems based on the primary health care approach continued. A set of 16 training modules on the organization and management of DHS/PHC was dev eloped and introduced in two workshops in 1997 and 1998 . All Member Countries of the Region participated.

The Work of WHO in SEA

The initiative on the Model District was continued. Under this project, two districts in each country in the Region launched activities in 1998 -1999 . Local-level planning was initiated to promote intersectoral action. Bangladesh, Bhutan, Indonesia, India, Myanmar, Nepal and Thailand completed the process while activities in the remaining countries are going on. Maldives conducted a Workshop on Strengthening Regional Health System through Intersectoral Action in June 1998 . Increasing attention is being paid to the health of indigenous people in the Region. Bhutan, DPR Korea, India, Indonesia, Sri Lanka and Thailand decided to conduct national workshops on the status and policy of DHS with the emphasis on indigenous, tribal or isolated populations. This helped in evidence-based prioritization of research problems in relation to the health of these people. A WHO Regional Working Group on Telemedicine has bee n established. A pilot project on Health Telematics was initiated in Bhutan with support from the Director-General’ s and Regional Director’ s Development Funds. Phase I of the project, which aims at Tele-education and Tele-consultation between Thimphu National Hospital and Mongar Regional Referral Hospital, was launched in June 1999 . The Health Telematics Centre in the Ministry of Public Health, Thailand, was designated as a WHO Collaborating Centre.

The Work of WHO in SEA

7 Human Resources for Health

Human Resources for Health Human Resources for Health (HRH) activities continued to be focused on qualitative aspects. Intensification of planned HRH programmes resulted in the devel opment of appropriate mechanisms to address the issues of the paramedical work force in SEAR; country-level plans for field -testing of health performance assessment methods and instruments; formulation of a set of proposals that would enable the countries of the Region to determine the equivalents of their medical degrees and diplomas; and the need to promote teaching and practical application of health ethics in the Region. At the country level, planned activities, such as strengthening of medical education; human resources management; advanced training of professionals, strengthening of national institutes; procurement of essential supplies and books and journals were supported. Some prominent activities included the proposal to strengthen the Royal Institute of Health Sciences, Bhutan; the development of a postgraduate curriculum in Nepal; and teacher/management training programmes for teachers and provincial health care delivery workers in Sri Lanka. Preliminary action for the implementation of HRH perfor mance assessment methods and instruments, in

The Work of WHO in SEA

collaboration with the University of Keele, has been initiated. The instruments and the workplan to implement activities for field-testing in a few countries have been finalized. The final phase of field-testing has been undertaken in Nepal and Sri Lanka and work on the preparation of the set of instruments for wider application is under way. Data collection and country studies on paramedical personnel were done by the principal investigators involving all the co untries except DPR Korea. WHO is now in possession of a comprehensive database with regard to the current situation, trends and issues related to paramedicals in the Region. There is a diversity of issues and problems, many of which could be addressed at he t regional or intercountry level. In this context, a workplan is being evolved for countries for the development of an optimal mix of the paramedical workforce. This subject is related to the overall issue of quality of health personnel education and training. It is therefore one of a series of initiatives that WHO is taking to improve the quality of these programmes. A beginning has been made with the formulation of a set of proposals that would enable the countries of the Region to determine the equivale nts of their degrees and diplomas. These have been discussed by national -level accrediting bodies. A high-level international Workshop on Quality of Medical Education was organized in December 1998 in Kandy, Sri Lanka. Representatives from the Education Commission for Foreign Medical Graduates (ECFMG), the Association of Medical Schools in Africa (AMSA), the General Medical Council (GMC), UK, and the World Federation for Medical Education (WFME) also participated in addition to participants from the countries of the Region. In collaboration with WHO headquarters, a Conference on Equity in health in South -East Asia: Trends, challenges and future strategies was held in November 1998 in Thimphu. The

The Work of WHO in SEA

Conference discussed country experiences in equity-related actions as well as those related to effects of recent economic/social trends on equity in health (e.g. the recent economic crisis in South-East Asia) and clarified the concepts of equity and governance in health development and their central role in health development. It also recommended ways to ensure the implementation of policy interventions and monitoring their effects on equity as also to reduce inequities in health and the role of the health sector in such interventions. A Workshop on Computer Projection Models for Human Resources for Health Manpower was held in Colombo in December 1998. In addition to participants from Sri Lanka, a few participants from Nepal, Myanmar and Indonesia were trained in the use of a computerized, step -by-step method of developing long-range projections for estimating HRH supply and requirements after reviewing the models currently available in this regard. The Workshop developed a strategic plan for filling the gap between HRH requirements and supply under different scenarios and recommended a plan to follow up activities needed in the local situations. The South-East Asia Health Ethics Network (SEAHEN) was further strengthened. The results of the qualitative and quantitative research aspects of the study were presented and discussed at the WHO meeting on Teaching and Application of Health Ethics in South -East Asia, held in October 1998 in Bangkok. A literature database, developed on health ethics in South-East Asia, is available via the internet. Having successfully conducted the Regional Training Programmes on Community Health Nursing, Critical Care Nursing and Midwifery Education for Safe Motherhood in 1997, similar training programmes were organized again at four nursing and midwifery educational institutes in India, Sri Lanka

The Work of WHO in SEA

and Thailand. The programme from September 1998 to April 1999 was attended by 30 participants from the Region. Maternal mortality and morbidity are major public health concerns in many countries of the Region. The Regional Office, therefore, developed St andards of Midwifery Practice for Safe Motherhood in order to assist Member Countries to enhance and ensure the quality of midwifery services with a view to addressing these problems. These standards, which included management of selected obstetric complic ations and emergencies, were field -tested in Bhutan, Indonesia, Nepal and Thailand. The field test demonstrated that, by implementing the standards, the quality of midwifery services improved and client satisfaction was enhanced. Guidelines were also devel oped to advise countries on how to effectively implement the standards. The Regional Office is promoting the use of these midwifery standards as a means to improve quality in midwifery in the Region. A meeting of MCH programme managers and midwife experts to provide directions and guidance to promote the use of the standards in SEAR countries was convened in November 1998 in the Regional Office. Guidelines for collaboration between nursing services and education to improve nursing care and education have be en developed. The use of these guidelines is being promoted in the Region to foster collaboration between nursing services and education in order to optimally utilize available resources for quality nursing care and education. Planning for nursing and midwifery development continued to receive attention. Support was provided for the development of national plans of action for nursing and midwifery development in Indonesia and Maldives. These action plans helped to facilitate concerted development in nursing and midwifery. As a follow-up to the plan, Maldives has now established the post of a

The Work of WHO in SEA

Director-General of Nursing who is responsible for nursing development in the country. Special attention was given to strengthening regulatory mechanisms in nursing and midwifery in order to ensure the quality of nursing and midwifery education and services as well as to safeguard the public. A system for accrediting nursing and midwifery educational programmes and institutions was set up in Nepal. This would facilitate improvement of quality in the educational programmes, particularly the auxiliary nurse -midwife programme that needed immediate attention. Technical assistance was given to Maldives and Sri Lanka for establishing nursing councils. Support was also given to Bangladesh for the development of standards for quality management of nursing education and services. Continued attention was given to nursing and midwifery education development. Technical support was provided for the strengthening of the Royal Institute of Health Sciences in Bhutan. Support was given for the development of post -basic and graduate nursing educational programmes as well as the diploma midwifery educational programme in Indonesia. Despite these developments, much remains to be done to improve the quality of nursing and midwifery services. The problem of continuing shortage of nursing and midwifery personnel and maldistribution in many countries of the Region needs to be critically addressed. New modalities for implementing fellowships have be en introduced by several countries. Indonesia instituted in-country fellowships, coordinated by the National Board of Fellowships. Bangladesh and Nepal changed their approaches in the planning and implementation of fellowships in an effort to match awards more closely with their national health priorities, making greater use of regional and in -country training facilities. This has

Fellowships

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resulted in a reduction in the number of extra-regional fellowships. As proposed by the Executive Board in January 1997, an evaluation tool has been introduced. As the tool would be used for follow-up at regular intervals, it is expected that its application on a regular basis covering one biennium at a time would improve all aspects of the fellowships programme and stimulate a review of national planning for human resources development. On its part, the Regional Office also continued to systematically monitor the implementation and utilization of fellowships through a reporting system. This includes questionnaires sent to fellows a nd training institutions during the study period and a questionnaire distributed 12 months after completion of studies to fellows and their national health administrations on the utilization of the fellows’services in their countries. Member countries have been requested to improve the return of the ‘ Termination of Studies Report’by fellows. They have also been urged to carry out evaluations on a regular basis, covering one biennium at a time, using the WHO Evaluation Tool and government/ national guidelines. Despite some reservations expressed earlier in certain quarters, it is believed that short, practical training abroad in specialized fields has its own educational value and is an essential strategy in the development of human resources for health. This is more so as such an approach would appropriately augment the currently available national training resources in most of the countries to address their basic needs at their respective national level. Keeping this in view, the training activities in SEAR have since been classified into two main categories: (a) fellowships, and (b) study tours, for the administration and management of which clear-cut guidelines have been further developed. Group training programmes in the areas of Primary Health Care, Maternal and Child Health, Epidemiology, etc. continued

The Work of WHO in SEA

to be organized in collaboration with respective centres of excellence within the Region. Under this arrangement, the Education and Training Support Unit in the Regional Office continued to support the participation of candidates from Member Countries in the seven-week Practical Training on Primary Health Care at District Level, conducted in collaboration with the ASEAN Institute of Health Development, Mahidol University, Thailand, the Centre for Education and Training for Health Personnel, Ministry of Health, Indonesia, and the National Institute of Health Sciences, Kalutara, Sri Lanka. During the reporting period, four rounds of the said seven -week PHC training programme were conducted in which 86 candidates from SEAR countries participated as WHO fellows. Similarly, participation of 32 WHO fellows was arranged in the six-week South-East Asian Regional Training Course in Reproductive Health, organized jointly by the National Institute of Health and Family Welfare, New Delhi, and the Centre for Education and Training for Health Personnel, in collaboration with the Family Health Division, Ministry of Health, Indonesia and WHO. In yet another group training activity, viz. Field Epidemiology Training Programme organized by the National Institute of Communicable Diseases, Delhi (WHO Collaborating Centre), the participation of 22 fellows was arranged. During the reporting period, the Regional Office received 1142 applications, of which 877 fellowships were awarde d. A detailed analysis of these fellowships is presented in Tables 2 and 3. As can be seen from Table 3, the proportion of extra -regional fellowships is 32.5 per cent. However, the cost estimates in respect of these fellowships were more or less eq ual to that of regional fellowships. As for other regions, the Education and Training Support Unit received 232 fellowship applications from AFRO, EMRO and WPRO, out of which 152 found placement in SEAR.

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Table 2. Distribution of fellowships awarded, by subject of study and country of origin of fellows (1 July 1997 to 30 June 1999) Subject Undergraduate studies Postgraduate specialities Postbasic/ Graduate nursing/ Midwifery education Public health sciences BAN 4 30 13 BHU DPRK IND 5 1 0 0 55 2 0 65 8 INO 0 0 2 MAV MMR 0 3 0 4 27 8 NEP 0 10 7 SRL 0 19 4 THA 1 0 0 Total 14

Per cent 1.6

210 23.9 44 5.0

25 3

21 14

63 10

13 0

24 109 2 14

51 5

65 21

9 0

446 50.9 85 9.7

Diagnostic and 16 laboratory sciences 13 Education, communication and research

5.6

Environment sciences Total

4 146

2 38

0 16

0 10

29 877

3.3 100

92 158

36 186

77 118

Table 3. Distribution of fellowships awarded, under WHO Regular budget,by region of study (1 July 1997 to 30 June 1999) Region of study Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Total Percentage American European 4 0 0 87 1 1 3 1 4 1 102 11.6 6 5 14 27 1 0 17 1 3 2 76 8.7

SouthEast Asia 107 31 54 24 13 30 149 74 103 7 592 67.5

Western Pacific 21 2 24 16 1 4 14 1 6 0 89 10.1

EMRO 1 0 0 1 0 1 1 0 1 0 5 0.6

More than one region 7 0 0 3 0 0 2 0 1 0 13 1.5

Total 146 38 92 158 16 36 186 77 118 10 877 100

The Work of WHO in SEA

Directory of training institutions

The Third Revision of the Directory of Training Institutions was published in August 1998 an d widely distributed to all countries in the Region as well as to other WHO regional offices. This latest edition serves as the main source of reference in identifying the appropriate training programmes and institutions, to be used by Member Countries, not only for nominating WHO fellows but also for conducting national training programmes.

MIS allied system (Fellowships)

The implementation and funding of fellowships processing as an essential allied system to form part of the current Activity Management System, was approved by the Worl d Health Assembly in May 1997. The Regional Office has been designated as the focal point for system development. A Workshop on User Requirement was held in Geneva in October 1998, which was attended by Regional Fellowships Officers, HQ Fellowships Coordin ator, and staff of WHO headquarters and the Regional Office. The Workshop recommended that basic system features should be developed to serve, inter alia, the main objectives of enabling the free flow of information between Member States, WHO Representativ es and regional offices as well as between regional offices and WHO headquarters, and creating a solid base for the evaluation of the fellowships programme.

Group educational activities

During the period under review, 102 meetings/group educational activities were held. The technical meetings covered a wide range of subjects such as polio laboratory network, telemedicine, suicide prevention, quality assurance methodologies in blood transfusion services, and special needs of street and working children. Table 4 shows the distribution of participation in in-country activities by type of activity.

The Work of WHO in SEA

Table 4. Distribution of participants in intercountry activities by type of activity, 1 July 1997 to 30 June 1999 Type of activity Regional Meetings Workshops Consultative Meetings Short Training Courses Total Number 37 21 35 9 102 Number of participants 713 193 812 422 2140

The Work of WHO in SEA

8 Action programme on essential drugs

Essential Drugs All Member Countries of SEAR have developed National Essential Drugs Programmes. WHO collaboration is aimed mainly to further develop, strengthen, implement, evaluate and revise the national drug policies, where necessary, so as to promote equity in the availability of and accessibility to essential drugs, especially at the primary health care level. India, Indonesia, Maldives and Nepal received WHO technical support for monitoring their national drug policies. The WHO Manual of Indicators for Monitoring National Drug Policies (1994) is a useful tool to strengthen the evaluation process in countries in accordance with the changing needs of the pharmaceutical sector. The intercountry projects in the area of essential drugs are the ASEAN pharmaceutical programme, the Bi-regional Technical Cooperation in Essential Drugs and the WHO/SEARO Working Group on Drug Financing. The Second Meeting of the Working Group on Bi-regional Technical Cooperation in Essential Drugs and the 17th ASEAN Working Group Meeting were held in Bangkok in March 1999. These two meetings facilitated further technical cooperation between the ASEAN countries as well as promoted intercountry cooperation among

The Work of WHO in SEA

the countries of the South-East Asia and the Western Pacific Regions. The ASEAN pharmaceutical programme is a success story in technical cooperation among the ASEAN countries in the SEA and WPR Regions of WHO. The first phase of the Programme was started in 1982 with technical and financial support from WHO and financial assistance from UNDP. As the programme evolved and matured, the issue of self -sustainability assumed greater importance with most of the ASEAN countries becoming more successful in their economic development. In early 1997, a Memorandum of Understanding (MoU) was signed between ASEAN and the World Health Organization represented by the South-East Asia and the Western Pacific Regions. The MoU prioritized nine areas of collaboration under the ASEAN Sub-committee on Health and Nutrition, including drug quality assurance. Because of the success of the ASEAN pharmaceutical programme, the South-East Asia and the Western Pacific Regions initiated bi-regional technical cooperation in the area of essential drugs in 1995. Using the mechanism of the ASEAN technical cooperation, countries of the two regions other than ASEAN are able to receive technical training and assistance through the centres of excellence developed by the ASEAN countries. Complementary to this activity was on-site training in Good Manufacturing Practices (GMP) by an expert from Indonesia from March to June 1997 in Bangladesh, Myanmar, Nepal and Sri Lanka. As drug financing has become an emerging option for the accessibility of essential drugs in some countries in the Region, the Regional Office, in collaboration with WHO headquarters, is assisting in this process. It is recognized that Member Countries should strengthen national and local drug financing schemes to

The Work of WHO in SEA

ensure equity and access (availability and affordability) to essential drugs. The Agreeme nt on Trade-Related Aspects of Intellectual Property Rights (TRIPS) is one of the agreements of the World Trade Organization. The Agreement links intellectual property with trade issues and provides minimum global standards for the protection and enforcement of intellectual property rights. WTO Members in the Region have to comply with the standards by modifying their national regulations. In doing so, public health issues, including those in the area of essential drugs, need to be protected. Most countries of the Region have improved the availability of essential drugs for primary health care. However, this availability needs to be translated into accessibility also in some situations where essential drugs cannot be provided at the PHC facilities.

Procurement of drugs, biologicals and contraceptives

The Regional Office Medical Supply Unit procured drugs, biologicals and contraceptives in support of WHO collaborative programmes from Regular budget and extrabudgetary funds.

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Quality of Care and Health Technology The major focus of this programme has been on augmenting and ensuring the reliability of results generated by the health laboratory services with the use of appropriate technology. Strengthening of blood transfusion services as well as assuring safety and quality of radioimaging services in the Member Countries to support quality health care has also been an important component of the programme. WHO has been consistently supporting the strengthening of quality assurance activities in various disciplines of laboratory services to improve clinical as well as public health activities. Technical support was provided to countries for effective integration of internal quality control measures in the functioning of laborator ies. A standardized methodology in the form of Guidelines for Quality Assurance in Bacteriology and Immunology, Standard Operating Procedures in Microbiology for Peripheral and Intermediate Laboratories and the revised edition of Health Laboratories Servic es in support of Primary Health care in SEAR countries were made available to Member Countries.

Technology for health care

The Work of WHO in SEA

Considerable progress has been made recently with some Member Countries, including Thailand, India, and Indonesia, steadily moving towards accreditation of all laboratories. The process of accreditation will further refine the quality of laboratory results and strengthen both curative and public health services. A quarterly newsletter on quality assurance (QA News) is being published with a view to disseminating information on quality assurance, stimulating activities by various Member Countries and providing direction for further progress in this field. With a view to strengthening the quality assurance programme in TB control, an intercountry training workshop o n the subject was held in Indonesia in April 1999. The workshop discussed strategies to improve sputum microscopy and made important recommendations in this regard. To help develop a regional strategy for the prevention and control of antimicrobial resista nce, technical support in Antimicrobial Resistance Monitoring (ARM) has been extended to India, Indonesia, Myanmar, Sri Lanka, Thailand, Nepal, Bhutan and Bangladesh. These activities are being undertaken in close collaboration with WHO headquarters. Three major activities being supported are: training of laboratory professionals in uniform technique; utilization of WHO developed computer software (WHONET4) for rapid analysis of data; and organization of policy meetings of specialists from various disciplines to develop a methodology for rational use of antimicrobial agents. A network of Gonococcal Antimicrobial Susceptibility Programme (GASP) has been made functional in the Region and is being technically supported. A manual on Laboratory Diagnosis of Gonor rhoea incorporating antimicrobial susceptibility testing has been published. A newsletter on GASP is being regularly published for disseminating information on methodology and monitoring trends in resistance.

The Work of WHO in SEA

WHO has consistently supported a number of initiatives to strengthen blood programme in the countries of the Region. As a follow-up of the Workshop on Strategies for Strengthening Blood Transfusion Services in Member countries, held in 1997, an intercountry training workshop was held in Bangkok in 1998 to train trainers in quality assurance methodology. Guidelines for national strategies have been developed with a view to ensuring safe blood transfusion. Countries have been urged to develop national policies for blood safety. Participation of representa tives from India, Myanmar, Nepal, Sri Lanka and Thailand at the International Conference on Blood Safety, held in Mumbai during November 1998, was supported. Training workshops on standardized methodology to improve the quality assurance programme and appr opriate use of blood were supported for India, Myanmar and Sri Lanka. Improvement in the quality of radioimaging services and radiotherapy is being consistently supported through three WHO collaborating centres and in collaboration with the International Atomic Energy Agency (IAEA) at Vienna. The Quality Assurance programme in this field has been extended to 150 centres, mainly in India, Myanmar, Nepal, Sri Lanka and Thailand, and is being extended to Bangladesh, Indonesia and DPR Korea. WHO supported a Tra ining Course on Appropriate Technology in Diagnostic Imaging and Radiation Therapy, including Quality Assurance, which was attended by scientists from India, Bhutan and Thailand. Similar training courses on the use of appropriate technology in radioimaging were supported in Nepal, Bhutan and Sri Lanka. Realizing the need for standard guidelines in undertaking clinical management of snakebite victims, an expert group meeting was organized in Thailand in November 1998 to prepare the guidelines. These were dis seminated to Member Countries. A training course for physicians was conducted in

The Work of WHO in SEA

Nepal to upgrade their skills in the management of snakebite cases. Recognizing the growing incidence of chemical poisoning in the Region, an intercountry consultation on the subject was held in New Delhi in December 1998 to formulate strategies for strengthening poison control in the Region. As a follow up, a number of action plans have been developed for implementation during 1999. A discussion paper on the subject has been prepared for the Regional committee.

Drugs and biologicals, quality, safety and efficacy

Quality, safety and efficacy of drugs and biologicals has been a long-standing priority programme of WHO. The Regional Office has been assisting Member Countries in improving the quality of pharmaceuticals which are produced locally as well as those available in the national markets. Because of these developments, the WHO Certification Scheme on the quality of pharmaceutical products moving in international commerce is now being applied more vigorously than ever before. The three centres of expertise on quality assurance of essential drugs located in Calcutta (India), Jakarta (Indonesia) and Nonthaburi (Thailand) are instrumental in ensuring the quality of medicinal drugs at the regional level. The centres act as referenc e laboratories for testing essential drugs, including raw materials and for providing training. A Training Course on Chemical Assay on the Production and Utilization of Regional Reference Substances was held in January 1999. By December 1997, 116 standard reference substances had been established since the commencement of the project in 1982. Capabilities in drug quality control vary among the Member Countries. While India, Indonesia and Thailand have excellent facilities, other countries require assistance , both in the areas of managerial and technical capabilities. The testing capacity of the

The Work of WHO in SEA

laboratory in Bangladesh, which has received additional inputs through the Fourth Population and Health Project, has now increased from 4 000 to 8 000 samples of drug formulations a year. Bhutan and Maldives are being assisted in establishing small drug laboratories for qualitative analysis of active ingredients in some essential drugs. During the period under review, the Region made considerable progress in ensuring he t quality, safety and efficacy of the vaccines utilized in EPI. Both in 1997 and in 1998, workshops were held for countries procuring vaccines to highlight the measures to ensure vaccine quality. Such workshops will now be held by WHO headquarters, as par t of its Global Training Network. The staff of the regulatory authorities in all countries in the Region are trained through the Global Training Network; 30 per cent of all trainees worldwide are from this Region. With the establishment of the Vaccine Regulatory Authority (NCA) in Thailand, the regulatory authorities in Indonesia, India and Thailand are now working with all their control functions in place. These are licensing, lot release, post -marketing surveillance, laboratory testing, GMP inspections, and clinical evaluation. The first four are also to be carried out by countries that are buying vaccines but only the first two are necessary for countries obtaining their vaccines through UNICEF or WHO. The National Control Laboratory Network is working we ll and annual meetings are held to update its members and potential members. The subjects covered in 1997 were: licensing, lot release and postmarking surveillance (field performance of vaccines) and in 1998: laboratory quality systems. In 1999, validation and statistical methods will be covered. In 1998, a regional training centre for cold chain equipment and solar-powered equipment was established at Auroville, Tamil Nadu, with help from WHO headquarters. Training of trainers has also started at this cent re.

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A prime area of concern in the delivery chain is the safety of injections. In 1997, a pilot survey conducted in Indonesia indicated that up to 90 per cent of all injections given were unsafe. The Government of Indonesia followed this up with a broad-based survey in 1998. The results indicated the need for re-training of personnel and improved supervision if the main syringe used is reusable, or the need to introduce an auto destruct syringe (ADS) to ensure safe injections. Since technology transfer from the USA and Europe has taken place and with withdrawal of duty on the import of basic equipment for the production of ADS by the Government of India, it is expected that production can start soon in the Region.

Traditional medicine

There is a great deal of interest in tradit ional medicine (TRM) in the Region. The Ayurveda, Unani or/and Siddha practices can be seen in Bangladesh, India, Nepal and Sri Lanka. Jamu is the traditional medicine of Indonesia and Koryo is practised in DPR Korea. Bhutan, Maldives, Myanmar and Thailand have developed their unique forms of traditional medicine. At the regional level, the three centres of expertise in TRM, located in the Indian cities of Jamnagar and Varanasi (Ayurvedic medicine), and Koryo medicine in DPR Korea, have been involved in the training of human resources. Within the context of the ASEAN pharmaceutical programme, Indonesia, the Philippines and Thailand are involved in standardization, quality control and utilization of herbal medicine.

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Promotion and Protection of Health Care

Section 4

Reproductive, Family and Community Health and Population Issues Regional-level activities were targeted towards supporting countries in effective implementation of the regional strategy in reproductive health (RH), with special focus on reducing the maternal mortality rate. World Health Day, 1998 was devoted to Safe Motherhood with the theme “ Pregnancy is special: Let us make it safe” . The Regional Office organized exhibitions as well as press briefings and supported countries by providing advocacy ma terials. In Nepal, advocacy campaigns were organized in all 75 districts by the Safe Motherhood Network of NGOs in collaboration with the Family Health Division. The Prime Minister of India inaugurated the Safe Motherhood Campaign in India in which the Director-General of WHO and the Regional Director, SEAR, participated. The Regional Office conducted a six-week training course on the planning and management of RH programmes for district-level managers, in collaboration with the Governments of India and Indonesia. In addition, training materials developed

Reproductive health

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for the management of essential reproductive health care for various levels are currently being field -tested. Support was provided for the development of a model for operationalizing the Integrated Reproduc tive Health Care Package in Indonesia. Following the consultative meeting of representatives of collaborating centres and centres of excellence in the area of Human Reproduction and Maternal and Child Health, held in September 1997, a follow-up meeting was held at the All India Institute of Medical Sciences, New Delhi (WHO Collaborating Centre for Neonatology). The meeting, on care of the newborn, was also aimed at strengthening networks and collaborating centres. Intercountry travelling seminars on Partnership for Safe Motherhood were organized in Nepal and Thailand. These provided an effective forum for the exchange of ideas and information on involvement of communities, intersectoral action as well as organization of referral systems and strengthening of emergency obstetric care (EOC) services. A joint planning exercise, held between staff of WHO headquarters and the Regional Office, identified several important mechanisms for strengthening linkages and involvement in each others’ activities. The activities identified were joint reviews of guidelines, training materials, job aids, etc. in the countries and sharing them with other agencies concerned. Another activity to be jointly carried out was intercountry consultations on improving the quality of family planning services. Currently, WHO is supporting countries in the development of RH programme profiles as one of the joint activities between countries, the Regional Office and WHO headquarters. In Bangladesh, technical support was provided for the development of a RH programme as a component of an essential service package. WHO is also assisting the

The Work of WHO in SEA

Government in strengthening the RH programme and in organizing leadership training to nationals at the Indian Institute of Health Manpower Research, Jaipur, andsupporting national and divisional orientation workshops on the concepts of reproductive health. In Bhutan, technical assistance focused on the training of health workers in IEC (Information, education and communication), in family planning and reproducti ve health in Indonesia and a study programme on STD/HIV in Thailand. In India, WHO support was provided for developing manuals on community needs assessment approach in participatory planning for the implementation of the Reproductive and Child Health (RCH) programme. The Indian Institute of Health and Family Welfare, Hyderabad, developed a two -week collaborative training programme with Mahidol University in Thailand in which various state-level trainers as well as programme managers participated. Several n i novative approaches are being undertaken with WHO support. These include exchange visits by paramedical workers and auxiliary nurse midwives (ANMs) from lesser developed states to better developed states, and partnership development by the Indian Medical Association between its members working in the private sector and the Government of India for increasing access to RCH care. The joint activities include the training of young practitioners and ANMs on RH, IEC activities, organization of health melas and mass communication activities and providing outreach services. These approaches have a high potential for expansion and learning by other countries as well. As health is a state subject in India, WHO support was provided for organizing three regional worksh ops to secure state endorsement of the national-level strategy as well as formulation of district and state-level communication plans. Support was also provided to improve the access and quality of family planning

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services through supporting national and s tate-level workshops on family planning, especially IUD, consensus building for injectable contraceptives and for improving the quality of clinical surgical procedures in general. In Indonesia, many initiatives were undertaken in the area of safe motherhoo d and reproductive health. Important ones include the development of a district model for accelerated reduction of maternal mortality and operational research coordinated by the WHO collaborating centre in Surabaya on the development of a model for the del ivery of essential RH package. A Safe Motherhood module, developed for medical schools, is being used by the Consortium of Health Sciences starting with the medical faculty of the University of Indonesia in 1997. Safe Motherhood modules are also being deve loped for faculties of public health. As maternal mortality is still high in Indonesia, IEC materials on danger signs during pregnancy and delivery have been developed by the Sub -directorate of Maternal Health and WHO, in collaboration with PKK and CCP/Joh ns Hopkins University. Support was also provided for adapting the WHO/PAHO gestogram to the Indonesian situation under the coordination of the Medical Research Unit of the Faculty of Medicine, Padjajare University. In Maldives, WHO provided necessary techn ical support for establishing a library in reproductive health to support national capacity development, implementing Home-Based Maternal Record (HBMR) in all the atolls, and developing guidelines for the delivery of essential reproductive health care. WHO midwifery guidelines have been translated into Dhivehi and are used locally. In Myanmar, WHO provided support to enhance the quality of reproductive health care services and to improve capabilities for programme management through in -country and outside training of operation managers and basic health staff.

The Work of WHO in SEA

In Nepal, WHO support was used for the expansion and strengthening of the National Safe Motherhood Programme. This included the addition of five new SMP districts and continued use of IEC materials and training. In Sri Lanka, WHO support was focused on providing necessary training for improving the quality of services. As anaemia in pregnancy is still a problem in the country, WHO support was also provided for training public health staff in the prevention of anaemia. Efforts have been made to improve the monitoring system as well as monitoring of morbidity and mortality. Advocacy meetings at various levels of the health system were supported to enhance community action in reproductive health care. Approp riate IEC materials were developed to disseminate reproductive health information among health care providers and the community. Research studies on contraceptive method mix and a township model for improving the quality of care in reproductive health have been carried out in collaboration with the Special Programme of Research, Development and Research Training in Human Reproduction. The findings of a study on the perception of reproductive morbidity among men, women and service providers, conducted in 1997 with financial assistance from WHO headquarters and the Population Council, are being analysed. Child Health programmes in the countries of the Region are focusing on major ongoing interventions, such as promotion of breast-feeding and growth monitoring, immunization, control of diarrhoeal diseases and Integrated management of childhood illness (IMCI). These activities are carried out in countries with technical support from several units in the Regional Office. In addition, WHO has supported national paediatric associations

Child health

The Work of WHO in SEA

and perinatal societies in conducting conferences and seminars which have provided a forum for advocacy for the cause of children as well as updating paediatricians’ knowledge on several child health issues.

Adolescent health

Adolescent health (ADH) has been receiving increasing attention in recent years. However, adolescent reproductive health is a priority area that needs strengthening but is still a sensitive issue. The Regional Office published and widely disseminated an advocacy and information booklet which provides information on adolescent issues and highlights the role of individuals and sectors. An Intercountry Meeting on Development of Strategies for Adolescent Health, held in the Regional Office in May 1998, was attended by representatives o f Member Countries, NGOs, UNICEF, UNFPA, UNESCO and WHO headquarters. The resulting strategies are intended to provide a framework for country-level adaptation. In Indonesia, WHO support was provided for the development of materials for adolescent reproduc tive health and training of health providers and peer groups. It is expected that these providers and peer groups will develop a strategy to enhance physical and psychological readiness of the adolescents for entering reproductive age. In Myanmar, adolescents participated in seasonal sports training conducted by the Department of Sports and Physical Education three times a year. A six-month training course on 12 sports disciplines for upcoming athletes under the age of 18 years was opened at the Institute of Sports and Physical Education, Kyaikkasan. Multisectoral collaboration involving NGOs has been helpful in propagating knowledge in health and physical fitness to communities. In Sri Lanka, three orientation programmes on health awareness on RH among scho ol children and adolescents were

The Work of WHO in SEA

conducted for school principals. As anaemia in adolescents is a serious problem which continues through pregnancy, WHO support was provided for initiating a programme for controlling anaemia and preventing chronic malnutrition among adolescent girls. Activities focused on the development and finalization of IEC materials consisting of posters, leaflets and radio spots to promote self -purchase of iron pills and to raise awareness. Operational research on adolescent health, initiated in the last biennium, is continuing as a useful tool in formulating and carrying out planned activities. A study was started in April 1999 involving effective linkages among health, the health-related sector, funding agencies and NGOs.

Prevailing ill-health among women in the Region is a major concern. These are being addressed through several programmes, e.g., Nutrition, Reproductive Health, Maternal and Child Health and Women, Health and Development in the Region. Accordingly, investment in women's health has been one of the actions identified in the Regional Health Declaration. It has been recognized in the Declaration that since women's health is integral to their development at large, a multisectoral approach will be needed through development of partnerships with other relevant sectors. Efforts are being initiated to collect the requisite information for developing strategies to address the issues of peri menopausal and post-menopausal women.

Women's health

Since the last decade, countries in the South-East Asia Region have been facing the double burden of communicable and noncommunicable diseases. Many of them occur among the ageing population, causing high mortality and disability. Realizing these problems, many countries have included ‘ Elderly Health’in their national health programmes. To increase public awareness on care of the elderly, Bangladesh provided teaching

Ageing and health

The Work of WHO in SEA

and learning materials and organized local workshops and training courses for health workers in urban and rural settings. Myanmar was support ed in organizing a training course on care of the elderly for different categories of health workers. A consultant assisted nationals in DPR Korea to develop a geriatric cardiology clinic at the WHO Collaborating Centre for Geriatrics and Gerontology. “ Active Ageing Makes the Difference”was the World Health Day theme for 1999. Member Countries are being supported in promoting awareness on the importance of active ageing among the general public.

Special Programme of Research, Development and Research Training in Human Reproduction

India, Indonesia and Thailand are members of the HRP Special Programme’ s Policy and Coordination Committee (PCC) under Category 2 – countries elected by the WHO Regional Committee. Election to one vacancy in the PCC took place at the fifty-first session of the Regional Committee in September 1998 as the term of India was extended for another two years. An International Conference on Reproductive Health was held in Mumbai in March 1998. It was attended by about 400 participants from India, Bangladesh, Indonesia, Nepal and Sri Lanka. This Conference dealt with researc h as well as programmatic issues related to reproductive health. HRP support to this Region has been in the form of Long -term Institutional Development Grant, Resources Maintenance Grant, as well as Research and Visiting Scientist Training Grant. Individual research projects are also supported. Long -term Institutional Development Grant has been extended to the Indian Institute of Research in Human Reproduction, Mumbai. Resource Maintenance Grant was awarded to the All India Institute of Medical Sciences, New Delhi. Research Training Grants have been given to Sri Lanka, Myanmar and Nepal. As regards

The Work of WHO in SEA

individual projects, studies on emergency contraception, abortion, injectable contraceptive, qualitative study of contraceptive use, dynamics and effect of vitamin E and low dose aspirin, alone and in combination with norplant, have been supported. Pregnancy prevention/HIV studies are being supported in India, Sri Lanka, Myanmar, Indonesia and Thailand. A new dimension has been added to the promotion of occupational health by laying emphasis on improving the health and safety of workers at the workplace. Several activities were undertaken during the reporting period. Following the International Conference on Occupational Health and Safety in the Informal Sector, held at Bali, in October 1997, concerted efforts are being made to protect and promote the health of the working people in the informal sector, including agriculture. Workshops and training courses for different categories of field health personnel and indus trial managers have been organized in Bangladesh, Myanmar and Sri Lanka. In India, a survey on the occupational health and safety situation in small-scale industries was conducted. The WHO Collaborating Centre on Occupational Health in India was supported in improving the database on occupational hazardous substances. A number of commissioned research studies, including biological monitoring in industries and development of occupational health, were undertaken in Thailand with WHO support.

Occupational health

The Work of WHO in SEA

Healthy Behaviour and Mental Health Mental and neurological problems are responsible for a great deal of suffering and disability throughout the world. Because of their nature, disabilities induced by mental problems prevent a large proportion of peopl e from realizing the full benefit of their capabilities and from being fully able to function in society. Coverage with basic mental health care has been increasing continuously over the last decade in all countries of the Region. This includes countries such as Bhutan and Maldives, where such care was previously virtually absent. Most countries have established National Mental Health Programmes (NMHP). Current activities encompass (a) the enhancement of optimal psychosocial development in infants and young children; (b) mental health promotion in schools focusing on efforts to support the advancement of life skills education in schools, and efforts to promote more supportive and caring schools using a child-friendly schools checklist; and (c) the assessment of mental well-being in adolescents and programmes for its enhancement. However, in many instances, updating of such programmes, and increasing their scope in

Mental health

The Work of WHO in SEA

terms of comprehensiveness and public mental health orientation have been slow. A mental health project in Bhutan was developed and implemented, with extrabudgetary funding (“ Nations for Mental Health” initiative), through the services of a psychiatrist from Myanmar. In Sri Lanka, a similar project was initiated which aims at a reduction of the large numbers of long-stay inpatients in mental hospitals and the establishment of an infrastructure of follow-up and family support. In India, a WHO-sponsored initiative to establish self-help/mutual aid groups of parents with a mentally retarded child in 1982 has, over the years, led to the establishment of a countrywide network of such parent associations. WHO is assisting these associations in project formulation and fund raising. The Regional Office held two regional consultations on the special needs of street and working children resulting in setting standards for good services for these highly vulnerable children. It is now hoped that funds can be raised for more intensive networking of NGOs/GOs committing themselves to such quality services. A meeting on suicide prevention was organized in Pattaya, Thailand, in July 1998. The objective of the meeting was to prepare a project proposal using ethnographic approaches, on harm to self and others, to be implemented in Indonesia, Sri Lanka and Thailand. A manual on psychosocial rehabilitation, “ Promoting Independence of People with Disabilities due to Mental Disorders” , prepared by the Regional Office, was brought out as a HQ publication for inclusion in the community-based rehabilitation (CBR) series. In order to increase the focus of psychiatric care and rehabilitation activities in general on caregiving families, the Burden Assessment Schedule (BAS) was developed and published by the Regional Office. This instrument will permit an

The Work of WHO in SEA

evaluation of the impact of various support measures to caregiving families and the establishment of treatment plans which will not only focus on a reduction of symptoms in patients but also on a reduction in the burden perceived by caregivers. Study tours of candidates from Bhutan, Myanmar and Bangladesh in the fields of Psychiatry, Psychiatric Nursing, and Community Mental Health Care, were implemented during 1998 -1999.

Substance abuse including alcohol and tobacco

WHO assisted FORUM, a regional network of NGOs active in the field of demand and harm reduction (including also NGOs in Pakistan and Malaysia) to obtain substantial funding support (US $ 2.5 million) from the European Union. It is through this network that the Regional Office promotes the open community approach to demand and harm reduction developed in the SEA Region with strong technical inputs from the Regional Office. This network was also instrumental in the development of oral buprenorphine maintenance for the prevention of HIV infection in injecting drug users. Such oral maintenance programmes are now available in all major cities in India. Two fellows from Myanmar were trained in community-based demand and harm reduction, including buprenorphine maintenance, in Delhi. They have started to implement such programmes in Myanmar where injecting drug use is very common and the rate of HIV infection in injecting drug users is already up to 90 per cent in some areas. For the past two decades, the South-East Asia Region has had the second highest annual growth rate in per capita adult cigarette consumption among the six WHO regions. Prevalence of the use of tobacco has increased steadily during the past five years. The regional focus has therefore been to reduce annual consumption levels and prevent initiation of tobacco use. In November 1997, a Regional Consultation reviewed the regional situation and made recommendations, which included the intensification of country control programme and integration of

The Work of WHO in SEA

tobacco control activities into development programmes such as poverty alleviation, women’ s development and HIV/AIDS con trol. A Regional Policy Framework and Plan of Action 2000-2004 was developed at a Regional Consultation, held in Bangkok in 1998. This forms the blueprint for the development and strengthening of country plans of action for the control of tobacco in the coming years. Compilation of a database on tobacco was initiated. The WHO Cabinet project, Tobacco Free Initiative, has received a favourable response in the Region. A communication on the Cabinet Project and the need for more effective control measures was sent by the Regional Director to all Heads of State and Government in the Region. The Regional Committee selected “ Tobacco control: Actions for the 21st century” , for Technical Discussions prior to its fifty-second session in September 1999. At the country level, Sri Lanka has developed national policies and smoking is banned in flights – both domestic and international – and islands, districts and schools have been declared smoke -free (Bhutan, India, Maldives and Indonesia). Public education and preventive interventions have been intensified in all countries. Countries have also been supported in participation in conferences and meetings on tobacco control. Stiffer health warnings on cigarette packets have been introduced in Thailand while Nepal banned tobacco advertisement on the electronic media. There is increasing recognition of the role of health promotion in health development resulting in an intensification of programme development in Member Countries. National policies and plans of action have been developed by Indonesia and Maldives. Staff continued to be trained through long- and short-term training programmes in Bangladesh, India, Indonesia, Sri Lanka and Thailand. In most countries, the infrastructure for health promotion and health education continued to be decentralized

Health promotion

The Work of WHO in SEA

to the community level. In Bangladesh, India and Thailand, national training curricula on health education have been revised to include aspects of health promotion. The focus of research is on risk factors for diseases; determina nts of health and healthy lifestyles, child development and quality of life. Health promotion for the elderly and adolescents, and health promotion at the workplace and hospitals were intensified. In July 1997, the Fourth International Conference on Health Promotion was held in Jakarta, the first of its kind to be held in a developing country. The Jakarta Declaration serves as a blueprint for health promotion development in the Region. Follow -up actions led to the organization of an Intercountry Consultation on WHO Mega Country Initiative on Health Promotion in February 1998 where representatives of three mega countries of the Region viz. Bangladesh, India and Indonesia, developed a regional strategic plan to initiate health promotion infrastructure and resource development through intercountry collaboration. National meetings and workshops to strengthen the concept and practice of health promotion were supported in Bangladesh, India, Indonesia and Thailand. Unlike in other WHO regions, the concept of health promoting schools is yet to gain wider implementation. However, a solid foundation has been laid. Following the Intercountry Consultation on Health Promoting Schools in December 1997, four countries, viz., Bangladesh, India, Indonesia and Thailand, have been supported to carry out situation analyses. The Health Ministers of the Region discussed school health at their sixteenth meeting in September 1998. Comprehensive recommendations made have provided added impetus to school health programmes and the develo pment of health promoting schools in the Region. Regional guidelines and a brochure on health promoting schools have been developed to support these activities. Action has been initiated for the establishment of a regional training programme in school heal th.

The Work of WHO in SEA

In keeping with the spirit of WHO’ s communications and public relations policy, the Regional Office has progressively moved closer towards improving the coordination and dissemination of information, enhancing the image of WHO, and developing informed public opinion on matters of health. Overall, interaction with the media has increased considerably. A highlight was the Intercountry Workshop on the Role of Media and Health Development in December 1998, which brought together policy-makers and field-level journalists with media spokespersons from health ministries as well as WHO staff who most often deal with the media in some of the Member Countries. An outcome was the formation of an informal health communicators network starting with the workshop participants. A media survey, carried out by the Indian Institute of Mass Communication (WHO Collaborating Centre on Communication for Health) provided a sampling of media coverage on health issues in the Member Countries. The Regional Office provides a consta nt interface between the media and the in-house technical expertise. At the Regional Office, the Information Unit obtains and provides information in response to media queries, including a large number on e-mail. Numerous press briefin gs have been organized and press releases and media alerts issued. In particular, through close collaboration with technical units, information outreach was undertaken for polio eradication, TB (technical briefing and a field trip to a DOTS centre); media workshops for supporting the WHO goal for leprosy eradication (Bangladesh and India), the dropsy epidemic (information sheets); safe motherhood and on active ageing. The Information Unit supported the development of an information kit on the budget reallocation and the Region’ s position, which was used extensively. The Unit also worked closely with the concerned technical unit on the information kit promoting procurement of essential drugs from within the Region.

Communications and public relations

The Work of WHO in SEA

WHO's 50th anniversary provided several oppo rtunities for media interaction and technical information dissemination: a special, short film on 50 years of WHO's work in SEAR was produced; the "Edge of Awareness" art exhibition brought in new partners into the health arena - artists, art critics, and art historians. The visits by the two Directors -General to the Regional Office in 1998 (Dr Hiroshi Nakajima on World Health Day, and Dr Gro Harlem Brundtland for the Regional Committee) provided an excellent opportunity for field visits, media coverage and interaction. In commemoration of the anniversary, a publication, “ 50 years of WHO – the South-East Asia Region, Highlights: 1948 -1998”was brought out.

Rehabilitation

The main emphasis of WHO’ s support to countries on rehabilitation is the community-based rehabilitation (CBR) approach. Integration of CBR into PHC services has been initiated in India and Bangladesh. To support this initiative, the WHO Manual on Community-based Rehabilitation was printed in Bangladesh, Bhutan and India. Bangladesh also translated it into the local language. India also initiated CBR for disadvantaged people in the slum areas of Mumbai. In October-November 1997, a four-week training course was organized for national CBR programme managers in Colombo. Following this training, several district training courses were organized in India, Bangladesh, Bhutan, Myanmar and Sri Lanka. An Intercountry Consultation on Strengthening Training of Health Workers in CBR was held in Bangkok in May 1999. Recommendations of the meeting would help improve the efficacy of CBR training in Member Countries.

The Work of WHO in SEA

Nutrition, Food Security and Safety Among several factors, nutritional status of population groups is closely interlinked with their health. It is therefore imperative to be fully aware of the various nutritional problems affl icting the different population groups in order to develop strategies to address them. The major burden of undernutrition in the Region is due to protein-energy malnutrition (PEM) and deficiencies of micronutrients, such as iodine, iron and vitamin A, afflicting a large section of vulnerable population groups. These nutritional problems are prevalent not only in the South-East Asian countries but also globally, particularly in less developed countries. Besides these, a set of new problems are emerging among the affluent sections of the population attributable to excess consumption of certain foods and changes in lifestyles that are not consistent with good health. Though the estimated prevalence of under -weight children has declined in some countries, over 70 per cent of the world's malnourished children live in South-East Asia. Over 600 million people in the Region are reported to be suffering from iron deficiency anaemia, predominantly affecting adolescent girls, pregnant women and young children with not much change in prevalence, over the last two decades. Approximately 212 million

Nutrition

The Work of WHO in SEA

are suffering from iodine deficiency disorder. Although available evidence indicates a worldwide decline in the prevalence of vitamin A deficiency, including in some SEA countri es, it is still a public health problem in most countries of the Region afflicting 1.3 million under -five children. WHO support was directed towards improving the quality of national programmes to address the major nutritional problems prevailing in the Region. Assistance for sustainable capacity building to the Member Countries was provided in various ways. The Regional Office organized, in November 1997, a Regional Consultation on Nutritional Status of Adolescent Girls and Women of Reproductive Age, the i frst time a regional consultation was held on this topic. The major recommendations outlined for action included: (a) developing a database for adolescent girls; (b) enlisting political commitment and social mobilization; (c) protection and promotion of ad olescent health; and (d) prevention and management of anaemia. In this connection, the Regional Office, together with the Institute of Nutrition, Mahidol University , Thailand, conducted a regional research methodology training course for maternal and adolescent nutrition in May 1999. The objective was to build local capacity and provide participants an explicit understanding about how applied research is done to enable them to design and implement projects on their own and be better consumers and implementers of research results. Research remains an important tool for the implementation of national plans of action for nutrition. The South-East Asia nutrition research-cum action network continued to exchange vital experience in moving forward the nutrition re search agenda, including promotion, protection and support of breastfeeding, appropriate and safe complementary food, iodine deficiency disorder (IDD) control and other micronutrient deficiencies. Relevant WHO collaborating centres and national centres of expertise are closely involved in this strategy.

The Work of WHO in SEA

The fifth meeting of the South-East Asia nutrition researchcum-action network was held in June 1999 at the Institute of Nutrition, Mahidol University, Bangkok, which is the current secretariat of the networ k. The primary objectives were to review: (a) the status of nutrition action research intended to be conducted by the participants outlined at the fourth meeting held in Jakarta in June 1996, (b) and the multicentric action research conducted by the four WHO collaborating centres in nutrition and the status of their implementation to achieve nutritional goals. The network also publishes a six -monthly newsletter, which is an important tool for the dissemination of information relating to nutritional activiti es and research findings of the network within and outside the Region. Foodborne diseases are common in most countries of the Region. Microbial contamination of food and water causes a large percentage of morbidity and mortality due to diarrhoea. In addition, increasing use of chemicals in agriculture and food processing has added new concerns for health. The international marketing of food further complicates the situation. These factors reinforce the need for the countries to ensure the safety of their food products. A WHO Regional Consultation on Development of a Strategic Plan for Food Safety in the South-East Asia Region was held in the Regional Office in October 1998 to enable the Member Countries to address this complex issue and develop a regional strategy for food safety improvement. The Consultation developed a ten-point regional strategy which covered: food safety policy, food legislation, food control and inspection, analytical capability, epidemiological system, establishing working relationships with the food industry and trade, establishing working relationships with food service providers and retailers, establishing effective relationships with consumers, education and training in food safety and research in food safety.

Food safety

The Work of WHO in SEA

In addition to the regional consultations, four collaborating centres in nutrition were technically assessed prior to redesignation. Support was provided to the countries individually: in planning, preparing study proposals and assisting in study design for household food and nutrition security, and undertaking IDD prevalence study. Assistance was also provided to Indonesia, Myanmar, Sri Lanka and Maldives in the preparation of detailed plans of action in nutrition and food safety programmes for the 1998 -1999 biennium as well as preparation of food safety strategies in their respective plans of action. The Regional Office participated in the 11th session of the CODEX Coordinating Committee for Asia at Chiang Rai, Thailand, and assisted the participating Member Countries with recent activities and scientific data on food safety issues. The nutritional situation in DPR Korea was reviewed. It showed a persistent poor nutritional status of infants, young and school-aged children and possibly women of reproductive age. Case management of hospitalized children with severe malnutrition was assessed and improved management was suggested to reduce mortality and enhance quick and sustainable recovery. A WHO consultant was assigned to make an in-depth analysis and recommend an action plan for nutrition. A training workshop was organized by nationals, with technical support from the Regional Office, in Myanmar in May 1999 to improve case management of severe malnutrition in hospitals in Myanmar. This was because the mortality rate among these children is high, recovery is slow and, in the absence of a systematic follow -up mechanism, the relapse rate is also reportedly high, as in many other developing countries.

Food aid

Technical support was provided through the World Food Programme in the school feeding and deworming programme, in selected districts in Nepal.

The Work of WHO in SEA

Environmental Health The focus of WHO support to countries was in two main areas– drinking water quality surveillance, and operation and maintenance. Expansion of national programmes of Drinking Water Quality Surveillance and Control continued in the countries of the Region, specifically in Bangladesh, Bhutan, India and Myanmar. Laboratory capabilities for the surveillance of drinking water quality were strengthened through procurement of laboratory equipment, reagents and tra ining in surveillance and laboratory techniques. Support was provided for the development of the Water Supply and Sanitation Master Plan for Bhutan and, after its adoption, to the expanded water supply and sanitation programme aiming at full coverage by 20 00. A consultant was fielded to provide assistance in the selection of an appropriate approach to the Drinking Water Quality Surveillance Programme. The Fifty-first World Health Assembly, in May 1998, adopted a resolution on strategy for sanitation for hig h-risk communities. This strategy, along with the Participatory Hygiene and Sanitation Transformation (PHAST) methodology and the sanitation promotion publication, was introduced to the SEAR countries during the regional consultation held in Pokhara, Nepal, in November 1998. A consultant assisted the Government of Maldives on the problem of hydrogen sulphide gas in the

Water supply and sanitation in human settlements

The Work of WHO in SEA

sewerage system of Male. Support was provided by the intercountry as well as country programmes in India and Bangladesh in response to the e mergency resulting from arsenic contaminated water supplies in both countries. Consultants were fielded to advise on suitable approaches to the solution of this problem, both in the identification of affected populations and on appropriate treatments, devi sing a comprehensive programme for alternative supply of water and to strengthen WHO representation at the Arsenic Conference, organized by the Dhaka Community Trust Hospital in February 1998. The National Environmental Engineering Research Institute, Nagpur (WHO Collaborating Centre), was engaged to carry out an evaluation of arsenic field-testing kits and to develop guidelines for their use. Development of an improved kit was supported as the next step. Training activities related to the arsenic problem w ere supported at the All India Institute of Hygiene and Public Health, Calcutta. The National Conference on Arsenic Mitigation, held in Dhaka in February 1999, as well as the UN round -table meeting that followed, were jointly supported in partnership with UNICEF and the World Bank. Experts from WHO headquarters and PAHO participated. Collaboration with PAHO on the introduction of household type arsenic removal kits was initiated. Input was provided to WHO headquarters and UNICEF on the development of a new questionnaire for monitoring the progress on water supply and sanitation programmes in Member Countries. Compilation of the questionnaire and data collection are under way to facilitate publication of end-of-millennium achievements.

Environmental health in urban development

Promotion of the Healthy Cities approach represented the main activity under this programme. Support was extended to the communities which have already initiated the Healthy Cities process as well as to those starting it in Bangladesh, India, Myanmar, Nepal and Sri Lanka. Further, capacity development continued with the training of promoters selected from

The Work of WHO in SEA

Bangladesh, Bhutan, India, Nepal, Sri Lanka, and Thailand in Healthy City Methodology, organized in Bangkok in November 1997, and provision of promotional materials to the interested communities. The Healthy City project in Banepa, Nepal, has been used to test an interprogramme approach for providing support to countries. A similar approach was initiated in Mandalay, Myanmar. The various Healthy City initiatives in the Region were reviewed. The experiences are being summarized in a regional publication, to be issued in 1999. While summarizing these experiences, the reasons for success and failure have been analysed and used as a basis for designing the Healthy City: Framework for Implementation, a product of the Regional Consultation on Healthy Cities, to suit the regional characteristics. This new approach, introduced during the Regional Consultation on Healthy Cities, held in April 1999, is the most important outcome of this Consultation and is expected to guide further expansion of the Healthy Cities/settings programme in SEAR.

The development of national capabilities to assess and promote the management of health hazards from air, water and land pollution continued to be an area of priority attention. As a follow-up to the Regional Consultation on Sound Management of Hospital Wastes, held in Chiang Mai in 1996, national consultations on Promotion of Improved Hospital Waste Management were held in India, Indonesia, Maldives, Mya nmar, Nepal and Sri Lanka. The legislation, regulations and model guidelines have been implemented in India and Indonesia. In Nepal and Bangladesh, action was initiated for improving hospital waste management. In Indonesia, training courses were conducted and training modules prepared for air pollution monitoring, health hazards in hospitals and detection of pesticide residue. In Bangladesh, Nepal and Sri Lanka, activities were

Assessment of environmental health hazards

The Work of WHO in SEA

initiated for monitoring air pollution. Activities were also carried out on health-risk assessment of chemicals, and strengthening capacity for environmental monitoring. A consultant assisted the Regional Office in the preparation of a questionnaire on hazardous waste management. This would facilitate the assessment of the hazardous w aste situation at the country level, and for the preparation of hazardous waste country profiles through national consultants.

Promotion of chemical safety

WHO continued to accord high priority to the promotion of chemical safety. The chemical safety profiles prepared for Bangladesh, Indonesia, Maldives, Nepal, Sri Lanka and Thailand enabled the Regional Office to assess the existing situation and identify problems and issues in the management of chemical safety programmes. Following the adoption of a framework of action for strengthening national chemical safety programmes in countries of the Region, action has been initiated to address some of the priority issues. These include strengthening of capacity in the areas of chemical risk assessment and management, information system and d atabase development, poison prevention and management, and chemical emergency preparedness. A Regional Consultation on Poison Control was held in the Regional Office in December 1998 which resulted in the development of action plans on: (1) Pesticide poiso ning database, (2) Poisoning prevention and treatment, (3) Strengthening analytical toxicological facilities, and (4) Multicentric study of organo phosphorus pesticide poisoning. In Indonesia, training was carried out on poison centre management, establishment of a chemical safety database, and introduction of toxicovigilance. The Hazardous Substances Act was reviewed while the development and testing of an environment health management information system was

The Work of WHO in SEA

completed. The network of poison control centres has been expanded by establishing four new centres. In India, action was initiated on: the preparation of a chemical safety profile; review of status of persistent organic chemical pollutants; registration of potentially toxic chemicals; training in chemi cal emergency preparedness; and expansion of poison control activity by establishing new centres at Calcutta and Chennai. Development of a core group for environmental epidemiological surveillance in highly polluted areas was initiated. A number of innovative actions, such as inventorization of chemicals in use and contamination of ground water by chemicals, inventory of abandoned landfill sites, detoxification of obsolete pesticides and strengthening of institutions for information exchange on chemicals etc. were initiated. In Bangladesh, a chemical safety programme and action to establish a poison control centre were initiated. In Nepal, training was carried out on environmental epidemiology and on poison information system. In Sri Lanka, activities related to chemical emergency response were carried out. A Regional Workshop on the Establishment of Pesticide Poisoning Database, held in the Regional Office, resulted in the development of implementation plans for India, Indonesia, Nepal and Thailand. A Training Course on Toxic Chemicals, Environment and Health, supported by the International Programme on Chemical Safety (IPCS) was held at Hyderabad and Baroda, India, in June 1999. The focus of this programme area is to mobilize the health sector to advocate the incorporation of health issues and concerns in various sectors that are involved in the planning and implementation of national development activities. Through the WHO Health-and-Environment (H&E) Initiatives, countries have been assisted in identifying and assessing health hazards and issues in such sectors as agriculture, industry and environment.

Incorporation of health concerns into environmental management

The Work of WHO in SEA

Nine countries have initiated the Health and Environment programme and six have either adopted or drafted plans of action, which involve intersectoral partnerships. Constraints have so far been the establishment/formalization of a national coordinating mechanism to monitor the progress of implementation and the lack of H&E programme implementation capacities in ministries of health and other sectoral ministrie s. A regional publication entitled, “ Sustainable Development and Health for All: Building the Capacity of National Health Authorities” , was published and disseminated to the authorities concerned in all Member Countries.

The Work of WHO in SEA

Integrated Control of Diseases

Section 5

Eradication/Elimination of Specific Communicable Diseases Since June 1996, no case of dracunculiasis has been detected or reported in India, the only country in the Region where this disease was present. To achieve certification criteria, WHO supported an independent evaluation of the guineaworm eradication programme in India with the participation of the international certification team in 1999. The report of this evaluation confirmed that India had been free from guineaworm transmission for the pas t three years. In February 1998, WHO officially certified Bangladesh, Bhutan, Indonesia, Maldives, Myanmar, Nepal and Sri Lanka free from dracunculiasis transmission. It is expected that DPR Korea, India, and Thailand will be certified as “ free from dracun culiasis transmission”at the next meeting of the International Commission for the Certification of Dracunculiasis Eradication (ICCDE), to be held in Geneva in February 2000.

Guineaworm (Dracunculiasis)/ Brucellosis

The South-East Asia Region accounts for 79 per cent of the global case burden in respect of leprosy; India contributes 90 per cent of the cases in the Region. The prevalence rate per

Leprosy

The Work of WHO in SEA

10 000 population varied from 0.5 in Thailand to 3.7 in Nepal and 6.0 in India in December 1998. Since MDT was introduced, 8.8 million patients have been cured. At present, more than 10 per cent of the new cases are single lesion cases (PB cases). While Bhutan, Maldives, Sri Lanka and Thailand have already achieved the national elimination target (prevalence rate below 1/10 000), Bangladesh, Indonesia and Myanmar are expected to achieve elimination by the year 2000. India and Nepal are expected to achieve the target by 2002. Emphasis has been laid on the need for continued political commitment to eliminate leprosy. Cooperation from the media for community mobilization is important. In this context, press briefings were carried out in India and Bangladesh in 1999. Vertical programmes will be gradually integrated into primary health care programmes by training medical officers and health staff from primary hea lth centres. The WHO policy and strategy since 1996 has been to find hidden/undetected cases, particularly in difficult/isolated/ neglected/tribal and slum populations. Leprosy elimination campaigns (LECs) were carried out in 1997 – 1999 in Bangladesh, India , Indonesia, Myanmar and Nepal. The campaigns have helped in the detection of hidden cases. Special action projects were carried out in Bangladesh, India, Indonesia, Myanmar and Nepal during 1997-99. In 1988, the World Health Assembly resolved to eradicat e polio globally by the year 2000. The epidemiological block of countries, Indonesia, Myanmar and Thailand, have not isolated wild poliovirus for more than two years. Critical for achieving a zero polio status has been the development of surveillance of ac ute flaccid paralysis (AFP). AFP

Poliomyelitis

The Work of WHO in SEA

surveillance relies on establishing a well -organized, facility-based network of reporting units dispersed throughout the country. Epidemiological and virological information is collected from each reported AFP case. Virolog ical support is provided by a network of 16 WHO-accredited laboratories in the Region that conduct poliovirus isolation from stool specimens collected from AFP cases. The results of clinical follow-up and virus isolation studies are used to classify AFP cases as polio or non-polio. AFP surveillance is evaluated by two key performance indicators: (1) the sensitivity of AFP reporting (target: non-polio AFP rate of >1.0 case per 100 000 children aged <15 years); and (2) the completeness of specimen collection (i.e. two adequate stool specimens from >80 per cent of persons with AFP). The non-polio AFP >1.0 was achieved in Indonesia (1997), India (1998), Thailand (1998) and Nepal (1999). In 1998, the percentage of AFP cases with two adequate stool specimens collected for virological culture within 14 days of paralysis onset reached 60 per cent in India, 70 per cent in Myanmar, and 78 per cent in Indonesia, Sri Lanka, and Thailand. Bhutan, Maldives, and Sri Lanka have had no wild poliovirus isolates for more than five years. Of concern is the less rapid development of AFP surveillance in DPR Korea and Bangladesh. In 1998, DPR Korea reported no cases of AFP compared to three cases in 1997; however, in 1999 it has reported eight cases. The non-polio AFP rate in Bangladesh was 0.26 in 1998 compared to 0.14 in 1997.

The epidemiological block of countries consisting of Bangladesh, India, Myanmar, Nepal and Thailand, synchronized NIDs (National Immunization Days) in December 1997 and January 1998 – the low season for poliovirus transmission. Synchronized NIDs were first initiated in 1996. Pakistan in the Eastern Mediterranean Region and China in the Western Pacific Region joined this effort, resulting in a

The Work of WHO in SEA

total number of >243 million children vaccinated, representing appr oximately 38 per cent of the world’ s children aged <5 years. Similar synchronized NIDs were repeated in December 1998 and January 1999 with intensified activities along the Myanmar– China border. In India, the biannual NIDs have been the largest public health campaigns ever conducted in a single country, reaching more than 130 million children in 1999. In 1997, Maldives and DPR Korea joined the eight other Member Countries of South -East Asia in conducting NIDs. During the period from January 1998 to July 1999, wild poliovirus types 1 and 3 were isolated only in Bangladesh and India. In 1997, no wild poliovirus type 3 was isolated in Bangladesh, suggesting that improvements in surveillance led to its detection in 1998. Wild poliovirus type 2 was last isolated in SEAR in Bihar and Uttar Pradesh, India, in 1998. Despite improved surveillance, wild poliovirus was last isolated in Sri Lanka (1993); Indonesia (1995); Myanmar (1996); and in Thailand (1997). The South-East Asia Region has over 25 per cent of the world’ s population and includes the largest polio endemic country (India); therefore, progress in SEAR is critical for the success of the global polio eradication initiative. To sum up, Indonesia, Myanmar and Thailand appear to have interrupted transmission and joined other polio-free countries in the Region – Bhutan, Maldives, and Sri Lanka. India has made substantial progress in surveillance, but continues to have widespread circulation of polioviruses type 1 and 3 with circulation of type 2 in 2 states. Ban gladesh and Nepal are progressing less rapidly, and data are lacking regarding progress in DPR Korea. Despite high NID coverage in India, 10 per cent of missed target population each year represents approximately

The Work of WHO in SEA

13 million children, often residing in areas of low coverage and crowded conditions. Reaching zero polio cases in India, Bangladesh, and Nepal by the end of 2000 will require: improving the quality of NIDs by strengthening supervision, adding extra rounds of NIDs and sub-NIDs and conducting house-to-house mopping-up immunization campaigns in areas with persistent transmission. Other countries will need to sustain their progress for certification of polio eradication. DPR Korea will need to provide an accurate assessment of its polio situation to ensure that the target is reached. Five countries are considered as having eliminated neonatal tetanus (NT). The remaining countries, viz. Bangladesh, India, Indonesia, Myanmar and Nepal, are developing and implementing plans, based on the high-risk approach, to reach the global target of less than 1 NT case per 1 000 live births by the year 2000. They aim at immunizing all women of child bearing age (WCBA) in high-risk areas with at least three doses of TT vaccine. Bangladesh is planning a combined measles -neonatal tetanus campaign, targeting 2.65 million women of childbearing age with three doses of TT. The first round is scheduled for implementation in September 1999. In addition, 1.22 million children aged 9-36 months are targeted for immunization with measles vaccine. In India, most NT cases occur in the states of Rajastan, Uttar Pradesh, Madhya Pradesh, Orissa, Assam, and Bihar. A campaign, organized in Rajastan in 1998-1999, was the start of intensified neonatal tetanus eradication (NTE) activities in India. Some 3.5 million married women between 15 and 30 years of age, plus 500 000 pregnant women were immunized with two doses of TT in April/May 1998, accounting for approximately 80 per cent of the target group. The third round is planned for early

Neonatal tetanus

The Work of WHO in SEA

1999. The campaign was organized with strong UNICEF support. India is currently developing a plan of action for neonatal tetanus elimination. In Indonesia, a strategy to eliminate NT has been developed, using a four-pronged approach: routine childhood immunizat ion with DTP3, routine TT immunization of pregnant women, campaigns targeting WCBA in high-risk areas, and school-based immunization of primary school students. The combination of the four strategies will hopefully allow Indonesia to stop routine TT immunization of pregnant women from 2008 onwards. All districts have been ranked as having either “ eliminated NT” , “ controlled NT” , or being at “ high risk for NT” , using a scoring system based on TT2+ coverage and safe delivery practices. The highest-scoring districts are targeted first with extra rounds of TT vaccine, targeting all WCBA. November has been declared “ School Immunization Month (“ BIAS” )”in Indonesia; during that month health workers visit all schools nationwide to administer one dose of DT or TT. Myanmar has identified 88 townships as high-risk areas, based on the occurrence of more than 1 NT case per 1000 live births and/or low routine TT2+ coverage. Women of child bearing age in these townships will be targeted for three extra rounds of TT vaccine in 1999/2000. Nepal has developed a plan of action for neonatal tetanus elimination.

Measles

Measles continues to be a major cause of morbidity and mortality in the Region, with 114 000 cases reported in 1997. The true incidence is likely to be several million cases. In the absence of a regional elimination target for measles, UNICEF, CDC/Atlanta and WHO have jointly agreed on a regional strategy for morbidity reduction (Bangladesh, DPR Korea, India, Myanmar and Nepal)

The Work of WHO in SEA

and outbreak prevention (Bhutan, Indonesia, Maldives, Sri Lanka and Thailand). All countries are recommended to strengthen routine immunization services, with special focus on the high-risk areas for measles (poor, underserved, densely -populated areas, such as urban and periurban slums). Countries aiming at outbreak prevention should also implement campaigns in highrisk areas, and, after careful review of the data, possibly catch -up or follow-up campaigns. Surveillance is to be strengthened, and should be linked to AFP surveillance after it has been shown that AFP has reached internationally-accepted standards. Bangladesh implemented special immunization activities in flood shelters in September 1998, during which some 15 000 children between 9 and 59 months received OPV and measles vaccine. A larger campaign, combined with TT for WCBA, is planned for 1999-2001. Bhutan has implemented a campaign targeting all children 9 to 59 months (as well as school children under 15 years), and may need to secure the achieved level of measles control through the implementation of a follow-up campaign. Similarly, Maldives has immunized all children aged 5 to 14 years with a supplemental dose of measles vaccine. In India, 20 cities are targeted for intensified measles immunization activities in high-risk areas in 1999 with UNICEF support. Indonesia plans to carry out a pilot study, looking into the feasibility and efficacy of adding a second measles dose to the school-based immunization programme. In Myanmar, a special campaign was organized in Yangon and Mandalay, tar geting all children aged 6 or 9 months to 59 months of age. The campaign was followed by an evaluation, revealing that more than 90 per cent of the targeted children had been reached, but also that about 1 in 3 unvaccinated children was missed by the campaign. Maldives, Sri Lanka and Thailand have established laboratory based measles diagnostic capacity and are using this facility to confirm outbreaks.

The Work of WHO in SEA

Control of Other Communicable Diseases Vaccine preventable diseases Vaccine production in the South -East Asia Region covers all EPI vaccines, including Hepatitis B vaccine. In India, recombinant hepatitis B vaccine is being produced on a small scale in collaboration with the government of Oman. Hepatitis B immunization has been introduced in the regular immunization programme in Bhutan, Indonesia, Maldives, Thailand, and, to a certain extent, in DPR Korea. Bhutan faced major problems with hepatitis B vaccine supply in 1997 and 1998 , due to insufficient resources. Bangladesh is planning a gradual introduction of hepatitis B vaccination in EPI in 1999, initially in urban areas. India and Myanmar also have high hepatitis B carrier rates but financial constraints have so far prevented widespread implementation. In India, hepatitis B vaccine is being administered through the private sector. Nepal is planning a burden of disease study in 1999, to assess in detail the need to introduce hepatitis B vaccine in the country. Studies on the burden of disease of Haemophilus influenzaeb (Hib) are being carried out in India, Indonesia and Thailand, and will hopefully provide useful information as to whether introduction of Hib vaccine is indicated.

The Work of WHO in SEA

The Regional Office is supporting Thailand development of a dengue recombinant vaccine.

the

Acute Respiratory Infections (ARI) and Control of Diarrhoeal Diseases (CDD) Programmes have been implemented in all SEAR countries since 1982. Since 1996 -97, most countries have tried to combine the training in these two areas to save on cost and provide for a better approach to clinical management of sick children. A CDD health facility survey (HFS) in Bangladesh in December 1997 showed a significant improvement in the quality of case management among health wo rkers. A collaborative (WHO, UNICEF, John Snow Inc., HMG Nepal) ARI strengthening programme was implemented in five districts in Nepal. The programme assessment results indicate that regardless of the level of the health worker, the quality of training and regular follow-up leads to correct management of sick children.

Acute respiratory infections and diarrhoea

Among the ten Member Countries in the Region, Bangladesh, Bhutan, Indonesia, India, Myanmar and Nepal, have relatively high under-five mortality ratio (>80 per 100 000 live births). These countries are considered as the IMCI target countries. By the end of 1998, Indonesia and Nepal had completed the early implementation phase in pilot districts (one district in Nepal and two districts in Indonesia). Adaptation and translation of training materials have been completed in both countries and used for training health staff at the district level. Training of first -level health workers has also been completed in pilot districts. A review meeting was also conducted in Nepal in September 1998. A draft plan of action for the expansion of IMCI to two newly-selected districts has been prepared. Bangladesh organized an IMCI orientation meeting in March 1998. Since then, an IMCI working group has been formed and

Integrated management of childhood illness (IMCI)

The Work of WHO in SEA

adaptation of training materials started. In November 1998, the CDR Medical Officer from Indonesia visited Bhutan to assist the national authorities in initiating IMCI in the country. A national-level consultation was organized by the Ministry of Health and Family Welfare, Government of India, in January 1999, for orientation of different programme managers on IMCI. An orientation workshop was conducted for members of the India Academy of Paediatrics in Delhi. Myanmar has started the Integrated Management of Maternal and Childhood Illness (IMMCI) programme with support from UNICEF. Some initial activities on IMCI pre-service training have been started in 15 medical colleges in Indonesia. In Nepal, the Institute of Medicine at Tribhuvan University, Kathmandu, organized, in collaboration with WHO headquarters, a Planning Workshop on IMCI Pre-service Training in December 1998. An Intercountry Workshop on Promotion of IMCI Training for Basic Health Workers was held in Chandigarh, India, in April 1998. Thirty participants attended the Workshop. Representatives of all countries agreed to introduce the IMCI training package for Basic Health Workers (BHWs) into their child health programmes. In countries where IMCI has not yet started, this kind of training may be started simultaneously with standard IMCI training (11 -day course) for first -level care health facility staff. Assistance was provided to the Ministry of Health, Indonesia, for developing an IMCI training course for BHWs based on the experience in India and Nepal. Through an agreement with a group of pa ediatricians in Nepal, the national version (in English) of IMCI training materials is being reviewed and finalized. In December 1998, an Intercountry Workshop was organized in Yangon to review the progress of CDD, ARI control programmes and IMCI strategy and to plan for initiating and improving IMCI strategy in Member Countries. Recommendations were made to improve the quality of three components of IMCI,

The Work of WHO in SEA

particularly in six target countries (Bangladesh, Bhutan, India, Indonesia, Myanmar and Nepal). Advocacy materials, which include desk calendars and posters, were printed and distributed to all Member Countries. To increase the pool of trainers and course directors in the Region, two intercountry IMCI courses were conducted in Indonesia (June 1998) and in Nepal (October 1998). There is a substantial improvement in the IMCI training capacity in the Region. By the end of 1998, at least 2 -3 medical officers from each target country had been trained in the standard 11-day IMCI course. Standard training courses were conducted to cover all first-level health facilities in three districts of Indonesia and Nepal. Two follow-up after-training activities were carried out in each country. Findings from the follow-up visit in Mahottari District in Nepal demonstrated the importance of follow-up and supervision after training. The performance of health workers on IMCI and the health system, particularly drug logistics/management and health facility support, improved as a result of the visits. A training Workshop on Regional Capacity Building on Breastfeeding Counselling was conducted in New Delhi, in the latter half of 1998. Six facilitators, 22 participants from six states of India and four course director trainees from Myanmar, Nepal and Sri Lanka were trained. As a follo w-up, similar workshops are planned at national and state levels in each country. Unique among the WHO regions, all countries in SEAR have accepted the WHO-recommended strategy of Directly Observed Treatment, Short-course (DOTS). The countries have begun implementation, and are reporting on programme performance. In the period covered, the population coverage of DOTS in the Region expanded dramatically, from 95 million to an estimated

Tuberculosis

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370 million. The number of patients treated under DOTS annually increased from 30 000 to 111 000, including an increase from 18 000 to 70 000 in the number of new smearpositive cases. However, this represents an increase of only 2.5 per cent of the estimated number of new smear -positive cases, as against the global target of 70 per cent detection. The quality of diagnosis in DOTS areas has been good, with more than half of the patients with pulmonary tuberculosis having laboratory confirmation of their disease. Treatment success rates in DOTS areas remains high, at approximate ly 77 per cent, compared with the global target of 85 per cent. Compared with non-DOTS areas, patients evaluated in DOTS areas are more than twice as likely to have an accurate diagnosis and are more than thrice as likely to be treated successfully. As a result of DOTS programmes, more than 50000 deaths have been averted, most of them among young adults in the most productive years of their lives. WHO has collaborated closely with the World Bank, which is supporting tuberculosis control programmes in India and Bangladesh, as well as with bilateral donor agencies. In the next biennium, the challenges will be, first, to expand DOTS nationally in the remaining countries and, second, to improve DOTS implementation in order to meet global targets for tuberculosi s control.

Emerging diseases, including cholera and other epidemic diarrhoeas, zoonoses and antimicrobial resistance

The South-East Asia Region is particularly vulnerable to the occurrence and spread of communicable diseases, accounting, as it does, for more than 40 per cent of the global disease burden. In view of this, the importance of developing a sensiti ve and efficient epidemiological surveillance system has been brought to the attention of policy-makers and health authorities. To address the problems relating to communicable diseases, and to focus on the border problems, bi -regional meetings were held n i Beijing in 1997 and in Chiang Mai, Thailand, in 1998. Malaria, HIV/AIDS, polio, TB and cholera were covered. The meetings helped to strengthen political commitment and bi-regional cooperation.

The Work of WHO in SEA

Case definitions for ten important communicable diseases were developed and field -tested in Myanmar and Indonesia in 1998 to develop regional guidelines. The Regional Office is developing a computerized disease surveillance database system to monitor the trends of priority communicable diseases with epidemic potential. Further, a system of regular monitoring of outbreaks and epidemics was established and more than 30 epidemics were monitored, information analysed and assistance provided to Member Countries, where needed. An Intercountry Consultative meeting on Epidemiological Surveillance and International Health Regulations was held in Colombo in December 1998. The meeting reviewed the current status of the epidemiological surveillance and reporting system and developed strategies for further strengthening rapid resp onse to disease outbreaks. To improve regional and national capacities in epidemiological and disease surveillance, technical support was provided by WHO for the two -year Field Epidemiology Training Programmes (FETP) in Indonesia and Thailand. The Thai FETP based at MoPH, Thailand, is under consideration for being designated as a Regional Training Centre for the two -year Field Epidemiology Training. Two participants from Myanmar, supported with WHO funds, are attending this programme. Technical and financial support was also provided for the three month training course conducted by the National Institute of Communicable Diseases (NICD), Delhi. A total of 26 public health officers from India, Maldives, Myanmar, Nepal, and Sri Lanka were trained in 1997 and 19 98. In addition, two ten day workshops were held for the training of trainers on outbreak investigations and response at the WHO Collaborating Centre for Epidemiology, NAMRU-2, in Jakarta, in November 1997 and in Kathmandu in October 1998. The protocols of the Revised International Health Regulations, developed by WHO, were field -tested by India, Sri Lanka and

The Work of WHO in SEA

Thailand and the constraints identified shared with WHO headquarters. To strengthen coordination with WHO collaborating centres and other centres of excellence, a consultative meeting was held in September 1997 to address possible areas of coordination on emerging and re -emerging infectious diseases.

Cholera

In 1997 and 1998, Bangladesh, Bhutan, India, Indonesia, Myanmar, Nepal and Sri Lanka notified cholera to the Regional Office. In 1997, all isolations were found to be Vibrio Cholera 01, serotype Ogawa or Inaba. No O139 sero-group was isolated. However, in 1998, most of the above countries had evidence of O139 sero-group. Antisera was provided to countries by the Regional Office. The very low case -fatality rate achieved is an indication of the importance of good case management and access to treatment facilities. All Member Countries have been encouraged to comply with the current International Health Regulations by notifying cholera cases to WHO and not to impose inappropriate measures (e.g. trade and travel restrictions) against the affected persons.

Other communicable diseases Japanese encephalitis

Together with WHO headquarters, the Regional Office conducted a Meeting on New Initiatives for Vaccines against Japanese Encephalitis (JE) in October 1998 in Bangkok. The meeting reviewed the existing epidemiological situation of JE in the endemic countries of the South-East Asia and the Western Pacific Regions. Recommendations were framed regarding surveillance, requirements and conditions for the use of JE vaccine based on scientific evidence, improvement in the quality of vaccine and policy on the adoption of JE vaccination as part of national immunization programmes in highly-endemic countries.

The Work of WHO in SEA

WHO continu ed to support hepatitis B control programmes in the countries of the Region. Hepatitis B vaccination, under the framework of EPI, was extended to more provinces in Bhutan, DPR Korea, Indonesia, Maldives, Myanmar and Thailand. A demonstration project on hepatitis B immunization continues in New Delhi. Plasma-derived hepatitis B vaccine is produced in DPR Korea, Indonesia and Myanmar. India had developed DNA recombinant hepatitis B vaccine for which field trials are under way. Mandatory screening of blood and blood products for hepatitis B is now being carried out in all the countries of the Region except Bangladesh. WHO supported the efforts of the countries in investigating outbreaks of hepatitis A and hepatitis B through technical support and provision of diagnostic reagents. Till recently, low priority was being accorded to influenza in the countries of the Region. However, after the “ bird flu” in Hong Kong with a new influenza strain (H5N1) in 1997, there is keen interest. WHO provided technical information and necessary laboratory diagnostic reagents to the countries. During April -May 1998, technical assistance was provided to Sri Lanka and Bhutan in conducting investigation and laboratory confirmation of cases of outbreak of influenza, by involving WHO collaborating centres in the UK and India. In both the Member Countries, the influenza outbreak was associated with influenza A H3N2 viruses, antigenically similar to a new variant, represented by A/Sydney/5/97/strain.

Viral hepatitis

Influenza

The regional guidelines for the preve ntion and control of dengue/DHF, developed and finalized at the Peer Review Meeting, held in Yangon, in November 1997, were published in 1999. The Regional Office developed simplified guidelines for case management of dengue/DHF in small hospitals, which were published in March 1999. The Queen Sirikit’ s National Institute of Child Health, Bangkok, was designated as the WHO

Dengue/Dengue haemorrhagic fever (DHF)

The Work of WHO in SEA

Collaborating Centre on Clinical Management of DF/DHF. The Institute trained several physicians from the Region in clinical management of dengue/DHF. A training video was also produced. In 1998 -99, a total of 17 dengue training/curative wards were established in endemic countries. WHO provided technical information kits containing WHO guidelines on different aspects of prevention and control of dengue infection. WHO supported an independent review of the dengue/DHF prevention and control programme in Thailand. The Review Mission identified constraints with dengue vector control activities and the lack of community involvement in the preventive measures. Technical support was provided to Indonesia in the containment of the dengue/DHF epidemic. Two consultants were assigned to India to suggest how to improve prevention and control of dengue/DHF with the special emphasis on epidemics. Meningococcal meningitis

WHO continued to provide up-to-date information to Member Countries regarding prevention and control of meningococcal meningitis, with the emphasis on early detection and treatment. Special attention was given to mass vaccination campaigns and active surveillance of pilgrims going to Mecca. Technical assistance was provided to the Government of Maldives for analysing the existing situation relating to meningitis/encephalitis. Particular attention was paid to the development of national guidelines and a plan of acti on for prevention and control of meningitis/encephalitis and conducting laboratory investigations on the specimens collected from suspected patients.

The Work of WHO in SEA

WHO-supported research on predictive surveillance of plague in some countries of the Region has demonstra ted that dog serosurveillance is more cost-effective and sensitive than sero surveillance of rodents. In the period under review, India and Indonesia were supported for the production of plague diagnostic reagents. The Regional Office also provided techni cal information and diagnostic reagents for hantaviruses, leptospirosis and brucellosis, on request, to countries of the Region. Following the informal consultation on rabies elimination, held in March 1998, countries of the Region are in the process of revising their respective national strategies for rabies control. Urban rabies eradication activities are likely to be undertaken in the next biennium.

Zoonoses

Rabies

As of March 1999, a total of 92,427 cases of AIDS have been reported in the Region – an increase of more than 40 per cent from 1 July 1997. Thailand, India and Myanmar account for more than 95 per cent of the cases reported from the SEA Region. Bhutan and DPR Korea have not yet reported AIDS cases, although Bhutan has diagnosed persons with HIV infection. It is estimated that less than 25 per cent of the total AIDS cases have been reported. An analysis of the recent data shows that 91 per cent of those affected were between the ages of 15 and 49 years and 4.6 per cent were children. The male to female ratio was 4:1. Based on sentinel surveillance data, it is estimated by WHO and UNAIDS that 5.5 million people in the South -East Asia Region are already infected with HIV (Table 5). This represents nearly 18 per cent of the global burden. The cumulative number of HIV infections is expected to rise dramatically in the Member Countries.

AIDS and sexually transmitted diseases

The Work of WHO in SEA

Table 5. AIDS and HIV infections in SEAR countries (As of 1 March 1999) Country Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Total 1

Reported AIDS cases 10 1 0 6 252 230 5 2 312 183 77 83 357 92 427

Date of last report 3/97 8/98 11/96 3/98 2/99 3/98 3/98 1/98 3/98 3/98

Estimated HIV infections 21 000 <100 <100 4 000 000 25 000 <100 440 000 25 000 6 000 950 000 ~ 5 600 000

Rate per 100 000 population1 16 <16 <1 418 12 <25 760 66 32 1 345 >358

1996 population estimates for all countries except Bhutan are based on UN population figures for mid -1994, with annual growth rates applied as appropriate.

While the AIDS epidemic continues to grow in the Region, all countries are responding to this threat with urgency. National AIDS Programmes have developed strategic plans and are implementing activities in partnership with various sectors concerned, including NGOs and the private sector. The emphasis of WHO support was on: (1)prevention and control of STD; (2) ensuring blood safety; (3) clinical care and counselling, and (4) epidemiological surveillance. The Regional Office developed, printed and distributed numerous technical and advocacy materials, e.g. (1) AIDS: The challenge; (2) AIDS in South -East Asia: No time for complacency; (3) Clinical management of HIV and AIDS at district level; (4) Strategies for safe blood transfusion; and (5) Planning and implementing HIV/AIDS care programmes: a step-by-step

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approach. In addition, the Regional Office continued to publish the quarterly newsletter AIDSWATCH. A regional review of the HIV/AIDS control programme has been completed. Advocacy kits were prepared and disseminated to Member Countries, including those for World AIDS Day. To assist Member Countries strengthen STD control efforts, the Regional Office developed guidelines on STD management as well as a set of training modules on STD syndromic management. A Training of Trainers Workshop on STD Syndromic Management was organized in Yogyakarta in April 1998. In March 1999, the Regional Office conducted an Intercountry Training on HIV/AIDS Clinical Management in collaboration with Bamrasnaradura Hospital, Nonthaburi, Thailand (WHO Collaborating Centre). Physicians responsible for future training at the country level were trained. Three participants from Nepal were nominated for a Training Course on Community-based HIV/AIDS Prevention and Care Strategies, held at Bangkok in March 1999. The training course was organized by the Asian Centre for Population and Community Development, Thailand. In December 1998, the annual meeting of national programme managers was held in Yangon. The meeting provided an opportunity to the participants to share country-level experiences and lessons learnt on STD/AIDS prevention and control activities. The border areas between Thailand, Myanmar, Lao People’ s Democratic Republic and China are recognized as the new epicentre for multidrug-resistant malaria. Widespread resist ance to chloroquine and sulfonamide/pyrimethamine combination has been reported in Myanmar and Thailand, while resistance to quinine and mefloquine is confined to border areas between Thailand and Myanmar in the north, and Thailand and Cambodia in the east. WHO headquarters supported a joint proposal from the South-East Asia and the Western Pacific Regions for the

Control of Tropical Diseases Malaria

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control of malaria in six Mekong countries affected by multidrug resistant malaria. The standard protocol for monitoring the therapeutic efficacy of antimalaria drugs, adopted in early 1997, has been implemented in Bhutan, Indonesia, Myanmar, Nepal, Sri Lanka and Thailand. An Intercountry Meeting of National Programme Managers, held in Pattaya, Thailand, in February 1999, endorsed the Roll Back Malaria Initiative of the Director-General of WHO and recommended country reviews of malaria programmes. The need for intersectoral cooperation in control efforts was stressed. Countries around India and Myanmar joined the collaborative programme and develope d synchronized activities between adjoining border districts. For this purpose, two meetings of the Task Force on Border Malaria were held, i.e., between Bangladesh, India, and Nepal in Patna, India, in July 1998, and between Bangladesh, India, Myanmar and Thailand in Pattaya, Thailand, in August 1998. Intercountry collaboration between Bhutan and India; India and Nepal; Myanmar and Thailand was implemented through sharing of resources and training facilities. ACTMalaria (Asian Collaborative Training Networ k for Malaria), established by Thailand in 1996 with the support of the Regional Office, conducted the first eleven -week training programme on management of Malaria Field Operation for mid level staff during October -December 1997. Theory and laboratory sessions were conducted in Thailand followed by field visits in Yunnan Province of China. Field visits for the second batch were held in Indonesia in 1998. Lymphatic filariasis

It is estimated that there are over 600 million people living in areas endemic to lymphatic filariasis in this region; over 60 million have various forms of the disease. The disease is geographically distributed throughout the Region; both urban and rural areas are affected. All filariasis -endemic countries in

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the Region have been urged to establish nation al programmes for control of lymphatic filariasis aimed at reduction of morbidity and/or elimination of the infection. Kala-azar is a major health problem in border areas shared by Bangladesh, India and Nepal. The Regional Office continues to support collaborative programmes between the three countries. Synchronized control measures for malaria and kala -azar in the border areas are being strengthened. The WHO Regional Office has been advocating minimizing of the use of insecticides for vector control. Mem ber Countries were motivated to establish a national insecticide policy for use in public health. While the status of mosquito vector resistance to insecticides and monitoring systems are being reviewed, information exchange at national, regional and global levels is being strengthened. A publication “ The Anopheline Species Complexes in South-East Asia” was issued under the WHO Technical Publications Series. A Consultative Meeting on Disease Vector Surveillance and Control at Ports and Airports handling international travel was organized in Bangkok in October 1998. Guidelines were developed following this Consultation. A regional Comprehensive Vector Control Course has been developed at the Vector Control Research Centre, Pondicherry (WHO Collaborating Centre for Research in Integrated Methods for Vector Control). The focus will be on control of all vector borne diseases. The course curriculum and training modules have been developed in close collaboration with WHO headquarters. WHO organized a Consultative M eeting on Alternative Approaches to Vector Control in Yangon in May 1999. This meeting helped to catalyze preparations of various interventions Visceral leishmaniasis (kala-azar)

Disease vector control

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and strategies at the local level to help minimize the use of insecticides.

Special Programme for Research and Training in Tropical Diseases (TDR)

The TDR Programme continued to supp ort activities and research in the Region focused on malaria (Bangladesh, India, Myanmar, Nepal, Sri Lanka, Thailand); lymphatic filariasis (India, Myanmar, Nepal, Sri Lanka); leprosy (India), and kalaazar (Bangladesh, India, Nepal). Research activities on malaria focused on drug resistance studies (Myanmar, Thailand); vaccine development (India, Thailand); vector control (Sri Lanka); monitoring of drug efficacy (Indonesia, Myanmar, Sri Lanka) and new drug regimen (Thailand). Studies on lymphatic filariasis covered the impact of mass chemotherapy with DEC or ivermectin (India, Myanmar, and Sri Lanka); filariasis endemicity (Myanmar, Sri Lanka); and insecticide impregnated curtain (Sri Lanka). Studies on kala-azar focused on the development of an animal model (India); clinical study with aminosidine and Miltefosine (India); impregnated bednets (Bangladesh); field evaluation of test kit (Nepal); and entomology (Nepal).

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Control of Noncommunicable Diseases WHO continued to promote an integrated preventive approach, which addresses common risk factors of major noncommunicable diseases, namely cardiovascular diseases, diabetes mellitus and cancers. The WHO Manual on Integrated Preventive Approach was provided to all Member Countries. India, Indonesia and Myanmar have already started implementing the approach in selected areas. To support this approach, efforts were made to increase public awareness and to strengthen progra mme management capabilities for PHC personnel. Bangladesh, India, Myanmar and Sri Lanka conducted training courses on prevention and management of noncommunicable diseases for medical and paramedical staff. Besides the three diseases mentioned above, count ry-specific problems were also addressed: for example, snakebite in Myanmar, pesticide poisoning in Sri Lanka and thalassaemia in Maldives. In April 1998, an Intercountry Workshop on Prevention and Control of Diabetes Mellitus was organized in Dhaka. Recommendations were made for strengthening national

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diabetes control programmes. An Intercountry Training Course on Palliative Care was also conducted in Calicut, India, in November 1998. Following the training, some countries initiated the development of a national policy for pain management and care of terminally-ill patients.

Oral health

WHO’ s oral health programme continued to focus on the prevention of dental caries and periodontal diseases. Most activities are aimed at communities and at school oral health. Bangladesh conducted several training courses on oral health for school children while India conducted a training course for dental professionals. Community training on oral health in Myanmar was expanded within the project townships. With technical support from WHO, Bhutan established a national oral health programme. Training courses on atraumatic restorative technology (ART) are being planned for Bhutan and DPR Korea. Essential equipment for training and for use at the training sites will also be provided.

Prevention of blindness and deafness

WHO continued its support to countries in developing basic eye care and ear care services at the PHC level, strengthening outreach interventions and improving technical capabilities for referral services. Support was also provided for reviewing the impact of the national programmes and for strengthening coordination of NGO activities. Bangladesh, Myanmar, Nepal and Sri Lanka organized several training courses on primary eye care and ear care for doctors and other PHC workers. In Bangladesh and Nepal, paramedical staff and school teachers were also trained in early detection and prevention of blindness and deafness. India has made commendable progress in trying to clear the backlog of cataract cases. Each year, about 2 million cataract

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operations are performed al l over the country. District programme managers were trained in primary eye care intervention and in strengthening information systems. Nongovernmental organizations were also involved in the implementation of the National Prevention of Blindness Programmes. Health education materials for school eye care and for mega eye camp activities were also provided. WHO supported Nepal in reviewing the Prevention of Blindness programme and in operating outreach mobile camps in remote areas. To address the problem of childhood blindness, an intercountry consultation was organized in Hyderabad in April 1999 in collaboration with the International Agency for Prevention of Blindness. Information on deafness and hearing loss in the Region remains inadequate. In 1998, the Regional Office supported a survey on the etiology of deafness and hearing impairments in India, Indonesia, Myanmar and Sri Lanka. The WHO Collaborating Centre for Prevention of Deafness in Thailand produced a manual on primary ear care for physicians and health staff at the PHC level with support from WHO. In 1998, the Jakarta Centre of Otology was designated as the WHO Collaborating Centre on Communication Disorders.

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Administrative Services

Section 6

Personnel Following restructuring of the Organization at WHO headquarters, the Regional Office was also reorganized to facilitate smooth coordination of the Organization’ s activities at headquarters, regional and country levels. The revised organizational structure of the Regional Office is given as Annex. There were 132 established professional posts in the South East Asia Region on 30 June 1999, as compared to 134 professional posts on 30 June 1998, and 130 on 30 June 1997. Table 6 shows the number of professional (P) staff appointed, and separated or reassigned out of the Region at the end of 30 June 1998 and 30 June 1999: Table 6. Professional staff appointed and separated or reassigned out of the Region, as of 30 June 1998 and 30 June 1999 No. of new P staff appointed Male As of 30.6.98 As of 30.6.99 7 2

No of P staff separated or reassigned out of the SEA Region Male 13 11

Female 4 2

Female – 3

Of the 96 professional staff in position as of 30 June 1999, 45 (46.9 per cent) were nationals of the SEA Region. Out of the

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total number of professional staff in position, 21 (22 per cent) were women. During the reporting period, 40 per cent of the appointments in the Region (including recruitments from outside the Organization and reassignments), wer e of women. The Regional Office has recognized the need to achieve and maintain an equitable representation of women and has established a recruitment threshold of 60 per cent to help achieve this objective. During the reporting period, 282 short-term staff were hired, of whom 178 (63 per cent) were nationals from the SEA Region. Out of the total number of short-term staff appointed, 56 (20 per cent) were women. As of 30 June 1999, there were 8 National Professional Officers appointed on fixed term to assis t WRs in five countries in the implementation of national health programmes.

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General Administration In 1993, the World Health Assembly authorized financing from the Real Estate Fund of an additional floor to the Annex of the Regional Office. Unable to obtain the necessary approval from the local authorities, the project was shelved in June 1998. Renovations to the 35-year old main building continued. The Library was completely renovated and adapted to use Internet, CD-ROM and video. The old building adjacent to the Annex was renovated to rationalize storage space and realize eigh t additional office rooms. To meet the growing need, further rationalization of space is taking place by converting space formerly used for storage into office space. All air handling units of the AC system throughout the premises were renovated and the co nnected heating system upgraded to comply with current safety standards. The main electrical distribution panels are also being replaced. An analysis and assessment of the quality of the indoor air in the Regional Office has been initiated. The Regional Office selected a new travel agent, who started operations on 1 April 1999.

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Budget and Finance During the 1996 -1997 biennium, increased use of the intercountry mechanism was initiated as a complementary tool to help reach 100 per cent implementation of the Regular budget allocation. The 1998 -1999 biennium began with a 3 per cent reduction in the working allocation under the WHO Regular budget. As of 30 June 1999, it looked unlikely that these funds would be released for use during this biennium. Implementation of WHO collaborative programmes in the Member States during the 1998-1999 biennium was once again focused on the timely delivery of quality technical programmes. Intercountry mechanisms were used to speed up financial implementation while, at the same time, technical quality was being stressed through increased scrutiny and review of commitment documentation. While the goal of 75 per cent financial obligation by 31 December 1998 for country activities was not reached, the goal of 100 per cent financial implementation of country activities by September 1999 was being vigorously pursued. Audit reviews highlighted the need for improved linkages between the planning, monitoring, and evaluation of

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programmes. In this regard, a consultant was engaged to re view more fully the technical quality of implementation and to recommend a process for its continued review. The Budget and Finance Unit provided support for the budgetary control and management of all accounts under the Regular and Extrabudgetary programm es in the Region.

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Annex

Organizational Chart Office of the Regional Director (RDO)

Regional Director Deputy Regional Director/ Director, Programme Management

Regional Cabinet (RCT)

Special Projects (SPP)

General Management (GMG)

Communicable Diseases (CDS) Sustainable Development and Healthy Environment (SDE) Evidence and Information for Policy (EIP)

Social Change and NonCommunicable Diseases (SCN) Health Systems and Community Health (CHS) Health Technology and Pharmaceuticals (HTP)

WHO Representatives WHO Country Offices WHO Field Staff

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Informations clés

Organisation Organisation mondiale de la santé (OMS)

Type de document Governing Bodies documents

Date d'adoption 10 octobre 1999

Source Organisation mondiale de la santé